Techniques for Dentists

Normal values for electromyography of jaw, neck muscles at rest – K7 Scan 9

Surface electromyography is very useful in the evaluation and treatment of TMD patients.  Hypertonicity of masticatory muscles at rest is indicative of TMD.  To determine hypertonicity, we need to know the normative data.  “Normal” values, in microvolts, for each muscle group comes from the work of Dr. Jeffrey Cram Ph.D. who did the research and published the normative data in his book “Clinical EMG for Surface Recordings: Volume 2” Aspen Publication 1998.  These values are:

Anterior Temporalis   (TA)          2.8 uV

Masseter                 (MM)            2.0 uV

Digastric                    (DA)            1.7 uV

Posterior Temporalis (TP)          2.2 uV

Sternocleidomastoid   (SM)        1.5 uV

Some have misinterpreted how these EMG norms are used by a clinician.  They are, in themselves, not diagnostic of TMD.  After all the clinician is the one who diagnoses the patient’s condition using many different metrics including EMG data.

It needs to be understood by the clinician that these normal values are similar to other physiologic metrics such as the ‘normal’ blood pressure of 80/120 mm of Hg.  Of course this blood pressure value is not applicable for all humans.  Many physically fit people have much lower ‘normal’ blood pressure and there are healthy individuals with a slightly higher normal blood pressure.

On K7 scan 9, resting electromyography of muscle Groups A & G, or A & B, the normal values are shown on the left and actual values on the right.  In this example below, LSM is hypertonic.  Even though the RTA value is within the norm, it seems to be hypertonic compared to LTA.

 In the example below, both TA’s are hypertonic, with the LTA clearly more so.  Even though RSM value is only slightly over the norm of 1.5  uV, it is nearly twice that of the LSM and so would be considered hypertonic.

16 year long headaches, neck pain, shoulder pain and disabling fatigue resolved with Neuromuscular fixed orthotic

Unrelenting headaches and neck pain resolved through Neuromuscular Fixed Orthotic when Topamax, pain management, chiropractic adjustments and pain medications did not help. TMJ splints by ‘specialists’ that estimated the jaw position worsened the headaches.

Carmen had a single crown done 16 years ago and ever since that procedure she has suffered with face pain, head pain then neck pain and shoulder pain later on. She felt as if her jaw joints were dislocated.

Carmen has seen several different doctors over the years from dentists, oral surgeons, rheumatologist to neurologists but no clear diagnosis was ever given. She was told that she was depressed and given Prozac. Based on a panoramic x-ray, she was told that there were no TMJ joint problems and prescribed Topamax and Medrol steroid pills. She has been through Prolotherapy, acupunture, trigger point injections and splint therapy and all were unsuccessful. She even had arthroscopic surgery done on both TM joints and only had 2 days of pain relief from it. The pain has been very intense for the past 10 years.

Carmen is an RN. With the medications, severe pain and disabling fatigue, she felt that it was no longer safe for her to work. She reduced her work load to part time and found even that was too much. So she completely quit the profession she loved, three years ago.

Carmen was then referred to Dr Raman for an evaluation. Following the TMD evaluation he felt confident that he can help her. CT scans and a series of Neuromuscular K7 jaw computer tests were done to determine the correct jaw/neck alignment. Carmen was then fitted with a fixed orthotic to maintain this diagnosed position. After 16 years of suffering, she was already 30-50% pain free after just 1 month. She was also able to go for 5 days without taking any anti-inflammatory medications after being on Naproxen or Mobic daily for 16 years. She was unable to gain weight for years because of the pain. She can eat better now and is happy that she has gained some weight.

To anyone that is dealing with unrelenting headaches, neck pain, ear pain & shoulder pain, Carmen says “Don’t give up. Find the right doctor to help you”.

Jaw surgery avoided through NeuroMuscular Functional Orthodontics / Orthopedics (NFOO)

If regular orthodontists & oral surgeons say that jaw surgery is the ONLY option to correct TMJ pain, joint / ear pain when chewing, DON’T accept that too quickly. NFOO has proven to be an EFFECTIVE and non-surgical resolution of such symptoms many, many times. Here is one case history.

Laramie started having really severe pain when chewing and ear pain when she was in grade school. Her mother thought that she was a finicky eater. But Laramie did not know what it is like to eat without pain in the ears and jaws. Her dentist referred her to an orthodontist even though her teeth looked straight, which is the usual reason for getting braces. After 3 ½ years of braces, she continued to have ear and jaw pain. The pain skyrocketed after her wisdom teeth were removed, which evidently aggravated her existing chronic pain.

Laramie’s mother was alarmed to see her continue to lose weight, down to 100 pounds. She realized that her daughter is not just a finicky eater, but it was painful for her to even chew any food. She only ate what she could swallow without chewing. Laramie was in constant ear pain and jaw pain. She became depressed but did not realize that the pain was causing it.

They consulted with the orthodontist that had previously treated her. He felt that it was beyond orthodontics and referred her to an oral surgeon. The surgeon believed that the only option was jaw surgery. They consulted with another orthodontist who also thought that it was beyond orthodontics at that point.

One of Laramie’s mother’s colleagues is Deb Waylon whom we treated for and resolved chronic migraines and jaw pain. She referred Laramie to us for a NMD consultation.

Traditional orthodontics improves the smile cosmetically by straightening the teeth. 4 out of 5 patients we treat for TMD had previously had traditional orthodontics. So they often have ‘nice smiles’ but their jaws were poorly aligned. Once the optimal bite was diagnosed through advanced Neuromuscular protocols, moving the teeth along with bone support and gum tissue to this position is called Neuromuscular Functional Orthopedics / Orthodontics (NFOO). Objective electronic measurements of jaw / neck muscle activity and CT scans of the TM Joints guide the entire treatment.
THAT is the difference between NFOO and traditional orthodontics.
Laramie remains pain free, happy, able to eat anything she wants to and got married during her treatment. Just because regular orthodontic braces therapy has not worked to correct TMD problems you don’t have to accept surgery as the only other option.

It may be hard to believe. But neuromuscular functional orthodontics / orthopedics (NFOO) can actually solve these problems in most cases without surgery. So if you are tired of the jaw pain and hate taking medications with no end in sight, there is hope.

Watch this video of Laramie, an actual patient who was helped through Neuromuscular orthotic and Neuromuscular Functional Orthopedics / Orthodontics (NFOO). She is pain free and able to chew any food she wants without pain.

It is hard to measure the life impact of this treatment in this young person’s life compared to how it would have been in her social life and general happiness if the unrelenting ear pain and painful chewing had continued. No wonder both Laramie and her mother believe that it was “definitely worth” the cost of NFOO.

Botox for TMJ / TMD treatment?

Botox – botulinum toxin type A – has been touted for lots of problems that ail us.

It started off being used for facial cosmetics – to ‘relax’ wrinkles such as ‘crow’s feet’ on the side of forehead by paralyzing the tiny muscles under the wrinkles. But more and more uses of this drug is promoted all the time.

Recently there is a big push to use Botox injections in the jaw muscles “to treat TMJ”. Pharamceutical companies are experts in marketing & have the big money to give grants, sponsor research and sponsor speakers to promote its use. I have seen many patients that had this done repeatedly with less and less effectiveness. They are more difficult to treat – not impossible – since these muscles have been damaged. This is not just my opinion based clinical experience. There are scientific studies that prove this. These jaw muscles are NOT like the tiny facial muscles that cause ‘crow’s feet’ wrinkles on the face that are paralyzed by Botox for cosmetic results. The jaw muscles are important functional muscles! Does paralyzing them with a neurotoxin make a lot of sense to anyone?

Why then do doctors do this to treat TMD & patients go through these injections? Are they just looking for a quick fix? Or are these doctors that push this ‘treatment’ for TMD just clueless?

What are your thoughts on Botox for TMD treatment? Any of you have personal experience with Botox for TMD? Are you thrilled with the results?

Primum non nocere (“First, do no harm”) Part 6

How do we KNOW that there is improvement with our therapy?  Of course, subjective reports are important.  But how do we know that it is simply not the case of a patient desperately hoping for an improvement that overstates the change?

Objective measures confirm or invalidate the subjective findings.

  TMJ CO Rt  TMJ Orthoticrt

 TMJ CT sagittal view Pre-OP
With Orthotic…confirming decompression

  TMJ COLt   TMJ OrthoticLt

  10ro

emg – muscle activity at rest on the left half and at light occlusion- gently touching teeth on right half

 

  10o   10orthotic

Muscle Activity while lightly touching on natural teeth Vs on orthotic shows much calmer muscles.

Primum non nocere (“First, do no harm”) Part 5

This is the continuation of Sue’s story.

Once the diagnostic tests revealed where the mandible SHOULD align, the next step is to make that change in a reversible way.  Remember!  Primum non nocere (“First, do no harm”).  IF for some reason the patient does not get better, we need to make her no worse.  That means reversibility to the condition when she presented at our office.

Fixed LVI orthotic was placed on the mandible and fine tuned with the K7 instrumentation.  The progress is measured 3 ways:

a. Subjective reports

b. Objective tests – K7 scans of emg and mandibular movements and CT scans of the joints and cervical spine

c. Objective / Subjective:  Palpations of jaw and neck muscles and TM joints.  The pressure of palapation is consistent and objective.  But the patient’s response is subjective.

The images of the orthotic are below:

  Close   IMG_7819ed

This is her report two weeks later.  Immediately after delivery Sue had gone on a long planned vacation and just returned for this follow up visit. 

2 wk progress front 

 2 wk progress back

Primum non nocere (“First, do no harm”) Part 4

This is the continuation of Sue’s story.

My challenge was to diagnose very precisely where the jaw fits now (where there are symptoms) and where the jaw SHOULD fit if all the jaw / neck muscles are unstrained AND the jaw joints are in an optimal position as well.

Our Neuromuscular diagnostic protocol includes measuring emg’s before and after these muscles are optimized.  The end result is the mounted casts aligned with the myobite taken at the end of these tests.  We KNOW that the muscles will be unstrained in this position because we measure these muscles when the natural teeth are occluding and when they are occluding on the myobite.  When we see that the muscles are much quieter with the myobite, it confirms the correctness of the bite relation.

FrontCasts View from front showing a larger “gap” on her right side, where recent restorations were done.

  RtCasts  LtCasts

The anterior posterior discrepancy would explain the many adjustments needed on her upper front teeth after veneers were done….and the pain since the mandible had to posteriorize to avoid this area from proprioception.  This explains the joint pain.

In the next post, we would show how this was corrected and the results.

Primum non nocere (“First, do no harm”) Part 3

Sue suffered with these symptoms (listed below) for over 6 months. She had seen a family physician and a neurologist who had tried various medications, as is the norm.  Nothing helped.  She finally heeded the advice of a friend who was treated with NM orthotic.  So very skeptically, Sue came for an evaluation.

  BaselineThis was her baseline form.  We choose to use a “comfort scale” instead of the usual “Pain scale”.  So a Zero is the worst.  Her pain when chewing and pain the TM joints were Zero – meaning constant, severe pain.  All her other symptoms were in the “Severe” range, as can be seen above.

I will describe the treatment in the next post – Part 4

Primum non nocere (“First, do no harm”) Part 2

This is a story of a nice lady that sought our help recently. 

Sue is a 40 something woman who wanted to improve her smile.  So her dentist provided aesthetic all ceramic crowns for the upper front teeth.   

            Ret co   

She also had tooth colored crowns to restore some Max  Mand of the back teeth with large amalgams.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sue had several bite adjustments to these restorations since it did not feel right.  The symptoms gradually progressed to the point of “debilitating”.  She loved her work caring for mentally challenged people.  But she simply could not carry on, when she had constant pain that had worn her down.  The list of symptoms is long and they were present constantly. 

 

I will talk about these symptoms and what was done….in the next post:  Part 3

Primum non nocere (“First, do no harm”) Part 1

Primum non nocere is a Latin phrase that means “First, do no harm.”

 

While this is often erroneously attributed to Hippocrates, this maxim has nevertheless been a foundational principle of medical ethics for many years.  I believe that it equally applies to the practice of dentistry as well.

 

Cosmetic dentistry and orthodontics provide tangible benefits to patients.  A confident smile and improved self esteem greatly improve the quality of life of many.  But if the principles of physiology and function are violated there could be more harm caused than no treatment at all.  “First, do no harm.”

 

This is by no means an indictment of all cosmetic or orthodontic services.  But it is a call for prudence and careful consideration of the patients that trust us as their dentist.

 

I will describe a case to illustrate this point in Part 2.