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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GNM Orthotic Effectiveness in Treatment

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

INDICATIONS FOR TM JOINT SURGERY

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Ask yourself the following questions to help you determine whether TM joint surgery is an absolute for your situation.

  1. Is your joint diseased that it needs to have surgery to remove the active pathology?
  2. Did you have failing prosthetic joints and or experiencing failed joint replacement surgery?
  3. Do your joints have any tumors or pathologic growth anomalies?
  4. Do you have absolute ankylosis of the TMJ that you cannot open or move your mouth open or closed?
  5. or did the doctors identify the existence of coronoid hyperplasia (elongation of the coronoid process)?

There are no objective criteria or indications for performing temporomandibular joint surgery for the more common pain and dysfunction disorders. This is good reason why the patient musts be educated and learn when joint surgery is indicated and reasonable.

If you don’t have these issues, then you may want to seek another opinion and or route to your treatment.

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INDICATIONS FOR TM JOINT SURGERY

CHOOSING A TMD/TMJ DENTIST

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by Clayton A. Chan, D.D.S.

Every dentist has different abilities and skills. Each have strengths and also weaknesses. Some are academics while others are clinicians. Some do ortho and others do not. Some understand how to do surgeries and others prefer not. Some have an interest to cut and modify your teeth and or do full mouth rehabs while others may not. Some are detailed and others are not. Some are quick operators and others are not. Some see many patients in a given day, while others do not. Some are focused on TMD while others just dabble in the subject amongst other things they do. Some like to measure and use instrumentation to track jaw positioning of their patients and measure muscle activity as part of their diagnosis while others may not. Some dentists prefer taking a medical approach to your care while other dentists take a dental approach to TMD and pain care. Some prescribe pharmaceutical meds Rx while others may not, some have a psychosocial perspective while others maybe of a bio-physologic perspective. Some are gnathologic in understanding and training while others maybe neuro-muscular oriented in the training and emphasis. Some dentists believe in occlusion and its importance and some don’t, while others focus on TM joints instead. Some believe in managing pain stressors and emotional factors while other focus on structural and postural alignment issues to muscular pains. Some focus on CNS issues while others may focus on musculature, myofunctional, tongue, etc. imbalance issues….some more than others. Some even focus on injection and botox methods, etc while others may not…PT or massage, chiropractic or accupunture therapies…. as one can see the list is endless…there is something for everyone…dentists all have different interests and reasons why they believe, do and provide what they offer for various reasons. Get to know those specific reasons. What makes a dentist tick?

Finding a dentist and ask them why they do what they do…and for what reason they provide those particular services as care givers. What is the dentists philosophy toward health – 1) Muscular, 2) Psychological and or 3) Occlusal or whatever combination of the above?

Every TMDer must have a clue as to what you personally believe in regards to your own health philosophy. Go with your instincts, your intuitions, based on your past and present experiences. Every dentist wants to treat you…but the questions is…. are they qualified, skilled, trained, experience, have knowledge and able?

Those are big questions…and at what price?

EDUCATE YOURSELF and LEARN
All patients are qualified to educate themselves and determine which philosophy and or approach is best for themselves. Once one determines which philosophy and approach they believe they then can can zero in and determine which doctors within the philosophy is best for them. A governing body that sets best practices and standards is only as strong as the weakest link in that process of governing and setting standards, as to what that governing body understands, believes and practices themselves. At present the governing bodies (committee of dental and medical professional) don’t always practice TMD on a daily bases.

DETERMINE YOUR OWN VALUES and BELIEFS

First you have to figure out what are your own values and belief’ are.

  1. Are you a person that believes medical medication approach and emotional stress philosophy will help and resolve your TMD issues and meet your needs? Yes, or No?
  2. or Do you believe your TMD issue is a muscular issue effecting the anxiety and stress or not? Yes, or No?
  3. or Do you believe your bite or occlusion (how your teeth come together) has anything to do with how your muscles and joints are functioning that causes muscle strains and CNS stresses? Yes or No?

That is where one may first start in figuring this huge TMD maze of philosophy and treatment options and the differences in TMD doctors thinking and approaches…this is foundational and very important to understand.

Read the following link to learn how to zero your understanding and philosophy down as to a philosophy and type of TMD dentist that is best for you.

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CHOOSING A TMD/TMJ DENTIST

Why Is There No Specialty Regarding TMJD?

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Another reason is that some dentists who are in the TMD/orofacial arena believe TMD is a medical issue (medical model toward diagnosis and treatment), while other dentists believe it is a dental issue toward diagnosis and treatment. The profession is rout with debate from a smaller group of bio-psychosocials vs wider accepted bio-physiologic occlusal view points (as the Alliance of TMD Organizations and others TMD treating clinician). The attempts by the few who want to control how TMD and or orofacial is diagnosed and treated have been declined for “TMD specialty” status numerous times at the ADA level when a majority of dentists who treat TMD. They are not willing to be dictated by the few dentists who have an agenda to perpetuate the pscyhosocial/orofacial pain perspectives (anti instrumentation) and hold similar biases with the NIH and orofacial pain groups who want to control the TMD arena from a medical perspective. What makes them qualified to diagnose and treat TMD in such a manner? That is what the TMD community is asking and wondering?

It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based on information obtained from the patient’s history, clinical examination, and when indicated TMJ radiology or other imaging procedures including the choice of adjunctive diagnostic procedures should be based upon published, peer-reviewed data showing diagnostic efficacy and safety. However, the consensus of these few anti-instrumentation advocates and their anti occlusion agenda continue to disregard the validity and scientific findings the ADA and FDA have concluded regarding CMS, EMG, ESG and low frequency myomonitor TENS as scientific, valid and acceptable aids in the diagnosis and treatment of temporomandibular joint dysfunction, masticatory dysfunctions and pain.

A long history of scientific literature about currently available technological diagnostic devices for TMDs has been available to the profession, but they refuse to acknowledge such evidence and findings perpetuating their dogmas opinions when in fact, they lack the evidence and credibility regarding the sensitivity and specificity in their own methodology and protocols required to separate odontogentic issues from masticatory muscles (somatic and neuromuscular pains (Axis I) vs psychologic, mood, anxiety, emotional stressors (Axis II). Diagnosing normal subjects from TMD pain groups or distinguishing among TMD subgroups seems to create a challenge many when they chose to diagnose without objective measured recordings that involve the use of electro- diagnostic instrumentation.

Currently, standard medical diagnostic, laboratory testings along with objective measured testings are ADA and FDA recognized to be used among trained dentists as in the medical profession for evaluating similar orthopedic, rheumatological and neuromuscular disorders utilized when indicated with TMD patients.

In addition, various standardized and validated psychometric tests may be used to assess the psychosocial dimensions of each patient’s TMD problem, but testings and diagnostics evaluation should not be limited to these classical assessments, but should include objectively measured evidence-based therapeutic modalities that involve tests of how the patients functional and resting status is, the quality of resting modes of the masticatory system, the quality of functioning modes of the system, the quality of positional modes of the masticatory system and joint sound quality (quiet or noisy) as well as quality of terminal contact balance to and from a terminal position (whether healthy or unhealthy). The later type of testings are not even included in most TMD/orofacial pain assessments.

What is missing in the diagnostic work?

It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time. While a smaller more complex and chronic group of TMDs have not shown to improve on their own because of this fact, it is very acceptable to use specific therapies that have been proven to be effective when addressing both the neuro-musculo-occlusal components to the masticatory system of this TMD patient subgroup . Many of the conservative modalities have proven to be effective in providing symptomatic relief compared to various forms of invasive surgical treatment.

Because of the increased diagnostic awareness by those clincian’s who implement these advanced instrumentation protocols their conclusions lead them toward a significantly lower chance of recommending joint surgery than those modalities and understanding toward surgery (“when all else fails” type of thinking. This kind of thinking and understanding present much higher risk of producing further harm to those who just don’t know. Professional treatment should be augmented with not only subjective doctors physical assessment, imaging assessment, patient’s history, psychosocial cursory evaluation, and a pharmacological assessment, but additionally an evaluation of the patient’s physiologic resting and functional body responses that go beyond subjective complaints – objective measured K7 data testing as an example.

Our patients who have presented with complex TMD problems, who have seen numerous clinicians within the medical and dental community who have tried to use the “Standard modalities” (“not uniformly effective” allows the judicious use of our modalities and teachings that are obviously “specific and justifiable” as well as conservative.

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Why Is There No Specialty Regarding TMJD?