Tuesday, April 8, 2014

The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders

The role of bioelectronic instrumentation in the documentation and management of temporomandibular disorders

Cooper, B.: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology Volume 83, Issue 1 , Pages 91-100, January 1997.


Temporomandibular disorders (TMDs) can affect the form and function of the temporomandibular joint, masticatory muscles, and dental apparatus. Electronic measurement of mandibular movement and masticatory muscle function provides objective data that are defined by commonly accepted parameters in patients with TMDs; these data can then be used to design and monitor therapy and enhance treatment therapy. In this study, data on 3681 patients with TMD are presented, including electronic test data on 1182 treated patients with TMDs. Electronic jaw tracking was used to record mandibular movement and to compare the presenting and therapeutic dental occlusal positions. Electromyography was used to analyze the resting status of masticatory muscles and occlusal function at presentation and after therapeutic intervention. Transcutaneous electrical nerve stimulation therapy relaxed masticatory muscles and aided in the determination of a therapeutic occlusal position. The data show a positive correlation between the clinical symptoms of TMD and the presenting occlusion, accompanied by muscle activity. A strong positive correlation also appears to exist between a therapeutic change in the dental occlusion to a neuromuscularly healthy position with use of a precision orthotic appliance and the significant relief of symptoms within 1 month and at 3 months.

Monday, April 7, 2014

Precision occlusal splints and the diagnosis of occlusal problems in myogenous orofacial pain patients

Precision occlusal splints and the diagnosis of occlusal problems in myogenous orofacial pain patients 
Glenn M. Kidder, DDS, FAGD and Roger A. Solow, DDS, General Dentistry, 2014 Mar/Apr; 62(2):24.

Myogenous orofacial pain is a common nondental pain. There is an unresolved debate on the etiology of this problem. Research has shown that occlusal interferences affect masticatory muscle comfort, coordination, and function. Resolution of these problems with precise occlusal correction indicates that dental occlusion is a causative or contributory factor in myogenous orofacial pain. However, some studies fail to confirm this and instead conclude that occlusion is unrelated to masticatory muscle pain or dysfunction. An explanation for this discrepancy in findings is that these nonconfirmatory studies had not documented any pretreatment or corrected occlusion. Diagnostic casts mounted in centric relation and precision occlusal splints are accurate modalities to diagnose the occlusal problem and its correction in a patient with myogenous orofacial pain. Computerized digital occlusal analysis provides objective data of occlusal contact time and force to accurately assess diagnosis and treatment. The rationale and requirements for proper occlusal splint fabrication with a verified therapeutic occlusion re presented.

"Patients cannot avoid the effect of traumatic occlusal contacts without dental treatment. Many myogenous orofacial pains do not follow a natural course of remission. A treatment approach based on accommodation to symptoms is not optimal if a structural cause is not identified and treated. Ignoring progressive nonpainful damage to teeth such as wear, fracture, and abfraction is not ethical when OS [occlusal splint] or OA [occlusal analysis] can limit that damage. Dentists are the only health care professionals trained to diagnose and treat myogenous orofacial pain that is related to occlusion. A default decision that pain or dysfunction is a psychological problem without ruling out a physiological cause is presuming a diagnosis."

Studies by Kerstein et al established the importance of objective occlusal analysis in TMD diagnosis and treatment.7,64-73 They proved a scientific rationale for anoptimal occlusion to prevent adverse force
on restorations and treat myogenous orofacial pain. These studies span 22 years; to date there is no literature that refutes the physiological model for masticatory muscle pain, the validity of the T-Scan
technology, or the documented clinical results. Computerized occlusal analysis objectively quantifies forces without relying on subjective and inaccurate patient input. Dentists can use this technology
to document and deliver an optimal OS occlusion.

Occlusal correction may play a significant role in the treatment of myogenous orofacial pain when a structural problem is confirmed with objective occlusal analysis. There is extensive literature showing
adverse occlusal forces are not beneficial to the patient and should be corrected as part of optimal care. It is the dentist’s responsibility to assess the structural component of each patient’s problem set.
Precision OS therapy can assist this evaluation and preview the effect of definitive occlusal correction.

Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients

Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients
Barry C. Cooper, D.D.S.; Israel Kleinberg, Ph.D., D.D.S., D.Sc. J. Cranio. Practice, April 2008, Vol. 26, No.2, pp. 104-117.

The objective of this investigation was to test the hypothesis that alteration of the occlusions
of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly,
rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

One theory proposed as the basis of TMD is that it is mainly the result of a dysfunctional masticatory system that is characterized by complicated interactions between various muscles, two temporomandibular joints, and a moveable mandible that supports a cadre of teeth that engage in complex and intermittent interdigitations. It then follows that a desired goal of treatment is to identify
and improve or correct any dysfunctions and correct the cause or causes of TMD and any related pain.

The objective of this study was to determine: (1) whether patients who presented with chronic symptoms of TMD could be objectively brought from a state of neuromuscular dysfunction to a state of neuromuscular function using the instrumentation mentioned above; (2) whether orthosis treatment can facilitate changing a nonphysiological neuromuscular situation to one that is physiological; and (3) most importantly, whether such alterations result in relief and/or reduction in TMD symptoms, especially one as discomforting as pain. The current study has tested these hypotheses by retrospective
analysis of symptom data obtained in patients examined and treated for TMD in a clinical practice, where objective instrument methodology was used in conjunction with the wearing of orthotic devices to correct neuromuscular malocclusions, and thereby relieve TMD symptoms such as pain.

313 TMD pain patients were studied, 49 patients (15.9% of the test population) had occlusions that were coincident with the TENS neuromuscular trajectory. 253 (82.1%) had over-closures (excess vertical freeway space). 221 (71.8%) had posterior mandibular displacements.
166 (53.9%) had lateral displacements. Findings: Study clearly demonstrates that there is a physical dysfunctional basis for TMD, which can be corrected by establishing a neuromuscular occlusion and the use of an oral orthosis that provides this corrected occlusion. Drastic reduction in TMD symptoms were observed.
Study clearly shows that using EMG and mandibular tracking of a TMD patient’s neuromuscular occlusion, and correcting such by using orthotic devices, can result in disappearance and or substantial reduction in the number and magnitude of many of a TMD’s patient’s symptoms. This includes headaches, which in this study resulted in a 91.7% reduction in their prevalence at three months.

This approach demonstrates that drastic reduction in the magnitude of TMD symptoms can be achieved in a relatively short period of time. 
This is consistent with the ultimate goal of therapeutic intervention, to bring patients from a less healthy to a more physiologic healthy state.
Reduces in the need for medications to control pain which at best can only be temporary and incomplete solution.