A new paradigm

When I was in Dental School, we were taught about the oral signs of systemic diseases, the importance of good oral hygiene for people with certain diseases such as Diabetes Mellitus, and were given brief instruction about how TMJ problems could manifest as headaches and other related symptoms.

About 50 years ago, Dr. Bernard Jankelson initiated the idea of using TENS (transcutaneous electrical neural stimulation) to relax the muscles innervated by cranial nerves V and VII.  This would allow the mandible to find its physiologic resting position without any manual manipulation (the traditional approach which has been followed for many years involves manually manipulating the mandible to a “reproducible” position).  The starting point for neuromuscular dental care is the physiologic rest position.  Since then, there have been and continue to be many advances in the approach to neuromuscular dentistry.  For example, TENS is now applied to CN XI to relax the musculatureof the neck and shoulders. The Las Vegas Institute for Advanced Dental Studies (LVI) is one of the main proponents and training centres for neuromuscular dental diagnosis and treatment.

The mandible is suspended from the base of the skull by a sling of muscles.  These muscles coupled with the muscles of the neck are responsible for the posture of the head and neck area.  When these muscles are relaxed and working in harmony with one another, many if not all of the symptoms of TMD can be eliminated.

The stomatognathic system is the “top block” of the postural chain.  Have you or any of your patients or anyone that you know ever had a treatment by a chiropractor, physiotherapist, massage therapist, or cranial sacral therapist, which resulted in improvement of symptoms, only to find that an hour or a day later the symptoms returned?  The missing link in this is often the mandibular position.  When it is stabilized, the entire body posture can improve.

This concept has even been applied to sports mouthguards where it has been found that a mouthguard built to a neuromuscular bite position has the ability to enhance athletic performance.  Athletes have found improvement in their strength, flexibility, range of motion and balance.

On-going research at LVI is showing with amazing consistency and accuracy the relationship between mandibular position and the alignment of the atlanto-occipital joint, and the atlanto-axial joint.  When the physiologic rest position of the mandible is found, the A-O, A-A joints line up.   The song we used to sing as children … “the knee bone connected to the thigh bone, the thigh bone connected to the hip bone” etc. is perhaps more correct than we had originally thought.

Another very significant matter and one that is intimately related to mandibular position and the muscles of the head and neck is sleep apnea, and airway patency.  There is ongoing research on these connections as well.

TMD’s (temporomandibular disorders) can fall into two main categories.  These are termed ascending TMD or descending TMD.  Ascending disorders have their origins below the neck and descending disorders originate above the neck.  Ascending disorders most likely will require a team approach to treatment involving not only dentists, but chiropractic, physiotherapy, massage therapy, and other modalities as deemed necessary.

Subjective symptoms of TMD include but are not limited to headaches, temporomandibular joint (TMJ) pain, TMJ sounds (clicking, popping, grating), limited opening of the jaws, ear congestion, vertigo, tinnitus, dysphagia, loose or shifting teeth, clenching or bruxing of the teeth, teeth that are sensitive to percussion, difficulty chewing, cervical pain, postural problems, paresthesia of the fingertips, thermal sensitivity of the teeth, Trigeminal Neuralgia, Bell’s Palsy, and nervousness and or insomnia.  Because of the variety of symptoms, TMD’s have often been referred to as the “Great Imposter”.  Other medical conditions which can cause similar symptoms should be ruled out before treatment for TMD’s are undertaken.

Objective signs of TMD can include facial asymmetries, forward head posture, decreased vertical dimension of occlusion, wear patterns on the teeth, crowding of the lower anterior teeth, and scalloping of the lateral borders of the tongue, to name a few.  Careful postural assessment is also of extreme importance.  We notice that in most cases of TMD the planes of the body are not perpendicular or parallel to the horizontal.

The neuromuscular approach to dentistry is useful not only in the diagnosis and treatment of people with TMD’s, but it is a beneficial adjunct in any dental treatments that might involve occlusal considerations such as prosthetic rehabilitations, orthodontics, esthetic treatments, and coronoplasty.

As can be seen from this brief paper, there are many connections between the health of the mouth, the position and posture of the mandible, and the healthy functioning of the body.  I am sure that as time goes on and with continuing research we will find even more interesting links that will help to enhance people’s quality of life and eliminate pain and suffering.

references

• Jankelson, Robert R.:  Neuromuscular Dental Diagnosis and Treatment, Ishiyaku EuroAmerica, Inc., 2005
  
• Thomas, N.R., Dickerson, W.G., Thomas, T.D., Davies, P. : The Relationship Between the Upper Cervical Complex and the Temporomandibular Joint in TMD and Its Treatment Correction, LVI Visions, pp. 61-68, April 2009
  
• D’Attilio, M.,  Filippi, M.R., Femminella, B., Festa, F., Tecco, S.:  The Influence of an Experimentally-Induced Malocclusion On Vertebral Alignment in Rats:  A Controlled Pilot Study, The Journal of Craniomandibular Practice, pp.119-129, April 2005