Monday, April 7, 2014

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.

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