Understanding,Assessing&TreatingDentomandibularSensorimotorDysfunction

MarkW.Montgomery,DDSRichardAmy,DC

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Notice:Knowledgeandbestpracticeindentistryareconstantlychanging.Asnewresearchandexperiencebroadentheprofession'sknowledge,changesinpractice,treatment,andtherapybecomenecessaryorappropriate.Readersareadvisedtocheckthemostcurrentinformationprovidedonproceduresdiscussedortheproductstobeusedoradministeredtoverifytherecommendedmethodandusageandanycontraindications.Itistheresponsibilityofthepractitioner,relyingontheirownexperienceandknowledgeofthepatient,tomakediagnoses

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ISBN978-0-9887037-0-4

MarkW.Montgomery,DMD

Dr.MarkWMontgomeryhasbeencommitted toexcellentpatientcare since graduating from Oregon Health Sciences University in1980.Hisexperienceinallaspectsofdentalcarehasbeenenhancedbyextensiveworkincontinuingdentaleducation.Thisbackgroundhasbuiltastrongcommitmenttocomprehensivehealthgroundedinbeautifulsmiles,excellentchewingfunction,andahealth/biological

focus.

Dr.Montgomeryhaslecturedandtaughtextensivelyregardingdentomandibularsensorimotorfunctionanddysfunction.Hehasdevelopedintegratedsystemstomanagepain,headaches,temporomandibularjointdisorders,andforcemanagedocclusion.Hehastaughtthousandsofdentiststousewell-definedsystemstoenhancetheirclinicalexcellence.

Heiswell-knownforhismasteryofskillsinInvisalignorthodontics,smileenhancementsandveneers,reconstructionandrestorationofwornanddamagedteeth,andincontrollingtoothgrinding,dentomandibularsensorimotordysfunction,andhead/facepain.

Dr.Montgomerycurrentlyteacheslivepatienthands-oncurriculaforpost-graduateclinicalstudiesintheareasofpain,headaches,sensorimotordysfunction,occlusion,andfull-mouthreconstruction.HealsoisChiefDentalOfficeratDentalResourceSystems,andhasbeenaneducatorwithPrideInstitute,PAClive,theHornbrookGroup,andAestheticMastersintheareaofClinicalManagement.Dr.MontgomerywasformerlyonthefacultyofAlignTechInstitute,trainingdentistsintheInvisalignsystem.

RichardAmy,DC

Dr. Richard Amy is an instructor, educator, researcher, author,inventor, and innovator in the healthcare arena. His pioneeringeffortshaveresultedintreatment-specificapproachesthatfocusonfunctionalneurologicalrestoration.

Havingworkedwithclinical trialdesignandreportingmetrics,hisprioreffortsresultedinthefirstFoodandDrugAdministration(FDA)clearanceforthetherapeuticusesofPhotobiomodulation/lowlevellasers.Sincethattime,he has catapulted his neurological healing applications, using lasers and othermodalities,toanumberofspecificareasofpioneeringinterest.

His background includes broad experience in neurology, orthopedics, generalmedicine,dentistry,nutrition,rehabilitation,andmolecularsciences.Thisgiveshim a well-rounded foundation for the treatment and correction of manymaladies.

Dr.Amyhasbeenaninstructorforfunctionalneurologycorrectionacrossmanyhealthcare disciplines. He incorporates the accepted standard for care andobjectivediagnosticmetricstoprovehissafeandnon-invasivemethods.Duringthe last two decades, he has not only instructed professionally, but hasvolunteeredhistimeatclinicsandhospitalsacrosstheglobe.

Over the last several years, he has focused much of his research efforts ondentistry andprovided instruction fordentalpractitioners, including specialistsandsurgeons,onanumberofneurologicallyrelatedproblemsaffectingthehead,neck, and mouth. Early detection of the signs and symptoms can allow forrelatively simple correction. His workmay well prove to be one of themostsignificantadvancementsindentistryforthe21stcentury.

Preface

MarkWMontgomery,DMD

RichardAmy,DC

Headaches,migraines,chronicdailyheadaches,tension-typeheadaches,myofascialpain,facialpain,temporomandibularjointdisorders(TMJ/D),TMJderangements,degenerativejointdisease,malocclusion,abnormaltoothwearpatterns,abfractions,parafunction,clenching,grinding,bruxism...

Formanyyearsnow,dentistshavebeenobserving,studying,andtreatinganumberofthesedisordersthatseemtohavecommonetiologiesandpatho-physiologiesrootedinthesensorimotorprocessingofthetrigeminalnerveandrelatedcranialnerves.Now,thelatestresearchintheneuroscienceofthetrigeminalnucleusbearsouttheobservations,suspicions,andtreatmenteffortsofthesedentists,somuchsothatwecannowbegintogroupmanyofthesedisordersintoacategorythatwecalldentomandibularsensorimotordysfunction.

Thesedysfunctionsaretheresultofthedirectinterplayoftheneuronalandnon-neuronalactivityofthetrigeminalnucleuswiththemusculatureoftheheadandneck.Thisistheoraltherapeuticcarewedentistsliveeverydaywhenmanagingthestomatognathicfunctionofourpatients.

Sensorimotorandsomatosensoryfunctionsareinextricablylinkedtoprotectivereflexes,hormonalresponses,andtheneurologythatisattheheartofimmunologyandinflammation.Trauma,stress,chronicinflammation,medicationoveruse,anddysfunctionarecombiningatanalarmingrateandcausingseverelifestylediseaseinourpatients.Undertheseconditions,painbecomesthediseaseweknowaschronicpain(i.e.,centrallymediatedpain,centralsensitization).Chronicpainbecomesaneurochemicalnegativefeedbackloopthatperpetuatesdysfunctionandneuro-inflammation.Thisthenleadsto

neurotransmitterdisordersthatcanmanifestasheadache,migraine,depression,anxiety,insomnia,andotherlifestylecopingmechanismsthatdamageanddestroyourpatients'lives(andtheirteeth).

Andallofthisishappeningrightunderournoses.

Painprocessedinthetrigeminalnucleus.

Paintravellingthetrigeminalthalamictract.

Affectingandaffectedbytheglialcellmodulationinthetrigeminalganglionandthetrigeminalnucleus.

Withcross-connectedcommunicationinthefacial,glossopharyngeal,vagus,andaccessorycranialnerves.

Correlatedwithproprioceptivefeedbackandsensorimotorfunction.

Affectedbyabnormalfunctionandtriggerpointpainandreferredpain.

And,maybemostimportantly,abletobeinfluencedbyre-establishingnormalfunctionofthedentomandibularsensorimotorsystem.

Includingnormalrangesofmotionofthemandibleandtheupperneck.

Includingnormalenvelopeoffunctionandforcebalanceofthedentition.

Ourprevioussystemsfortreatingheadachesandpainhaveincludedre-establishingmandibularpositionandcarefulinterdigitationofthedentition.Wehaveusedavarietyofmodalities,suchasorthotics,orthodontics,myofascialrelease,physicaltherapy,restorativedentistry,etc.Thesehaveallenjoyedamodicumofsuccessandhavebeenutilizedinasomewhatsymptom-driven,trialanderrorapproachbymanydentists.Untilnow,though,thecomprehensiverehabilitationtherapyapproachhasnotbeenusedeffectivelytogetattheheartofthedysfunctionandsensorimotorinfluence.

Asyou'llseeinthisvolume,thiscomprehensive,calibrated,combination

approachtoassessingandrehabilitatingthedentomandibularsensorimotorfunctionisthemostthorough,effective,andconservativesystemtodate.Itcanbeusedwhennothingelsehasworked.Itcanbeusedatthetimeofinitialinjury.Itcanbeusedasafirstlineoftherapytoavoidcostlyandextensiveinvasiveprocedures,wherepossible.Anditcanbeusedtogetattheheartofpainandheadaches.Havingasystemlikethisbringsnewhopeforthepatientssufferingfromthemanyvariousmaladiesassociatedwiththesepervasiveproblems.Thissystemistrulythemissinglinkindentalmedicinetoday.

Wewishgreatsuccessinhealthandhealthcareforyouandyourpatients.

MarkWMontgomery,DMD

RichardAmy,DC

Diagnostics,

Discoveryand

Dentistry's

Expanding

Capabilities

Sincethefirstmassproducedtoothbrushinthelate1700s,andmovingintothe1800swiththeintroductionofmoderntoothpasteanddentalfloss,dentistryhasevolvedrapidly.Theprofessionhasexperiencedaproudhistoryofinnovativelyapplyingresearch,technology,andproventechniquesinordertoaddressconditionsanddiseasesaffectingtheoralcavity.1Today,bothprofessionalsandpatientsenjoygreateroralhealth,andthedentaltreatmentstheyreceivelastlongerandfunctionmorepredictably.Manydentistsarerealizingagreaterlevelofprofessionalsatisfactiondueinparttoprovidingahigherlevelofpersonalizedcareinanenvironmentthatrecognizesthevalueoforalhealth.Newandinnovativetechnologies,aswellastechniquesenablingtheirapplicationtooralhealth,arecontributingtosuchenhancedlevelsofpatientcare.

Thesetechnologicalinnovationshave,inmanyways,transformeddentistryfromasurgicalprofessionintooneemphasizingpreventionandearly

intervention.2Preventionandearlyintervention,ofcourse,arepredicatedonearlyandprecisediagnosticinformation.Theadventoftechnologicallybaseddiagnosticdeviceshasenhancedthedentist'sacuityforidentifyingoraldiseasesand,insomeinstances,theircauses.Byempoweringdentistsandoralhealthcareproviderstoidentifyandmanageoraldiseasesatthefirstsigns,whethercariesororalcancer,diagnosticandtreatmentadvancesareimprovingandsimplifyingtheinterventionsthatareultimatelydeemednecessary.

Forexample,thewayinwhichcariesaredetectedandmanagedtodayisnolongerdependentuponvisualassessmentandtraditionalradiographs,butisinsteadbasedondiagnosticswithgreatersensitivityandspecificity.Devicesincludingchairsidetestsofsaliva,plaque,andbiofilm,andbioluminescence,alongwithtrans-illumination,laserfluorescence,andimaging,nowenabledentiststodetectthepresenceofdiseaseatitsearlieststagesbasedonanunderstandingofthevisualchangesthatrepresentthepresenceorriskofdisease.3-6Asaresult,theynowcanprevent,arrest,reverse,and/orrestoretoothstructurefaster,moreminimallyinvasively,andmorepredictably.

Similarly,salivarydiagnosticsusesasalivasampletoidentify,prevent,orevaluateriskfactorsfordisease.Duetothefactthatsaliva'scontentsareanextractionofthecellsfoundinthebloodstream,thefluidrepresentstheproteincompositioncirculatingthroughoutthebodyandwhetheritishealthyordiseased.Currently,salivarytestsarebeingrefinedforidentifyingmarkersfordiseasesincludingbreastandpancreaticcancer,cardiovasculardisease,incipientinfection,anddiabetesmellitus.7Also,salivarydiagnosticshaverelevancefordetectingperiodontaldiseaseanditsriskfactors(e.g.,inflammation),aswellasHPV.8

Withinthepastdecade,cytologybasedDNAimagingtestsandlighttechnologiesthathavefocusedonthelossofautofluorescencealsohavebeguntoprovidedentistswithscientificallyproven,chairsidemethodsfortheearlyscreeninganddetectionoforalcancer.9Whentheresultsofthesetechnologicallybaseddiagnostictoolsarecombinedwithclinicalassessment,oralhealthcareproviderscanincreasetheevidenceonwhichtheybasetheirdecisions.

Likewise,conebeamcomputedtomography(CBCT)hasbeenavaluableimagingtoolfordentistsincasesrequiringthreedimensionaldetails,suchasrelatingimplantpositiontothemandibularcanal,assessingimpactedthirdmolar

rootrelationships,andplanningorthognathicsurgery.Additionally,CBCThasbeenbeneficialinendodontics,particularlyforidentifyingadditionalrootcanalsinteeththatarenotreadilyvisibleinconventionaltwodimensionalimages.6Thistechnologymayalsorevealcoincidentconditions,includingcondylarpathologiesandnon-tooth-relatedabnormalitiesintheheadandneckregion.

•AdvancementsinUnderstandingtheGreaterDentomandibularComplex

Interestingly,itisthisarea-thegreaterhead,neck,anddentofacialregion-forwhichothertechnologicalandmaterialscienceinnovationshavebeenintroducedwithinthepast25yearsforeitherdiagnosingortreatingoral-basedproblems.

Numeroussystems,suchashighstrengthceramicsorin-officeCAD/CAMsystems,respondtotheneedtorestorativelyresolvetheeffectsofdestructiveconditions(e.g.,wear,bruxism,toothdecay).10-12Theneedfordevelopingsuchenhancedmaterialshasbeenpredicatedonaclinicalandresearchunderstandingoftheeffectsoftheoralenvironmentonthelongevityofrestorations,aswellasopposingnaturaldetentionandtheoverallmasticatorysystem.13

Othersystems,suchascervicalrangeofmotiondevices(CROM),orinstrumentalocclusalanalysisequipment(T-Scan),offerinsightsintophysiologicalandfunctionalissues.Theseareissuesthatcouldbeaffectingthegreaterdentomandibularcomplexand/orcontributingtorelatedhealthproblemsinthegreaterhead,neck,anddentofacialarea(Figure1.1).14-18Dentistshaveappliedthesetechnologiesineverythingrangingfromdiagnosisandplanningtoimplantprocedures.Theyhavealsobeenappliedtodeterminerestorativerehabilitationscenteringonocclusaladjustments.Forexample,withtheavailabilityofelectronicaxiographictracers,themovementsofthecondylescanbeassessed,andmagneticresonancetomographyimagingcanbeusedtoanalyzetheanatomicalrelationofthejointsurfacestothedisk.18Additionally,pressuresensitivefoilsenableananalysisofmasticatoryforces,inconjunctionwithtimeresolution,inordertoplotthedistributionofforceswithintheocclusion.15-17Theunifyingobjectiveofutilizingtheseassessmenttechnologiesistoprovidepatientswithcarethathelpstoestablishlong-termstabilitywhilealsocontributingtohealth.

Theserestorativeanddiagnosticapproachescollectivelyrecognizeandreflectagreaterknowledgeandincreasingunderstandingoftheinterrelationshipbetweenforceoverloadanddisease.Theyalsoacknowledgeabetterunderstandingofdysfunctionwithintheoralenvironment,alongwiththemasticatorysystemofwhichitisapart.Improper,unbalancedforcescanresultinopenmargins,fractures,abfractions,wear,sensitivity,mobility,orevenfailedrestorations,allofwhichrequiretreatmentorretreatment.19,20Insomeinstances,strongerandmoredurableall-ceramicrestorationsthatcanwithstandtheforcesofmasticationarenecessary.

Symptomsandresultsofsuchdiseaseshavecollectivelybeenaddressedinrestorativerehabilitationswithanemphasisonocclusion.Inthepresenceofaweaksystemandclenching/bruxing,occlusalinstabilitycontributestothebreakdownofnaturaltoothstructureandrestorativedentistry.13-21Regardlessoftheocclusalphilosophythatisfollowedinordertocompleterestorations,recognizingthesymptomsofmalocclusionhasbeeninstrumentalinhelpingtoprovidepredictable,reliable,andlong-lastingdentaltreatments.

Malocclusionreferstotheinterdigitationoftheteethorthelocationofteeth,scentricstopsthatresultindamagetotheintegrityofthetoothanatomy,periodontalinterface,stomatognathicsystemasawhole,orpain.Abnormalforcesbetweensomeorallteethcontributetosuchaninterdigitation.Thisdefinitionallowsaperspectiveonocclusionthataddressesthedirectrelationshipoffunctionalphysiologytoobservedandtreateddiseaseanddegeneration.22-24

Painresultingfromtheeffectsofmalocclusionmaymanifestashypersensitivity,deeptoothpain,jawpain,orpainintheheadandneckregionthatisservedbythetrigeminalcervicalnucleus.24-26Therefore,itisunderstandablethatthesignsandsymptomsofabnormalforcescaninvolvetheteeth,muscles,orjoints(Figure1.2).Thesecombinetoformthetriadofanatomywhichisreferredtoasthe"dentalfoundation".24Whenabnormalforcesaffectthedentalfoundation,alterationsandadaptationscanoccurtothemasticatorymusculatureandthe

temporomandibularjoint(TMJ),aswellasthecondyleanditsabilitytofunction.24,27Infact,malocclusionisjustoneofthemanyissuesthatcanresultfromadisruptioninthenormalfunctionofthemusculature.Aspatientsdeveloppathologyorevensufferseeminglynon-dentalrelatedtrauma,changescanoccurtothebalanceandfunctionofthemandible.Thiscanalsooccurwhenpatientsundergodentaltreatments,whethertheyarerestorations,orthodontics,orimplanttherapies.Changesinthedentalfoundationcanbeassimpleassoreorsensitiveteethafterrestoration,orascomplexasthecreationofanadaptedinterdigitationtoavoidextremeforces.Regardless,thepatient'sproprioceptivesystemisconstantlychanging.Thesechangesmayresultinthedislocationofcondylesduringmastication,clenching,orearlydiskmovementthatoftenprecedesdiskdisplacement.Otherresultsmayincludepatternsofself-equilibration.24,28-30

Adaptivechangesoccasionallycontributetotheconversionofacutepaintochronicpain.Thesequelaeofpainprocessesthenleadtofurtherneurochemicaladaptations,aswellascompensatorymuscleactivitythatcanresultinalimited

rangeofmotion(e.g.,mandibularorcervical)and/ortriggerpointmusclespasms.30-32Dentistryisclearlycognizantofthefactthatanindividual'sdentalocclusionmustbeaddressedbeyondtheteeth.Thepresenceofmalocclusion,alongwiththeforcescontributingtoit,affectsthelongevityofrestorations,thejoints,periodontalstructures,headandneckmuscles,function,andqualityoflife.13-33

Thevastmajorityofdentalrelateddiseasescanbecategorizedaccordingtothreeprimaryissues(Table1.1).Otherrestorativetreatmentmaydirectlyresultfromforcerelatedproblemsthatoriginatefromabnormalforcesappliedtotheteethbyanindividual'smuscles.Therefore,thegoalofmodernocclusalrelatedtreatmentshasbeentobalancethemasticatoryforces.Thishelpstopreventstressanddysfunctionwiththedentalfoundationandthedentomandibulararea.13,21,22,34

Tothisend,aforce-balancedocclusionistheobjectivewhenrelievingindividualsofocclusaldysfunction.Aforce-balancedocclusionisonedefinedasanormalorhealthyocclusioninwhichthesystemofinterdentalforcesiswelldistributedaroundthearch,withanunhinderedpathtoclosureandtomastication.Akeyaspectofrelievingocclusaldysfunctionisensuringthattheinterdentalforcesaredistributeddownthelongaxisoftheposteriorteeth,sothatthetotalforcesarebalancedina50/50,right/leftratioduringafullclosuretointerdigitation.Additionally,duringthisprocess,theclosuremusclesshouldfunctionwithsymmetry.ThereshouldalsobemusculoskeletalstabilityandsymmetryoftheTMJcondyles,whilethedisksarenormallyinterposedatfullclosure.13,35,36

Whentheocclusionisforcebalanced,anindividualiscomfortableinrestandfullclosure.Theirmandibularrangeofmotioniswithinnormallimits(e.g.,53mmto57mm),andtheindividualdoesnotexperienceacuteorchronicpain.Fromaqualityoflifeperspective,thepersondemonstratesnormalposture,workabilities,andtherearenodietaryrestrictionsduetolimitationsofdentalfunction.13,24,37,38

•OpportunitiesPresentedbyNeedandKnowledge

Bycombiningtechnologicalinnovationswithclinicalobservationandevaluation,agreaterunderstandingofthesignificanceofmuscleforcestoocclusalproblems,aswellasthepainpatientsexperienceinthedentomandibularregion,hasbeenachieved.35,36Practicalmeasuringinstrumentshavesuccessfullyidentifiedocclusalinterferencesandheaviercontacts(i.e.,forces),alongwithmuscleresponsesandpainsymptomsthatoccurduringmasticatoryfunction.13,35,36Technologyhasalsodemonstrateditsutilityinrevealingsignificantdiscrepanciesinjawpositionandmusclefunctionthatcontributetochronicdailyheadaches.39

Theavailabilityofsuchobjectivedataconcerningpainstimuliinconjunctionwithmasticatoryfunction,combineswithongoingresearchintoTMJ,orofacial,headache,andothersystemicpainresponsesattributabletomuscleforces.Thiscombinationofdataandongoingresearchhasusheredanotherparadigmshiftinthemannerinwhichdentistryaddressespatientswhosufferfromcomplex,sometimesdebilitatingdiscomfortissues.

Forexample,intheabsenceofdefinitivetissuepathology,greateremphasishasbeenplacedonunderstandingthatpaininsomeindividualsmayresultfromalteredcentralnervoussystempainprocessing.Thisparticularlyinvolvesthemasticatorymusclesandsofttissuesinthegreaterheadandneckarea.40Increasedmuscletensionandforce,asassociatedwithparafunctionalhabitsandstress,arepredictorsofjawandfacialpain.41Additionally,headacheisnowpartiallyexplainedbyreferredpainfrommyofacialtriggerpointsintheposteriorcervical,head,andshouldermuscles.Itisintheseareasinwhichperipheralmechanismscontributetopericranialtendernessandtheactivationorsensitizationofnociceptivenerveendingsbyliberatingchemicalmediators.42

Reversingparafunctionalhabitssuchasgrinding,clenching,andbruxingthroughbehaviormodificationhasdemonstratedpromiseinreducingthepainindividualsexperiencefromTMJdisorders(TMJ/D)andmyofacialissues.43,44AmongthepainconditionsthatdentistsmayencounterareTMJ/D,neuropathicpaindisorders,andheadaches,whethertheyarecommon,chronic,ormigraine.Deprograinmershavebeenpartoftheprocess"educating"or"re-training"themasticatorymuscles,acknowledgingthemuscles'roleintheforcescontributingtopain.Theyalsoacknowledgethefactthatcontrollingtheperpetuatingfactors(i.e.,force)canhelpcontrol,reduce,oreliminatepain.44,45Infact,inusclehyperactivityisaknownpotentialsourceofsymptomatologyinindividualswithTMJ/Dandotherdentomandibular-relatedpain,sinceitcreatesafeedbackmechanisminvolvingthetrigeminalnerve.46Interestingly,itistheinterrelationofthemusclesofmastication,thetrigeminalnerve,andtheeffectofforceonthiscomplexthatplacestheassessmentandtherapeuticrehabilitationofpatientssufferingwithheadacheanddental-relatedpainwithintherealmofdentistry.47AccordingtotheAmericanDentalAssociation,dentists'expertiseliesnotonlyintreatingtheteethandgingivaltissues,butalsoincaringforthemusclesofthehead,neck,andjaw,aswellasthenervoussystemofthehead,neck,andotherareas.48

Inparticular,thetightconnectionsthatthetrigeminalnervepathwayshavewithallheadandnecknociceptiveneurologycomprisetheprimaryneuralafferentandefferentsystemofthedentomandibularregion.47Researchintoneurophysiologyandneuroplasticityfurthersuggeststhedentist'sroleinassistingwithnormalneurologicalfunction,includingpaincontrol,bymanagingnormalfunctionintheheadandneckThis,ofcourse,encompassesnormalmastication,airwaymanagement,normaldeglutition,normalexpression,and

especiallynormalforcebalanceviatheproprioceptiveandsomatosensorysystems.49

Therefore,anypatientwithproblemsbasedintheteeth,muscles,orjointsorinthetrigeminalcervicalnucleusshouldbecaredforbyaknowledgeabledentistinordertorealizethegreatestopportunityforpainresolution.47-49Othermedicalprofessionalswhotreatsomeofthese"foundation"problemscanachieveshort-termsuccessbecausetheyarenotaddressing,norcantheycontrol,theafferentsignalsfromtheteethtothetrigeminalcervicalnucleus.Thisbrainstempathwayconductsalltheinformationregardingheadache,headandfacepain,andTMJ/Drelatedpaintothepatient'sthalamusandontothecortex.Approximately40percentoftheafferentcontrolintothispathwayoriginatesfromthedentomandibularareasurroundingtheteethandjaws.47,49

Thenumberofpatientssufferingfrompainanddiscomfortthatoriginatesinthisareaisstaggering.AccordingtotheNationalHeadacheFoundation,morethan29millionAmericanssufferfrommigraines.Thecausesincludetriggerfactorssuchasdietaryfactors,hormonalvariations,sleepdisorders,andothersthatexcitebraincellsandultimatelytriggerareactioninthetrigeminalnerve,resultinginpain.50Individualssufferingwithmigraineslosemorethan157millionworkandschooldayseachyearduetopain.51Inadditiontomigrainesufferers,anestimated90percentofthepopulationsuffersfromheadaches.51

DentiststhemselvesarealltooawareoftheincreasingnumbersofpatientssufferingwithTMJ/Dissues.TheNationalInstituteofDentalandCraniofacialResearch(NIDCR)estimatesthatmorethan10millionAmericanssufferfromTMJ/D,butthenumbercouldactuallyfallbetweenatotalof15and45millionpatientswithsometypeofTMJissue.52

•TheTimeIsNow

Unquestionably,treatmentsforTMJ/D,pain,anddysfunctionhaveevolvedovertheyears.Thisisduetodiagnostics,clinicalfindings,andnewtherapeuticregimensthatenabledentiststorelievepatients'suffering.53However,withtheincreasingunderstandingofthemechanismsthatexacerbateand/orcausepainintheface,head,oralenvironment,andthejointsandmusclesintheseareas,nowisthetimefordentistrytoembraceanewparadigmintheassessment,rehabilitation,andtreatmentofdestructiveforcerelateddentalproblems.

Foryears,dentistsandtheirstaffhaveoftenbeenthefirstlineofdefenseandinterventionfortheirpatients.Thishasbecomeincreasinglyso,astheassociationbetweenoralandsystemicdiseaseshastakencenterstageindentistryandmedicine.Whetherbasedonsuspicionsandclinicalfindingsindicatingsleepdisorderedbreathing,snoring,uncontrolleddiabetesthatcorrelatestoperiodontalpathogens,oreatingdisordersreflectedinlingualtoothwearanderosion,dentistshavehelpedtomanagetheoverallhealthandwell-beingoftheirpatients,aswellasserveasaprofessionalresourcefordental-relatedtherapies.54-55

Justasdentistryhasmovedintotherealmoforalsystemiccareasacollaborativepartnerwithitsphysiciancolleaguesinmedicine,nowisthetimefordentistrytoembracedentalheadachecare.Itisalsotimefordentistrytoprovidereliefandtherapyforpainsymptomsassociatedwiththegreaterhead,neck,anddentofacialarea.56Withtheresearchandtechnologythathasbeendevelopedfor,andproveneffectivein,otherdisciplines,includingsportsmedicineandrehabilitation,dentistsarenowwellpositionedtoaddressthepatientpopulationthatsufferswiththedebilitatingsymptomsofdentomandibularsensorimotordysfunction.

References

1. DiMatteoAM.Dentalinventorsandthegreatestinnovationsindentalhistory.InsideDentistry.May2009:88-102.

2. DiMatteoAM.Dentistry:Didyouchoosetherightprofession?InsideDentistry.Nov/Dec2006:52-59.

3. TwetmanS,AxelssonS,DahlenG,EspelidI,MejareI,NorlundA,TrameusS.Adjunctmethodsforcariesdetection:Asystematicreviewofliterature.ActaOdontolScand.2012May28.[Epubaheadofprint]

4. KarlssonL.Cariesdetectionmethodsbasedonchangesinopticalpropertiesbetweenhealthyandcarioustissue.IntJDent.2010;2010:270729.[Epub2010Mar28]

5. StrasslerHE,SensiLG.Technology-enhancedcariesdetectionanddiagnosis.CompendCantinEducDent.2008Oct;29(8):464-5,468,470passim.

6. PetteGA,NorkinFJ,GanelesJ,HardiganP,LaskE,ZfazS,ParkerWIncidentalfindingsfromaretrospectivestudyof318conebeamcomputedtomographyconsultationreports.IntJOralMaxillofacImplants.2012May-Jun;27(3):595-603.

7. BrinkmannO,SpielmannN,WongDT.Salivarydiagnostics:movingtothenextlevel.DentToday.2012Jun;31(6):54,56-7;quiz58-9.

8. GiannobileWV,McDevittJT,NiedbalaRS,MalamudD.Translationalandclinicalapplicationsofsalivarydiagnostics.AdvDentRes.2011Oct;23(4):375-80.

9. PalmerO,GrannumR.Oralcancerdetection.DentClinNorthAm.2011Jul;55(3):537-48,viii-ix.

10. TysowskyGW.Thesciencebehindlithiumdisilicate:ametal-freealternative.DentToday.2009Mar;28(3):112-3.

11. StrubJR,RekowED,WitkowskiS.Computer-aideddesignandfabricationofdentalrestorations:currentsystemsandfuturepossibilities.JAmDentAssoc.2006Sep;l37(9):1289-96.

12. KugelG.Materialscontinuetoexpanddentistry'soptions.CompendCantinEducDent.2012Jan;33(1):80.

13. DawsonP.FunctionalOcclusion:FromTMJtoSmileDesign.Canada:Mosby,Inc.;2007.

14. OginceM,HallT,RobinsonK,BlackmoreAM.Thediagnosticvalidityofthecervicalflexion-rotationtestinCl/2-relatedcervicogenicheadache.ManTher.2007Aug;12(3):256-62.

15. GargAK.Analyzingdentalocclusionforimplants:Tekscan'sTScanIII.DentImplantolUpdate.2007Sep;18(9):65-70.

16. KoosB,GodtA,SchilleC,GozG.Precisionofaninstrumentation-basedmethodofanalyzingocclusionanditsresultingdistributionofforcesinthedentalarch.JOrofacOrthop.2010Nov;71(6):403-10.

17. KoosB,HollerJ,SchilleC,GodtA.Time-dependentanalysisandrepresentationofforcedistributionandocclusioncontactinthemasticatorycycle.JOrofacOrthop.2012May;73(3):204-14.

18. TymofiyevaO,ProffP,RichterEJ,JakobP,FanghanelJ,GedrangeT,RottnerK.CorrelationofMRTimagingwithreal-timeaxiographyofTMJclicks.AnnAnat.2007;189(4):356-61.

19. SimonJ.Biomechanically-induceddentaldisease.GenDent.2000SepOct;48(5):598-605.

20. FrancisconiLF,GraeffMS,MartinsLdeM,FrancoEB,MondelliRF,FrancisconiPA,PereiraJC.Theeffectsofocclusalloadingonthemarginsofcervicalrestorations.JAmDentAssoc.2009Oct;140(10):1275-82.

21. HessLA.Therelevanceofocclusioninthegoldenageofesthetics.InsideDent.2008:38-44.

22. McNeillC.Occlusion:whatitisandwhatitisnot.JCalifDentAssoc.2000Oct;28(10):748-58.

23. MackieA,LyonsK.Theroleofocclusionintemporomandibulardisorders--areviewoftheliterature.NZDentJ.2008Jun;104(2):54-9.

24. MontgomeryMW,ShumanL,MorganA.T-scandentalforceanalysisforroutinedentalexamination.DentToday.2011Jul;30(7):112-4,116.

25. FrisardiG,ChessaG,SauG,FrisardiF.Trigeminalelectrophysiology:a2x2matrixmodelfordifferentialdiagnosisbetweentemporomandibulardisordersandorofacialpain.BMCMusculoskeletDisord.2010Jul1;11:141.

26. HegartyAM,ZakrzewskaJM.Differentialdiagnosisfororofacialpain,includingsinusitis,TMD,trigeminalneuralgia.DentUpdate.2011Jul-Aug;38(6):396-400,402-3,405-6passim.

27. OkesonJP.Occlusion,condylarpositionandTMD:Whereisthecontroversy?Whereistheevidence.Lecture.148thAmericanDentalAssociationAnnualSession;September28,2007:SanFrancisco,CA.

28. SchindlerHJ,RuesS,TurpJC,SchweizerhofK,LenzJ.Jawclenching:muscleandjointforces,optimizationstrategies.JDentRes.2007Sep;86(9):843-7.

29. KampeT.Functionanddysfunctionofthemasticatorysysteminindividualswithintactandrestoreddentitions.Aclinical,psychologicalandphysiologicalstudy.SwedDentJSuppl.1987;42:1-68.

30. LodettiG,MapelliA,MustoF,RosatiR,SforzaC.EMGspectralcharacteristicsofmasticatorymusclesanduppertrapeziusduringmaximumvoluntaryteethclenching.JElectromyogrKinesiol.2012Feb;22(1):103-9.[Epub2011Nov17]

31. OhrbachR,FillingimRB,MulkeyF,GonzalezY,GordonS,GremillionH,LimPF,Ribeiro-DasilvaM,GreenspanJD,KnottC,MaixnerW,SladeG.Clinicalfindingsandpainsymptomsaspotentialriskfactorsforchronic

TMD:descriptivedataandempiricallyidentifieddomainsfromtheOPPERAcase-controlstudy.JPain.2011Nov;12(11Suppl):T27-45.

32. Fernandez-de-Las-PenasC,GeHY,Alonso-BlancoC,Gonzalez-IglesiasJ,Arendt-NielsonL.Referredpainareasofactivemyofascialtriggerpointsinhead,neck,andshouldermuscles,inchronictensiontypeheadache.JBodyMovTher.2010Oct;l4(4):391-6.

33. VellyAM,LookJO,CarlsonC,LentonPA,KangW,HolcroftCA,FrictonJR.Theeffectofcatastrophizinganddepressiononchronicpain--aprospectivecohortstudyoftemporomandibularmuscleandjointpaindisorders.Pain.2011Oct;152(10):2377-83.

34. AckermanJL,AckermanMB,KeanMR.APhiladelphiafable:howidealocclusionbecamethephilosopher'sstoneoforthodontics.AngleOrthod.2007;77(1):192-194.

35. ManessWL.Forcemovie.Atimeandforceviewofocclusion.CompendCantinEducDent.1989;10:404-8.

36. KersteinRB.Treatmentofmyofacialpaindysfunctionsyndromewithocclusaltherapytoreducelengthydisclusiontime-arecallstudy.JCraniomandibPract.1995;13(2):105-15.

37. OkesonJP.ManagementofTemporomandibularDisordersandOcclusion,6thEdition.Mosby:2008.

38. WrightEF.ManualofTemporomandibularDisorders.2ndEdition.Wiley:Blackwell:2009.

39. DidierH,MarchettiC,BorromeoG,TulloV,D'amicoD,BussoneG,SantoroF.Chronicdailyheadache:suggestionfortheneuromuscularoraltherapy.NeurolSci.2011May;32Suppl1;S161-4.

40. CairnsBE.PathophysiologyofTMDpain-basicmechanismsandtheirimplicationsforphannacotherapy.JOralRehabil.2010May;37(6):391-410.

41. GlarosAG,WilliamsK,LaustenL.Theroleofparafunctions,emotions

andstressinpredictingfacialpain.JAmDentAssoc.2005Apr;136(4):451-8.

42. Fernandez-de-las-PenasC,CuadradoML,Arendt-NielsonL,SimonsDG,ParejaJA.Myofascialtriggerpointsandsensitization:anupdatedpainmodelfortension-typeheadache.Cephalalgia.2007May;27(5):383-93.Epub2007May14.

43. GlarosAG.Temporomandibulardisordersandfacialpain:apsychophysiologicalperspective.ApplPsycholphysiolBiofeedback.2008Sep;33(3):161-171.

44. OkesonJP,deLeeuwR.Differentialdiagnosisoftemporomandibulardisordersandotherorofacialpaindisorders.DentClinNorthAm.2011Jan;SS(l):lOS-20.

45. McKeeJR.Comparingcondylarpositionsachievedthroughbimanualmanipulationtocondylarpositionsachievedthroughmasticatorymusclecontractionagainstananteriordeprogrammer:apilotstudy.JProsthetDent.2005Oct;94(4):389-93.

46. KersteinRB.Reducingchronicmasseterandtemporalismuscularhyperactivitywithcomputer-guidedocclusaladjustments.CompendCantinEducDent.2010Sep;31(7):530-4,536,538.

47. BogdukN.Theneckandheadaches.NeuralClin.2004Feb;22(1):151-71,vii.

48. AmericanDentalAssociation.Dentists:DoctorsofOralHealth.http://www.ada.org/4504.aspx.AccessedJuly3,2012.

49. SessleBJ.Mechanismsoforalsomatosensoryandmotorfunctionsandtheirclinicalcorrelates.JOralRehabil.2006Apr.33(4):243-61.

50. NationalHeadacheFoundation.http://www.headaches.org/education/Headache_Topic_Sheets/MigraineAccessedJuly3,2012.

51. Headache.USNewsandWorldReport.

http://www.ada.org/4504.aspxhttp://www.headaches.org/education/Headache_Topic_Sheets/Migraine

2006.http://health.usnews.com/health-conditions/brain-health/headache.AccessedJuly3,2012.

52. NationalInstituteofDentalandCraniofacialResearch.http://www.nidcr.nih.gov/DataStatistics/ByPopulation/Adults/

53. DymH,IsraelH.Diagnosisandtreatmentoftemporomandibulardisorders.DentClinNorthAm.2012Jan;56(1):49-61.

54. MohseninN,MostofiMT,MohseninV.Theroleoforalappliancesintreatingobstructivesleepapnea.JAmDentAssoc.2003Apr;l34(4):442-9.

55. AshcroftA,MilosevicA.Theeatingdisorders:2.Behavioralanddentalmanagement.DentUpdate.2007Dec;34(10):612-6,619-20.

56. FrictonJR,OkesonJP.Broadsupportevidentfortheemergingspecialtyoforofacialpain.TexDentJ.2000Jul;117(7):22-5.

http://health.usnews.com/health-conditions/brain-health/headachehttp://www.nidcr.nih.gov/DataStatistics/ByPopulation/Adults/

Chapter1Self-AssessmentQuiz

1. Approximately40percentoftheafferentcontrolintothetrigeminalcervicalnucleusoriginatesfromtheareasurroundingtheteethandjaws.

a.True.

b.False

2. Whichofthefollowingisnotanindicationthatanindividual'socclusionforceisbalanced?

a.Theyarecomfortableinrestandfullclosure.

b.Theirmandibularrangeofmotioniswithinnormallimits.

c.Theyexperienceacuteorchronicpain.

d.Alloftheabove.

3. Balancingthemasticatoryforceshelpstoachievewhichofthefollowing?

a.Preventstresswithinthedentalfoundation

b.Preventdysfunctionwithinthedentomandibulararea

c.Distributedentalforcesdownthelongaxisofposteriorteethina50/50right/leftratio.

d.Alloftheabove.

4. Adaptivechangesinthedentomandibularareacanresultinwhichofthefollowing?

a.Conversionofacutepaintochronicpain.

b.Limitedmandibularrangeofmotion.

c.Bothaandb.

d.Noneoftheabove.

5. Headachecannolongerbepartiallyexplainedbyreferredpainfrommyofacialtriggerpoints.

a.True.

b.False.

Dentomandibular,

Sensorimotor

Dysfunctionand

ItsRolein

ChronicPain

Dentomandibularsensorimotordysfunctiondescribesconditionsandphysiologythatarerelatedtothestimulusandresponsethattakeplaceintheorofacialarea,head,andneckviaappliedneurologyandmusculaturelinkedbythetrigeminalcervicalnucleus.1-3Thedisorderinvolvesthetemporomandibularjoints(TMJs),masticatorymusculature,jawfunction,dentalforces,andthecommonneurologyofthesestructuresandfunctions.Dentomandibularsensorimotordysfunctioncangenerallyinvolveaspectrumofconditionsandsymptoms(Table2.1).

Thecommonelementinalloftheseconditionsistheeffectofunbalancedoroverloadedmuscleforcesrelatedtosensorimotorandsomatosensoryproprioceptiveornociceptivephysiology.1-3Characterizedbytheforcesgeneratedbythemusclesinthisarea(Figure2.1),dentomandibularsensorimotordysfunctionresultsfromtheabnormalforcesthatcauseanunbalanceddentalfoundation.Similarly,reflexproprioceptionresultsindysfunction,asdoinjuryandpain.4Dysfunctionthencontributestofurtherdamageordisability.Thedentalfoundationisconsidered

tobeoutofbalancewhenanyofseveralconditionsexist(Table2.2).

Clinicallymanagingtheseproblemsreliesoncontrollingpainandinflammation.Italsoreliesuponrehabilitatingthesystemtonormalfunctionandrangeofmotion,aswellasorthopedic,orthodontic,anddentalstabilizationofthestomathogathicsystem.However,doingsoispredicatedonasolidunderstandingoftheanatomyandphysiologyoftheheadandneck.Thisisthencombinedwithaddressingapatient'sdentaltreatmentissues.5Formanyreasons,dentistshavetraditionallyisolatedtheteethandtheirpathologyfromthefunctionalandparafunctionalphysiologythatcancausewear,damage,fracture,abfractions,failureofrestorations,andpainfortheirpatients.Thesetraumasanddegenerationsareonlythesignsandsymptomsoftheforcerelated,underlyingproblem.

Thenexusoftoothrelatedproblems,inrelationtomusculoskeletalandneurologicalphysiology,isthepointwhereforcesareappliedtotheteethorabolusoffoodinawaythatdevelopsanddeterminesthepatternsofmuscleactivitythroughthesensorimotorneurologyviathebrainstem.Theforcesbetweentheteethviathemusculaturearealteredwhenvariouscircumstancesoccur.Theyarealteredwhenneurologyisabnormal(e.g.,chronicpain).Theycanalsobealteredwhenmusclepatternsaredrivenbycentralnervoussystemrequirements(e.g.,parafunctionduringsleepdisturbances),orwhentheproprioceptionoftheteethisaltered(e.g.,sensitizationorrestorative

changes).6-9

•MusculatureandJointConsiderations

Inorderfordentiststobetterinterprethowthenormalfunctionofthesensorimotorapparatuswillassistinrelieving,reversing,orreestablishinghealthinapatientwithdentomandibularsensorimotordysfunction,theymustunderstandthecranialandcervicalnervesthatservethearea,relatedmusculature,andthecentralneurologyofthetrigeminalcervicalnucleus(Table2.3).1-3Thisparadigmshiftinthethoughtprocessesforassessingandsubsequentlytreatingforcerelatedconditionsthatresultindentalproblemsandchronicheadandneckpaininherentlyleadstorehabilitation,therapy,andtreatment.Allofthisisdesignedtoresolvetheissuesinahealthyandbalancedmanner.

Duringmastication(Figures2.2through2.5),thejawopensandthefirstmovementofthecondyleinopenpositionisdownward.TheTMJisaginglymo-arthrodialjoint.Aginglymusjointisahingejoint,andanarthrodiajointisaglidingjoint.TheTMJistheonlyjointthatbothhingesandglides.Itdoesnotrotateinastatichingeposition,butessentiallyhasamultifocalaxiswherebytheaxisfocalpositionisconstantlychanginguponeverymovementofthejaw.Thesearetermedinstantaneouscentersofrotation.

ThereisoneconsistentfactortotheTMJuponopening.Thefirstmovementofthejawuponopeningisalwaysadownwardmovement.Acriticalcomponentofthisprocessisthemandibularcondylarcartilage,whichhelpstofacilitatearticulationwiththeTMJdisk,whilealsoreducingloadsontheunderlying

bone.10Allteethshouldtouchatthesametimethatthelowerjawfollowsthearcofclosure,thusdistributingtheforcesinabalancedwayandpreventingactivationofthemuscles.Inotherwords,thesystemisatrestandstress-free.5-7However,themedialpterygoidmuscleismostheavilyloadedduringclenching,andtheaccentuatedhorizontalforceprovokesthehighestloadingwithinthemedialandlateralpterygoids.11,12Dentalsymptomscausedbyclenchingandgrindingincludewearandrestorativefailure,amongothersymptoms.Researchhasdemonstratedthatindividualswithrestoreddentitiondemonstratemoreparafunctionalactivityandhigherlevelsofmusculartension.13Musclehyperactivityisaknownfactorleadingtoincreasedandabnormalforcethatisdegenerative,destructive,andpainful.Anincreasedvolumeofperiodontalligamentcompressionscreatesadditiveandexcessivefunctionalmusclecontractionsviaafeedbackmechanisminvolvingthetrigeminalnerve.14

•NeurophysiologicalConsiderations

Theroleofthetrigeminalnerve,whichisthelargestandmostcomplexofthecranialnerves,inorofacialpainandTMJdisorders(TMJ/D)iswellrecognized.15Eventhefirstandsmallestdivision(i.e.,ophthalmic),whichispurelysensoryandafferentinfunction,maybeimplicatedinorofacialpain.16Themaxillary,orsecond,divisionofthetrigeminalnerveprovidessensorycommunicationtoallstructuresinandaroundthemaxillaryboneandmidfacialregion.Thisincludes-butisnotlimitedto-thesoftpalate,maxillarygingiva,upperlip,roofofthemouth,andmaxillaryteeth.17Thiscomplexdivisionofthetrigeminalnerveiscloselylinkedtoorofacialpain.However,thelargestdivisionofthetrigeminalnerve,themandibularorthirddivision,isconsideredamixednervethatconveysafferentfibers,aswellasefferentfibers,tothemasticatorymuscles(i.e.,mylohyoidandanteriordigastricmuscles)andothers.18Intimatelylinkedwithdentistry,thiscomplicateddivisionofthetrigeminalnervereferspaintootherareaswithinitsbranches,aswellastoothertrigeminaldivisions,suchasthemaxilla.Itisthispathwayofcircuits,reflexes,motorcontrol,proprioceptiveandnociceptiveprocesses,andreferredpainthatperpetuatesdentomandibularsensorimotordysfunction.2Asthemusclesworkagainsteachothertoadapttoocclusalimbalances,triggerpointsdevelop.Thesecontributetoreferredpain,whichisexperiencedinotherareas.Itishighlylikelythat

individualswithdentomandibularsensorimotordysfunctionhavemultipletriggerpointsinthe

musclessurroundingthehead,neck,andjaw(Figures2.6through2.8).19Nociceptiveinputfromperipheraltendermusclescanresultincentralsensitizationandchronicheadacheconditions.

Duetothefactthatalloftheseareasaresimilarlycontrolledbythebrachialarchcranialnervesthatbegininthebrainstem,theyareconstantlyreceivingnervesignals.Asaresult,itisnotuncommonforpatientswithTMJIDtoexperiencesevereandchronicpainanddisability.20Injuries,trauma,orinflammationtothedentomandibularandcraniofacialtissues(e.g.,muscles)affectthetransmission,modulation,andadaptationofnociceptivesignalsinthebrainstein,whichunderliespain

intheface,mouth,andhead.21Infact,orofacialanddentomandibularpainofteninvolvesinflammationofthesofttissuesinthisarea.Also,peripheralandcentralneuralprocessesareinvolvedwiththispain.22

Ifabnormal,forcerelatedconditionsthataffectthe

processesofnon-neuralglialcellsinthenervoussystemarenotaddressed,peripheralandcentralsensitizationcanplayaroleinanindividual'songoingdiscomfort.22Glialreceptorsarestimulatedduringphysiologicalconditions,releasingglutamateandplayinganactiveroleinpainperception.23-26Glutamate-evokedjaworneckmusclepainislinkedtoseveralclinicalconditionsinthecraniofacialandcervicalregions.27Whendeeptissuetraumaandpainoccur,alteredmuscleactivityintheorofacialandcervicalregions(e.g.,abnormalforces,bruxism,clenching)arelikelytobeinvolvedinalteredneuromuscularactivity.

•ImplicationsforDentomandibularandHeadachePainTreatments

Ithaslongbeenunderstoodthatheadachesaremediatedbythetrigemino-cervicalnucleus.Headachepainresultsfromaggravatingstimulationofthenerveendingsthatunitewithinthisarea,orfromirritationtothenervesthemselves.28However,referredpainfromdisordersoccurringelsewhereinthebody-suchasthedentomandibularregion-canbeperceivedasheadache.Thisisaresultoftheconvergencebetweentrigeminalafferentsandthoseofthecervicalnervesinthetrigemino-cervicalnucleus.29

Sinceonlystructuresthatareinnervatedbycertaintrigeminalbranchesareknowntocauseheadache-includingthemuscles,joints,andligamentsinthemandibleandmaxilla-theroleofdentomandibularsensorimotordysfunctioninheadachepainbecomesclear.30Comorbiditiesoftensionandmigraineheadachesinvolveneurologicdisordersthatcauserecurrentorpersistentpain.31IndividualswithTMJ/Dandfacialpainsymptomshavedemonstrated

significantlygreaternumbersofheadachesymptomsthanthosewhodonot.Theirheadacheswerealsomoresevere.32

Clearly,theessenceofforcerelateddentaldisease,includingitseffectsonthehead,orofacial,anddentomandibularareas,isdeterminedbythemannerinwhichabnormalforcesaremanaged,sensed,andadaptedto.1-7Duetotheroleneurologyplaysinthedisruptiveprocessesassociatedwithdentomandibularsensorimotordysfunction,establishingnormalfunctionandrelievingpatientsofpainsymptomsrequiresthattheneurology,muscleactivity,andbrainchemistrybe"reset”21,22Dentistscanbettermanageindividualsexperiencingdebilitatingpainbyrehabilitatingproperbiological,physical,andneurophysiologicalfunctions.

Acrucialaspectofrehabilitationiscreatingabalancedfoundation,whichinvolvesmorethanbalancingforces.Rather,itrequiresadherencetoaspecificprotocolinwhichthesymmetryofthemusclesandjointsistheinitialfocalpointofcare.Thispathwaytocarecanthenenabledentiststotreatdentomandibularsensorimotordysfunction.Italsoenablesthemtorelievepatientsofitsassociatedsymptomsbycontrollingmuscleforcesandforcebalance,andrehabilitatingandrestoringnormalfunctionandrangeofmotion.Theycanalsoachievereliefbyresettingengrampatternsofpain,dysfunction,andmuscleactivity.Balancingthedentalfoundationrequiresbalancingthemuscles,joints,andteeth,aswellascontrollingtheproprioceptivefeedbackloops.Inconjunctionwiththis,rehabilitationofmusculoskeletalinjuries,includingthoseresultingfrommasticatoryforces,iseffectivewhenprovidedinatimelyandappropriatemanner.Whetherinsportsorgeneralphysicalrehabilitation,therapeuticprotocolprogressessequentiallytocontrolpain,restorerangeofmotion,retraintheneuromuscularcomplex,andre-establishnormalfunctionandactivity.33Thecommonlyusedtherapeuticmodalitiesincludeultrasoundandelectricalstimulation.34Additionally,researchhasshownthathabitreversaltechniquesmaybepromisinginreducingdentomandibular-relatedpain.4

•EmbracingNewOpportunitiesforAssessmentandTherapy

High-levelsportsmedicinehasrecognizedthatrehabilitationprogramsshouldbedesignedtoincludeaproprioceptivecomponent.Thiscomponentwouldaddresscognitiveprogrammingandbrainstemactivitytopromotedynamicjointandfunctionalstability.Givenwhatisunderstoodaboutthetrigeminalnerve,as

wellasthemusclesofthedentomandibularcomplexthatitaffectsandthepainsymptomsindividualsexperienceasaresultofabnormalforcesinthisarea,dentistrycanembraceassessmentandtherapeuticmodalitiesthatcompleteacrucialtask.Theyencompassafferentfeedbacktothebrain,nervepathways,andneuromuscularfeedbackasameanstoassessandrelievethecausesofanindividual'spainandprovidealong-termfoundationofhealthandwell-being.35

Forexample,professionalathletesbenefitfromspecializeddoctors,therapists,andtrainers.Theyincorporateaprotocolofdiagnostics,treatment,andrehabilitationprocedures,withaplantoenhancetheirskillsasprofessionalhealers.Followinginitialrecovery,athletesundergospecificworkand/ortherapythatenablethemtoregainthefitnessorhealthrequiredfornormalfunction.36Justasanorthopedistmustbalancetherehabilitationofapatient'smuscles,ligaments,andjointswiththedevelopmentofaplannedprosthesis,dentistscanapproachrehabilitationbeginningwiththemostadaptabletissues:themuscles.Theythenproceedtojointrehabilitation,andtheyfinalizetherapywithdentaltreatmentoftheteeth.Althoughmanyproblemswiththedentalfoundationhaveachickenortheeggetiology,alltherapyfordentalfoundationorbiteimbalancecanbeapproachedcomprehensively,dealingwithallfoundationalelementsinordertoachievesuccess.

Whenalltheelementsofteeth,muscles,joints,neurology,pain,andforcebalanceareaddressed,thepatientwillhavethebestchanceforanexcellentoutcome.Similartotheprovenmodalitiesandmethodsofsportsmedicine,thisprocesscanbeginwithimagingandassessmenttechnologies,alongwithupdatedtreatmentparadigms.37Sportsrehabilitationmethodsbeginwithbasicmeasuresandprogressthroughrehabilitationwithquantitativefeedbacktoevaluatephysiologicresponsetotherapy.38Byfollowingasimilarfunctionalprogression,dentistscanensurepatientsareappropriatelyrespondingtotreatmentandmanagingtheircondition.

Thisrehabilitationapproachisthecornerstoneofamedical-dentalsynergy.ItisaninnovativeassessmentandtreatmenttechnologynowavailablefordentalpracticescalledTruDenta.Itenablesanobjectiveassessmentofmuscleandforcedysfunction,aswellaspainmanagementthroughphysicalrehabilitationofthemusculoskeletalphysiology.TheTruDentasystemisauniqueandcompletecombinationofequipment,technology,software,andtherapeuticprotocols,allofwhichhavebeenwelldevelopedandtestedtohelpachievepredictableresultsthroughstraightforward,conservativecare.

References

1. JungeD.OralSensorimotorFunction.MedicoDentalMediaInternational,Inc.:1998.

2. SessleBJ.Mechanismsoforalsomatosensoryandmotorfunctionsandtheirclinicalcorrelates.JOralRehabilitation.2006;33:243-261.

3. MontgomeryMW,ShumanL,MorganA.T-scandentalforceanalysisforroutinedentalexamination.DentToday.2011Jul;30(7):112-4,116.

4. GlarosAG.Temporomandibulardisordersandfacialpain:apsychophysiologicalperspective.ApplPsycholphysiolBiofeedback.2008Sep;33(3):161-l71.

5. KooistraJH.Dynamicsofthehumanmasticatorysystem.CritRevOralBiolMed.2002;13(4):366-76.

6. DawsonP.FunctionalOcclusion:FromTM!toSmileDesign.Canada:Mosby,Inc.;2007.

7. HessLA.Therelevanceofocclusioninthegoldenageofdentistry.InsideDent.2008;36-44.

8. WilliamsonEH,LundquistW.Anteriorguidance:Itseffectonelectromyographicactivityofthetemporalandmassetermuscles.JProsthetDent.1983;49(6):816.

9. CarlssonGE.Somedogmasrelatedtoprosthodontics,temporomandibulardisordersandocclusion.ActaOdontolScand.2010Nov;68(6):313-22.

10. SinghM,DetamoreMS.BiomechanicalpropertiesofthemandibularcondylarcartilageandtheirrelevancetotheTMJdisc.JBiomech.2009Mar11;42(4):405-17.

11. SchindlerHJ,RuesS,TurpJC,SchweizerhofK,LenzJ.Jawclenching:muscleandjointforces,optimizationstrategies.JDentRes.2007

Sep;86(9):843-7.

12. SimonJ.Biomechanically-induceddentaldisease.GenDent.2000Sep-Oct;48(5):598-605.

13. KampeT.Functionanddysfunctionofthemasticatorysysteminindividualswithintactandrestoreddentitions.Aclinical,psychologicalandphysiologicalstudy.SwedDentJSuppl.1987;42:1-68.

14. KersteinRB.Reducingchronicmasseterandtemporalismuscularhyperactivitywithcomputer-guidedocclusaladjustments.CompendCantinEducDent.2010Sep;31(7):530-4,536,538.

15. ShanklandWE2nd.Thetrigeminalnerve.PartI:anoverview.Cranio.2000Oct;18(4):238-48.

16. ShanklandWE2nd.Thetrigeminalnerve.PartII:theophthalmicdivision.Cranio.2001Jan;19(1):8-12.

17. ShanklandWE2nd.Thetrigeminalnerve.PartIII:themaxillarydivision.Cranio.2001Apr;19(2):78-83.

18. ShanklandWE2nd.Thetrigeminalnerve.PartIV:themandibulardivision.Cranio.2001Jul;19(3):153-61.

19. Fernandez-de-las-PenasC,CuadradoML,Arendt-NielsonL,SimonsDG,ParejaJA.Myofacialtriggerpointsandsensitization:anupdatedpainmodelfortension-typeheadache.Cephalalgia.2007May;27(5):383-93.[Epub2007May14]

20. VellyAM,LookJO,CarlsonC,LentonPA,KangW,HolcroftCA,FrictonJR.Theeffectofcatastrophizinganddepressiononchronicpain--aprospectivecohortstudyoftemporomandibularmuscleandjointpaindisorders.Pain.2011Oct;152(10):2377-83.

21. SessleBJ.Recentinsightsintobrainstemmechanismsunderlyingcraniofacialpain.JDentEduc.2002Jan;66(1):108-12.

22. SessleBJ.Peripheralandcentralmechanismsoforofacialinflammatory

pain.IntRevNeurobiol.2011;97:179-206.

23. OverstreetLS.Quanta!transmission:notjustforneurons.TrendsNeurosci.2005Feb;28(2):59-62.

24. PetersA.Afourthtypeofneuroglialcellintheadultcentralnervoussystern.JNeurocytol.2004May;33(3):345-57.

25. HuangYH,BerglesDE.Glutamatetransportersbringcompetitiontothesynapse.CurrOpinNeurobiol.2004Jun;14(3):346-52.

26. VolterraA,SteinhauserC.Glialmodulationofsynaptictransmissioninthehippocampus.Glia.2004Aug15;47(3):249-57.

27. WangK,SessleBJ,SvenssonP,Arendt-NielsenL.Glutamateevokedneckandjawmusclepainfacilitatethehumanjawstretchreflex.ClinNeurophysiol.2004Jun;l15(6):1288-95.

28. BogdukN.Anatomyandphysiologyofheadache.BiomedPharmacother.1995;49(10):435-45.

29. BogdukN.Theneckandheadaches.NeuralClin.2004Feb;22(1):151-71,vii.

30. BogdukN.Theanatomicalbasisforcervicogenicheadache.JManipulativePhysiolTher.1992Jan;l5(1):67-70.

31. RobbinsMS,LiptonRB.Theepidemiologyofprimaryheadachedisorders.SeminNeural.2010Apr;30(2):107-19.

32. PettingillC.Acomparisonofheadachesymptomsbetweentwogroups:aTMDgroupandageneraldentalpracticegroup.Cranio.1999Jan;17(1):64-9.

33. MahanPE,WilkinsonTM,GibbsCH,etal.SuperiorandinferiorbelliesofthelateralpterygoidmuscleEMGactivityatbasicjawpositions.JProsthetDent.1983;50(5):710-718.

34. ChapmanBL,LiebertRB,LiningerMR,GrothJJ.Anintroductionto

physicaltherapymodalities.AdolescMedStateArtRev.2007May;l8(1):11-23,vii-viii.

35. LephartSM,PinciveroDM,GiraldoJL,FuFH.Theroleofproprioceptioninthemanagementandrehabilitationofathleticinjuries.AmJSportsMed.1997Jan-Feb;25(1):130-7.

36. WilliamsRJ3rd.Gettinginjuredplayersbackonthefield.TheNewYorkTimes.January22,2011.http://goal.blogs.nytimes.com/2011/01/22/getting-injured-players-back-on-the-field/

37. CatesW,CavanaughJ.Advancesinrehabilitationandperformancetesting.ClinSportsMed.2009Jan;28(1):63-76.

38. Borg-SteinJ,ZaremskiJL,HanfordMA.Newconceptsintheassessmentandtreatmentofregionalmusculoskeletalpainandsportsinjury.PMR.2009Aug;l(8):744-54.

http://goal.blogs.nytimes.com/2011/01%20/22/%20getting-injured-players-back-on-the-field/

Chapter2Self-AssessmentQuiz

1. Clinicallymanagingtheconditionsandsymptomsofdentomandibularsensorimotordysfunctionisdependentuponwhichofthefollowing?

a.Controllingpainandinflammation.

b.Rehabilitatingthesystemtonormalfunctionandrangeofmotion.

c.Dentalstabilizationofthestomatognathicsystem.

d.Alloftheabove.

2. Theforcesbetweentheteethviathemusculaturemaybealteredwhenneurologyisabnormal.

a.True.

b.False.

3. Treatingdentomandibularsensorimotordysfunctioncanachievewhichofthefollowing?

a.Painrelief.

b.Restorationofnormalfunctionandrangeofmotion.

c.Bothaandb.

d.Noneoftheabove.

4. Whichofthefollowingdoesnotdescribethemandibularorthirddivisionofthetrigeminalnerve?

a.Amixednervethatconveysafferentfibersandefferentfiberstothemasticatorymuscles.

b.Purelysensoryandafferent.

c.Referspaintootherareaswithinitsbranches,aswellastoothertrigeminaldivisions.

d.Noneoftheabove.

5. Dentomandibularsensorimotordysfunctionisperpetuatedbywhichofthefollowing?

a.Proprioceptiveandnociceptiveprocesses.

b.Referredpain.

c.Dentalstabilization.

d.Bothaandb.

TheTruDenta

Systemfor

Assessingand

Treating

Dentomandibular

Sensorimotor

Dysfunction

Thetreatmentsavailableforaddressingtemporomandibularjointdisorders(TMJ/D),pain,anddysfunctionhaveevolvedovertheyears.Thediagnostics,accuracyofclinicalfindings,andnewtherapeuticregimensarealsoenablingdentiststorelievepatientsofpain.1Therehasbeenarecentincreaseintheunderstandingofthemechanismsthatexacerbateand/orcausepainintheface,head,oralenvironment,andthejointsandmusclesintheseareas.Asaresult,dentistryispoisedtoembraceanewparadigmintheassessment,rehabilitation,andtreatmentofdestructiveforcerelateddentalproblems.

These"foundation"problemsmustbeaddressedandcontrolledattheheartoftheproblem.Thisinvolvestheafferentsignalsfromtheteethtothetrigeminalcervicalnucleus.Thetrigeminalcervicalnucleusisthebrainstempathwayinthedentomandibularareathatconductsalloftheinformationregardingheadache,headandfacepain,andTMJ/D-relatedpaintothepatient'sthalamusandontothecortex.2,3Therefore,itstandstoreasonthatpatientswhopresentwithsuchproblemscenteredintheteeth,muscles,joints,ortrigeminalcervicalnucleuscanbecaredforbyknowledgeabledentistsandrealizethegreatestopportunityforpainresolution.2-5

Fortunately,dentistsnowcanobjectivelyassesstheforcescausingtheseproblemsandsystematicallytreatandmonitortheirpatientswhoexperiencesymptomsofmuscleandforcedysfunction.Researchandtechnologydevelopedfor,andproveneffectivein,disciplineslikesportsmedicineandrehabilitationareenablingdentiststoaddressthepatientpopulationexperiencingthedebilitatingsymptomsofdentomandibularsensorimotordysfunction.Incombinationwithneuroscienceandsystematicandobjectiveassessment/monitoring,theTruDentasystemallowsacomprehensiveapproachtobeappliedtotreatment.6-11

ThepremiseoftheTruDentasystemistoenabledentiststosimplyredirectthefocusoftheexaminationprocessesandinitialcaresequences.Indoingthis,theycanaddresstheunderlyingparafunctionalphysiology.12-19Theevolutionaryand

revolutionarysystemisbuiltuponvariouscommonconcepts.Itisbasedontheconceptsofocclusion,20-23dentalanatomy,20masticationphysiology,15-20oralsensorimotorfunction,3-24andthemusculoskeletalanatomyandfunctionoftheheadandneck.20,24,25Thecareprogramalsohaselementsoftheappliedneurologyoftheafferentandefferentpathways,whichareinvolvedwithsensation,proprioception,pain,reflexmotorcontrol,andcompensatoryadaptationsandengramsoffunctionandparafunction.26-29

ByutilizingtheTruDentasystem,dentistscanoffertheirpatientstheopportunitytodealwiththeirsymptomsandproblemsinawaythatassuresthemofapathwaytolong-termpredictablehealthanddentalstability.Inaddition,byaddressingtheproblemsatthelevelofmechanicalcausation(i.e.,dentalforcerelatedconditions),dentistscanexpandtheircaretoincludeexcellentresultsformanyindividualswithintractable,late,orendstagedisorders.Thesemayincludeseveredentaldisease,aswellasheadandneckpain,rangeofmotiondisabilities,andacceleratedaging.Allofthiscouldberelatedtodysfunctionandpoorlyhealedinjuries.30,31

Fundamentally,onceTruDentatreatmentshaveachievedfunctionalanddynamicoptimization,thenthemechanicalaspectsofocclusioncanbeaddressed.Thisrationalestemsfromtheunderstandingthat,generallyspeaking,anytimethereisaneedtoaddressapatient'ssymptomsconnectedtothedentalfoundation,itisintheindividual'sbestinteresttohavethefoundationstabilizedandbalanced.Thisshouldoccurpriorto,orasapartof,anytreatmentfortheproblem.Ifanyrestorativetreatmentisneededforthepatient,thebestpossibleoutcomewillresideintheapproachthatbuildsabalancedfoundationasthefirststeptocare.3,15,23,25

•TheScientificallyProvenComponents

TheTruDenta®assessmentandtreatmentsystemisacomplete,state-of-the-artsystemfortheassessment,treatment,andmanagementoffunctional,dynamicforceimbalances(Figure3.1).Theseimbalancesareassessedusingacombinationofhardwareandsoftwarethataresupplementedbyextensiveclinicaltrainingandongoingpracticeimplementationassistance.TheequipmentintheTruDentasystemarealldevicesclearedbytheFoodandDrugAdministration,andtheyhavebeenutilizedinsportsmedicinerehabilitationforoveradecade.Physiciansanddentistsinhospitalsandclinicsaroundtheglobe

utilizethisequipmentintheroutinedeliveryofcare.32-34

•ExaminationsandHistories

Aswithanydiagnosticandclinicaltreatmentprotocol,thefirststepintheTruDentaapproachtopatientcareistheexamination.Duringtheexamination,thecondition(s)thatmaybeamenabletotreatmentareassessed.TheTruDentasystemincludesawell-describedanddocumentedscreeningandexaminationprotocolthathelpstoidentifythosepatientswhowillberesponsivetoTruDentatreatmentandthosewhowillnot.35,36

Theexaminationprocessincludesaheadhealth,medical,andheadachehistory,aswellasapharmacologicalassessment.Thesefindingsarecombinedwithastandardofcarepanoramicradiographicexamination.37Thoroughdental,periodontal,airway,orthodontic,andocclusalexaminationsarealsorecommendedandencouraged.

Thepanoramicradiographisutilizedtoscreenformanydentalconditionsthatpatientsmayhave,butfortheTruDentaassessmentandrehabilitationapproach,itprovidesinsightintocertainareasimplicatedindentomandibulardysfunctionsandimbalances(Figure3.2).Byreviewingthepanoramicradiograph,dentistscanconfirmtheirfindings.Theycanalsodeterminetheextentoftheproblemsanddirecttreatmentorfurthertest-mg.Additionally,computedtomography(CT)scansalsomaybeutilized.

Forexample,screeningmaysuggestthepresenceofabnormallyshapedorsizedmandibularcondyles.Thisconditionmaybeduetoinjuryordisease(e.g.,degenerativecondyles).38SomeofthemostcommoncausesforthisdegenerationincludeTMJcapsule,arthritis(i.e.,osteoarthritisandrheumatoidarthritis),andavascularnecrosisrelatedtoinjuryduringgrowth.Othercausesincludechronicinjury,microtrauma,orrapiddecelerationinjury(e.g.,

whiplash),aswellashyperactivityofthemusclesofmastication.Additionally,panoramicradiographsandCTscansmayidentifyantegonialnotchingofthelowerborderofthemandible,whichisrelatedtoexcessiveactivityinbothfrequencyandforceofthemassetersandmedialpterygoidmuscles.39Thisisoftensuggestiveofasensorimotordysfunction,whichisrelatedtotheparafunctionalactivityofclenchingand/orgrinding.

Similarly,mandibularasymmetriesalmostalwayswillestablishanasymmetricalmandibularmovementrelatedtounbalancedmandibularmusculature.Thisoccursinbothanatomicallyandincompensatorymovements.Theseimbalancesandsubsequentabnormaldevelopmentofthemandiblecanresultfromasymmetricalmusclefunctionorinjury,poortongueposition,airwaydisorders,and/ordysphagia.Theycanalsoresultfromlossofcondylarheightfrominjuryofdegenerativedisease,and/orexcessivecondylarsizerelatedtoneoplasm/growthdisorder/tumor.40

Manyoftherootcausesofdentomandibularsensorimotordysfunctionalsocontributetosleepdisorderedbreathing.TheTruDentaassessmentevaluationseekstodetermineifpatientssufferfromupperairwayrestrictionscausedbyexcessivelylargeturbinates,nasalpolyps,inflammationoftheturbinates(e.g.,allergicreactionsorinfection),deviatednasalseptum,orotherdevelopmentalconstrictions.Alloftheseconstrictionscanberelatedtonarrow,V-shaped,underdeveloped,asymmetrical,and/orhighlyvaultedpalates.Airwayissuesrelatedtodentomandibularsensorimotordysfunctioncanresultinpoorairflowornasalbreathingwithresultantdecreaseornoproductionduringsleep,poorsleeppatterns,poortonguefunction,anddysphagia.Theycanalsobeaccompaniedbysnoring,sleepdisturbances,obstructivesleepapnea,aswellaspoorvascular

tonefromendothelialdysfunctionthatresultsinmetabolicdisorders,mouthbreathing,anditsresultingsequelae(e.g.,drymouth,increasedacidity,in-creasedperiodontalinfection,poororalmucosaandimmunemanagement).41,42

Theexaminationprocessalsoin-eludesmusclepalpation(Figures3.3and3.4).Thisinvolveslocatingtriggerpoints.Triggerpointscanbelatentoractive,withthelattercausingpainandrestrictingmotion.Painmaybemerelyannoying,oritmaybesevere,excruciating,debilitating,orevenparalyzing.Alatenttriggerpointrestrictsrangeofmotion,anditisusuallyexperiencedasstiffness.Latenttriggerpointsarepainfulwhendirectlypressed.43

Patientsmaybeabletoindicatethelocationofsomeactivetriggerpointsintheirhead,neck,andshoulders.However,itisthelatenttriggerpointsthataremostoftenmissedwithoutathoroughmusclepalpationexamination,sincedirectpressureisrequired.TheTruDentasystempairsthephysicalmusclepalpationexaminationwiththedigitalrangeofmotionevaluation.Thisisbecauserestrictedmotionindicatesthepresenceoftriggerpointsthatrequirerehabilitation.

•TheDigitalAssessmentModalities

Thephysicalexaminationissupplementedbytheobjectivefindingsfromthemandibularrangeofmotion(ROM)disability,cervicalrangeofmotiondisability(digitally),andadigitalforceanalysis(TruDentaScan).ItisimportanttonotethattheROMportionoftheassessmentprocessprovidesobjectivedatathatspeakstotheAmericanMedicalAssociationguidelinesfortheratingofpainanddisability.TheseTruDentaassessmentdevicesobjectivelymeasureandvisuallyillustratethecauseofpatientsymptomsastheyrelatetodentomandibularsensorimotordysfunctions.Suchvisualizationenhancespatientacceptanceoftreatmentandcontributestogreaterassessmentobjectivityandtreatmentmonitoring.TheTruDentaexaminationofforcesplacedonthemasticatorysystemplaysalargeroleindeterminingtheextentofthesensorimotordysfunction.Abnormal,excessive,orimbalancedforcesarereliableindicatorsofdysfunctionandinjury.

•ForceMeasurement

Inparticular,thesystemusesT-Scandigitalforcemeasurementtechnologytoevaluatetheamountandimbalanceofforcesduringclosure,atclosure,andwhilechewing(Figures3.5and3.6).TheT-Scanusestechnologythatconfirmsthebalanceorimbalanceofapatient'sdentalfoundation.Theuseoftheseforceanalysisdevicesincorporatestimeresolutionandplotsofthedistributionofforceswithintheocclusion.Theyhavealsobeenshowntobesuperiortoothermethodsformoreaccuratelymeasuringocclusalforces.44-46

TheT-Scanfacilitatespatienteducationandscreeningduringevaluation.Itstechnologyalsoallowsdentiststobalancethedentalfoundationaspatientsproceedalongthepathofrehabilitationofthemusclesandjoints.Themusclesmustberehabilitatedpriorto,orwithout,the

rehabilitationofthejointsandjointligaments.Itisonlyafterthishasbeenachievedthatfurtheranalysisandadjustmentscanbemadetothedentitiontoharmonizethemfornormalfunction.

Forexample,aspatientsundergorehabilitationandthemusculoskeletalsystemimproves,dentistsusetheT-Scantechnologytomonitorprogress(Figures3.7through3.9).Subsequently,asneeded,theymakesmallbutsignificantchangestotheteeth.Initially,thesemodificationswillslightlyallowforchangesinproprioceptiveafferentinputtothesensorimotorsystem.Then,asthesomatosensoryfunctionimproves,theteethcanbebroughtmoreandmoreintobalancedfunction.

•RangeofMotionAssessment

AnotherassessmentcomponentofthesystemisthecomputerizedTruDentaROM(RangeofMotion)assessmenttool(Figure3.10),whichmeasuresthecervicalrangeofmotionasexpressedinthepatient'sheadmovements(Figure3.11).A

cervicalrangeofmotiondisabilitycanbedirectlycorrelatedwithamandibularrangeofmotiondisability,animbalanceinthedentalfoundation,dysfunctionofthejaw,andabnormalneurophysiologyofthetrigeminal-cervicalsensorimotorreflexsystem.Thisdirectlyaffectstheproprioceptivefeedbacksystemofthedentalocclusion,TMJ,andthemusclesofmastication.MeasurementsmadewithROMdeviceshavebeenshowntobereliableinallmovementdirections(Figures3.12through3.15),includingindividualswithsofttissuetraumafromwhiplash.47-49

Limitedrangeofmotionequatestodisability.Thedentist'sabilitytoobjectivelymeasuretherangeofmotionoftheheadatopthecervicalspinegreatlyenhancespatientunderstandingoftheirdisability.Therangeofmotionexaminationdemonstratestopatientswhatisnormalandwheretheirownmouth,head,andneckareatthetimeofexamination.Anormalopeningforanadultis53mmto57mm.Limitedorrestrictedrangeofmotion(lessthan40mm)isareductioninanindividual'sabilityfornormalrangeofmovement.50-52Alongwithopeningmovement,anindividualshouldbeabletoslidetheirjawtotheleftandtotherightatleast25percentoftheirtotalmouthopeninginasyinmetricalfashion.53

Whenrestrictedmovementexists,animbalanceinthesystemispresent,andbreakdownofthatsystemislikelytooccur.Inthecaseofthemouthrangeofopening,whenanindividualcannotopentheirmouthveryfar,themusclessupportingtheTMJarerestrictedduetopain,strain,inflammation,swelling,injury,disease,oranothercause.54,55

Therangeofmotionmeasurementalsoincludesareviewofthejointnoisesandvibrations.ThisisbecauseanynoiseintheTMJsisintimatelyrelatedtorestrictioninthemandibularrangeofmotion.NormalTMJsdonotmakesoundsorhavevibrations.Ifthejointsarenotsmoothand/orquiet,thisindicatesdysfunction.56

•TheRehabilitationModalities

OncetheconditionisdeterminedtobeamenabletoTruDentatherapyprotocols,

patientsreceiveaseriesoftreatmenttherapies.Theseincludeusingaproprietarycombinationoffrequency,time,andmodulationofPhotobiomodulationtherapy,therapeuticultrasound,andmicrocurrenttocontrolmuscleforcesandforcebalance,rehabilitateandrestorenormalfunctionandrangeofmotion,andresetengrampatternsofpain,dysfunction,andmuscleactivity.Balancingthemuscles,joints,andteeth,aswellascontrollingtheproprioceptivefeedbackloops,achievesnormalfunctionandastablefoundation.

TheTruDentatreatmentmodalitiesarewelldescribedintextbooksandliteraturethatspecificallyteachmanyoftheprinciplesthatunderpinthefoundationoftheTruDentaprotocol.Clinicaltrialoutcomes,whichwereperformedduringtheFDAclearanceprocessofthetherapeuticmodalitiesusedintheTruDentatreatmentplan,supportitsefficacy.

ThemultipleTruDentatreatmentmodalitiesareaprovencombinationofsportsmedicinerehabilitationandadvanceddentistrytechniques.Thiscombinationhasbeenshowntospeedthehealingofjointsandforcerelatedtraumas.6-11TheTMJrespondstotherapiesinasimilarmannerasankles,knees,shoulders,andotherjoints,whicharetypicallytreatedinsportsmedicine.

•TherapeuticUltrasound

Thegoaloftherapeuticultrasoundtreatmentistoreturncirculationtosore,strainedmusclesthroughincreasedbloodflowandheat(Figure3.16).Anothergoalistobreakupscartissueanddeepadhesionsthroughsoundwaves.9,57

Therapeuticexposuretoultrasoundreducestriggerpointsensitivityandhasbeenindicatedasausefulclinicaltoolformanagingmyofacialpain.9Additionally,ultrasoundalsohasbeenshowntoevokeantinociceptiveeffectsontriggerpoints.57

•MicrocurrentElectrotherapyStimulation

Sub-thresholdmicrocurrentstimulationreducesmusclespasmandreferralpainthroughlowelectricalsignal(Figures3.17and3.18).Italsodecreaseslactic

acidbuild-upandencourageshealthynervestimulation.11-58Inparticular,microcurrentelectrotherapyhasbeenshowntohelpincreasemouthopeningsignificantly.58

•Photobiomodulation/LightTherapy

Photobiomodulation/lighttherapydecreasespainandinflammation,accelerateshealingofmuscleandjointtissue25to35percentfasterthanusual,andreconnectsneurologicalpathwaysofnervestothebrainstem,therebyinhibitingpain(Figures3.19and3.20).7,8,59-61

Photobiomodulationtherapy,incombinationwithelectricalstimulation,hasbeenshowntoimprovemouthopeninginpatientsdiagnosedwithTMJ/D.56Itdecreasespainbypromotingthemusculoskeletalsystem'snaturalhealingability.ItalsopromotesstabilityoftheTMJ.7,8

•ManualMuscle/TriggerPointTherapy

Manualtriggerpointtherapydecreasesandeliminatespainandtensionintriggerpoints(Figure3.21).Thisoccursasaresultofbreakingupmuscleknotsandincreasingbloodflowinordertodecreaseinflammationandpain.10

Theimpetustotreatmorethanjoint/jawpositionanddentalconditionsinisolationcomesfromtheneedforpredictabilityandconservativecare.Additionally,directcareofthemusculature,inconjunctionwithknownsystemsofjawpositionanddentalocclusion,canreducepain,speedrecoverytimes,increasestability,andreducetheneedforpharmaceuticalsandradicaldental

procedures.

Therefore,theTruDentarehabilitationapproachalsoincludesadentistmonitoredhomecarekit/deprogrammerandintraoralorthotic(Figures3.22and3.23).Overall,theTruDentaassessmentandrehabilitationapproachaddressesdentalfoundationproblems,aswellas

thoseassociatedwithdentomandibularsensorimotordysfunction,throughthedevelopmentofanappropriatepathwaytocare.

References

1. DymH,IsraelH.Diagnosisandtreatmentoftemporomandibulardisorders.DentClinNorthAm.2012Jan;56(1):49-61.

2. BogdukN.Theneckandheadaches.NeuralClin.2004Feb;22(1):151-71,vii.

3. SessleBJ.Mechanismsoforalsomatosensoryandmotorfunctionsandtheirclinicalcorrelates.JOralRehabil.2006Apr.33(4):243-61.

4. AmericanDentalAssociation.Dentists:DoctorsofOralHealth.http://www.ada.org/4504.aspx.AccessedJuly3,2012.

5. FrictonJR,OkesonJP.Broadsupportevidentfortheemergingspecialtyoforofacialpain.TexDentJ.2000Jul;117(7):22-5.

6. CameronMH.PhysicalAgentsinRehabilitation,3rdEdition.Saunders:2009.

7. ÖzS,Gökçen-RöhligB,SaruhanogluA,TuncerEB.Managementofmyofacialpain:low-levellasertherapyversusocclusalsplints.JCraniofacSurg.2010Nov;21(6):1722-8.

8. MariniI,GattoMR,BonettiGA.Effectsofsuperpulsedlow-levellasertherapyontemporomandibularjointpain.ClinJPain.2010Sep;26(7):611-6.

9. SrbelyJZ,DickeyJP.Randomizedcontrolledstudyoftheantinociceptiveeffectofultrasoundontriggerpointsensitivity:novelapplicationsinmyofacialtherapy?ClinRehabil.2007May;21(5):411-7.

10. AguileraFJ,MartinDP,MasanetRA,BotellaAC,SolerLB,MorellFB.Immediateeffectofultrasoundandischemiccompressiontechniquesforthetreatmentoftrapeziuslatentmyofascialtriggerpointsinhealthysubjects:arandomizedcontrolledstudy.JManipulativePhysioloTher.2009Sep;32(7):515-20.

http://www.ada.org/4504.aspx

11. ZuimPRJ,GarciaAR,TurcioKHL,HamataMM.Evaluationofmicrocurrentelectricalnervestimulation(MENS)effectivenessonmusclepainintemporomandibulardisorderspatients.JApplOralSci.2006;14(1):61-6.

12. ShanklandWE2nd.Thetrigeminalnerve.PartIII:themaxillarydivision.Cranio.2001Apr;19(2):78-83.

13. ShanklandWE2nd.Thetrigeminalnerve.PartIV:themandibulardivision.Cranio.2001Jul;19(3):153-61.

14. SimonJ.Biomechanically-induceddentaldisease.GenDent.2000Sep-Oct;48(5):598-605.

15. KampeT.Functionanddysfunctionofthemasticatorysysteminindividualswithintactandrestoreddentitions.Aclinical,psychologicalandphysiologicalstudy.SwedDentJSuppl.1987;42:1-68.

16. Fernandez-de-las-PenasC,CuadradoML,Arendt-NielsonL,SimonsDG,ParejaJA.Myofascialtriggerpointsandsensitization:anupdatedpainmodelfortension-typeheadache.Cephalalgia.2007May;27(5):38393.Epub2007May14.

17. PetersA.Afourthtypeofneuroglialcellintheadultcentralnervoussystern.JNeurocytol.2004May;33(3):345-57.

18. HuangYH,BerglesDE.Glutamatetransportersbringcompetitiontothesynapse.CurrOpinNeurobiol.2004Jun;l4(3):346-52.

19. VolterraA,SteinhauserC.Glialmodulationofsynaptictransmissioninthehippocampus.Glia.2004Aug15;47(3):249-57.

20. DawsonP.FunctionalOcclusion:FromTMJtoSmileDesign.Canada:Mosby,Inc.;2007.

21. Hess,LA.Therelevanceofocclusioninthegoldenageofesthetics.InsideDent.2008:38-44.

22. McNeillC.Occlusion:whatitisandwhatitisnot.JCalifDentAssoc.2000Oct;28(10):748-58.

23. OkesonJP.ManagementofTemporomandibularDisordersandOcclusion,6thEdition.Mosby:2008.

24. JungeD.OralSensorimotorFunction.MedicoDentalMediaInternational,Inc.:1998.

25. KoolstraJH.Dynamicsofthehumanmasticatorysystem.CritRevOralBiolMed.2002;13(4):3.

26. BogdukN.Anatomyandphysiologyofheadache.BiomedPharmacother.1995;49(10):435-45.

27. SessleBJ.Recentinsightsintobrainstemmechanismsunderlyingcraniofacialpain.JDentEduc.2002Jan;66(1):108-12.

28. SessleBJ.Peripheralandcentralmechanismsoforofacialinflammatorypain.IntRevNeurobiol.2011;97:179-206.

29. LermanMD.Themuscleengram:thereflexthatlimitsconventionalocclusaltreatment.Cranio.2011Oct;29(4):297-303.

30. LephartSM,PinciveroDM,GiraldoJL,FuFH.Theroleofproprioceptioninthemanagementandrehabilitationofathleticinjuries.AmJSportsMed.1997Jan-Feb;25(1):130-7.

31. Borg-SteinJ,ZaremskiJL,HanfordMA.Newconceptsintheassessmentandtreatmentofregionalmusculoskeletalpainandsportsinjury.PMR.2009Aug;l(8):744-54.

32. SantosJD,deOliveiraSM,daSilvaFM,NobreMR,OsavaRH,RiescoML.Low-levellasertherapyforpainreliefafterepisiotomy:adoubleblindrandomisedclinicaltrial.JClinNurs.2012May30;10:1365-2702.[Epubaheadofprint]

33. WakefieldRJ,D'AgostinoMA,NaredoE,etal.Aftertreat-to-target:canatargetedultrasoundinitiativeimproveRAoutcomes?PostgradMedJ.2012

Aug;88(1042):482-6.

34. LinYC,LentzFA.Distributionandresponseevokedbymicrostimulationofthalamusnucleiinpatientswithdystoniaandtremor.ChinMedJ(Engl).1994Apr;107(4):265-70.

35. Straub-MorarendCL,MarshallTA,HolmesDC,FinkelsteinMWInformationalresourcesutilizedinclinicaldecisionmaking:commonpracticesindentistry.JDentEduc.2011Apr;75(4):441-52.

36. HuffK,HuffM,FarahC.Ethicaldecision-makingformultipleprescriptiondentistry.GenDent.2008Sep-Oct;56(6):538-47.

37. EpsteinJB,CaldwellJ,BlackG.Theutilityofpanoramicimagingofthetemporomandibularjointinpatientswithtemporomandibulardisorders.OralSurgOralMedOralPatholOralRadialEndod.2001Aug;92(2):236-9.

38. MagnussonC,NilssonM,MagnussonT.Degenerativechangesinhumantemporomandibularjointsinrelationtoocclusalsupport.ActaOdontolScand.2010Sep;68(5):305-1l.

39. BeckerMH,CoccaroPJ,ConverseJM.Antegonialnotchingofthemandible:anoftenoverlookedmandibulardeformityincongenitalandacquireddisorders.Radiology.1976Oct;l21(1):149-51.

40. TripathiT,SrivastavaD,RaiP,SinghH.AsymmetricClassIIIdentofacialdeformities-wideningthehorizon.Orthodontics(Chic.).2012;13(l):e162-80.

41. SimmonsJH.Neurologyofsleepandsleep-relatedbreathingdisordersandtheirrelationshipstosleepbruxism.JCalifDentAssoc.2012Feb;40(2):159-67.

42. BektasD,CankayaM,LivaogluM.Nasalobstructionmayalleviatebruxismrelatedtemporomandibularjointdisorders.MedHypotheses.2011Feb;76(2):204-5.[Epub2010Oct30]

43. WrightEF.Referredcraniofacialpainpatternsinpatientswith

temporomandibulardisorder.JAmDentAssoc.2000Sep;l31(9):1307-15.

44. KoosB,GodtA,SchilleC,GozG.Precisionofaninstrumentation-basedmethodofanalyzingocclusionanditsresultingdistributionofforcesinthedentalarch.JOroJaeOrthop.2010Nov;71(6):403-10.

45. GargAK.Analyzingdentalocclusionforimplants:Tekscan'sTScanIII.DentImplantolUpdate.2007Sep;18(9):65-70.

46. KoosB,HollerJ,SchilleC,GodtA.Time-dependentanalysisandrepresentationofforcedistributionandocclusioncontactinthemasticatorycycle.JOrojacOrthop.2012May;73(3):204-14.

47. AudetteI,DumasJP,CoteJN,DeserresSJ.Validityandbetween-dayreliabilityofthecervicalrangeofmotion(CROM)device.JOrthopSportsPhysTher.2010May;40(5):318-23.

48. WilliamsMA,McCarthyCJ,ChortiA,CookeMW,GatesS.Asystematicreviewofreliabilityandvaliditystudiesofmethodsformeasuringactiveandpassivecervicalrangeofmotion.JManipulativePhysiolTher.2010Feb;33(2):138-55.

49. WilliamsMA,WilliamsonE,GatesS,CookeMW.Reproducibilityofthecervicalrangeofmotion(CROM)deviceforindividualswithsub-acutewhiplashassociateddisorders.EurSpineJ.2012May;21(5):872-8.

50. PlackoG,Bellot-SamsonV,BrunetS,GuyotL,Richard0,CheynetF,ChossegrosC,OuaknineM.[NormalmouthopeningintheadultFrenchpopulation].RevStomatolChirMaxillofac.2005Nov;l06(5):267-71.

51. GallagherC,GallagherV,WheltonH,CroninM.ThenormalrangeofmouthopeninginanIrishpopulation.JOralRehabil.2004Feb;31(2):110-6.

52. ZawawiKH,Al-BadawiEA,LoboSL,MelisM,MehtaNR.Anindexforthemeasurementofnormalmaximummouthopening.JCanDentAssoc.2003Dec;69(11):737-41.

53. MapelliA,GalanteD,LovecchioN,SforzaC,FerrarioVF.Translationand

rotationmovementsofthemandibleduringmouthopeningandclosing.ClinAnat.2009Apr;22(3):311-8.

54. GuptaSK,RanaAS,GuptaD,JainG,KalraP.Unusualcausesofreducedmouthopeninganditssuitablesurgicalmanagement:Ourexperience.NatlJMaxillofacSurg.2010Jan;1(1):86-90.

55. ReiterS,WinocurE,GavishA,EliI.[Severelimitationofmouthopening].RefuatHapehVehashinayim.2004Oct;21(4):36-46,95.

56. ChristensenLV.Physicsandthesoundsproducedbythetemporomandibularjoints.PartI.JOralRehabil.1992Sep;l9(5):471-83.

57. SrbelyJZ,DickeyJP,LowerisonM,EdwardsAM,NoletPS,WongLL.Stimulationformyofascialtriggerpointswithultrasoundinducessegmentalantinociceptiveeffects:arandomizedcontrolledstudy.Pain.2008Oct15;139(2):260-6.[Epub2008May27]

58. DijkstraPU,KalkWW,RoodenburgJL.Trismusinheadandneckoncology:asystematicreview.OralOncol.2004Oct;40(9):879-89.

59. FikackovaH,DostalovaT,VosickaR,PeterovaV,NavratilL,LesakJ.Arthralgiaofthetemporomandibularjointandlow-levellasertherapy.PhotomedLaserSurg.2006Aug;24(4):522-7.

60. NunezSC,GarcezAS,SuzukiSS,RibeiroMS.Managementofmouthopeninginpatientswithtemporomandibulardisordersthroughlow-levellasertherapyandtranscutaneouselectricalneuralstimulation.PhotomedLaserSurg.2006Feb;24(1):45-9.

61. ChowRT,JohnsonMI,Lopes-MartinsRA,BjordalJM.Efficacyoflowlevellasertherapyinthemanagementofneckpain:asystematicreviewandmeta-analysisofrandomizedplacebooractive-treatmentcontrolledtrials.Lancet.2009Dec5;374(9705):1897-908.[Epub2009Nov13)

Chapter3Self-AssessmentQuiz

1. Afferentandefferentpathwaysareinvolvedwithwhichofthefollowing?

a.Sensation.

b.Proprioception.

c.Engramsoffunctionandparafunction.

d.Alloftheabove.

2. TheTruDentasystemwasdevelopedbasedoncommonconceptsinwhichofthefollowingareas?

a.Occlusion.

b.Appliedneurologyofafferentandefferentpathways.

c.Bothaandb.

d.Noneoftheabove.

3. Musclepalpationinvolveslocatinglatentandactivetriggerpointsthatcouldrestrictrangeofmotion.

a.True.

b.False.

4. DigitalanalysisofforcesisperformedusingwhichofthefollowingTruDentasystemcomponents?

a.Microcurrent.

b.T-Scan.

c.Ultrasound.

d.Lowlevellaser.

5. WhichofthefollowingisnottrueabouttheTruDentatreatmentmodalities?

a.Theyhavebeenshowntospeedthehealingofjointsandforcerelatedtraumas.

b.Theyincludeaproprietarycombinationoflowlevellasertherapy,therapeuticultrasound,andmicrocurrents.

c.TheyaredevicesclearedbytheFDA.

d.Noneoftheabove.

LifeChanging

Dentistry:

Implications

fortheTruDenta

PathwaytoCare

Currently,dentalpatientscanbenefitfromanenhancedlevelofcare,greateroralhealth,andoverallwellbeing.Thoseexperiencinganyofthemultiplesymptomsofdentomandibularsensorimotordysfunctioncanalsobenefitfromdentistry'sabilitytohelpresolvetheirpainfulconditions.Dentistscantreatpatientspresentingwithproblemsbasedintheteeth,musclesoftheneck,headandface,orjawjoints.Therefore,theirpatientscanexperiencereliefandlife-changingresults.1,2TheTruDentasystemandpathwaytocareenabletherestorationofbalance,functionalharmony,andstabilitytoapatient'sdentalfoundationinastraightforwardmanner.

TheTruDentacareprogramcantreatmanydifferentaspectsofdentomandibularsensorimotordysfunction.Theprogramcanalsotreatthespectrumofdisordersthataregenerallyattributedtothestimulusandresponseinvolvedintheorofacial,head,andneckareasviaappliedneurologyandmusculature.Suchtreatmentissupportedbythe

TruDentaapproachofaddressingtheafferentsignalsfromtheteethtothetrigeminalcervicalnucleus.Italsoaddressesthosefromthebrainstempathway,whichconductsalloftheinformationregardingheadache,headandfacepain,andtemporomandibularjointdisorders(TMJ/D)relatedpaintothepatient'sthalamusandontothecortex.Thedentomandibularareasurroundingtheteethandjawsisthepointatwhichasubstantialamountoftheafferentcontrolintothispathwayoriginates.1,2

Asaresult,TruDentahasnumerousindicationsandapplications.Dentistscancareforindividualsrangingfromthosesufferingfromheadachesandmigrainestothosewithpainandlimitations.Theycanalsocareforpatientsrangingfromthosewithclenching,grinding,andlimitedrangeofmotionproblemstoindividualsshowingearlysignsoftoothwearorevidenceofimbalanceandwhoneeddentaltreatment.

Temporomandibular-typepainsaremostoftenassociatedwithothercommonpainsandrarelypresentalone.3SevereheadachesormigraineareoftenfoundasacomorbidconditionalongwithTMJ/Dtypeneck,back,andjointpains.4Additionally,migraineisthemostprevalentprimaryheadacheinindividualswithTMJ/D.5Also,TMJ/Dsymptomsaremorecommoninthosewithmigraine,tension-typeheadaches,andchronicdailyheadaches,comparedtopeoplewithoutheadaches.6Dentalfoundationproblemsoftenco-existwithheadachepain,whetherchronicorepisodic.Therefore,dentistshaveanopportunitytoprovidetreatmenttoalargenumberofindividualswhomaynothaveexperiencedlonglastingandeffectivepainreliefbecausetheunderlyingcauseoftheproblemhasnotbeenaddressed.TheTMJ/headachepainconnectiontodentomandibularsensorimotordysfunctionisalogicalbasisonwhichdentistscanprovidetreatment.Incomparison,thereareotherless-obviousyetsimilarlyrelatedconditionsthatareequallydemandingofTruDentatreatment.Individualswithhyperextension/hyperflexioninjuriesofthecervicalspine(i.e.,whiplash)oftenexperienceTMJ/Dsymptoms,internalderangement,effusion,andinflammation.7Individualswhosufferwhiplashalsoexperiencesuchsymptoms,includingjawandneckpain,massetertriggerpoints,andopeningandclosingjawmusclehyperactivity.8Individualized,patient-focusedtherapiesandrehabilitationhavebeeneffectiveforpatientswithdebilitatingsymptomsfromwhiplash.9ThissuggeststhattheTruDentastrategiesmaybeappropriatecareforsuchindividuals.

PatientsexperiencingorofacialanddentomandibularpainasaresultofdentaltreatmentscanalsobenefitfromTruDentatreatment.OrthodonticpatientsmaycomplainofTMJ/Dpainthatrequiresresolutioneitherduringoraftertreatment.10Whenthereisariskofflare-upsofpersistentperiapicallesionsfollowingendodontictreatment,patientsmayexperiencepainfulexacerbationswheneatingandtoothbrushing.11Duetothefactthattheareasaffectingthispatientpoolaredirectlytiedtothetrigeminalcervicalnucleus,TruDentatreatmentmaybebeneficialinhelpingtorelievetheirpain.

Additionally,prosthodonticcarealsomaybenefitpreoperativelyandpostoperativelyfromTruDentatreatment.Thisincludesfull-mouthreconstruction,cosmeticprosthodonticsprocedures,dentures,andimplant-supportedtherapy.

•TheTruDentaRehabilitationProcess

TheTruDentatreatmentprograms,procedures,andpatientcareenabledentistsandtheirteamstobring"inhouse"themajorityofconservativemusculoskeletalcare.Thispathwaytocarecanbeequallydirectedtopain,headache,andmigraine,ortothedegenerativesensorimotordysfunctionthatdestroysthedentition.Overall,TruDentatherapiesareappliedtopatientswithmanytypesofdentomandibularsensorimotordysfunctionandforceimbalancesinthedentalfoundation.

TheTruDentapathwaytocareincorporatesfourparts.Theseincludeanin-officerehabilitationtreatment,arehabilitationorthotic,homecaresystemforpatientuse,anddentalforcemanagementthroughocclusaladjustmentprocedures.Theuseofallorsomeofthesecomponentsisdeterminedbythepatient'sassessmentandlevelofcareforwhichtheyaretreatmentplanned.Patientscanbeclassifiedintooneoffourlevels,dependingonassessmentfindings(Table4.1).Nomatterwhichtreatmentlevelpatientsmaybeclassifiedas,thegoalistorestorebalance,functionalharmony,andstabilitytothepatient'sdentalfoundationinthemosteffectiveandtimeefficientmanner.Balanceisrestoredpriortoinitiatingdentaltreatment,sinceperiodontaltreatmentsoranyotherdentalproceduresonabalanced,stabledentalfoundationresultinlongerlastingandmorepredictableoutcomes.12-14Theneedforrestorativedentistryisthendetermined,ifappropriate,inasystemofbalanceandstability.Thisallowsthepatienttoproceedwithdentaltreatment,whichwillbemorepredictableandcanbeaccomplishedatacomfortablepace,withouttheurgencyofpain.

Everypatientisdifferentandrequirespersonalizedandindividualizedtreatment,sosomepatientsmayrespondquicklyandotherswithinafewweeks.Thepatientwhopresentswithanacuteproblemmayproceedquicklythroughrehabilitationtodentalrestoration.However,patientswithlimitedrangeofmotioninthemandibleorcervicalspinewillrequiremoretimetorehabilitatethemusculatureandreducepainanddisabilitypriortodentalrestoration.

TruDentatherapyortreatmentappointmentsarecomprisedofseveraldifferentandsynergistictreatmentmodalities(Table4.2).Theseincludetherapeutic

ultrasound,transcutaneouselectricalstimulation,andlowlevellasertherapy(Figures4.1through4.3).Allofthesetreatmentsprovidepredictableresultsthroughstraightforward,conservativecare.Themodalitiesareusuallyallutilizedinaspecificsequence,withspecificsettingsandtreatmenttimes.Typicaltherapyprotocolismostappropriateandsuccessfulwhenitprogressessequentiallythroughpaincontrol,restoringrangeofmotion,neuromuscularretraining,andreturntonormalfunction.15,16Asthedentistbeginstobalancetheocclusion,theyproceedbybalancingtheforcesappliedtotheteetharoundthedentalarch,usingbothadditiveandsubtractiveprocedures.Thiscreatesanddevelopsabalancedfoundationthroughtherehabilitationprocess.TheT-Scanforanalyzingdentalforceimbalancesisusedinthisprocesstoevaluatenumerouscharacteristics.Theseincludecentricocclusion,rightandleftlateraldisclusion,protrusion,hindrancestoclosure,balanceduringclosureandatfullclosure,anddisclusionlocations(e.g.,canines,group,posterior,incisors,etc.).

•RealizingLifeChangingResults

Patientssufferingwithobviouspainsymptomsappreciateitwhendentistsandhealthcareprovidersareprimarilyconcernedaboutenhancingtheirqualityoflife.Theydothisbyprovidingthemwithaneffectivewaytorelievetheirpain.17Thisisespeciallytruewhenpractitionersfirstshowthemwherethepaincomesfromandthenprovidethemeanstoexperiencerelief.Bytreatingthepain

firstthroughrehabilitationofthedentalfoundationtoahealthystate,restorativedentistrycanfollowlater.

Ofcourse,itisnotuncommonfordentiststoencounterpainpatientsreluctanttocommittotherecommendedlevelofcare.However,presentingan''allornothing"approachiscounterproductive.Dentistryhasembracedaphasedapproachtotreatmentinordertohelppatientsacceptnecessarycare.Inthissamemanner,dentistscanalsoproposethatpainpatientsbeginrehabilitationsomewhere.18

Althoughapatientwhooptsforalowerlevelofcarewillmostlikelyachievealesserresult,doingsodoesstartthemintherightdirectiontowardrehabilitation.Forexample,evenjustutilizingtheorthotictorelievemusclefiringcanbegintoeasetheirpain.19Additionally,whileonlyoneortwotherapyappointmentsmaynotachievelong-termresults,theycanbepalliative.Careduringtheseappointmentscanbuildtrustintheprocessandeventuallyleadtoacommitmenttotheentirerehabilitationprocess.20

TheTruDentarehabilitationprocessoutlinedforeachpatientlevelclassificationprovidesthemosteffectiveandefficientwaytorestoredentalfoundationbalanceandachievetheidealresults.Thisrehabilitationapproachdedicatestheappropriatetimeandfrequencyofeachtherapeuticmodalitytopatients,dependingontheextentofinjuryanddegreetowhichtheirconditionhasbecomechronic.Theserehabilitationprocesseshavebeenclinicallyproveninsportsmedicine,andadditionalclinicalresearchwillconfirmthevalidityandefficacyoftherespectivetherapeuticprotocols.

Basedonwhatisnowunderstoodaboutthemechanismsthatexacerbateand/orcausepainintheface,head,oralenvironment,andthejointsandmusclesintheseareas,dentistscannowtrulyofferlifechangingtreatments.ByfollowingtheTruDentapathwaytocare,dentistsandtheirteammemberscanassess,rehabilitate,andtreatdestructiveforcerelateddentalproblems.WiththeTruDentasystem,theycanalsomanagetheoverallhealthandwell-beingoftheirpatients.

References

1. BogdukN.Theneckandheadaches.NeuralClin.2004Feb;22(1):151-71,vii.

2. SessleBJ.Mechanismsoforalsomatosensoryandmotorfunctionsandtheirclinicalcorrelates.JOralRehabil.2006Apr.33(4):243-61.

3. PleshO,AdamsSH,GanskySA.Temporomandib