TMD/MIGRAINE THERAPIES SEMINAR

1. TMD/MIGRAINE THERAPIES SEMINAR

2. INTRODUCTION • Approximately 37% of people in the USA have symptoms of TMD • Most of them are women. 15% of these people have Migraines. • In patients that have TMD, tension headaches and/or Migraines, we are seeing more people in their mid 30’s and older that are having these conditions. The lifetime of a compromised stressed occlusion and muscle/joint systems will accelerate the wear and tear of the teeth and the temporomandibular joints.

3. Dr. Terry Tanaka in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition • Dr. Tanaka was truly a doctor ahead of his time in understanding TMD and it’s treatment. He said: “You can describe a TMD patient as simply a fellow human in need of help. Anxiety is present in varying degrees, depending upon the degree of pain and/or degree of reinforcement by their companions and friends. The patient may already be envisioning the catastrophe of some type of disease, or may even have a contributing depressive condition”.

4. Dr. Terry Tanaka in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition • “Patients want to be listened to and understood. It sounds simple, but only the very best of doctors ever fully attain that goal in treating these patients. Patients expect professional competence. They expect you to be a scholar and knowledgeable about all the recent innovations in your field of study. Patients want to be kept informed. Patients want not to be abandoned. When there is no one else to refer to, and the patient is on the verge of addiction to pain medication, the caring role of the doctor becomes larger than the curing role.

5. Dr. Terry Tanaka in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition • The multifaceted nature of these TMD pain disorders may require multiple therapies from different disciplines, such as physical therapy, behavioral therapy and splint therapy to successfully resolve the pain”. (Dr. Tanaka made these statements over 20 years ago) (Dr. Terry Tanaka, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition. Clinical Professor, Graduate Prosthodontics. Formerly Director, Facial Pain Clinic University of Southern California School of Dentistry).

6. The head and face are the focus of much human activity • The face is the main vehicle for communication, both through words and facial expression, for perception, for taking sustenance and air, for love and play. And as such, it becomes the world’s window into our innermost being. The head is crowded with complex structures reflecting its many functions, while the neck contains many delicate structures needed for support and precise orienting of the head, as well as communication between the brain and the body. It should not surprise us that this complexity of function should be mirrored in a common and highly varied series of complaints, some rooted in organic disease, some rooted in the preoccupation of the human mind, some rooted firmly in both.

7. The head and face are the focus of much human activity • These complaints most commonly express themselves as pain of the head, neck and temporomandibular joint, and the intricacy of the underlying anatomy and psychology demands an intelligent and cooperative approach from many of the health sciences.

8. Charles McNeill DDS, Loma Linda Dental School, in his seminar: “Demystifying TMD” • Dr. McNeill said:“Old ideas and concepts about treating TMD, head and neck pain and Migraines do not always hold up. Old ideas can be difficult to change, even though more knowledge has and is becoming available and more specific management of joint symptoms and muscle disorders are becoming better understood. Years ago splints and adjusting the bite were all we were taught and those ideas do not necessarily work for many patients, because muscle and joint disorders that have been developing over one or more decades in these patients can become a large contributing factor in the diagnosis, management and improvement in the patient’s progress”.

9. Neuromuscular Patterns • We need to know and understand how neuromuscular patterns affect these conditions and their relationships to the head, neck, joints, loss of range of motion, clenching and bruxing, and even headaches, Migraines, occlusal wear patterns, tinnitus, etc. We also need to know and understand why these symptoms become more noticeable and pronounced in the 4th and 5th decade of their lives.

10. Neuromuscular Patterns • These questions come up. Does traumatic/stressed occlusion contribute to these symptoms and problems or do these symptoms and problems cause traumatic/stressed occlusion? Which is a bigger factor? Also, does clenching and grinding contribute to the cause of these symptoms and problems or is it a result of these symptoms and problems? • Many factors may cause questions to arise in our diagnosis. What contributing factors might we consider? For example, we might have etiological factors, trauma, hormonal, behavioral, overmedications, stress and anxiety response, chemical (brain chemistry changes), bad habits, poor diet, sleeping posture/patterns, poor body posture positions during the day, etc.

11. We also need to consider the following: • 1.  Lack of universally accepted criteria in our exam and diagnosis. • 2.  Lack of knowledge regarding quite disparate TMD symptoms. • 3.  Etiologic factors and their contribution to TMD and headaches. • 4.  Occlusal factors. Are they a cause or an effect of TMD? (The latest clinical data shows that many times occlusal factors are a result of long standing muscular patterns that result in clenching/grinding and in occlusal wear patterns that ultimately increase the strain and stresses in the muscle joint systems and neuromuscular patterns). • 5.  If there is an occlusal imbalance, when and how did it develop and how might it be addressed?

12. We also need to consider the following: • 6.  What sort of muscle and joint problems could be involved and how could they be treated? • 7. What might be the correct strategy and timing of various treatment protocols? • 8.  When and should we use medications? • 9. Are there alternative ways to treat patients without medications? • 10. When should we use a splint? How should we use a splint? • 11. When, why and how should we assess, address and correct contributing occlusal factors? • 12. What might be some accepted and often FDA approved alternative therapy modalities that could be used?

13. We also need to consider the following: • 13. Is clenching/bruxism a condition that can be corrected….and if so, how can we accomplish that? How does the clenching habit develop? • 14. Is it possible to reestablish healthy muscle/joint/TMJ and occlusal relationships and maintain them? If so, how could that be accomplished? • 15. Can overmedicated patients with brain chemistry problems from Migraines and Migraine like headaches (long standing tension headaches) be improved…..and if so how?

14. We also need to consider the following: • 16. Are these patients typically chronic types? And if so, what kind of maintenance program could be used after their condition has improved? • 17. Why do many patients with TMD have difficulty moving comfortably into chewing excursions? Why are some of these patients not even able to negotiate chewing excursions? • 18. Can we promote healthy excursion movements…and if so, how?

15. Every one talks about TMD, but not many dentists treat it • Dr. Christensen says that general dentists should be treating these patients on a regular basis (Dr. Christensen said in Dentistry Today Feb 2000) • Since dentists see their patients regularly for their oral maintenance visits, would it not make sense that the dentist and hygienist would be sure to evaluate them for any of these symptoms at least once a year. Understanding the contribution that muscles and joints contribute to TMD and headache conditions helps us to realize the need for including them in a possible care process. (Dr. Christensen said in Dentistry Today Feb 2000)

16. Every one talks about TMD, but not many dentists treat it • Because of the complex dynamic multifaceted nature and relationship between head and neck posture, jaw position, headache and head and neck related discomfort and stressed dental occlusion, resulting in the ultimate disturbance that may be seen in TMJ dysfunction, would it not make sense to provide a multidisciplinary and appropriate treatment protocol sequence. • Abfraction, associated by many dentists and researchers with occlusal stresses placed on teeth is well known. For years, dentists thought the mysterious occurrence of deep slots on the facial of teeth were caused by toothbrush abrasion. Current concepts support the belief that these may be caused by traumatic occlusal forces. We also see these worn areas on other teeth as well. (Dr. Christensen said in Dentistry Today Feb 2000)

17. What’s In A Bite? • By Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain • An unstable occlusion at 20 will tear up the joints in the female by age 40. As the joints age the back teeth take more force. Many patients have different dental materials that wear at different rates and can be hard on an occlusion. A dysfunctional relationship begins when any anatomical structure ages at an accelerated rate as compared to the individual’s ability to adapt, remodel or repair the structure. Occlusal force that interferes with either a braced centric closure or eccentric jaw movements alters the lateral pole position of the condyles. Some individuals will be able to physiologically adapt over a lifetime, but most do not.

18. What’s In A Bite? • The third decade of life uncovers the sometimes-subtle periodontal changes of a stressed occlusion. There is a strong relationship between the periodontal ligaments that support the teeth and the posterior lateral ligament of the T.M. meniscus. A stressed occlusion has the teeth and the muscles trapped between the joint and teeth ligaments. This is usually the decade of the popping jaw joints, abfractions, periodontal pockets, cracked and/or broken tooth syndrome and muscle tension headaches. If ligaments fail to function or are stressed, stretched or torn, then the muscle must adapt and help the ligaments hold the jaw and teeth tight. Muscles cannot contract for long periods of time without fatigue.

19. What’s In A Bite? • Ligaments, muscles, teeth and periodontal health must all work in harmony to prevent an occlusion from prematurely aging. As the joint ages, the patient will lose ability to hold centric in all functional positions. Even though many people adapt and live with this condition for years with no trouble, under excess stress it can, and many times does lead to muscle triggers, ligament pain and more pathology within the joint. (Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

20. The million dollar question is • “What process is doing the guiding?” The answer to this question is the best-kept secret in dentistry because it can change over time. The answer is:All the anatomy together is the process responsible for a functional occlusion. Dysfunction begins when form and function are not in harmony and the anatomy must work against itself”. (Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain) • The analogy that I like to use with our patients to describe how the posterior teeth should fit together is similar to closing a perfectly balanced door.

21. The million dollar question is • When the mandible closes, the two healthy T.M. joints (the hinges) rotate the lower posterior teeth (the door) to stop and fit perfectly into the upper posterior teeth (the frame). In this position, all the posterior teeth should stop with equal simultaneous contact in one single plane. A perfect true closure with up to 32 teeth coming into equal stops at exactly one plane favors theory more than reality. A lot of puzzle pieces have to fit perfectly in order for any system to function clean every time. If a door closes poorly, drags on the floor, or wedges into the frame before closure, the system is in poor function. The door is able to close but the space between the door and the doorframe is not symmetrical. (Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

22. The million dollar question is • The question now becomes, “Is it the door, the hinges, the door frame or all three that are out of alignment?” Healthy condyles in a good braced centric position are similar to tight door hinges. Pathologic T.M. joints promote poor anterior guidance and eventually the door and the doorframe continue to force each other out of alignment. It is important that the first occlusal contact be one of stability, occurring simultaneously on as many teeth as possible. This can only happen when the teeth surfaces are in harmony with the dictates of the correctly seated condyles. (Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

23. Dr. Peter Dawson explains in a similar way in his textbook, “Evaluation, Diagnosis, and Treatment of Occlusal Problems” • “The occlusal contours of all the posterior teeth are dictated by both condylar guidance and anterior guidance. No posterior tooth should interfere with either anterior guidance or condylar guidance. Posterior teeth may either be discluded from any lateral contact by the anterior teeth, or they must be in perfect harmonious group function with them and the condyles.”

24. Studies have shown • That at age 18 the occlusal pattern is totally set and now you can predict how an occlusion will age and which teeth are taking all the force. Understanding how the occlusion ages and the status of the current function is the initial step to a successful and predictable treatment plan. The occlusion ages as the patient develops unhealthy wear patterns, such as chewing more on one side, and when different restorations (amalgams, composites, porcelain, gold, etc.) are gradually introduced into the patient’s mouth. Each restoration wears differently and the opposing teeth also wear differently. As the occlusion becomes more and more unstable it creates dysfunctional muscle positioning as the muscles try to adapt to the occlusal changes.

25. Studies have shown • Ultimately the TMJ condylar positioning becomes compromised. In many cases, these patients may begin to develop symptoms of TMD, such as headaches, Migraines, tinnitus and other muscle and joint problems of the head and neck.

26. What other components may be involved? • For example: Airway anatomy, muscle anatomy, teeth anatomy, condyle anatomy, periodontal anatomy and head posture anatomy patterns all have an effect on the overall function of the occlusion. The sensory input from the teeth is directly related to the motor output of the cranium. • Slides courtesy of Dr. Robert Supple “Digital Occlusion/Habitual Patterns” research article • The anatomical components (1. Airway 2. Trapezius Attachment 3. Occlusion & Periodontal 4. Lateral Pole of Condyle) from growth set the framework for the force distribution we see in digital occlusion. Asymmetric anatomy at a young age will, over time, stress the anatomical systems to adapt or fail by altering the muscles, TM joints, teeth and foundation that supports the teeth. (Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain) • Dr. Janet Travell[i], the master of muscle physiology and trigger points, taught that T.M. disorders have a cervical neck trigger. Poor posture pulls the mandible off center and elevates Cranio pain disorders. (Posterior HFP’s (Habitual Force Patterns**) all have elevated neck triggers.) Travell J. Simons D. Myofascial pain and dysfunciton the trigger point manual. Lippincott williams & wilkins. 1999 Volume 1: 279 • **The HFP starts young and the adult pattern is complete at about 15 years old. Some additional growth may alter the force signature, but not by much. Most 8 year olds have a straight center horizontal pattern. By age 12, the child has picked a side, usually to the side that the airway is limited. Digital signatures (HFP) relate to the anatomy. For example: Airway anatomy, muscle anatomy, teeth anatomy, condyle anatomy, periodontal anatomy and head posture anatomy patterns, all have an effect on the overall function of the occlusion. The sensory input from the teeth is directly related to the motor output of the cranium. Habitual anatomical patterns like wear facets, muscle pain, abfractions or periodontal pockets, are diagnostic clues for the dentist.

27. What other components may be involved? • The anatomical components (1. Airway 2. Trapezius Attachment 3. Occlusion & Periodontal 4. Lateral Pole of Condyle) from growth set the framework for the force distribution we see in digital occlusion. Asymmetric anatomy at a young age will, over time, stress the anatomical systems to adapt or fail by altering the muscles, TM joints, teeth and foundation that supports the teeth. (Robert Supple DMD. Dr. Supple graduated from Tufts Dental in 1980. He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

28. What other components may be involved? • Dr. Janet Travell, the master of muscle physiology and trigger points, taught that T.M. disorders have a cervical neck trigger. Poor posture pulls the mandible off center and elevates Cranio pain disorders. (Posterior HFP’s (Habitual Force Patterns**) all have elevated neck triggers.) See Slide #30. Travell J. Simons D. Myofascial pain and dysfunciton the trigger point manual. Lippincott williams & wilkins. 1999 Volume 1: 279

29. What other components may be involved? • **The HFP (Habitual Force Patterns) starts young and the adult pattern is complete at about 15 years old. Some additional growth may alter the force signature, but not by much. Most 8 year olds have a straight center horizontal pattern. By age 12, the child has picked a side, usually to the side that the airway is limited. Digital signatures (HFP) relate to the anatomy. For example: Airway anatomy, muscle anatomy, teeth anatomy, condyle anatomy, periodontal anatomy and head posture anatomy patterns, all have an effect on the overall function of the occlusion. The sensory input from the teeth is directly related to the motor output of the cranium. Habitual anatomical patterns, like wear facets, muscle pain, abfractions or periodontal pockets, are diagnostic clues for the dentist.

30. Tscan Digital Imaging Tscan Digital Imaging was used in 7a picture below. • See slide #32 and #50 for more Tscan details. • Slides courtesy of Dr. Robert Supple “Digital Occlusion/Habitual Patterns” research article • The most common trigger in the human body, according to Dr. Janet Travell (7b picture) • All force patterns that are located in the posterior quadrant will have a trapezius trigger on that side! Excessive force over time (functional and dysfunctional) cracks teeth as demonstrated as in the next slides.

31. Tscan Digital Imaging • The Trapezius trigger is diagnostic to a forward head posture and the position of the cranium is directed by the patterns like sleeping, eating, driving, working etc. The trigger is easy to check in a dental chair because the cranium is supported on a headrest. As the patient is lying down the muscle attachment is in a perfect position to palpate. All force patterns that are located in the posterior quadrant will have a trapezius trigger on that side! Excessive force over time (functional and dysfunctional) cracks teeth as demonstrated below.

32. Tscan Digital Imaging Continued • The HFP is heavy and wide left, altering the envelope of function. Extra Force of ML #19 & DL #18 (Red Lines). Fractured distal/lingual cusp on #19. The distal/lingual cusp will be the next cusp to fracture. Slides courtesy of Dr. Robert Supple “Digital Occlusion/Habitual Patterns” Fractured distal/lingual cusp on #19, the Distal Lingual of # 18 will be the next cusp to fracture

33. Tscan Digital Imaging • The most powerful diagnostic information about digital occlusion is the ability to predict future stress on the occlusion. The patterns are present a decade ahead of most occlusion related disorders, like fractured teeth, chronic muscle trigger and condyle ligament pathology. • Facial and neck muscles, which undergo prolonged or sustained contraction without adequate periods of rest, can develop pain, fibrous adhesions and scar tissue within the actual muscles themselves. The muscles can also develop trigger point areas within the muscles themselves. These trigger points can actually refer pain to other areas in and around the Temporomandibular joint and the brain as well.

34. Para functional habits • Para functional habits such as clenching and bruxism have been commonly implicated as part of the problem of a TMD condition. Many times it is a neuromuscular response to the occlusion becoming dysfunctional and traumatic. Clenching and other parafunctional habits can not only cause wear facets of the enamel/dentin, but also put a load on the muscles and can adversely load the TM joint, making the overall TMD condition worse. • There also may be other contributing factors that can initiate and even contribute to the symptoms. Common contributing factors are whiplash, high stress levels and anxiety, poor posture (as found in computer programmers), poor sleeping positions and habits and so on.

35. Dr. Peter Dawson said: • Dr. Peter Dawson said: That when the anatomy is forced to work against itself under function, over time, the system must adapt. Ligaments, facets and abfractions appear, muscles develop trigger points and the periodontal system is stressed. (Functional Occlusion: From TMJ to Smile Design by Peter Dawson, DDS 2006)

36. How important is occlusion? • It is important that the first occlusal contact be one of stability, occurring simultaneously on as many teeth as possible. Squeezing the teeth after contact should not produce any apparent sliding of the mandible in order to affect a complete closure, and this can only happen when the teeth surfaces are in harmony with the dictates of the correctly seated condyles. • Dr. Gordon says: “Many dentists are afraid of occlusion….there is extreme controversy about what concept of occlusion is correct, and I do not see any relief to that controversy. Occlusion is a discipline that you learn overtime and should never stop learning during your entire career.” • (Dr. Gordon says in Dentistry Today, February 2004)

37. How important is occlusion? • Dr. Gordon also said in JADA, Vol. 132, January 2001 that dentistry today is involved with mostly three major diseases or conditions: Dental caries, periodontal disease and occlusal conditions. Dental caries and broken teeth and periodontal disease are what most people associate with dental care. He asks: Are there many people who have occlusal disease or conditions? He answers: With our aging population there are more challenges in occlusion and TMD problems than used to be the case. Excessive tooth grinding and clenching is the most prevalent and destructive occlusal condition. Excessive tooth grinding can eliminate canine and incisal guidance in the dentition.

38. How important is occlusion? • If conditions like these are not treated, not only do we see excessive dentition wear, but increase of TMD symptoms, broken restorations and teeth, and periodontal disease. On a routine basis, almost every dentist inadvertently causes occlusal trauma in these patients when placing restorations in their teeth. In Dentistry Today 2000 Dr. Gordon asks an interesting question: How does an occlusion age? Or a better question is: Is your patient’s occlusion aging at a faster rate than the patient’s age? (Dr. Gordon says in JADA, Vol. 132, January 2001)

39. What is pain? • Pain may be real or imagined. It is usually a warning that something is wrong. It is important to understand that all pain is real to the patient, even though the physical cause may not be immediately evident to all examiners. When your TMD patients hurt, they suffer, and when they suffer, this suffering can be expressed through certain behaviors. It becomes imperative that the clinician recognizes and treats the cause of the pain, as well as recognizes the pain behavior. In addition, the health professional must be able to differentiate between the site of the pain and the source of the pain. • In the case of pain disorders of the head and neck and temporomandibular joint, most of the patients may have been misdiagnosed by different types of professionals, and therefore mistreated. The resolution of these pain disorders may have been compounded and complicated by the long-term use of tranquilizers, antidepressant medications and narcotics.

40. What is pain? • Another major reason for the inadequate management of these patients has been the improper application of the knowledge that we have available. The reasons for this include the lack of cohesive and organized teaching of medical and dental students, physicians, dentists, and other health professionals in the management of patients with these disorders, and the progressive trend toward specialization. This fragmented, specialized approach is conducive to viewing pain problems in a very narrow scope. Unfortunately, we tend to see only that which we are trained to see. • Acute pain disorders can be readily diagnosed and can readily respond to treatment. When the pain becomes chronic, however, psychological and neurological factors begin to affect the pain response and the patient may exhibit a pain behavior seemingly unrelated to the cause of the pain.

41. What is pain? • This pain behavior requires careful evaluation, consideration and understanding to be successfully managed. The unwillingness of some practitioners to consider this psychological and neurological component can lead to the incomplete resolution of the pain disorder. It is therefore important to recognize and understand the many components that make up the pain formula.

42. Importance of a comprehensive diagnosis • A comprehensive and accurate diagnosis upon which a definitive treatment plan formulated must be the basis for the successful management of pain disorders. • In our office we have found that some of the most common symptoms of TMD that patients may have are ringing in the ears, also head, neck and shoulder pain, tension headaches and/or Migraines. Rebound Headaches are also getting very common, because the longer a person stays on Headache and Migraine medications, the worse the Headaches and Migraines become and the stronger the medications needed, and eventually the medications stop working as well. Most headaches are caused by tenderness of the muscles and joints of the head and neck and clenching and grinding, as well as referral pain coming from the TMJ and from muscle trigger zones. Migraines usually also have a dysfunctional brain chemistry component.

43. Here is a list of information that we may need to know 1. A detailed analysis of their symptoms 2. How long has their problem been in development 3. Causative factors, such as whiplash, etc 4. Has their jaw ever locked out, how often has that occurred and did they have to go to the hospital to have it reset 5. Their age 6. Description of their headaches, and are they classic Migraines or Migraine like (a long standing tension headache can simulate a Migraine, but without the Aura) 7. What treatments they have had for their condition and how successful they were 8. What types of doctors have they seen 9. A careful range of motion analysis of neck, shoulders and oral movements, such as opening and closing and side to side movements.

44. Here is a list of information that we may need to know 10. What sort of response do they have to stress 11. Have they had orthodontics 12. What medications are they on 13. Has a neurologist treated them 14. Which is more important, getting better or how much the insurance will pay. (I really do not need to ask this question, it almost always comes up) 15. Does the prospective patient try to control the conversation I do not make appointments with every patient. The telephone interview, when done properly, will help me determine which ones I really do not want to treat and which ones that I can help. This brief interview actually saves me a lot of time. I get very few broken appointments, because I have already developed a relationship with this person and gained their confidence. • Remember, Dr. Terry Tanaka, in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition, said: “Patients want to be listened to and understood. It sounds simple, but not all doctors ever fully attain that goal in treating these patients. Patients expect professional competence. They expect you to be a scholar and knowledgeable about all the recent innovations in your field of study. Patients want to be kept informed. Patients want not to be abandoned. When there is no one else to refer to, and the patient is on the verge of addiction to pain medication, the caring role of the doctor becomes larger than the curing role”. • Therapy Equipment I, and my staff therapist apply a comprehensive in office treatment service, which may include the following: (not necessarily in the order listed) • Ultrasound: FDA approved and clinically proven. As muscles become stressed and inflamed, fibrous adhesions and scar tissue form. The longer the muscles stay in this condition, the more the potential for developing trigger zones in these muscles. These trigger zones send referred pain to other areas, including the brain. The Ultrasound gradually helps to heal these areas.

45. Range of Motion Points of Interest 1. What does a range of motion analysis tell us? 2. Why is it important to do one? 3. How do we accomplish this exam? 4. How do we interpret the findings? 5. What are some of the causes of decreased range of motion? 6. Why is it necessary to establish healthy range of motion early in treatment? 7. What happens to a muscle to make it lose range of motion? 8. How can decreased range of motion affect neuromuscular pathways? 9. How can inflamed muscles affect and change neuromuscular pathways and memory patterns? 10. How do these neuromuscular changes develop?

46. Range of Motion Points of Interest continued In answer to some of these questions, we might mention some preexisting nerve pathways that already exist in a newborn at birth, such as the crying instinct, suckling, uncoordinated hand and foot movements, crawling, walking and language centers. As the newborn gradually grows older, with good habits, these pathways become highly developed, reinforced and usually become healthy neuromuscular pathways with increased range of activity. Also new pathways are established, good or bad, depending on the development of the child and habits that are introduced into their life. Also, the preexisting pathways can change for the good or bad.The good news is that neuromuscular pathways have memory and damage to them can be corrected by reestablishing healthy pathways in these areas.

47. Range of Motion Points of Interest continued The question is: Can healthy neuromuscular pathways be reestablished and if so how might that be accomplished? First we need to understand why these pathways become disturbed and what might become the end results. To mention a few of the causes of changed or disturbed neuromuscular changes, we might discover such things as bad habits, sports injuries, stress, poor sleeping posture, negative thinking patterns, whiplash, inflammation, scar tissue, fibrous adhesions and toxicity in muscles, aging of the occlusion, and muscle adaptive ability to these changes, and possibly a clenching habit. Decreased range of motion can commonly be seen as a result of the above. The following slides suggest a few possible methods of correction.

48. Range of Motion Points of Interest continued To form a positive habit or change of a neuromuscular nature, a “Habit Circuit” must be built in your brain. This circuit will initially be weak, but can be strengthened by the release of Dopamine, which is provided by a “reward”(i.e, piece of food you like, after exercising). With continual training (and dopamine release therein) the Habit Circuit becomes so strong that it doesn’t require the reward (e.g., the food reward is not needed). A new positive habit circuit has now been created that is self sustaining. Another we can look at it is explained this way: A person (patient) that has developed complex TMD symptoms, headaches, clenching and occlusal wear patterns of such a nature, that they require a comprehensive therapy approach, has also developed destructive neuromuscular pathways, that not only perpetuate the condition, but continue to make it worse.

49. Range of Motion Points of Interest continued These destructive pathways also can affect brain chemistry activity in a negative way. To repeat, “To form a positive habit or change of a neuromuscular nature, a “Habit Circuit” must be built in your brain”. The following slides 50-59 help to understand how that might be accomplished and provide some insight and ways that help to reset nerve pathways.

50. Therapy Equipment I, and my staff therapist apply a comprehensive in office treatment service, which may include the following: (not necessarily in the order listed) Ultrasound: FDA approved and clinically proven. As muscles become stressed and inflamed, fibrous adhesions and scar tissue form. The longer the muscles stay in this condition, the more the potential for developing trigger zones in these muscles. These trigger zones send referred pain to other areas, including the brain. The Ultrasound can gradually help to heal these areas.