Dr. Tucker’s Self Help Guide to the Diagnosis & Treatment of Temporo-mandibular Disorders

1. Dr. Tucker’s Self Help Guide to the Diagnosis & Treatment of Temporo-mandibular Disorders Jeffrey Tucker, DC, DACRB 11600 Wilshire Blvd. #412 Los Angeles, CA 90025 310-473-2911 www.DrJeffreyTucker.Meta-ehealth.com

2. WHAT YOU CAN LEARN IN THIS SELF GUIDE: • To identify problems of craniomandibular function and appropriate self care. • To determine if your jaw muscles are overactive and learn a corrective exercise treatment. • To screen yourself for problems related to activity limitations with chewing, swallowing, speaking, respiration, and emotional expression. • Learn specific nutritional recommendations. www.DrJeffreyTucker.Meta-ehealth.com

3. DIAGNOSIS of Temporomandibular Disorders (TMD) TMD is a collective term for a broad range of disorders displaying a variety of signs – radiating pain in the face, neck, or shoulders; limited movement or locking of the jaw; painful clicking or grating when opening or closing the mouth; and a significant change in the way the upper and lower teeth fit together. Other common symptoms include headaches, earaches, dizziness, hearing problems, and difficulty swallowing. www.DrJeffreyTucker.Meta-ehealth.com

4. The Jaw Symptom Questionnaire consists of the following questions: • Does it hurt when you open wide to yawn? • Does it hurt when you chew or use the jaws? • Does it hurt when you’re not chewing or using the jaws? • Is your pain worse upon waking? • Do you have pain in front of the ear, or earaches? • Do you have jaw muscle or cheek pain? • Do you have pain in the temples? • Do you have pain or soreness in the teeth? • Do your jaws make noise so that it bothers you or others? • Do you find it difficult to open your mouth wide? • Does your jaw ever get stuck/lock as you open it? • Does your jaw ever lock open so that you cannot close it? • Is your bite uncomfortable? www.DrJeffreyTucker.Meta-ehealth.com

5. Jaw Symptom Questionnaire • In my experience if a patient answers more than three of the above questions they will benefit by education, an anti-inflammatory home care program including dietary changes, nutritional supplements, heat or ice applications, avoidance of mechanically stressful activities, and resting the jaw (practice the “lips apart and jaws relaxed” procedure). www.DrJeffreyTucker.Meta-ehealth.com

6. “Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache?” Your Dentist can evaluate if you have the following: • Disorders of the teeth Atypical Odontalgia Silent draining abscess • Oral lesions Carcinomas of the oral cavity • Vascular lesions (see specific nutrition recommendations next slide) Temporal arteritis Facial migraine www.DrJeffreyTucker.Meta-ehealth.com

7. General Nutrition for TM Disorders • EC Matrixx™is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix. • Chondro-Relief Intensive Care— 3-6 capsules daily with food. Joint & soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and ASU. • Inflavonoid Intensive Care— 3-9 tablets daily with meals. For relief of minor pain. • E-Complex 1:1— 2-4 softgels daily. 1:1 ratio of alpha and gamma tocopheryls. www.DrJeffreyTucker.Meta-ehealth.com

8. “Do I have a disorder of the mouth, face or Temporo- mandibular joints manifesting as neck pain or headache?” • Your Dentist can evaluate if you have the following: • Disorders of the teeth • Atypical Odontalgia • Silent draining abscess • Oral lesions • Carcinomas of the oral cavity • Vascular lesions (see specific nutrition recommendations next slide) • Temporal arteritis • Facial migraine www.DrJeffreyTucker.Meta-ehealth.com

9. Headache: Vascular / Migraine Nutrition • In conjunction with UltraInflamX • NOTE: in all forms of headaches, sensitivities to certain food or environmental factors can be a significant entity to address. If determined to be, add to the outlined protocols Perimine. www.DrJeffreyTucker.Meta-ehealth.com

10. Headache: Vascular / Migraine requires nutrition for Inflammation Management: Cleanse, Repair& Put Out the Fire • A natural strategy should attempt to support the production of substances in the body that protect tissue integrity and relieve pain and inflammation. This goal can be achieved by targeted nutritional support: • Key anti-inflammatory nutrients, such as: • Ginger to inhibit pro-inflammatory prostaglandin and leukotriene production • Turmeric to scavenge nitric oxide production and inhibit pro-inflammatory prostaglandin production • Quercetin to inhibit lipoxygenase, tumor necrosis factor alpha, and nitric oxide • Potent antioxidant nutrients, such as: • Mixed carotenoids, zinc, manganese, selenium, rutin, rosemary, and vitamins A, C & E to reduce free radical generation • GI-supportive nutrients, such as: • L-glutamine to protect the integrity of the gastrointestinal mucosa barrier • Vitamin B5 (along with zinc and quercetin) to promote GI healing • Rice bran fiber to promote the growth of beneficial GI bacteria; decrease betaglucuronidase, mucinase, and nitroreductase activities; and increase bile excretion • Eicosanoid-balancing nutrients, such as: • Magnesium, zinc, and vitamins C, B3 & B6 to support healthy essential fatty acid and eicosanoid metabolism • Citrus bioflavonoids, such as: • Hesperidin to inhibit arachidonic acid metabolism and histamine release, thus resulting in analgesic and anti-inflammatory activities • Detoxifying nutrients, such as: • N-acetylcysteine and sodium sulfate to promote sulfation in phase II detoxification activities (often compromised in inflammatory conditions) • Limonene to induce glutathione conjugation and glucuronidation • 2 scoops of UltraInflamX includes all of the above. www.DrJeffreyTucker.Meta-ehealth.com

11. Headache: Vascular / Migraine Nutrition • In conjunction with UltraInflamX • NOTE: in all forms of headaches, sensitivities to certain food or environmental factors can be a significant entity to address. If determined to be, add to the outlined protocols Perimine. www.DrJeffreyTucker.Meta-ehealth.com

12. Migraine Headache: Preventive Maintenance supplements • Trancor— 4 capsules daily. Helps balance between the calming influence of GABA and the excitatory effects of glutamate. • Somnolin— 4 capsules daily (2 in the AM and 2 in the PM). After headaches are under control for 4-6 weeks decrease by 1 pill per week until lowest dose is found that maintains the patient symptoms. Features a complementary blend of 5-HTP, theanine,and targeted B vitamins. • EPA-DHA Extra Strength— 2 softgels 2-3 times daily with meals. Essential fatty acids from cold water fish. Natural anti-inflammatory documented to benefit migraine sufferers. www.DrJeffreyTucker.Meta-ehealth.com

13. Migraine HeadacheAt Onset: • Trancor™ - 4 capsules daily.Trancor is formulated to support a sense of tranquility in those who may feel worried or nervous by beneficially modulating the balance between the calming influence of GABA and the excitatory effects of glutamate. www.DrJeffreyTucker.Meta-ehealth.com

14. “Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache?” Your Dentist or Chiropractor can evaluate you for the following: • Neurological lesions Atypical facial pain Typical trigeminal neuralgia Atypical trigeminal neuralgia Pre-trigeminal neuralgia Tic douloureux See specific nutritional recommendations next slide www.DrJeffreyTucker.Meta-ehealth.com

15. Specific nutritional recommendations:Atypical facial pain, Typical trigeminal neuralgia, Atypical trigeminal neuralgia, Pre-trigeminal neuralgia, Tic douloureux • Ceralin Forte®— Three capsules daily. Ceralin Forte is formulated to provide well-rounded support for brain and nerve protection, addressing multiple pathways involved in neurological health. • Wellness Essentials™ For Men/Women formula — 2 packets daily. Key Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition. www.DrJeffreyTucker.Meta-ehealth.com

16. “Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache?” Your Physician can evaluate you for the following: • Disorders of the eyes Eye strain Acute glaucoma • Disorders of the ears Ear pain (otalgia) (specific nutrition recommendation) www.DrJeffreyTucker.Meta-ehealth.com

17. Ear pain of unknown origin. General Treatment Strategies: • Assume problem has a dietary component until proven otherwise. • Eliminate all dairy products for at least three weeks. • Eliminate refined sugars and “junk food.” • Address food intolerance (begin with most simple and inexpensive). • eliminate foods that are on the “common offenders” list, or • perform elimination/provocation (E/P) testing • if E/P is unsuccessful you may wish to proceed to serum IgG, IgE or IgM—invasive and costly but very useful. • Eliminate trans fatty acids from diet. • Decrease omega-6 intake while increasing omega-3 intake. • Reduce intake of meat and eggs unless person is malnourished. • Address biomechanical problems with Chiropractor i.e. TM dysfunction. www.DrJeffreyTucker.Meta-ehealth.com

18. “Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as a disorder of the nose and throat?” • Chronic nasal airway obstruction (CNAO) or • Sinusitis - Signs and Symptoms • Tenderness to palpation, swelling, redness, and opaque trans-illumination of involved sinuses • Fever, chills: suggest expansion of the infection beyond the sinuses • Nasal congestion and serous or mucopurulent discharge (usually yellow or green) • Malaise • Headache and/or dizziness that changes with position and is worse lying down or bending over • History of upper respiratory infections, dental problems, nasal allergies, or injury to the area • Nasal mucosa is red and swollen, and the exudate may be seen in the turbinates corresponding to the infected sinus(es) www.DrJeffreyTucker.Meta-ehealth.com

19. SinusitisAcute Nutrition Management • Sinuplex - Features a unique, ephedra-free blend of vitamin C, quercetin, nettle root extract, bromelain, and N-acetylcysteine. Supports healthy sinus, nasal, lung, and respiratory function. May help support healthy eicosanoid synthesis. • Ingredients are carefully selected and manufactured with advanced processing technologies to preserve the potency and stability of delicate components such as bromelain. • NOTE: If patient has a history of antibiotic use, add UltraFlora Plusto the protocol. Advanced Probiotic Nutrition with Immunoglobulins www.DrJeffreyTucker.Meta-ehealth.com

20. Chronic Sinus Condition Management • Perimine— 1-2 tablets twice daily with food. Patented, Flavonoid-Rich Perilla Seed Extract. Perimine features a patented extract of Perilla seed (Perilla frutescens), a unique herb that supports a healthy immune response in individuals who may be sensitive to certain food or environment factors. Dried Perilla seed and leaves have both historical and modern applications in Traditional Chinese Medicine to alleviate chest fullness, support healthy mucus secretion, and promote healthy breathing. • Sinuplex— 2-4 tablets daily as needed. Healthy sinus and lung support. • Nazanol—1-2 tablets 2-3 times daily (based on severity of condition) on empty stomach. Natural, stimulant-free herbal support for healthy sinus, nasal and lung function. www.DrJeffreyTucker.Meta-ehealth.com

21. “Do I have a disorder of the cervical spine (neck) or headache manifesting as pain in the orofacial or TM apparatus area?” Ask your Doctor to rule out: • Vascular lesion Carotidynia Thomboangiitis obliterans (Buerger’s disease) • Neurological lesions Neck-tongue syndrome • Arthritic Disease RA, SLE, AS, Psoriatic arthritis (see nutritional recommendations) www.DrJeffreyTucker.Meta-ehealth.com

22. Core Nutritional Support Protocol for RA, SLE, AS, Psoriatic arthritis • UltraInflamX® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to address underlying inflammation. • Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet • LactoFlamX™ — 1 capsule dailyLactoFlamX features L. plantarum 299V — a strain-identified probiotic that has been specifically shown to support the integrity and healthy function of the muscosal lining. • EPA-DHA 6:1™ Enteric Coated— 2 softgels three times daily. EPA-DHA 6:1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions. • Iso D3™— 1 tablet three times daily. Vitamin D3 with Isoflavones. Iso D3 is designed to support optimal metabolism of vitamin D to its active form. If there is a soy sensitivity use: • D3 1000™— 2 microtablets three times daily. High potency vitamin D3 — the most bioactive form of supplemental vitamin D. www.DrJeffreyTucker.Meta-ehealth.com

23. “I have been diagnosed with aTemporal muscle tendinitis” • Perform corrective exercise stretches in this presentation. • Nutrition: EC Matrixx™ is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix. www.DrJeffreyTucker.Meta-ehealth.com

24. SELF TEST: MANDIBULAR FUNCTION MOVEMENT PATTERN • Seated or standing in front of a mirror. • Slowly open & close mandible. • Qualification: Pass/fail You fail if your mandible (lower jaw) protrudes on initial phase of opening. Follow the exercises in this presentation. www.DrJeffreyTucker.Meta-ehealth.com

25. Normal Opening                                               Three fingers width                       www.DrJeffreyTucker.Meta-ehealth.com

26. www.DrJeffreyTucker.Meta-ehealth.com

27. General Signs & Symptoms of TMD • Pain on opening • Trismus (limitation of mouth opening) or deviated jaw mobility • Joint noises (clicking, popping, grinding) • Pain on chewing • Tenderness or pain felt in the jaw joint or muscles, or both • Pain felt in the area of the ear, temples, or cheeks • General Signs & Symptoms of TMD, con’t • Ear “fullness” • Subjective hearing loss • Change in occlusion • Abnormal wear of the teeth • Headache (most common presentation are frontotemporal & suboccipital) • Muscle hypertonicity • Hypertrophy of the jaw muscles • Tinnitis • Dizziness • Neck pain • Upper trapezial pain • Upper extremity pain & paresthesia • Difficulty swallowing Steigerwald, D.P., Whiplash and Temporomandibular Disorders: An Interdisiplinary Approach to Case Management. Keiser Publishing, San Diego, CA., 1992 www.DrJeffreyTucker.Meta-ehealth.com

28. www.DrJeffreyTucker.Meta-ehealth.com

29. Major Categories of TMDS • Muscle Disorders (treat with corrective exercises & nutrition) Muscle pain Protective muscle splinting (trismus, bracing, guarding) Myospasm Myositis Myofascial pain (trigger point activity) Contracture Hypertrophy Dyskinesia (muscle incoordination) Dstonia Bruxism These disorders are treated by a Rehabilitation Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms. www.DrJeffreyTucker.Meta-ehealth.com

30. Nutrition for Muscle Disorders • EC Matrixx™is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix • Muscle Spasm Remedy is a high quality, handmade homeopathic remedy designed to relieve muscle aches, spasms, or pain. • Chondro Relief Intensive Care— 3-6 capsules daily with meals. Comprehensive joint & soft tissue support, with MSM, Green Lipped Mussel, Hyaluronic Acid, and ASU. • E-Complex 1:1— 1 softgel 2 times daily with food. E Complex-1:1 is a unique, natural vitamin E supplement that features a 1:1 ratio of alpha- to gamma-tocopherol; this ratio more closely resembles the tocopherol profile found naturally in vitamin E-rich plants. • Avoid caffeine, menthols. • Dietary Suggestions: Anti-Inflammatory Diet www.DrJeffreyTucker.Meta-ehealth.com

31. Major Categories of TMDS • Ask your Doctor which Temporomandibular joint disorders do you have: • Disc displacement or internal derangement • Arthralgia • Capsulitis or synovitis • Arthritis disease (systemic) • Degenerative disease (osteoarthritis) • Traumatic articular disease (sprain or strain, fracture) • Disc displacement without reduction (closed lock) • Disc displacement with reduction • Subluxation of the condyle • Dislocation of the condyle These disorders are treated by a Rehabilitation Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms. www.DrJeffreyTucker.Meta-ehealth.com

32. General Nutrition for TM Disorders • EC Matrixx™is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix. • Chondro-Relief Intensive Care— 3-6 capsules daily with food. Joint & soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and ASU. • Inflavonoid Intensive Care— 3-9 tablets daily with meals. For relief of minor pain. • E-Complex 1:1— 2-4 softgels daily. 1:1 ratio of alpha and gamma tocopheryls. www.DrJeffreyTucker.Meta-ehealth.com

33. Major Categories of TMDS:Inflammatory disorders Continuous pain that is increased with function Core Nutritional Support Protocol • UltraInflamX® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to address underlying inflammation. • Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet • Kaprex®— 2 tablets twice daily. Non-responders by day 5 move to 3 tablets 2-3 times daily. Time to benefit: Immediate to 10 days. Kaprex is a clinically tested herbal dietary supplement that provides natural joint relief that is easy on the gastrointestinal (GI) tract. It works by interfering with signals in the body that initiate the production of damaging compounds that cause minor pain and negatively impact cartilage and other joint tissues • EPA-DHA 6:1™ Enteric Coated— 2 softgels three times daily. EPA-DHA 6:1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions. • Iso D3™— 1 tablet three times daily. Vitamin D3 with Isoflavones. Iso D3 is designed to support optimal metabolism of vitamin D to its active form. • If there is a soy sensitivity use: • D3 1000™— 2 microtablets three times daily. High potency vitamin D3 — the most bioactive form of supplemental vitamin D. www.DrJeffreyTucker.Meta-ehealth.com

34. Anti-Inflammatory Diet www.DrJeffreyTucker.Meta-ehealth.com

35. Major Categories of TMDS • Disorders of mandibular mobility (hyper- or hypo-mobility) Hypermobility Adhesion Ankylosis Coronoid process elongation Fibrosis of muscle (contracture) These disorders are treated by a Rehabilitation Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms. www.DrJeffreyTucker.Meta-ehealth.com

36. Major Categories of TMDS • Growth disorders Hypoplasias Hyperplasias Neoplasias These conditions require co-management of multiple doctors. www.DrJeffreyTucker.Meta-ehealth.com

37. OROFACIAL DISORDERSFUNCTIONAL ANATOMY Primary Functions of the Masticatory System: • Mastication • Swallowing • Speech Secondary Functions: • Respiration • Emotional expression www.DrJeffreyTucker.Meta-ehealth.com

38. MANDIBULAR POSTURAL REST POSITION (MPRP) The normal MPRP is in equilibrium between the downward pull of gravity and the myotatic reflex contraction of the mandibular elevators. MPRP depends on muscle tonus of the anterior and posterior cervical muscles, head posture, and the inherent elasticity of muscles. www.DrJeffreyTucker.Meta-ehealth.com

39. MANDIBULAR POSTURAL REST POSITION (MPRP) • Normally there is no occlusal (tooth-to-tooth) contact during MPRP. This interoccclusal space is termed freeway space and is usually 3-5 mm when measured from MPRP to full occlusal contact. This dimension is increased in mouth breathers and is decreased in people who brux or clench. • Significance of MPRP is that, under normal conditions, it is a time for rest and repair of the TMJ system. • Head posture is probably the single most important factor governing MPRP. A Chiropractor is the most skilled practitioner to evaluate your head posture. www.DrJeffreyTucker.Meta-ehealth.com

40. MANDIBULAR POSTURAL REST POSITION (MPRP) • Significance of MPRP is that, under normal conditions, it is a time for rest and repair of the TMJ system. www.DrJeffreyTucker.Meta-ehealth.com

41. MUSCLES OF MASTICATION • Elevators (jaw closing) of the mandible: (these are commonly overactive) • Masseter • Medial pterygoid • Temporalis muscles www.DrJeffreyTucker.Meta-ehealth.com

42. MUSCLES OF MASTICATION • The posterior fibers of the temporalis can retract the mandible and maintain the condyles posteriorly. The superficial fibers of the masseter protrude the jaw. The deep fibers act as a retruder. The medial pterygoid can protrude and lateral deviate it to the opposite side. www.DrJeffreyTucker.Meta-ehealth.com

43. MUSCLES OF MASTICATION • Depressors (jaw opening) of the mandible: Digastrics • Protrusion (jaw jutting forward) of the mandible: Inferior lateral pterygoid www.DrJeffreyTucker.Meta-ehealth.com

44. MASSETER MUSCLE • Actions: Elevate the mandible and close the jaw. Deep fibers also retrude the mandible. • Synergist: Temporalis, medial pterygoid • Antagonist: Digastric, inferior lateral pterygoid • It is frequently overactive and can become tight. www.DrJeffreyTucker.Meta-ehealth.com

45. Masseter muscle nutrition • Fibroplex® Plus provides targeted nutritional support for soft tissues in those with muscle tenderness and discomfort. Featuring a blend of specific vitamins, minerals, and amino acids in an easy-to-use delivery form, this specialized formula works by supporting cellular energy production and muscular and nervous system function. • Provides targeted nutrition for soft tissue in those with muscle tenderness and discomfort. • Provides targeted support for energy metabolism and neuromuscular function. • Supports cellular energy production and mitochondrial function. • Provides magnesium in the form of an amino acid chelate designed to be easily absorbed www.DrJeffreyTucker.Meta-ehealth.com

46. Tinnitis caused by the Masseter Muscle • Unilateral tinnitus may be associated with trigger points in the upper posterior portion of the deep layer of the masseter muscle. Unilateral tinnitus also may arise from TMJ intracapsular disease. If the tinnitus is bilateral, one should suspect a systemic, rather than a myofascial cause (Travell). • Vitamin-deficiency of niacinamide and thiamine may be related to tinnitus. (see next slide for nutrition) www.DrJeffreyTucker.Meta-ehealth.com

47. Tinnitis: Nutrition • Appropriate Wellness Essentials™formula — 1-2 packets daily. Key Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition. • CoQ10 ST 100— 1 softgel three times daily. Stabilized, Highly Absorbable Coenzyme Q10 with Natural Vitamin E. According to a German study published in Otolaryngol Head Neck Surg. 2007 Jan; 136(1):72-7, “For a Subgroup of people CoQ10 may provide relief from the symptoms of tinnitus.” The test group was administered 100mg. of CoQ10 three times daily for 12 weeks. • If a history of antibiotic use: • Ultra Flora IB— 1 capsule daily with food. (minimum of 2 bottles). Ultra Flora IB is an enhanced potency probiotic formula designed to help relieve bowel irritation and related functional discomforts by promoting a healthy balance of intestinal microflora. • If on prescription diuretics: • MG/K Aspartate— 2 tablets daily with food. Magnesium and Potassium combination designed to optimally replace lost potassium levels. www.DrJeffreyTucker.Meta-ehealth.com

48. MASSETER MUSCLE Exercise 1) Passive Mandibular Self-stretch 2) Three-step resistive exercise: 1. resistance held for 10 sec as the patient actively, gently tries to close the mouth while it is held wide open. 1a. Relax. 2. patient tries to open the mouth as wide as possible with gentle assistance from the hand, slightly increasing the range of motion. 3. active opening effort of the patient is resisted by the hand. Repeat 3X. The patient then opens and closes the mouth through the maximal active range of motion several times without resistance. www.DrJeffreyTucker.Meta-ehealth.com

49. TEMPORALIS MUSCLE • Actions: Elevation (closure) of the mandible. The posterior fibers, in addition, are important for retrusion and lateral deviation of the mandible to the same side. • Synergists: ipsilateral: masseter, superior lateral pterygoid, medial pterygoid. contralaterally: same plus temporalis. • Antagonist: inferior lateral pterygoid, anterior digastric, omohyoid, mylohyoid. www.DrJeffreyTucker.Meta-ehealth.com

50. TEMPORALIS MUSCLE • Trigger points may be activated: by bruxism & clenching; direct trauma i.e. fall on the head, impact from a ball, auto accident; prolonged jaw immobilization; cervical traction; excessive gum chewing. • Self Treatment: Massage the muscle and rub out the tender points found. www.DrJeffreyTucker.Meta-ehealth.com