Annual Conference Airfare Promotion!

We will buy your airfare to this year's BioRESEARCH Annual Conference May 3rd-5th MIlwaukee, WI  Call 800-251-2315 to Register 2012 BioRESEARCH Annual Conference  Milwaukee, WI - This year's Annual Conference is going to be the best one yet. This conference will include live clinical exams, treatment plans, and case presentations involving biometrics.  We will also be featuring our workshops with many new topics and presenters. Please go to our website to download the brochure.    Click here to see a video on why you should come to this year's Annual Conference  We will buy the airfare of the first 10 doctors that register.  Call 800.251.2315 to register. If it is after hours, please leave a message and we will be able to tell what time you called. *not valid for international travel Other Events from BioRESEARCH 3/1-3/2 Biometric Diagnostics in Dentistry, Kiev, Ukraine 6/1-6/2  JVA and T-scan Integration, Dr. Mike Smith, Milwaukee 6/4-6/10 BioRESEARCH International Week, Milwaukee 6/8-6/9 Biometric Interpretation, Dr. Ray Becker, Milwaukee 6/10 Ortho, Sleep, and TMD applications of Biometrics, Dr. Roy Jolley, Milwaukee 8/3-8/4 Biometric Staff Certification, Dr. Cynthia Wiggins, Milwaukee 8/3-8/4 Business of Biometrics (Making Biometrics Profitable), Milwaukee 8/7-8/12 BioRESEARCH International Week, Milwaukee 8/10-8/11 Biometric Interpretation, Dr. Ray Becker, Milwaukee 8/12 The Innovative Smile, Biometric Application of Implants, Dr. Sangiv Patel, Milwaukee 10/15-10/17 BioRESEARCH coming to Hawaii *****limited number of spots******* Call 800.251.2315 or email info@bioresearchinc.com to request a brochure Save We will buy the airfare of the first 10 doctors that register.  Call 800.251.2315 to register. If it is after hours, please leave a message and we will be able to tell what time you called. *not valid for international travel Offer Expires: 3/15/12

JVA to Predict Appliance Therapy - Video

The Joint Vibration Analysis by BioRESEARCH Associates, Inc can guide you with your Appliance and Orthodontics production, yielding more accurate finishing results.

For more information on the Joint Vibration Analysis, check out these resources by clicking here.

Top 3 Questions - JVA (Joint Vibration Analysis)

While starting to implement the JVA into the Dental practice, many dentists and staff members frequently have some basic questions.

Here are the Top 3 FAQ's with Answers to help you Troubleshoot:

1. Q: I get an error message when I go to "Record Mode." What does this mean and what should I do?

• A: Usually this means that the JVA USB cord was unplugged and re-plugged in and the "Instacal" program needs to be re-run to acknowledge the USB driver for the device.
• First, make sure the USB cord is plugged into the computer
• Go to Windows Start Menu, find Instacal, and open the program (use the search field if you cannot find it.
• This Window should then pop-up:

• Click OK and then Record Mode should work.  If this window does not pop up and the USB is plugged in, contact us to troubleshoot further at 800-251-2315.

2. Q: How do I change the Windows View Layout under Review Mode?

• A: Under the Review Mode, you can manually change the layout of the windows to you own configuration by changing window size, adding the FFT view (if you like), or changing the order/arrangement.
• After you have the arrangement you like, Click Options>Screen Layout>Save.

3. Q: How do I change/write comments in the Printout Summary and Patient Narrative?

• A: In Review Mode, Click Narrative and you can edit the content.  The information automatically saves - there is no 'save' button to click.
• you can add personal comments, details, notes, etc to this narrative.

For other questions, email nathanr@bioresearchinc.com and I'll update this content!



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Sleep Apnea in Children by Dr. Paul Mitsch, DMD

Sleep Apnea in Children, an article by Paul Mitsch, DMD

Paul Mitsch Biography
Augusta Family Dentistry
401 State Street
Augusta, KS  67010 
Phone: 316-775-2482
Email: drmitsch@earthlink.net
http://www.mitschdentistry.com/home 

A Healthy Smile, a Healthy Life by Dr. Eric Farmer, DDS

A Healthy Smile, a Healthy Life from Wichita Family Magazine

For more information on Dr. Eric Farmer and his Dental practice in Wichita, KS, visit http://www.ericfarmerdds.com/index.htm


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Why it is Important to Evaluate the TMJ Before Dental Treatment

Why it’s Important to Evaluate the TMJ before Dental Treatment?

Dr. Manminder Singh Sethi

Temporomandibular joint is the skeletal foundation of masticatory system. The temporomandibular joint serves primarily to allow movement and its secondary function is to provide a fulcrum upon which muscles apply force. During destructive changes in masticatory system TMJ remodels and adapts by disc displacements and also by arthritic changes.  Disc displacement is the quick response change in the TMJ during an imbalance in the masticatory system followed by more complex and difficult to treat arthritic changes. Moreover these changes in the joint are a progression, from simple disc displacement with reduction they progress into more complex disc displacements and finally into degenerative changes involving the bony parts of the joint.  There is a need to identify the pathology in the joint to identify the treatment plan and the long term prognosis.

Most patients who come into our operatory for reconstruction are with tooth structure loss, with or without any Oro-facial pain. Most of the wear other than erosion comes from the imbalance between various components of masticatory system.  Since the loss of tooth structure is the most apparent consequence a patient can see, he/she lands in our office. We dentists traditionally are tooth oriented.  We look at teeth and do a routine dental exam involving the teeth and its supporting structures.  Although some of us do a TMJ exam, it is very subjective and has a low success rate in evaluating the TMD’s. For a complex treatment like reconstruction we need to specify the reason/reasons for that particular situation in which the patient finds him or herself.

The concept of centric relation is the mainstay of treatment planning of both edentulous as well as dentate patients. The modern concept of centric relation is that the condyles should be in their most superior-anterior position in the glenoid fossa, that they are fully seated against the posterior slope of the articular eminence and that the articulating discs are perfectly interposed between the condyles and the eminentia, throughout the range of motion of the masticatory cycle.  Some authors term this as the orthopedically stable joint position.

The other concept of joint stability is that when condyles translate down the posterior slope of eminence the articulating discs follow the condyles. For normal TM joint function the disc assembly must be in perfect synchronization. In healthy subjects the working condyle (chewing side) moves posterior to the intercuspal position which may be 1mm or less, but in the case of joint disorders the condyle moves further posterior causing a direction of the force towards the retrodiscal tissue.  Since this area is highly vascular and is rich in sensory fibers, pain and discomfort are caused in the joint.  Muscles may become hyperactive causing further discomfort to the patient.  This may lead further to parafunction and a vicious cycle continues, leading to more tooth wear and so forth. The first step of dental reconstruction should be to diagnose the joint for long term asymptomatic function for the long term survival of new restorations. Without objective analysis of the joint function we clinicians cannot evaluate the true condition of patient’s joints when he/she comes to us.

So it’s very important to evaluate joint disorders and treat them, if present, before a prudent dentist moves further ahead into treating the dentition. Here I would strongly recommend reviewing Piper’s classification of temporomandibular joint disorders.

Methods used to evaluate the TMJ

1.        Patient complaint/history

2.        TMJ palpation

3.        TMJ Auscultation

4.        TMJ Imaging

5.        Joint Vibration Analysis

Research has proved the inadequacies of first three methods.^1-4 Imaging is subjective and only shows the morphology in two static positions; 1) at maximum intercuspation and 2) at maximum opening.^5-7 The Research Diagnostic Criteria for TMD has recently been called into question.^8-10  In contrast, Joint Vibration Analysis (JVA) works on the principle that if joint is normal, there is no rough surface there would be no vibration produced during function.  However, if there is rough surface among various moving parts of the joint they are bound to produce vibrations.  Since 1988 Bioresearch Associates, Inc. has developed their JVA system whereby one could analyze the joint vibrations during function.  And there is convincing evidence in literature about the accuracy and principle that it works on.^11-26

The sensors are placed over both the right and left joints.  (See Figure 1.)  Next, we need to measure the maximum opening of the jaw and any lateral deflection of the mandible at maximum opening.  The patient is asked to open wide and close and the opening and closing by the patient is coordinated by a metronome on the computer screen. The vibrations are transferred from the sensors and digitized by the computer software (BioPAK). The software converts this vibration data into waveforms.  (See Figure 2.)  Since most of the vibrations are in the opening half of the cycle, they are identified and analyzed. And with the help of a flow chart you can identify the joint disorder and treat it accordingly before proceeding to restorative part of the treatment plan.  (See Figure 3.)

The Clinical Importance of JVA in Reconstruction:  The Importance of Diagnosis

Diagnosis is important to devise a treatment plan and is important in all the three phases of treatment that is; pretreatment, during treatment and post treatment. Before we need to reconstruct teeth we need to identify what were the reasons for tooth loss.  Only then we can identify were we could end up with our treatment and achieve our goals. So it’s of prime importance that we evaluate and diagnose all the components of masticatory system which would involve. When there is disharmony between various components of masticatory system, each component of the system will try to adapt. Often the weakest link in this system breaks the first, and when patients come to you with loss in tooth structure (erosion being an exception), we can safely presume that there is remodeling in the joint, alteration in muscle function as well as changes in the mandibular movement pattern.

References;

1. Eriksson L, Westesson PL and Sjoberg H. Observer Performance in Describing Temporomandibular Joint Sounds. J Craniomandib Pract Jan 1987; (5)1:32-35.
2. Hardison JD, Okeson JP. Comparison of three clinical techniques for evaluating joint sounds. Cranio. 1990 Oct;8(4):307-11.
3. Paesani D, Westesson PL, Hatala MP, Tallents RH, Brooks SL.  Accuracy of clinical diagnosis for TMJ internal derangement and arthrosis. Oral Surg Oral Med Oral Pathol. 1992 Mar;73(3):360-3.
4. Yatani H, Suzuki K, Kuboki T, Matsuka Y, Maekawa K, Yamashita A.  The validity of clinical examination for diagnosing anterior disk displacement without reduction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Jun;85(6):654-60.
5. Kobs G, Bernhardt O, Kocher T, Meyer G. Critical assessment of temporomandibular joint clicking in diagnosing anterior disc displacement. Stomatologija. 2005;7(1):28-30.
6. Barclay P, Hollender LG, Maravilla KR, Truelove EL.  Comparison of clinical and magnetic resonance imaging diagnosis in patients with disk displacement in the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Jul;88(1):37-43.
7. Schmitter M, Kress B, Rammelsberg P. Temporomandibular joint pathosis in patients with myofascial pain: a comparative analysis of magnetic resonance imaging and a clinical examination based on a specific set of criteria. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Mar;97(3):318-24.
8. Schmitter M, Ohlmann B, John MT, Hirsch C, Rammelsberg P. Research diagnostic criteria for temporomandibular disorders: a calibration and reliability study. Cranio. 2005 Jul;23(3):212-8.
9. Visscher CM, Naeije M, De Laat A, Michelotti A, Nilner M, Craane B, Ekberg E, Farella M, Lobbezoo F.  Diagnostic accuracy of temporomandibular disorder pain tests: a multicenter study. J Orofac Pain. 2009 Spring;23(2):108-14.
10. Emshoff R, Brandlmaier I, Bösch R, Gerhard S, Rudisch A, Bertram S.  Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup - disc derangement with reduction. J Oral Rehabil. 2002 Dec;29(12):1139-45.
11. Widmalm SE, Westesson PL, Brooks SL, Hatala MP, Paesani D.  Temporomandibular joint sounds: correlation to joint structure in fresh autopsy specimens.  Am J Orthod Dentofacial Orthop. 1992 Jan;101(1):60-9.
12. Christensen LV, Orloff J.  Reproducibility of temporomandibular joint vibrations (electrovibratography).  J Oral Rehabil 1992 May;19(3):253-63.
13. Christensen LV.  Physics and the sounds produced by the temporomandibular joints. Part I.  J Oral Rehabil 1992 Sep;19(5):471-83.
14. Ishigaki S, Bessette RW, Maruyama T The distribution of internal derangement in patients with temporomandibular joint dysfunction--prevalence, diagnosis, and treatments.  Cranio. 1992 Oct;10(4):289-96.
15. Christensen LV.  Physics and the sounds produced by the temporomandibular joints. Part II.  J Oral Rehabil 1992 Nov;19(6):615-27.
16. Paiva G, Paiva PF, de Oliveira ON.  Vibrations in the temporomandibular joints in patients examined and treated in a private clinic.  Cranio 1993 Jul;11(3):202-5.
17. Ishigaki S, Bessette RW, Maruyama T.  Vibration analysis of the temporomandibular joints with meniscal displacement with and without reduction.  Cranio. 1993 Jul;11(3):192-201.
18. Ishigaki S, Bessette RW, Maruyama T.  Vibration analysis of the temporomandibular joints with degenerative joint disease. Cranio. 1993 Oct;11(4):276-83.
19. Olivieri KA, Garcia AR, Paiva G, Stevens C.  Joint vibration analysis in asymptomatic volunteers and symptomatic patients.  Cranio 1999 Jul;17(3):176-83.
20. Widmalm SE, Williams WJ, Yang KP.  False localization of TMJ sounds to side is an important source of error in TMD diagnosis.  J Oral Rehabil. 1999 Mar;26(3):213-4.
21. Radke J, Garcia R Jr, Ketcham R.  Wavelet transforms of TM joint vibrations: a feature extraction tool for detecting reducing displaced disks.  Cranio 2001 Apr;19(2):84-90.
22. Widmalm SE, Williams WJ, Ang BK and McKay DC.  Localization of TMJ sounds to side.  J Oral Rehabil. 2002 Oct;29(10):911-7.
23. Mazzetto MO, Hotta TH, Carrasco TG, Mazzetto RG.  Characteristics of TMD noise analyzed by electrovibratography.  Cranio. 2008 Jul;26(3):222-8.
24. Honda K, Natsumi Y, Urade M.  Correlation between MRI evidence of degenerative condylar surface changes, induction of articular disc displacement and pathological joint sounds in the temporomandibular joint.   Gerodontology. 2008 Dec;25(4):251-7. Epub 2008 Feb 27.
25. Hwang IT, Jung DU, Lee JH, Kang DW.  Evaluation of TMJ sound on the subject with TMJ disorder by Joint Vibration Analysis.  J Adv Prosthodont. 2009 Mar;1(1):26-30. Epub 2009 Mar 31.
26. Goiato MC, Garcia AR, dos Santos DM, Pesqueira AA.  TMJ vibrations in asymptomatic patients using old and new complete dentures. J Prosthodont. 2010 Aug;19(6):438-42. Epub 2010 Jun 8.

2012 Business of Biometrics Class

2012 Business of Biometrics Course

Learn Screening Protocols that fit your practice!

Workshops on:
*Patient Referrals
*Billing and Insurance
*Social Media
And more!!

Register today by phoning Nathan Riopelle at 414-202-5430 or email nathanr@bioresearchinc.com

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AutoCPAP machines and the AutoPAP

Here is a new site for AutoPAP machines - Auto CPAP.

Dentists can treat mild sleep apnea with appliances, but what about moderate and severe?  CPAP machines are still the needed method for those that are both tolerant and have higher AHI levels for snoring and sleep apnea.

If you are using a CPAP machine and you are 'tired' of doing all the sleep tests, an AutoPAP machine might be a good option.  The difference between the Auto CPAP machines and the normal CPAP is that the Auto PAP automatically adjusts to the pressure.

Depending on a number of sleep patterns and changes, your breathing may vary.  If you have a normal CPAP machine, the pressure is always the same.  If you have an Auto PAP machine, it can adjust depending on these factors that change your breathing:

• Under the influence of sleep medications
• Changed sleep patterns due to travel or work schedule
• Stuffy nose or airway due to colds or sinus infections
• Alcohol consumption
• changes in breathing at different sleep stages

For those just getting a CPAP machine, it is suggested that you might need to take a few extra sleep tests (polysomnograms) to titrate, or get the air pressure levels set up correctly.  Often time this can be a burden for those needing to take the tests, and it can be costly.  Auto CPAPs allow for automatic adjusting so often times the extra sleep tests are not necessary.

Prior to getting an AutoPAP device, you will need to see a sleep physician and take an official sleep test or polysomnogram.  If you are always feeling sleepy, take a quick checklist test at SleepTest.com.

You may peruse different models of AutoPAP machines by visiting: http://www.autocpap.org/ShopAutoCPAP

Sleep Apnea Linked to Silent Strokes | February 15, 2012 | Sleep Report | Sleep Review

Click Here for Sleep Apnea Linked to Silent Strokes | February 15, 2012 | Sleep Report | Sleep Review

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What is Jaw Tracking?

by Nate Krey

Jaw Tracking is the ability to track mandibular movements.  This can be useful in function and in rest (and everywhere in between).  Some of the various tests done with jaw tracking are Range of Motion (ROM), Velocity, Freeway Space Measurement, Mastication and Speech Analysis.  ROM is important to determine a baseline for a patient as well as give us clues as to what might be wrong with a patient.  Restrictions and/or asymmetries can give us an inside into whether we are dealing with an intracapsular (inside the joint) or extracapsular (muscle or occlusal based) problem as well as be useful in determining maximum medical improvement to end treatment.  Maximum Opening, lateral excursions, and protrusions (which can be very useful for clinicians making sleep appliances) are usually measured in this test.  Deviations and deflections also give us an insight into what might be happening inside the patients jaw joint. 

Velocity is a test in which the patient is asked to move their jaw at certain speeds, much like a “stress test” in cardiology.  From this test we can see if the patient can reproduce a consistent pattern or if they produce “slow downs” or asymmetries that might lead us to believe there is a muscle or joint problem.  Freeway Space is used to determine if the patient has a normal physiologic rest position, if their teeth touch when they swallow (which can suggest a tongue thrust {which might be an airway issue}), what their closing trajectory looks like, and what we have to work with for “freeway space.” 

Mastication is the study of one of the most important things we do to survive…chewing.  People who have normal joints have normal chewing patterns.  People that chew their food efficiently have less digestion problems and are overall healthier than those who struggle to chew their food.  We study how effectively people chew their food and see if there are ways to improve their chewing.  This is also helpful in designing new dentistry.  If a person is having significant dentistry done, it is important to give them a more effective chewing scheme, just as important as it is to give them the esthetic result they desire.  Speech is also used for function and esthetics.

Jaw Tracking can also be used simultaneously with JVA so that we know when a disk is reducing or displacing.  Some believe that the earlier a disk recaptures, the easier it is to treat.  Next time, I will be talking what protocols to use to effectively implement JVA and Jaw Tracking!

Occlusal Wear: Why Do My Jaws Hurt So Much?

by Mark P. Kraver DDS

Cape Dental Care

239.549.8921

http://www.capedental.com/

Original Document Blog: http://www.capedental.com/2011/occlusal-wear-why-do-my-jaws-hurt-so-much/

What do you think the expected life span of a human being was 100 years ago?  Forty-three.  Life is so much more complicated today!  Are we living longer than our teeth were design to last?  Do people have more stress in their lives than way back then?  These are a few of the complicating factors I will attempt to explain in answering the question, “Why do my jaws hurt so much?”

History

Humans have been grinding their teeth since before we knew how to write.  Ancient fossil records show relatively young people had already ground their teeth flat.  This is attributed to their diet of unprocessed food, but shows that grinding is nothing new.  With the introduction of sugars into our diet we have seen a marked increase in cavities.  With cavities comes extractions or at least letting the tooth rot out of the head.  Loss of a tooth can significantly impact how a person bites their teeth together.

Causes of Grinding Teeth:

Malocclusion-

• Naturally occurring misaligning of the teeth happens.  Teeth come in rotated, tipped, and are sometimes just missing. This can cause crossbites,  overbites and underbites.  Why do you think we have so many orthodontists?
• Loss of a tooth/teeth.  When teeth erupt into the mouth they are pushed into the familiar arch shape by the actions of the lips and tongue.  Once into this arch form they remain fairly stable for the rest of your life.  This is until you loose one of your teeth in the archway.  The Romans knew how strong an arch can be when they designed bridges, buildings and aqueducts.  Individual teeth “lean” onto the one in front of it for their support.  If one is lost the teeth behind the one lost begin to drift forward.  This can significantly impact the way that you bite your teeth together.
• Trauma such as a broken jaw or tooth/teeth can impact the way that you bite.
• Iatrogenic Dentistry.  This is improperly placed restorations that can sometimes be placed inside your mouth by the dentist or his staff.  Just think about it.  You go to the dentist and need a crown.  He/she gets you so numb you don’t know whose mouth they are working on.  They prepare your tooth and make an impression by having you bite your teeth together.  From that mold they make a crown and cement it into your mouth.  Most people can tolerate a little mistake in their bites and don’t really notice that high spot when they slide their teeth sideways. After all if you think about it, most dentists only check your bite by clicking your teeth up and down.  So now your bite is off just a little from the crown and a little from the natural formation of your teeth.  You then have to have a filling done, then a bridge, then another crown.  At some point all of these discrepancies build up and you begin to grind your teeth to try and settle them into a more comfortable bite.
• Orthodontics.  They may look pretty, but do they bite right?
• Tempromandibular Joint.  Which came first: The malocclusion or the tempromandibular joint disfunction?  Both answers can be correct under the right circumstance.  A significant malocclusion can start the joint clicking and popping, and a worn down joint can cause malocclusion.

Central Nervous System-

This is not a very common condition but does afflict some unfortunate individuals.  It is usually diagnosed after all other causes have been “eliminated.”  It is where the brain has a condition that makes the muscle of mastication not function properly.

Occlusal Interferences-

Wouldn’t it be great if you could straighten out your teeth by grinding and clenching them into a good bite!  Well that is exactly what your body thinks it can do.  If it finds a high spot, it will usually try to wear it down or avoid it all together.

• Destroyers. These are want I call people who grind out their interferences.  You can look into their mouths and see teeth worn right off, cracked or broken.   They destroy crown, fillings, bridges, partial dentures and implants, too.  This in some cases can even contribute to periodontal disease and the death of the tooth’s nerve.
• Avoiders. Someone with a premature interference in their mouth somewhere, but it is too painful or disruptive to chew on so they shift their bite to some where else.  The most common other place is the front teeth.  Ever seen someone with flat front teeth? Avoider!
• Avoider/Destroyer. Occasionally someone will have both these conditions in their mouth.  In this case both the front and back teeth are worn down.

Examination:

This is where things begin to get interesting.  Ask 100 chefs how to cook lasagna and you will get 100 different recipes.  I have been going to TMJ continuing education course and workshops for over 25 years and have never heard the same treatment plan twice.  The most complete series of courses I had the privileged of attending was with Dr. Henry Gremillion’s at the University of Florida’s Parker Mayhem Craniofacial Pain Center.  Unfortunately, Dr. Gremillion is now the Dean of LSU School of Dentistry and the UF center has been closed due to budget constraints.

So, with all of the various treatment plans out there waiting to pounce on my back, I will attempt to carry you through how we treat our patients at Cape Dental Care.

History

• Complete health history is a must.  Medications, history of trauma, history of previous treatments preformed for this condition,and surgeries, just to name a few.
• Race: Strangely enough, Afro-American decent have less TMJ problems than other races.
• Past History of Oral Surgery consult and/or treatment
• Past History of any splint therapy
• Parafunstional habits: Nail biting, chewing ice, eating hard candy/foods, history of bruxing (grinding at sleep), clenching (grinding while awake) and/or heavy gum chewing.  You know cows are made to chew all day, not human beings.
• History of smoke/chewing tobacco or excess drinking of alcohol
• Does it bother them only during their menstrual cycle?  This maybe one of those central nervous system problems I alluded to, or not.
• Chronic headaches?
• Difficulty sleeping or history of snoring
• History of any trauma to the head and neck
• History of extensive tooth restorations

Physical Examination

• Clicking and/or popping of the joints
• Ligamentitis. Discomfort when the joint is pressed from the outside.
• Capsularitis. Discomfort when the joint is pressed from inside the ear canal.
• Medial pterygoid muscles
• Temporalis Muscles
• Masseter muscles
• Sternocleidomastoid muscles
• Digastric muscles
• Back of the neck muscles
• If the jaw joint translates.  The TMJ is really the only “double joint” in the entire body.  It has two main function: rotation and translation.  Translation is where the joint actually slides down the base of the skull to open the mouth as wide as it can.
• Eminence click.  When the jaw translates it usually stops before it runs out of skull to slide upon.  But with very flexible people (mainly women) they can slide too far and pop their jaw over the end of the translation zone and make a click.  This is also the spot where an open lock occurs.  An open lock is when you open your mouth too wide and it gets stuck open!  If this ever happens DO NOT PANIC!  Forcing it closed can cause a life time of damage to the tender apparatus of the TMJ.  Call a dentist immediately and/or try to move your jaw side to side.  The dentist will manually pull your jaw down and forward to unlock it. Remember do not force it close! Avoid open locks by not yawning very wide, don’t eat large piece of food (subway) and don’t sing to loud!
• Maximum mouth opening without pain.
• Deviation of the mandible right and left during opening
• Midline deviation of the mandible at rest
• Overbite/overjet.  This is how much you teeth overlap when closed.
• Sometimes I will take diagnostic models of the teeth to see if there is some other factors I may have missed. This involves making and impression of the teeth and getting a very accurate bite with a facebow.  A facebow  is simply an apparatus to record how your mandible relates to your maxilla and help in mounting the models onto an articulating chewing machine.
• Crossbites.  These happen when the upper teeth are inside the lower teeth when biting. Normally, the upper teeth are outside the lowers when biting.
• Angles Classification.  This is broken down into Class 1 (normal), Class 2 (overbite), and Class 3 (underbite).  This may involve only the teeth or it may indicate a skeletal problem between the mandible and maxilla.  I find less TMJ problems with the Class 3 patient and is probably due to the restricted biting platform.
• Periodontal status.  If there is gum disease the teeth may not be stable.  This may cause the teeth to move around and may make it harder to figure out where they bite.
• Soft tissue.  There maybe swelling or redness indication an infection, pathology or malignancy.
• Frankfort Mandibular Plane Angle.  This is an imaginary angle created between drawing a line from under the eyeball to the ear hole and from the lower border of the mandible.  It is used to see just how much the teeth are “leaning” onto each other in the arches.

Joint Vibration Analysis

This is a very sensitive microphone placed over the joints like small headphones.  It picks up the sound frequencies that come from the joints when they open and close.  This is not used to diagnose TMJ problems, it is just a tool to help the doctor figure out what is wrong.  It uses a computer to analyze the different frequencies and is a good tool to use before any major work is done to your mouth.  It is a physical record of the status of your joints and can be used in the court of law.  Everyone wishes they had had one of these before they had their car accident to show just how badly they were damaged during the accident.

We mainly use it to rule out any TMJ problems or to show that our treatments have not change the TMJ for the worse. Fortunately, over 80 percent of what people call a TMJ problem (including medical doctors) is not TMJ oriented, but instead myofacial pain (or pain from over worked muscle).  What is the main cause of myofacial pain?  Malocclusion.

NOTE: We do have a CBCT (cone beam CT) scanner and a panograph in the office, but I feel having a picture of it is over kill and too much radiation to subject my patients to just to know there is something wrong in the joints.  If I can hear something wrong, then there is something wrong.  MRI’s are much better for seeing the joint than CAT scans (and without any radiation).

TekScan

Wow!  What a great tool.  Everything in dentistry can be boiled down into having a good bite.  The ways we are taught to check the bite in dental school is in a word, “inadequate.”  They teach the simplest way by using bite paper alone.  Oh, they say they are “manipulating” the jaw into the right positions to see if the bite is correct, but that is about it.  Big dots or little dots. Why does it matter?  I have seen some dentists put the bite paper into the mouth, see a large spot and then attack it like a shark!  If they would have used the TekScan they may have seen that that big spot that attracted their eye wasn’t the spot to adjust.  Instead, it was that tiny little speck next to it that was the problem.  Still others I have seen ask the patient where they feel their teeth touching first and then spend the next hour chasing spots around the mouth. It isn’t until the patient gets tired of getting their teeth ground down and the dentist gets worried about all the teeth they have altered that it ends.  Then after that the patient dares not to bring the subject up and the dentist doesn’t bring it up for fear they will have to go at it again.

TekScan was developed for dentistry back in the 1980′s.  Now it has expanded into many other manufacturing techniques like tire fabrication, robotics, and space flight.  Dr. Scholl’s has it in their foot diagnostic centers in the malls.  But in dentistry it has not taken off.  One really good reason is the cost.  Another reason it is not widely used is it is complicated.  Believe it or not, there are dentists in this country who do not even have computers in their office!

The TekScan is a pressure sensitive sensor that makes a movie of how your teeth come together.  I put it on a TV monitor right over the patient’s head when we use it.  Once you see it work a few time, the patient can see the results themselves.  When you show the patient that they are biting on their right side 75% more than their left, they get it.  If you just used bite paper you would never know that.  Sure you would have dots the same as what we get at the end of the movie, but you would not see what the movie was really about.  It would be like reading the last sentence of a great novel before you read the book!  You would have an idea how it ended, but not how you got there.

Treatment:

NTI

Nociceptive trigeminal inhibitor.  Cool name?  Not really.  Cool devise?  Yes, really!  If this was all the treatment your dentist did for you when you showed up at their office with extreme myofacial pain, then God bless them!  Is it good long term treatment? NO!

Several blogs could be written about the NTI, but here I am going to attempt to explain it in simpler terms.  We use the NTI in our practice as a simple diagnostic tool, only.  If it works preventing your pain, then it is most likely your bite causing your pain (when the JVA is negative, of course).  It takes me about 15-20 minutes to manufacture a NTI for your mouth and you should wear it as much as possible for the first week.  In most cases, it will reduce or completely eliminate the myofacial pain.

The NTI is a small piece of plastic that snaps onto your front teeth only.  You can take it in and out.  I like to use it on the upper teeth when I can, it makes people look like Jerry Lewis in the Nutty Professor.

The way it works is complicated and has to do with the nerves of  your front teeth.  The front teeth are wire to the spine in a biofeedback loop.  When they touch together they cause the muscle of mastication to loosen up and relax.  This is thought to be so the front teeth will not become damaged while eating hard foods.  We can then exploit this biofeedback loop to our advantage. If relaxing the chewing muscle helps the pain go away, then bingo!

This is written in the chart and explained to every patient who receives a NTI:

Informed Consent, Reviewed health history, THIS APPLIANCE IS ONLY INTENDED FOR USE WITH ACUTE MYOFAICAL PAIN EPISODES. CHRONIC USE CAN CAUSE POSTERIOR TOOTH ERUPTION WHICH COULD WORSEN SYMPTOMS AND CAUSE MALOCCLUSION.

Nociceptive Trigeminal Inhibitor manufactured with acrylic over the maxillary/mandibular central incisors. Trimmed and polished.  Patient counseled on how to and when to wear.  OHI (wash appliance with soap and water and/or toothpaste and keep in box when not in use).

Wear the appliance when sleeping and daily during the most stressful times.  Never wear while eating. Discontinue all chewing gum. This is NOT an orthodontic device and should not be worn 24/7.  It REQUIRES the teeth come together each day for at least 8 hours to keep the teeth in proper position. Neuromuscular parafuntional habits may not resolve immediately and can be aggressive in maintaining itself. If it becomes uncomfortable, too tight or loose, or irritating in any way, the patient has been instructed to contact the office immediately for a follow-up visit.  Risks, benefits and alternative discussed.

Dogs love to eat NTI. If lost, the patient understands a new one can be made for another full fee.

Next Visit: Re-evaluation of myofacial pain

The TekScan Series of Appointments

If myofacial pain syndrome is diagnosed, then the patient is offered two modalities of treatment.  This first is a hard night guard.  It is a 50 cent piece of plastic that we manufacture and delivery to you to wear in your mouth at night for the rest of your life.  We of course charge more than 50 cents, but the idea is it is for LIFE.  This plastic hard (NOT SOFT) night guard is then adjusted with the TekScan to simulate the proper occlusion in your mouth.  We can grind on this all day without altering your teeth in the slightest.  This is a very popular way to treat both myofacial pain and TMJ problems.  The fact that it is in good occlusion helps the myofacial pain and the thickness of the appliance helps the TMJ.

The other way to treat myofacial pain is through what I call the TekScan series of appointments.  This is a complete equilibration of your teeth.  I was very please to hear from one of my old associates the other day when he said he went to a continuing education course on TMJ dysfunction and Myofacial pain and they said dentistry was getting away from complete equilibrations.  No doubt it was because too many dentists were getting in trouble grinding the heck out of peoples teeth.  It didn’t surprise me, because if they were doing it the way they learned in dental school, they could screw up a lot of mouths if excessively applied.

The TekScan series of appointment is separated into 3 or more appointments, the first one is 2 hours long!  Yes, and we use every bit of that time.

TekScan 1

• Line up the dots- We as dentists have learned where and where you should not bite your teeth together.  Lining up the dots is done in maximum intercuspation or how your teeth come together naturally.  The features that interest me are biting more on one side than the other; slides in the bite, and hitting the wrong parts of the teeth.
• Right and left lateral excursions- This is when you slide your teeth sideways onto your canines.  I look for working and non-working side interferences and guidance.  That is when you put food on one side of your mouth to chew you should only touch on that side and not the other.  This is a major cause of myofacial pain is is essential to a successful equilibration.
• Protrusive excursion- This is when you grind your teeth forward onto only your front teeth.  Normally all the back teeth should not touch when you move you jaw forward.  This is the most forgotten and hardest to detect part of a complete equilibration.

TekScan 2

• 2 Week to 1 Month Recall
• Look for relapse.  Relapse happens when a tooth was previously hitting so hard that it was actually hammered into the gum line.  If it erupts some and begins to hit once again, symptoms may reoccur.
• We go through another quicker version of the first to look for any relapse and then adjust it.
• It is usually easier than the first because the patient knows already how to move their jaw and is familiar with the sensor itself.

TekScan 3

• 2 Week to 1 Month Recall
• Look for more relapse
• TekScan 3 can be repeated in the future as needed, PRN.

Along with the myofacial pain treatment, I also recommend they pay attention to their posture (in particular carrying their chin over their sternum), and taking vitamin/mineral suppliments (600mg magnesium in divided doses, 1000mg vitamin C, 1200mg calcium, and vitamin B100 suppliments) to improve their metabolism in their muscles and central/peripheral nervous system.

This has been surprisingly effected in treating myofacial pain and I have used it to reduce the pain in some TMJ dysfunctioning patients as well.  I always stress that it is NOT a cure for TMD but it will sometime help less the discomfort.

Case Study: I have a patient who is a chiropractor from down the street.  His TMJ sounds like a box of rocks falling off the back of an old truck.  He was in chronic pain for years.  He had joint surgery and still was in pain.  His JVA was atrocious.  I did a TekScan Series of appointments on him and he has been relatively pain free for over two years.  What a good referral!

I will be the first to say that some patient who have myofacial pain cannot be helped by a complete equilibration.  Their bites are so bad there is simply no way to equilibrate them.  A hard night guard can help.  Sometimes new restorations are needed.  On occasion a full mouth reconstruction or comprehensive orthodontics are needed.

Contact Cape Dental Care @ 239-549-8921 if you have any issues with your joints or facial pain. Get a thorough analysis today!

References:

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