Carl Gugino, D.D.S., M.S. Robert Grove, Ph.D.

1. Advances in the Management of Oral Habits and Mouth Breathing: Part I InnerSmilePro RESPIRATION AND ORAL HABITS AWARENESS TRAINING Carl Gugino, D.D.S., M.S. Robert Grove, Ph.D. Bringing Oral Habits Under Control in Your Office Today: A Realistic Model for the Average Practitioner Using Existing Staff Version 1.0 01-27-08

2. DISCLOSURES AND PROPERTY RIGHTS • Drs. Gugino and Grove want you to know that they are co-owners in the products on which this presentation is based. They also own the intellectual property. • The material presented here is based on the intellectual property of the presenters. The final product is based on 27 years of development. • ACKNOWLEDGEMENTS • We could never do this by ourselves. We wish to thank hundreds of colleagues for their help over the years. Special thanks to Dr. Ivan Duc of Italy, Dr. Carl.F.Gugino’s Florida Study Group, The Bioprogressive Society of Japan, including Dr.Hiroshi Nezu, Dr. Kenji Nagata, Dr.Katsura Imai, Dr.Osamu Watanabe, Dr.Makoto Nakao, and Dr. Dr. Joseph Caruso, and Dr. James Farrage of Loma Linda Dental School, California, for their leadership.

3. Loma Linda Mafia

4. The Three Musketeers

5. Carl Gugino Worked with Ricketts. Developed multi-modality office management. Brought Breathing, Exercise, and Psychophysiology to Case Management. Master Teacher of ‘ZeroBase’ – case management by level of difficulty. Started sEMG in 1970s with the Cram Scan. International Mentor – Europe, South America, Japan. Brought together Grove and Duc in Italy to form SEMG team. CoOwner, InnerSmilePro.

6. Ivan Dus Works with Gugino in Europe. Extensive knowledge of physiology. MD. Set up ‘ZeroBase’ computer team – case management by level of difficulty. Brought together Grove to Italy to develop sEMG team. Got degree in neurophysiology and behavior.

7. Bob Grove Medical Psychologist @ neuropsychophysiology, biofeedback. Primate surgery lab. Full physiology research laboratories. Founded Neuronal Regulation Society. Three times President, Biofeedback Society of California. Rheumatology research. Soft-tissue evaluations. Hundreds of sEMG CMD evaluations. The missing link – psychophysiology in severe dental-ortho cases. Pedodontic swallowing breathing researcher. Loma Linda Dental School. Co-Owner, InnerSmilePro.

8. SWALLOWINGFUNCTION andSTRUCURE.Concept of degree of difficulty.Neutral Zone – Neutral Matrix.Ortotropic.Phagias.

9. DEVELOPMENTAL PHYSIOLOGY,ORAL HEALTH and INNER SMILES It is commonly acknowledged that structural lesions produce disturbances of function. Muscular imbalance, ineffective motor patterns and postural strain cause symptoms by themselves and often precede structural changes. from Brownstein, B. and Bronner, S. Functional Movement in Orthopaedic and Sports Physical Therapy: Evaluation, Treatment and Outcomes (1997, p. 159)

10. PHYSICAL THERAPY? ORAL EXERCISES? EXERCISES for INNER SMILING? “General exercises may neglect individual muscle contributions to specific movements. If an inhibited muscle is not firing, continued practice of that exercise may never trigger it, thus perpetuating and possibly amplifying impaired muscle function and imbalances.” from Brownstein, B. and Bronner, S. Functional Movement in Orthopaedic and Sports Physical Therapy: Evaluation, Treatment and Outcomes (1997, p. 159)

11. AMERICAN PRACTICES ONLY. Who pays? 1. Biofeedback Billing Codes 90901 90875 90876 90911 2. Evaluation Six Sessions Re-Evaluation

12. The Problem: • Oral Habits Can lengthen and reverse any Bite Normalization Procedure. • Blocked airways are emerging as a MAJOR cause of Bite Regression. • Tongue-Thrusting mouth devices do not open airways nor reverse habits. • Oral Habits – grinding*, bruxing*, poor posture- also add to Bite Regression. * Bruxing and grinding will not be covered in the presentation. We have other software to specifically address the behavioral aspects of these issues.

13. The Good News: • Oral Habits can be reversed in an average of 6 sessions for Class II Open Bites. The need for follow-up visits are re-evaluated at that time, especially if severe Class III. • This finding has been replicated in 3 counties over 27 years. • The effect is not due to placebo effect and is in most cases, permanent. • Habit Retraining can be done in about 20 minutes.

14. Background: • Historically Awareness Training began before the computer, as • ‘Manual Awareness Training.’ developed by Dr. Gugino in the 1970s: • Clinics in France report habit reversal using ‘manual’ – non-computer- techniques- over many sessions. • Computerized versions have been in use since 1990, first in Italy, then Japan, and the USA, called ‘Computer-aided Awareness Training.’: • Computerized Clinics in Japan and Loma Linda report reversals in about 6 sessions. • More difficult cases can benefit from Habit Retraining/Awareness coupled with bite normalization. • Breathing difficulties with mouth breathing can also be reversed with Habit Retraining in many cases (Rule out with NuTom nasal cavity images). • Nasal reflexes can be trained that open up most airways very quickly. These are part of our training program,

15. The Bad News: • Offices are reluctant because no one in their office can do it. • Patients are unlikely to ever go to an out-of-office referral for habit retraining. • Offices are unsure of how to market habit retraining. • Few have ever incorporated behavioral training, and need assistance for marketing, training and payment strategies.

16. SUMMARY: CURRENT BELIEFS ABOUT HABIT TRAINING FOR OFFICES: • There is a common belief that it is too complex for the average office.

17. THE PROCEDURES So how difficult is it?

18. Take the fear out of what to say.. ‘Neutralize staff fears first! EVERY STEP IS GUIDED BY A VIRTUAL INSTRUCTOR

19. Respiration and Oral Habits go together. How we break Oral Habits, using InnerSmilePro. (Next Slide)….

20. POLYGRAPH ASSESSMENT TAKES 15 Minutes ASSESSMENT-BASED EXERCISES TAKES 20 Minutes SIMPLE HOMEWORK EXERCISES Monitor Success at next visit INTERNET-SUPERVISED EXERCISES Schedule Home Sessions POLYGRAPH RE-ASSESSMENTS Re-Assess every 6 sessions

21. PART I: HOW TO FIND WHERE TO BEGIN TREATMENT: POLYGRAPH ASSESSMENT KEY: Take a computerized ‘snapshot’ of the mouth and breathing during mouth movements, breathing exercises, different postures and different swallows..

22. Sensor Placement takes about 3 minutes: Left Masseter Right Masseter Digastric (Tongue) Remember. Yellow is Tongue.. Respiration Belt Heart Rate- ECG Electrodes

23. The final result is a polygraph report of reactivity to standardized mouth, posture and breathing exercises. It looks like this (next slide)…..

24. THE RESP-ORAL HABITS ASSESSMENT PROFILE Quantifying the Functional Matrix . Left Masseter Right Masseter Digastric (Tongue) ORAL Respiration Heart Rate RESP Typical ‘Swallowing’ Profile

25. This Polygraph profile provides a wealth of information. Let’s begin with a look at one component, the DRY SWALLOW. Dry Swallows can be categorized into 6 different patterns, Like this (Next Slide)…..

26. SWALLOW TYPES

27. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • The Perfect Swallow • Masseter-Dominant • Tongue-Dominant • Incomplete / Double Swallows • Asymmetric Masseter Swallow • Swallow with poor timing. THE ORAL COMPONENT

28. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • The Perfect Swallow – which one? Left Masseter Right Masseter Digastric (Tongue)

29. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • Masseter-Dominant Left Masseter Right Masseter Digastric (Tongue)

30. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • Tongue-Dominant Left Masseter Right Masseter Digastric (Tongue)

31. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • Incomplete / Double Swallows Left Masseter Right Masseter Digastric (Tongue)

32. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • Asymmetric Masseter Swallow Left Masseter Right Masseter Digastric (Tongue)

33. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE? So what does the profile show? Here are a few examples: • Swallow Patterns: • Swallow with poor timing. Left Masseter Right Masseter Digastric (Tongue)

34. MICRO-ANALYSISOFSWALLOWDYNAMICS

35. The Swallow Pattern needs to be broken down into its components. Here is the swallow – slow and weak: But this is a DRY Swallow.. Timing is good: Masseters contract and release with tongue.

36. The Swallow Pattern needs to be broken down into its components. DRY Swallow.. Compare it to A Wet Swallow. Drink 4 oz of water…: Conclusion: WET or DRY – the muscle activity is still weak.

37. Conclusion: WET or DRY – the muscle activity is still weak. Compare it to Touching Teeth:: LEFT touches more strongly than right when the Tongue is silent. Take out the swallow and Masseters contract strongly With Asymmetry.

38. Compare it to Tongue Contraction Alone: REVERSAL: Tongue alone reverses the effect: Right touches more strongly than Left Conclusion: Tongue Movement alone is also WEAK.

39. PUT IT ALL TOGETHER AND WHAT DO YOU GET? TONGUE * TOUCH TEETH * SWALLOW * DRINK WEAK STRONG WEAK WEAK Right>Left Left>Right Right=Left Right>Left Conclusion: The weak swallow is due to poor tongue control. Swallow timing is good. Masseter asymmetry is reversed by a swallow or tongue movement. Bite stabilization is indicated – then retest.

40. RESPIRATIONand SWALLOWING What do you call the swallowing of air? When does swallowing stop?

41. THE RESPIRATION COMPONENT BREATHING COMPONENT ANALYSIS • BREATHING MUST STOP DURING SWALLOWING. • But where in the breath cycle does a patient stop? • STOP DURING INHALE? • This is bad. It can trigger AEROPHAGIA. • STOP DURING EXHALE? This is normal. • Take a look at the following slide (Next Slide)..

42. Breathing is in BLUE. TONGUE CONTRACTIONS are in YELLOW. Tongue Contraction On Exhale EXHALE So when does the breath stop to swallow? Here the breath stops during exhale or at the end of exhale. Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

43. Muscle Fatigue and Swallowing

44. Muscle Fatigue and Swallowing

45. Muscle Fatigue and Swallowing

46. Muscle Fatigue and Swallowing

47. LINKING SWALLOW to BREATHING

48. LINKING SWALLOW to BREATHING

49. LINKING SWALLOW to BREATHING

50. LINKING SWALLOW to Autonomic Balance Advanced Topic- for a full 4 hours. Hint: ECG patterns derive a signal which gauges sympathetic dominance. Sympathetic dominance is linked to the muscle spindle.