Techniques for Dentists

Can the lancinating pain of Trigeminal Neuralgia (TN) really be ‘cured’ by correcting jaw alignment?

Isn’t TN only managed with medications or resort to (irreversible and risky) neuro-surgery? That is exactly what someone suffering with these symptoms would hear from their physicians – Primary care, neurologists or neurosurgeons.

It may sound far-fetched but it is true. Disabling, lancinating (stabbing) facial pain, commonly diagnosed as TN could be resolved in most cases, by precisely correcting jaw alignment through Physiological Neuromuscular Dentistry (PNMD).

Is it just a coincidence or is it the treatment paradigm that is making the difference? Is the real difference, our paradigm, our understanding of the origin of these symptoms? Is it nerve injury or increased input in to the Trigeminal nerve from structural discrepancy that causes these stabbing, shocking facial pain symptoms?

These three cases of physician diagnosed TN were completely resolved of TN symptoms in a matter of days through PNMD. Each case is slightly different but the common denominator is the PNMD approach of diagnosing the discrepancy.

Mary Beth https://youtu.be/V8RaZ65pxO4
Pansy https://youtu.be/nQLQDOLnOl0

 

Angie Symptoms https://youtu.be/EtZ68pDJYx0  Angie Solution  https://youtu.be/BGvvAzSJRfQ

 

What exactly  is TN? Trigeminal neuralgia is a disorder that causes debilitating nerve pain in the jaw area that can feel like a lighting strike. The accepted medical explanation is that it is due to damage to the Trigeminal nerve’s myelin sheath. As such, TN symptoms can only be managed with medications for life or when that fails resort to irreversible and risky neurosurgical procedures including nerve surgery or brain surgery.

I have copied and pasted authoritative information from the National Institutes of Health that describes the medical paradigm of this condition. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Trigeminal-Neuralgia-Fact-Sheet  Underlines were added for emphasis. My comments are italicized...

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve……

Another synonym is suicide disease. If there is no end in sight for this debilitating pain, it is understandable that some sufferers would choose to end their lives instead.

TN is a form of neuropathic pain (pain associated with nerve injury or nerve lesion.) The typical or “classic” form of the disorder (called “Type 1” or TN1) causes extreme, sporadic, sudden burning or shock-like facial pain that lasts anywhere from a few seconds to as long as two minutes per episode. These attacks can occur in quick succession, in volleys lasting as long as two hours. The “atypical” form of the disorder (called “Type 2” or TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than Type 1. Both forms of pain may occur in the same person, sometimes at the same time. The intensity of pain can be physically and mentally incapacitating.
TN can be caused by a blood vessel pressing on the trigeminal nerve as it exits the brain stem. This compression causes the wearing away or damage to the protective coating around the nerve (the myelin sheath).

This is a widely accepted ‘theory’ similar to many other theories in medicine about migraine, fibromyalgia etc. But if this theory is correct, then everyone that gets Micro Vascular Decompression surgery to place a protective cover over the nerve would get better. That is not the case. Or the surgeon would find the sheath damaged by a vessel each time. That is not the case either. Or if the myelin sheath of this nerve is missing as seen on MRI, then that patient would have symptoms. That is not true either. So, this is a theory with many holes in it.

Pain varies, depending on the type of TN, and may range from sudden, severe, and stabbing to a more constant, aching, burning sensation. The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. Bouts of pain rarely occur at night, when the affected individual is sleeping.

As listed above, some additional stimulation of the Trigeminal nerve usually triggers pain. During sleep, most people are relaxed and slack jawed resulting in less stimulation of the Trigeminal nerve. So, this points to any solution that could LESSEN the stimulation of the Trigeminal nerve as a viable treatment. Does it not?

TN diagnosis is based primarily on the person’s history and description of symptoms, along with results from physical and neurological examinations. Other disorders that cause facial pain should be ruled out before TN is diagnosed.

This is very similar to the other “diagnoses of exclusion (DOE)” such as Migraine, Fibromyalgia etc. Diagnosis is based primarily on what the patient subjectively reports. All the medical tests are done to ‘rule out’ another cause for the symptom – that they know of – and hence confirm their initial diagnosis. Because most physicians including specialists are simply unaware of the Physiologic Neuro Muscular Dental approach (PNMD), poor jaw / neck alignment is NOT ruled out as a cause of the symptoms. Dentists are trained to repair teeth and gums. They usually look at where the teeth fit together (occlusion) but not the physiologic alignment of the jaws as a dentist trained in PNMD does. So simply consulting with any dentist ‘to rule out jaw alignment problems’ will not be helpful either.

A diagnosis of classic trigeminal neuralgia may be supported by an individual’s positive response to a short course of an antiseizure medication. Diagnosis of TN2 is more complex and difficult but tends to be supported by a positive response to low doses of tricyclic antidepressant medications (such as amitriptyline and nortriptyline), similar to other neuropathic pain diagnoses.

Drugs that reduce ALL nervous system activity is similar to a dimmer switch on the entire house. They do reduce the Trigeminal input in to the brain as well. But do so indiscriminately, with side effects and only for a few hours. So, if the symptoms get reduced with these drugs, how does THAT PROVE that the myelin sheath damage is the real cause of the symptoms? Is that logical to come to that conclusion and give no end in sight for patients besides taking drugs for the rest of their lives?

Eventually, if medication fails to relieve pain or produces intolerable side effects such as cognitive disturbances, memory loss, excess fatigue, bone marrow suppression, or allergy, then surgical treatment may be indicated. Since TN is a progressive disorder that often becomes resistant to medication over time, individuals often seek surgical treatment. ………
Some degree of facial numbness is expected after many of these procedures, and TN will often return even if the procedure is initially successful. Depending on the procedure, other surgical risks include hearing loss, balance problems, leaking of the cerebrospinal fluid (the fluid that bathes the brain and spinal cord), infection, anesthesia dolorosa (a combination of surface numbness and deep burning pain), and stroke, although the latter is rare.

So when the drugs are not enough, do invasive, irreversible and risky surgeries that do not work all the time is the only option left? Why not even consider a non-invasive and completely reversible treatment that actually lessens the input in to the Trigeminal nerve by correcting the structural discrepancy of the jaw / neck alignment that is necessitating constant over-work of this nerve to compensate for that structural discrepancy? THAT in a nutshell, is PNMD. THAT can only be described as a CURE as evidenced by many cases including the three examples given earlier.

Climbing Mount Everest and Full Mouth Reconstruction

When I started teaching dentists from around the world as a clinical instructor for Full Mouth Reconstruction (FMR) courses in 2002, I saw my role as a Mount Everest guide. I have often shared that analogy with those doctors, experts all, to be taking that course in the first place, to emphasize the dangers on their path to the summit of successfully completing FMR. In dentistry, preparing all of the teeth at one time – 28 or even 32 teeth at times – while precisely maintaining the jaw alignment through the provisional stage and in the bonded porcelain restorations is the equivalent of an Everest climb. There are so many things that can go wrong and the path to successful completion is quite narrow. The doctors will still have to do the climb. My role when teaching FMR is to keep them in that narrow predictable path to success for the patient and the treating dentist just as an expert guide would on Mount Everest.
As I provide this FMR option to my own TMD / CCMD patients as a phase 2 solution, the financial cost is a barrier for many. It is even beyond the reach of many. That is why I never recommend any treatment option. My role is always to educate the patients on the options and their consequences first. Then once they choose an option, competently delivering that treatment option is also my role.
What does FMR has to do with Mount Everest, besides my comparing them to my students? The dangers of cutting corners.
“Deliverance from 27,000 Feet” on NY Times from yesterday is a superbly written and illustrated article by John Branch. It chronicled the death of three climbers from India who perished on the mount. He shined the spotlight on one aspect. https://nyti.ms/2kG615e    “Climbing Everest is an expensive endeavor……. Some spend $100,000 to ensure the best guides, service and safety.” Speaking of those that perished, Branch writes, “These four climbers measured monthly salaries in the hundreds of dollars. ..….They cut costs and corners, because otherwise Everest was completely out of reach.”

In the end three of the four suffered a horrible death on the mountain. The fourth one only survived because of the kindness of a self-sacrificing stranger who gave up his own climb to save that woman.
The lesson? Don’t cut corners and opt for a cheaper way to get Full Mouth Reconstruction. Risking your health and quality of life when things go awry is only slightly better than the fate of these climbers.

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