Classification of J5 Myomonitor Muscle Stimulation/Dental TENS

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J5 Myomonitor is a 510K regulatory Class: II device classified as an ultra-low frequency, battery operated “muscle stimulator” used to relax the muscles of the head and neck. (Yes, you are technically correct as to its not classified as a “TENS machine”, but it is recognized by FDA to be used to relieve symptoms associated with muscle spasm, to treat temporomandibular joint (TMJ) dysfunction and associated pain, to relax muscles and establish a physiologic occlusion, to take occlusal registrations, to take denture impressions, to increase local blood circulation and to increase or maintain mandibular range of motion.

Many within the dental TMD community recognize and acknowledge “dental” neuromuscular stimulation occurs when a low-amplitude, low frequency, intermittent BILATERAL stimulation that causes muscles to alternately contract and relax in a pumping manner, are applied bilaterally over the coronoid notch, where the stimulus reaches the mandibular region of the trigeminal nerve (V) deep to the mandible as well as the superficial facial (VII) nerve. (This is dental use and application of such a “muscle stimulator” – specific to how one can enhance a more optimal bite registration, a neuromuscular occlusal dental key).

Dixon established the parameters for low frequency TENS
B. Jankelson hypothesized that when a stimulus was placed at the coronoid notch one can stimulate all V and VII nerves and muscles that are effected.

Choi and Mitani document that the stimulus from the Myomonitor is neurally mediated. All muscles of mastication are pulsed by the stimulus and muscle relaxation is verified by sEMG recordings.

Williamson study conducted during oral surgery would stimulate muscles but would give succinylcholine that would block the stimulus – myo-monitor stimulus. Oral surgeon then gave Nyloxone which would reverse reaction thus allowing stimulus to continue, proving and validating that muscle stimulation via the coronoid notch was in fact neurally mediating the neuro-muscular responses via the trigeminal and facial nerves…. thus a transcutaneous electroneural (TENS) response was recognized.

Strictly speaking, the FDA classification of J5 calls it a Dental Electrical Muscle Stimulator. The term Dental TENS has stuck for over 50 years because dentist recognize that the Myomonitor when used in Dentistry via the coronoid notch application as indicated for its dental use is a neural mediated muscle stimulus (producing an involuntary response of all muscles of mastication, thus Dental TENS as specified is capable of stimulating either two or four muscle groups at once bilaterally via Vth and VII nerves.

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Classification of J5 Myomonitor Muscle Stimulation/Dental TENS

Refuting TMD Guideline Misconceptions about NM Occlusion Part 2: RCDSO Draft Guidelines for Diagnosis and Management of TMD

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RCDSO 2018 Draft TMD Guidelines (Page 6): “The clinical value of a number of diagnostic aids currently in use has not been demonstrated in well-controlled and scientifically based studies; these include jaw tracking devices, EMG recording and sonography (Doppler).”

Myotronics Response to the above statement:

Proper diagnosis of any medical/ dental condition is made by the treating doctor and begins with obtaining the patient’s medical history and performing a comprehensive clinical examination of the affected area.  The temporomandibular disorders (TMD) diagnostic process and treatment plan are greatly enhanced using technologies that can scrutinize the anatomic and functional components of the masticatory system, providing reliable and precise objective measurement data.  Surface Electromyography (EMG) is a well-accepted modality that is safe and effective for the evaluation of masticatory muscle function of TMD patients, for providing objective milestones in planning treatment and for documenting patients’ response to treatment.

A significant body of the scientific literature published in peer-reviewed journals over the past 60 years has concluded that the TMD patient population has an elevated resting EMG muscle activity and weak or asymmetrical functional EMG muscle activity.1-59

  1. Perry HT: Muscular changes associated with temporomandibular joint dysfunction. Journal of Am Dent Res 1957; 54:644-653.
  2. Lous L, Sheikholeslam A, Moller E: Postural activity in subjects with functional disorders of the chewing apparatus. Scand J Dent Res 1970; 78:404-410.
  3. Moller E, Sheikholeslam A, Lous L: Deliberate relaxation of the temporal and masseter muscles in subjects with functional disorders of the chewing apparatus. Scand J Dent Res 1971; 79:478-482.
  4. Munro RR: Electromyography of the masseter and anterior temporalis muscles in patients with atypical facial pain. Australian Dent J 1972:131-139.
  5. Moss JP, Chalmers CF: An electromyographic investigation of patients with a normal jaw relationship and a class III jaw relationship. Am J Orthod 1974; 665:538-556.
  6. Yemm R: Neurophysiologic studies of temporomandibular joint dysfunction. Oral Science Rev 1976; 7:31-53.
  7. Kotani H, Kawazoe Y, Hamada T, Yamata S: Quantitative electromyographic diagnosis of myofascial pain dysfunction syndrome. J Prosthet Dent 1980; 43:450-456.
  8. Sheikholeslam A, Moller E, Lous L: Pain, tenderness and strength of human mandibular elevators. Scand J Dent Res 1980; 88:60-66.
  9. Sheikholeslam A, Moller E, Lous L: Postural and maximal activity in elevators of mandible before and after treatment of functional disorders. Scand J Dent Res 1982; 90:37-46.
  10. Riise C, Sheikholeslam A: The influence of experimental interfering occlusal contacts on the postural activity of the anterior temporal and masseter muscles in young adults. J Oral Rehabil 1982; 9:419-425.
  11. Sheikholeslam A, Riise C: Influence of experimental interfering occlusal contacts on the activity of the anterior temporal and masseter muscles during submaximal and maximal bite in the intercuspal position. J Oral Rehabil 1983; 10:207-214.
  12. Riise C, Sheikholeslam A: The influence of experimental interfering occlusal contacts on the activity of the anterior temporal and masseter muscles during mastication. J Oral Rehabil 1984; 11:325-333.
  13. Moller E, Sheikholeslam A, Lous L: Response of elevator activity during mastication to treatment of functional disorders. Scand J Dent Res 1984; 90:37-46.
  14. Keefe FJ, Dolan EA: Correlation of pain behavior and muscle activity in patients with myofascial pain-dysfunction syndrome. J Craniomandib Disord Facial Oral Pain1984; 2:181-184.
  15. Sherman RA: Relationships between jaw pain and jaw muscle contraction level: Underlying factors and treatment effectiveness. J Prosthet Dent 1985; 54(1):114-118.
  16. Naeije M, Hansson TL: Electromyographic screening of myogenous and arthrogenous TMJ dysfunction patients. J Oral Rehabil 1986; 13(5):433-441.
  17. Balciunas BA, Staling LM, Parente FL: Quantitative electromyographic response to therapy for myo-oral facial pain: a pilot study. J Prosth Dent 1987; 58(3):366-369.
  18. Burdette BH, Gale EN: The effects of treatment on masticatory muscle activity and mandibular posture in myofascial pain-dysfunction patients. J Dent Res 1988; 67(8):1126-1130.
  19. Cram JR, Klemons TM: EMG: Comparisons in craniofacial muscles following therapy for head and neck pain. Med Electr 1988:106- 110.
  20. Gervais RO, Fitzsimmons GW, Thomas NR: Masseter and temporalis electromyographic activity in asymptomatic, subclinical and temporomandibular joint dysfunction patients. J Craniomandib Pract 1989; 7:52-57.
  21. Chong-Shan S, Hui-Yun W: Postural and maximum activity in elevators during mandible pre- and post-occlusal split treatment of temporomandibular joint disturbance syndrome. J Oral Rehabil 1989; 16:155-161.
  22. Chong-Shan S, Hui-Yun W: Value of EMG analysis of mandibular elevators in openclose- clench cycle to diagnosing TMJ disturbance syndrome. J Oral Rehabil 1989; 16:101-107.
  23. Shi CS. Proportionality of mean voltage of masseter muscle to maximum bite force applied for diagnosing temporomandibular joint disturbance syndrome. J Prosthet Dent 1989; 62(6):682-684.
  24. Harness DM, Donlon WC, Eversole LR: Comparison of clinical characteristics in myogenic, TMJ internal derangement and atypical facial pain patients. Clin J Pain 1990; 6(1):4-17.
  25. Choi J: A study on the effects of maximal voluntary clenching on the tooth contact points and masticatory muscle activities in patients with temporomandibular disorders. J Craniomandib Disord Facial Oral Pain 1992; 6:41-46.
  26. Kroon GW, Naeije M: Electromyographic evidence of local muscle fatigue in a subgroup of patients with myogenous craniomandibuthe postural activity of the anterior temporal and masseter muscles in young adults. J Oral Rehabil 1982; 9:419-425.
  27. Visser A, McCarroll RS, Oosting J, Naeije M: Masticatory electromyographic activity in healthy young adults and myogenous craniomandibular disorder patients. J Oral Rehabil 1994; 21(1):67-76.
  28. Abekura H, Kotani H, Tokuyama H, Hamada T: Asymmetry of masticatory muscle activity during intercuspal maximal clenching in healthy subjects and subjects with stomatognathic dysfunction syndrome. J Oral Rehabil 1995; 22(9):699-704.
  29. Erlandson PM, Poppen R: Electromyographic biofeedback and rest position training of masticatory muscles in myofascial pain-dysfunction patients. J Prosthet Dent 1998; 62:335-338.
  30. Liu ZJ, Yamagata K, Kasahara Y, Ito G: Electromyographic examination of jaw muscles in relation to symptoms and occlusion of patients with temporomandibular joint disorders. J Oral Rehabil 1999; 26(1):33-47.
  31. Pinho JC, Caldas FM, Mora MJ, Santana-Penín U: Electromyographic activity in patients with temporomandibular disorders. J Oral Rehabil 2000; 27(11):985-990.
  32. Alajbeg IZ, Valentic-Peruzovic M, Alajbeg I, Illes D: Influence of occlusal stabilization splint on the asymmetric activity of masticatory muscles in patients with temporomandibular dysfunction. Coll Antropol 2003; 27(1):361-371.
  33. Glaros AG, Burton E: Parafunctional clenching, pain, and effort in temporomandibular disorders. J Behav Med 2004; 27(1):91-100.
  34. Pallegama RW, Ranasinghe AW, Weerasinghe VS, Sitheeque MA: Influence of masticatory muscle pain on electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders. J Oral Rehabil 2004; 31(5):423-429.
  35. Bodéré C, Téa SH, Giroux-Metges MA, Woda A: Activity of masticatory muscles in subjects with different orofacial pain conditions. Pain 2005; 116(1-2):33-41.
  36. da Silva MA, Issa JP, Vitti M, da Silva AM, Semprini M, Regalo SC: Electromyographical analysis of the masseter muscle in dentulous and partially toothless patients with temporomandibular joint disorders. Electromyogr Clin Neurophysiol 2006; 46(5):263-268.
  37. Tosato Jde P, Caria PH: Electromyographic activity assessment of individuals with and without temporomandibular disorder symptoms. J Appl Oral Sci 2007; 15(2):152-155.
  38. Ries LG, Alves MC, Bérzin F: Asymmetric activation of temporalis, masseter, and sternocleidomastoid muscles in temporomandibular disorder patients. J Craniomandib Pract 2008; 26(1):59-64.
  39. Tartaglia GM, Moreira Rodrigues da Silva MA, Bottini S, Sforza C, Ferrario VF: Masticatory muscle activity during maximum voluntary clench in different research diagnostic criteria for temporomandibular disorders (RDC/TMD) groups. Man Ther 2008; 13(5):434-440.
  40. Bodéré C, Woda A: Effect of a jig on EMG activity in different orofacial pain conditions. Int J Prosthodont 2008; 21(3):253-258.
  41. Tecco S, Tetè S, D’Attilio M, Perillo L, Festa F: Surface electromyographic patterns of masticatory, neck, and trunk muscles in temporomandibular joint dysfunction patients undergoing anterior repositioning splint therapy. Eur J Orthod 2008; 30(6):592-597.
  42. Santana-Mora, U, Cudeiro J, Mora-Bermudez MJ, Rilo-Pousa B, Ferreira-Pinho JC, Otero- Cepeda JL, Santana-Penin U: Changes in EMG activity during clenching in chronic pain patients with unilateral temporomandibular disorders. J Electromyography and Kinesiology 2009; 19(6):e543-549.
  43. Ardizone I, Celemin A, Aneiros F, del Rio J, Sanchez T, Moreno I: Electromyographic study of activity of the masseter and anterior temporalis muscles in patients with temporomandibular joint (TMJ) dysfunction: comparison with the clinical dysfunction index. Med Oral Patol Oral Cir Bucal 2010; 15(1):e14-19.
  44. Botelho AL, Silva BC, Gentil FH, Sforza C, da Silva MA: Immediate effect of the resilient splint evaluated using surface electromyography in patients with TMD. J Craniomandib Pract 2010; 28(4):266-273.
  45. Hermens HJ, Boon KL, and Zilvold G: The clinical use of surface EMG. Medica Physica 1986; 9:119-
  46. Goldensohn E: Electromyography. In: Disorders of the temporomandibular joint. Lazlo Schwartz, ed. Philadelphia/London: W.B. Saunders Co., 1966:163-176.
  47. Lloyd AJ: Surface electromyography during sustained isometric contractions. J Applied Physiology 1971; 30(5):713-719.
  48. Burdette BH, Gale EN: Intersession reliability of surface electromyography. Journal of Dental Research, [Abstract No. 1370], Vol 66, 1987.
  49. Christensen LV: Reliability of maximum static work efforts by the human masseter muscle. Am J Orthod Dentofacial Orthop 1989; 95(1):42-45.
  50. Burdette BH, Gale EN: Reliability of surface electromyography of the masseteric and anterior temporal areas. Arch Oral Biol 1990; 35(9):747-751.
  51. Ferrario VF, Sforza C: Coordinating electromyographic activity of the human masseter and temporalis anterior muscles during mastication. Eur J Oral Sci 1996; 104(5-6): 511-517.
  52. Buxbaum J, Mylinski N, Parente FR: Surface EMG reliability using spectral analysis. J Oral Rehabil 1996; 23(11):771-775.
  53. Castroflorio T, Icardi K, Torsello F, Deregibus A, Debernardi C, Bracco P: Reproducibility of surface EMG in the human masseter and anterior temporalis muscle areas. J Craniomandib Pract 2005; 23(2):130-137.
  54. Castroflorio T, Icardi K, Becchino B, Merlo E, Debernardi C, Bracco P,Farina D: Reproducibility of surface EMG variables in isometric sub-maximal contractions of jaw elevator muscles. J Electromyogr Kinesiol 2006;16(5):498-505. Epub 2005 Nov 15.
  55. Castroflorio T, Bracco P, Farina D: Surface electromyography in the assessment of jaw elevator muscles. J Oral Rehabil 2008; 35(8):638-645. Epub 2008 May 9.
  56. De Felicio CM, Sidequersky FV, Tartagalia GM, Sforza C: Electromyographic standardized indices in healthy Brazilian young adults and data reproducibility. J Oral Rehabil 2009; 36(8):577-583. Epub 2009 Jun22

 Surface Electromyography of masticatory muscles together with electronic jaw tracking and joint vibration recording devices are clinically efficacious diagnostic aids for objective quantification of the physical components of Temporomandibular Disorders in patients screened for treatment. (1-17)

  1. Pantaleo, T., Prayer-Galletti, F., Pini-Prato, G., and Prayer-Galletti, S. An electromyographic study in patients with myofacial pain- dysfunction syndrome, Bulletin Group. Int. Rech. sc. Stomat. et Odont. 1983; 26:167- 179.
  2. Stohler, C., Yamada, Y., and Ash, M.M. Antagonistic muscle stiffness and associated behavior in the pain dysfunctional state. Helv Odont Acta 29:2,1985, in Schweiz. Mschr. Zahnmed. 95:719-13, 1985.
  3. Stohler, C., and Ash, M.M. Demonstration of chewing motor disorder by recording peripheral correlates of mastication. J Oral Rehab. Vol. 12 p 49- 57, 1985.
  4. Cooper, B.C., Alleva, M., Cooper, D., and Lucente, F.E. Myofacial pain dysfunction: Analysis of 476 patients. Laryngoscope 1986; 96:1099-1106.
  5. Nielsen I, Miller AJ. Response patterns of craniomandibular muscles with and without alterations in sensory feedback. J Prosthet Dent. 1988 Mar;59(3):352-62.
  6. Mongini, F., Tepia-Valenta, G., and Conserva, E. Habitual mastication in dysfunction: a computer-based analysis. J Prosthet. Dent. 1:484-494, 1989.
  7. Williamson, E.H., Hall, J.T., and Zwemer, J.D. Swallowing patterns in human subjects with and without temporomandibular dysfunction. Am J Orthod Dentofac Orthop. 98:507-511, 1990.
  8. Nielsen IL, McNeill C, Danzig W, Goldman S, Levy J, Miller AJ. Adaptation of craniofacial muscles in subjects with craniomandibular disorders. Am J Orthod Dentofacial Orthop. 1990 Jan;97(1):20-34.
  9. Kuwahara T, Miyauchi S, Maruyama T: Clinical classification of the patterns of mandibular movements during mastication in subjects with TMJ disorders. Int J Prosthodont 1992; 5(2):122-129.
  10. Tsolka P, Preiskel H. Kinesiographic and electromyographic assessment of the effects of occlusal adjustment therapy on craniomandibular disorders by a double-blind method. J Prosthet Dent 1993; 69:85-92.
  11. Kuwahara T, Bessette RW, Maruyama T: Chewing pattern analysis in TMD patients with unilateral and bilateral internal derangement. J Craniomandib Pract 1995; 13(3):167- 172.
  12. Tsolka P, Fenion M, McCullock A, Preiskel H. Controlled clinical, electromyographic and kinesiographic assessment of craniomandibular disorders in women. J Orofacial Pain 1994;8:80-9.
  13. Cooper B.  The role of bioelectric instrumentation in the documentation of management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 1997; 83:1, 91-100
  14. Heffez L, Blaustein D: Advances in sonography of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1986; 62(5):486- 495.
  15. Gay T, Bertolami CN, Donoff RB, Keith DA, Kelly JP: The acoustical characteristics of the normal and abnormal temporomandibular joint. J Oral Maxillofac Surg 1987; 45(5): 397-407.
  16. Ishigaki S, Bessette RW, Maruyama T: A clinical study of temporomandibular joint (TMJ) vibrations in TMJ dysfunction patients. J Craniomandib Pract 1993; 11(1):7-13.
  17. Deng M, Long X, Dong H, Chen Y, Li X: Electrosonographic characteristics of sounds from   temporomandibular joint disc replacement. Int J Oral Maxillofac Surg 2006; 35(5):456-460.

Surface Electromyogrphy, Jaw Tracking and Joint Vibration monitoring devices objectively document patient status, create objective milestones in planning treatment and document patient’s response to treatment. (1-20)

  1. Moller, E. Clinical electromyography in dentistry. Int. Dent. J 1969; 19:250-266.
  2. Kawazoe Y, Kotani H, Hamada T, Yamada S. Effect of occlusal splints on the electromyographic activities of masseter muscles during maximum clenching in patients with myofascial pain dysfunction syndrome. J Prosthet Dent l980; 43:578-80.
  3. Myslinski, N. R.., Buxbaum, J. D., and Parente, F. J. The use of electromyography to quantify muscle pain. Meth. and Find. Exptl. Clin. Pharmacol 1985; 7(10):551-556.
  4. Sheikholeslam, A., Holmgren, K., and Riise, C. A clinical and electromyographic study of the long-term effects of an occlusal splint on the temporal and masseter muscles in patients with functional disorders and nocturnal bruxism. Journal of Oral Rehabilitation 1986; 13:137-145.
  5. Jankelson, R.R. Analysis of maximal electromyographic activity of the masseter and anterior temporalis muscles in myocentric and habitual centric in temporomandibular joint and musculoskeletal dysfunction. Pathophysiology of Head and Neck Musculoskeletal Disorders. Bergimini M (ed), Front Oral Physiol. Basel, Karger, 7:83-98, 1990.
  6. Lynn, J.M. Craniofacial neuromuscular dysfunction vs. function: A comparison study of the condylar position and intro-articular space. Pathophysiology of Head and Neck Musculoskeletal Disorders. Bergamini M (ed) Front Oral Physiol. Basel, Karger Vol. 7, p 136-143, 1990.
  7. Coy RE, Flocken JE, Adib F. Musculoskeletal Etiology and Therapy of Craniomandibular Pain and Dysfunction. Cranio Clinics Intl 1991; 163-173.
  8. Lynn, J.M. and Mazzocco, M. Intraoral splint therapy: muscles objectively. Funct Orthodont. p 11-27 Nov/Dec 1991.
  9. Jankelson, R.R. Validity of surface electromyography as the “gold standard” for measuring muscle postural tonicity in TMD patients. Anthology of Craniomandibular Orthopedics Vol. II, ed. Coy, R. pp. 103-125, 1992.
  10. Lynn J, Mazzocco M, Miloser S, Zullo T. Diagnosis and Treatment of Craniocervical Pain and Headache based on Neuromuscular Parameters, American Journal of Pain Management 1992; 2:3, 143-151.
  11. Hickman DM, Cramer R, Stauber WT. The effect of four jaw relations on electromyographic activity in human masticatory muscles. Archs Oral Biol 1993; 38:3, 261-264.
  12. Hickman DM, Cramer R. The effect of different condylar positions on masticatory muscle electromyographic activity in humans. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 86(1):2-3.
  13. Deng M, Long X, Dong H, Chen Y, Li X. Electrosonographic characteristics of sounds from temporomandibular joint disc replacement. Int J Oral Maxillofac Surg. 2006; 35(5):456-60. Epub 2006; 19.
  14. Widmalm SE, Lee YS, McKay DC: Clinical Use of Qualitative Electromyography in the Evaluation of Jaw Muscle Function: A Practitioner’s Guide. J Craniomandib Pract 2007; 25:1-11
  15. Hugger A, Hugger S, Schindler H. Surface electromyography of the masticatory muscles for application in dental practice. Current evidence and future developments. Int J Comput Dent 2008; 11(2):81-106.
  16. Cooper B, Kleinberg I. Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients. J Craniomandibular Practice, 2008; 26(2) 104-115.
  17. Cooper B.  The role of bioelectric instrumentation in the documentation of management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 1997; 83:1, 91-100.
  18. Weggen H, Schindler H, Hugger A: Effects of myocentric vs. manual methods of jaw position recording in occlusal splint therapy – a pilot study. Journal of Craniomandibular Function 3 (2011), No. 3: 177-203.
  19. Weggen T, Schindler H, Kordass B, Hugger A: Clinical and electromyographic follow-up of myofascial pain patients treated with two types of oral splint: a randomized controlled pilot study.Int J Comput Dent. (2013), No.16 (3): 209-24.
  20. Ortu E, Pietropaoli D, Adib F, Masci C, Giannoni M, Monaco A: Electromyographic evaluation in children orthodontically treated for skeletal Class II malocclusion: Comparison of two treatment techniques. Cranio (2017) Nov No.16:1-7.

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Refuting TMD Guideline Misconceptions about NM Occlusion Part 2: RCDSO Draft Guidelines for Diagnosis and Management of TMD

Refuting TMD Guideline Misconceptions about NM Occlusion Part 1: RCDSO Draft Guidelines for Diagnosis and Management of TMD

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RCDSO 2018 Draft TMD Guidelines (Page 6): The concept of “neuromuscular occlusion” is based on the diagnostic value of electromyography for TMDs and treatment is based on the use of electrical stimulation of the muscles of mastication to establish appropriate occlusal positioning. Controlled studies suggest that there is a wide range of results and inconsistent findings using electromyography, which minimize its usefulness as a diagnostic test for TMD. Specifically, differences between TMD patients and healthy controls were not consistent. Regarding the clinical efficacy of TMD treatment based on electrical stimulation of the muscles of mastication, there is insufficient data from well controlled studies to rule out a placebo effect. Until properly controlled studies are available, there is insufficient evidence to support the clinical use of these techniques.

Myotronics Response to the above statement:

Neuromuscular occlusion is a stable maxillo-mandibular position of dental occlusion arrived at by isotonic contraction of relaxed masticatory muscles, achieved by stimulation of those muscles, with a Dental TENS, on a trajectory (arc) beginning at a muscularly rested mandibular position. NM occlusion is in harmony with relaxed, healthy muscles and properly functioning temporomandibular joints.

Studies published in peer reviewed journals, including two randomized controlled studies, substantiate that the establishment of a neuromuscular occlusion, facilitated by the use of a Dental TENS, provides improved mandibular and masticatory function in a large group of TMD patients with notably significant reduction or resolution of symptoms. (1-4)

  1. Cooper B: The role of bioelectric instrumentation in the documentation of management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 83(1): 91-100.

 Abstract

Temporomandibular disorders (TMDs) can affect the form and function of the temporomandibular joint, masticatory muscles, and dental apparatus. Electronic measurement of mandibular movement and masticatory muscle function provides objective data that are defined by commonly accepted parameters in patients with TMDs; these data can then be used to design and monitor therapy and enhance treatment therapy. In this study, data on 3681 patients with TMD are presented, including electronic test data on 1182 treated patients with TMDs. Electronic jaw tracking was used to record mandibular movement and to compare the presenting and therapeutic dental occlusal positions. Electromyography was used to analyze the resting status of masticatory muscles and occlusal function at presentation and after therapeutic intervention. Transcutaneous electrical nerve stimulation therapy relaxed masticatory muscles and aided in the determination of a therapeutic occlusal position. The data show a positive correlation between the clinical symptoms of TMD and the presenting occlusion, accompanied by muscle activity. A strong positive correlation also appears to exist between a therapeutic change in the dental occlusion to a neuromuscularly healthy position with use of a precision orthotic appliance and the significant relief of symptoms within 1 month and at 3 months.

  1. Cooper B, Kleinberg I:. Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients. J Craniomandib Pract 2008; 26(2):104-117.

Abstract
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

  1.  Weggen H, Schindler H, Hugger A: Effects of myocentric vs. manual methods of jaw position recording in occlusal splint therapy – a pilot study. Journal of Craniomandibular Function 3 (2011), No. 3: 177-203

 Abstract

Occlusal splint therapy is a central element of the treatment of temporomandibular disorders (TMD). However, little has been reported about the effect of transcutaneous electrical nerve stimulation (TENS)-based methods of myocentric jaw position recording on the effect of splint therapy. In this randomized clinical trial, 40 patients with myofascial pain of the jaw muscles were treated with occlusal splints fabricated using bimanual manipulation (Michigan group, n = 20) or myocentric jaw position recording (myocentric group, n = 20) for determination of centric vs. myocentric relation. Therapeutic effects were evaluated based on the change in pain symptoms and the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) procedure after 4 and 12 weeks of treatment. The extent of change in mandibular position was determined by condymeter measurements and magnetic kinesiography as well as by comparison with a healthy control group. Twelve weeks of wearing the respective splints at night resulted in the significant relief of symptoms in both groups, as determined based on subjective pain reports and visual analog scale (VAS) scores. Group comparison revealed that the VAS scores were significantly lower in the myocentric group. Myocentric positioning of the mandible led to mandibular position changes of similar extent in TMD patients and healthy controls. The use of TENS to establish myocentric relation for splint therapy is therapeutically effective and achieves a greater reduction in pain. Furthermore, TENS treatment alone also has a significant pain-relieving effect

  1. Weggen T, Schindler H, Kordass B, Hugger A: Clinical and electromyographic follow-up of myofascial pain patients treated with two types of oral splint: a randomized controlled pilot study. Int J Comput Dent. (2013), No.16 (3): 209-24

Abstract

Increased resting electromyographic activity (EMG), reduced EMG during maximum voluntary clenching, and a shift to lower frequencies of the mean/median power frequency (MPF) of the EMG power spectrum have been reported for patients with temporomandibular disorder pain. It is unclear, however, whether these electrophysiological phenomena can be correlated with symptom improvement during the follow-up of myofascial pain patients in treatment. The objective of this study was to monitor the therapeutic effects of two different splint concepts (standard method and a complex splint procedure assisted by transcutaneous electrical nerve stimulation, TENS) for a period of 12 weeks, by use of clinical outcome criteria and EMG recordings. We tested the hypotheses that both measures evaluated will change in parallel during treatment and that the different splint concepts will result in no outcome differences between the variables studied. For two randomly selected groups, each containing 20 non-chronic myofascial pain patients, the clinical course after splint insertion was documented over a period of 12 weeks on the basis of pain and pain on palpation ratings, in parallel with EMG recording. Baseline values were monitored for matched healthy subjects. Although there was no correlation between the course of symptom improvement and significant changes in EMG data, MPF differed significantly (p < 0.05) between healthy subjects and patients. The therapeutic effects of splints of different clinical complexity differed significantly (p < 0.05) between the patient groups, in favor of the complex oral appliances, and substantial (p < 0.001) but temporary pain relief was achieved by additional TENS. For non-chronic myofascial TMD pain patients treated with splints, the course of symptom improvement is not paralleled by significant changes in EMG data. MPF can, however, be used to distinguish between healthy subjects and patients. Splints of different clinical complexity differ in their therapeutic effects in non-chronic myofascial TMD patients, and substantial temporarily limited pain relief can be achieved by additional muscle stimulation by TENS.

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Refuting TMD Guideline Misconceptions about NM Occlusion Part 1: RCDSO Draft Guidelines for Diagnosis and Management of TMD

GNM Orthotic Effectiveness in Treatment

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GNM Orthotic effectiveness in treatment requires attention to the following:

  1. Optimal jaw position to be determined using K7 jaw tracking with TENS,
  2. Detailed micro occlusal adjustment protocols done by the trained dentist,
  3. Time and doctor skills,
  4. Patient time and understanding of this process,
  5. A realization that changes will occur and will be required to modify the occlusal surface by either adding to or taking away from the orthotic surface to accommodate the positive changes that will occur in order to assist in the healing process of the masticatory cervical system.

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hope the information you read will bring some light to enlighten and bless you.

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Optimal Physiologic Rest is the Place to Start

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My Wishes for the Dental Profession

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I wish more doctors would objectively measure the functional and resting responses of the TMD patient. This would help the world community gain specific data as to what techniques and methods work and or don’t work. Which methods and protocols are effective vs. not effective. Objective measurements would also help remove the mysteries of TMD. Dental schools need to change their paradigms about K7 instrumentation data gathering if they desire to be cutting edge leaders and researchers to influence their students and dental community. Dentists need to learn what the K7 data means and how to properly use it and interpret the data accurately to appreciate their significance in clinical diagnostic interpretation and to aid in deciding how to implement effective treatment to the TMD patient. Without objective data and measurements, and with out proper understanding of the data confusion and mysteries will continue.

It is costly to society and to the profession when doctors and patients don’t know what should be known.

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My Wishes for the Dental Profession

Something Dramatically and Significantly Is Missing in Dentistry

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The fact that there are over 37000+ members on various TMD forum groups indicates that no matter how many new technologies, ideas, methods, therapies, exercises or appliances that are promoted there still is something dramatically and significantly missing and many TMD folks all know it.
 
Many TMD problems exists because dentists failed to understand something in their diagnosis (or lack of diagnosis), they failed on so many different levels even though they are good at doing promoting so many ideas and ways. But they are not short on coming up with excuses when things don’t work… electro-diagnostic technologies to 3D scans and imaging that helps everyone visualize this and that body part, yet the dental profession as a whole can’t seem to get the bite and occlusion right (the application and implementation of the treatment) after all these years even with the simple splint. It has to make one wonder?
 
The technology industry (all great) can come up with all kinds of things for dentists to ooh and ah at, buy and promote to their patients, but the industry can’t seem to help dentists be more comprehensive (I don’t mean more comprehensive in cutting more teeth) in helping them understand what homeostasis is. How to establish neutrality to abnormal forces that we all know creates the havoc to the masticatory system. But instead they have not helped educate and or train dentists in becoming precise operators based on a homeostatic model of health. Rather the industry has influence the dentist toward a consumer mentality to sale more things, different and the newest dental services. They treat cases yet overlook the need to get the masticatory system to homeostasis (an underlying factor that would establish body heatlh and neutrality) diminishing the abnormal forces in the body.
 
If our profession and industry would understand that,,,they would have so much more dentistry to do, beyond their expectations, patients would get healthier, more prevention, more conservation, but will require more dental skills, mainly dental educational awareness. But getting the TMD patient to move toward neutral…rather than throwing band aid treatments at the problem one after another, day after day, year after year.
 
Dentists are easily influenced by their environments and peers….what ever the newest in-thing is, the newest in-idea, latest teaching, news discovered concept, new terminologies, etc….. for this year….next year it repeats again with new terms…that is how the masses of dentist shift in their thinking….they never learned to apply what they all ready learned in a more accurate homeostatic manner. That is what they should have learned in dental school, but didn’t!
 
They don’t even understand what it means to establish homeostasis for their patients. They vicariously look for things to do on their patients that is “wrong” and offer some method of treatment, but have no perspective of ultimately getting the patient healthy. Most dentistry is based on redoing things, remaking, rebuilding, reconstructing, “rejuvenating”, but have no specific goals or objective documentable parameters of establishing healthy. They only fix what they see as failing or breaking down. They only treat the teeth, maybe joints…and if they happen to learn ortho, they will make teeth straight with what ever ortho system conveniences their dental practice model.
 
If it is broken they fix it to that existing habitual position. If the joint is hurting, just inject it to remove the temporary hurt, but don’t deal with the underlying cause, etc…. Most dentist have no parameters or guidelines to establish healthy jaw relationships for optimal comfortable function and stability. They do what ever looks right. If the patient complains…they refer the case out to the next specialist…whoever that maybe. The TMD cycle continues…the cycle of dentistry… very little new IS under the sun!

That is all.

Clayton Dentistry

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Something Dramatically and Significantly Is Missing in Dentistry

Traditional Beliefs of Evidence-Based Research or Meta-Analyses of Scientific and Objectively Derived Data

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Article Written by Bruce Greenstein, DMD, Pinecrest (Miami), Florida

The question to ask of this doctor is “What are your “traditional beliefs”?

Part of the challenge in the TMJ arena is that it is significantly more difficult to perform “evidence-based” research or meta-analyses of “scientific” and objectively derived data. It is far easier to compare in the lab when evaluating the strengths of certain biomaterials – subjecting them to multiple tests in vitro by crushing or plying them apart and recording all the numbers and data for comparison. In those situations, very specific protocols can be followed and monitored throughout the experiment. The same holds true for comparing the seal of root canal treated teeth when you section them and use dyes to identify leaks.

Within the NM arena, we can objectively evaluate muscle EMGs and determine whether hyperactive vs “normal” (though work must be done to determine whether some muscles are relaxed versus fatigued as well as trying to compare electrode placement, interface with the skin surface and differences in muscles from one person to another affecting scan results). ESGs tell us about the location and intensity of noises and we interpret what is occurring within the joint complex based on spikes and deviations in the scans. CMS indicates the extent and quality of Md movement all of which is influenced by multiple factors – agreed.

To claim, as many doctors do, that evidence-based approaches to this science prove that occlusion plays only a minor (10-15%) role in symptoms ascribed to TMJD is disingenuous. I would ask how such articles evaluated the role played by bite adjustments – a “placebo effect”? Dentists pretending to adjust teeth, but really didn’t and the patient claimed all TMJ symptoms disappeared? What kind of evidence-based follow-up was done on these patients? How did one quantify that the patient had TMJ symptoms to begin with? Was the bite adjusted in CO or done in the old or new CR position or with use of ULF TENS unit?? So many variables to try to control, it’s no wonder things seem all over the place!

As just one example of bias, a recent author’s response under the heading “Rationalism” as erroneous support for successful splint therapy reads as follows …. “This kind of “junko logic” ignores all the possible theories on how splints might work (implying that occlusion plays limited to no role). For instance, Clark offers 5 possibilities: occlusal disengagement, restored occlusal vertical dimension, maxillomandibular realignment, TMJ repositioning, and cognitive awareness”. This comment cements my contention above about reasoning being disingenuous. One cannot claim that gnathologists and occlusal therapy (ex. removable orthotics or “splints”) plays a limited to no role in TMJ therapy, then turn around and claim “alternate possibilities” that have everything to do with occlusion!

Occlusal disengagement = eliminating interferences (isn’t that part of occlusal therapy?)
Restored Occlusal Vertical Dimension, Mx/Md realignment and TMJ repositioning all occur by virtue of using OCCLUSION-ORIENTED SPLINTS! Is that not what an orthotic does? It is exactly the intricate gearing along the biting surface of a micro-occlusally, well-adjusted orthotics that allow for the change in mandibular position and TMJ realignment. Otherwise, how did the jaw position or joint complex rearrange itself in the first place?
(I’m not about to get into a debate over cognitive awareness and behavioral issues a la Orofacial Pain theory. There’s room for many sorts of treatments and if that alone does the trick, fantastic, but when it doesn’t, where to next?)

This entire arena is based on a combination of BOTH objective data gathering and subjective data gathering from both doctor and patient. At no point have I seen anywhere how the GNM approach has discounted the role of posture, airway, soft tissue anatomy, health history or anything else that can influence outcomes in this field. The OC manuals are replete with references to these areas of influence. The pissing contest between CR, NM, PBD, BFDO, GNM, OFP (any other acronyms?) is ego-driven and fraught with political motivations that have less to do with patient and more to do with those debating.

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Traditional Beliefs of Evidence-Based Research or Meta-Analyses of Scientific and Objectively Derived Data