TMJ Disorders have long been considered to be primarily a dental problem related to bite and occlusion as well as muscle function. Costen’s Syndrome was the original medical term for TMJ disorders and was named by Dr. James B. Costen, a St Louis Otolaryngologist, who partially characterized it in 1934.
In recent years there has been an emphasis on the psychosocial aspectes of TMD disorders and an attempt to treat the problems with psychotherapy and drug therapy following the medical model. While this works for some patients it often requires heavy dosages of powerful drugs. Recent work in the fields of Neuromuscular Dentistry and Sleep Medicine have shown that a large proportion of female TMJ / TMD patients actually have UARS, Upper Airway Resistance Syndrome. These patients do not need to be medicated but rather need their airways protected, particularly at night.
The Physiologic approach is a safer and more efficacious approach for most patients. While there is disagreement in dentistry over treatment philosophies almsot all patients have 50% or more improvement with orthotic or splint therapy. The treatment utilizes mechanical means to achieve physiologic results.
The Chiropractic community, especially the Sacro-Occipital (SOT), Cranio-Sacral, Atlas-Orthoganol and NUCCA practioners also use mechanical interventions to achieve physiologic success. Dr Ira L Shapira was invited to give a paper on Neuromuscular Dentistry at the SOTO Research Conference and a second lecture on Sleep Apnea and Sleep Disorders at the Clinical Symposium.
Dr Shapira is a pioneer in the field of Dental Sleep Medicine and did research in the 1980’s as a Visiting Assistant Professor at the Sleep Disorder Center of Rush Medical School. He worked very closely with Dr Rosalind Cartwright who published the earliest papers on treatment of sleep apnea with oral appliances. Dr Shapira’s research involved utilizing Neuromuscular Dental Measurements with the Mandibular Kinesiograph to evaluate the jaw position of patients with sleep apnea. His research showed that the jaw position of male sleep apnea patients were very similar to female TMJ patients.
The National Heart, Lung and Blood Institute (NHLBI) published a report with similar findings almost 20 years later. The report: CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS actually considers Sleep Apnea to be a TMJ disorder. UARS is a mild form of sleep disordered breathing. According to the NHLBI: “Although broad longitudinal and cross-sectional epidemiological studies have not been carried
out, TMD is estimated to affect about 12% of the general population, representing more than 34
million Americans. The majority of those seeking treatment are women in their reproductive
years. As for many other pain conditions, the clinical scenario of TMD also tends to be more
severe in women than men. TM disorders are considered a serious health problem because
many individuals lose their ability to hold regular jobs and to function productively even within
the context of a household environment.”
The approach of the SOT Chiropracters is to correct the posture and physiologic function of the whole body while adjusting the TM Joint and surrounding areas. They work closely with Neuromuscular Dentists to idealize the whole body as integral to proper TM Joint function. Their starting point is in the pelvis region. The approach is similar to the Craniosacral group.
The Atlas-Orthoganol Chiropracters look at the first two vertebrae and there connection to the occiput of the head as a starting point. They also address the full body posture as part of comprehensive treatment. Some NUCCA doctors believe that only correcting the Atlas/ Axis/ Occiput is all that is necessary to treat a patient. The Atlas- Orthoganol doctors take a more global view.
The Neuromuscular Dentist usually considers the bite and jaw position to be of primary importance and the rest of the body posture corrections done after a positive set point has been achieved.
All of these doctors as well as physical therapists and muscle physiologists and rehab specialists understand the importance of a holistic approach to care. The Neuromuscular Diagnostic Orthotic helps restore breathing, swallowing and other respiratory functions to return to a normal healthy state. The diagnostic orthotic is worn while the body systems are reorganizing to a healthier state. The neuromuscular bite is a resetting mechanism for the jaw muscles and for the entire postural change.
A more complete description of Neuromuscular Dentistry can be found at http://www.sleepandhealth.com/neuromuscular-dentistry.
Dr Shapira can be contacted thru his website: http://www.delanydentalcare.com/neuromuscular.html
More information on Headaches and TMD can be found at www.ihateheadaches.org
The following are excerpts from position paper from SOTO:
Chiropractic and Dentistry in the 21st Century: Guest Editorial, SOTO-USA’s Dental Chiropractic Position Statement
Originally published by: Blum CLThe Journal of Craniomandibular Practice Jan 2004; 22(1): 1-3.
Chiropractic and Dentistry in the 21st Century: Guest Editorial
As interdisciplinary healthcare matures, understanding that patient care should ultimately be our focus, hopefully differences can be put aside in light of our common goal. Within the cranial manipulative field mutual research cooperation between chiropractors, osteopaths, and physical therapists will hopefully be imminent in the 21st Century. This is presently happening with the multi-divisions of dentistry as relating to the field of craniomandibular/temporomandibular dysfunction (TMD/CMD) and conditions affecting condylar positions, functional orthodontic care, and the relationship of occlusion to the stomatognathic system and posture. The best way for us all to proceed is with an open mind and heart and willingness to learn and work together.
The Journal of Craniomandibular Practice (Cranio) has been a guiding light for those of us in the field of TMD/CMD since its inception in the early 1980s. When Cranio was started there was a paucity of literature substantiating care of the TMJ and often times healthcare professionals would chalk up a patient’s profound symtomatology as solely emanating from a psychosomatic disorder.
In the early 1980s it was common to see the chiropractic and dental fields working separately with patients suffering with TMD/CMD. Often times our paradigms and mode of diagnosis were completely different. While it is not uncommon for chiropractors to treat patients presenting with TMJ disorders 1-13 often times that care can reach a “roadblock,” and the patient’s ability to improve can only be resolved with help from those in the dental field.
Dental – Chiropractic co-treatment models are being developed and what appears to be essential in these early stages is educating each other to a syntax that can be readily understood between both fields. Initially a large obstacle between the dental and chiropractic fields related the dynamics of the craniofacial sutural system. The chiropractic field, particularly those practicing Sacro Occipital Technique (SOT), worked under the premise that the cranial and facial bones were not completely fused in adulthood. 14-19 That concept was not readily accepted by those in the dental field since the whole paradigm of craniofacial orthopedics and orthodontics would have to be viewed in a completely new light. However in spite of this the dental field is beginning to open up to these possibilities, 20 which has also opened the door to greater co-treatment possibilities with the chiropractic profession.
As the issue of cranial and facial bone compliance and its affect on occlusion and TMJ functioning has gained greater acceptance in the dental and chiropractic fields what has become a common theme between our professions is the relationship between the stomatognathic system and posture. 21-24 While the pelvis and TMJ might seem to be distal and unrelated aspects of our patient’s presenting symptoms, research is suggesting otherwise. 25-27 “Before fitting dental splints or equilibrating the occlusion, the sacroiliac joints should be examined for proper function and any sprain should be reduced. Correspondingly, after occlusion-altering (or potential occlusion-altering) dental procedures, the sacroiliac joints should be examined for proper function to determine if they show ongoing functional stability.” 27 The rationale for greater relationships between chiropractors and dentists has been discussed in the literature, since in some cases the only possible chance of a patient having any resolution of their TMD/CMD was with co-treatment. 28-31
SOT chiropractors have found that patients can present with ascending problems, which are , lower extremity, lumbosacral or cervical spine dysfunction or at other times descending problems which are lumbosacral or cervical spine dysfunction secondary to craniomandibular or occlusion imbalance. Working together with a dentist familiar with CMD/TMD is sometimes the only way to help patients suffering from this complex condition. One way the professions can advance a working relationship is by developing methods of determining when a patient’s case is a dental or chiropractic primary. Presently there are no absolute gold standards, but evaluation of the TMJ in standing, sitting, and supine postures, for instance, can help determine if there are lower extremity, pelvic or other related conditions affecting the TMJ, independent of the occlusion. There are other tests and modalities being used by both dentists and chiropractors evaluating neuromuscular functionality of the body and its relationship to TMD and further need to be agreed upon and developed. 32
Sacro Occipital Technique Organization (SOTO) – USA is a multidisciplinary organization formed to promote the awareness, understanding and utilization of the Sacro Occipital Technique method of chiropractic as founded and developed by Major Bertrand DeJarnette, DC, DO. SOTO-USA has conferences and symposiums yearly and incorporate dental chiropractic co-treatment models, helping to integrate both professions.
Robert Walker, DC of “Chirodontics” has often stated that “The most complex case for a dentist is the easiest for a chiropractor to help and the most complex case for a chiropractor is the easiest for a dentist to help.”