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The following is the fourth of 15 responses to 15 exclusive interview question that was asked to answer. As one of many globally renowned clinicians, academicians and researchers I was asked by Dr. Sushil Koirala, Founder and Coordinator – MiCD Global Academy, Chief- Editor of MiCD Clinical Journal, to sharing my experience, clinical and research findings on the subjective of “TMDs – Confusion & Consensus: Expert’s Advice“.
4. In your opinion, what are the areas that are still controversial in TMD diagnosis, prevention, and management, and what are the issues that are already in consensus so far?
Within our dental profession some do not believe that dental occlusion has anything to do with TMD/Orofacial pain problems. Some do not believe that grinding/bruxism can be resolved with proper physiologic occlusal form. Bruxism is more than just a restricted airway breathing problem. Other professionals also do not realize that clenching can be resolved. We recognize that clenching goes beyond giving the excuse that it is a peripheral central nervous system problem.
Over the past 20 years there has been a growing awareness and consensus that measuring technology is scientific, valid and clinically relevant today. There is a growing group of dentists around the world who recognize the value and effectiveness when using low frequency “Dental” TENS. They found that dental TENS breaks up spastic proprioceptive muscular engrams that negatively impact muscle tonicity. Hyper-muscle activity and abnormal muscle memory (engrams) contribute to a posteriorizing of the mandible. This clinically means the closing path of the mandible is often less than ideal. When muscles strain, torque and twist the associated structures, the mandible and occlusion is posteriorly positioned. These unseen factors contribute to unwanted occlusal forces, slides and bite imbalance.
Involuntary jaw movements produced by low frequency dental TENS have clinical relevance and must be distinguished from voluntary (habitual/accommodating) jaw closing movement patterns. Most clinicians treating TMD do not recognize these important physiologic functional factors. The involuntary closing path (myo-trajectory) of the mandible must equal the voluntary (habitual) trajectory and vice versa. Whenever there is a difference between these two closing paths based on scientific jaw tracking measurements one will realize the bio-physiologic disparity. This disparity in jaw closing path conditions is what causes muscles to strain, teeth to wear, facet, grind down, become achy, sensitive and periodontal bone loss to occur.
There is a growing awareness that a habitual centric occlusion (CO) or the maximum intercuspal position (MIP) may not always be the most ideal (physiologic healthy) position when establishing a patient’s bite (terminal contact occlusal position), especially when muscle pains, joint symptoms and displaced disc are present. A limited mouth open (decreased mandibular range of motion) is one of many musculoskeletal occlusal signs indicating that the bite/occlusion is not optimal and TMD problems exist. We know from our many years of teaching and practice dentists have recognized some of these mentioned factors as problematic. Some dentists may unknowingly ignore them. Why? Because they lack an awareness and the teachers did not know how to treat these kinds of problems effectively – getting to the source of the problem.
Physiologic rest position can be measured and recorded to distinguish from a pathologic/habitual rest position. The important concept of the mandible’s physiologic rest position is a key diagnostic principle that is controversial. Why? Because most dentist were never trained to understand what it means to establish a true physiologic rested mandibular position (homeostasis) and what it looks like from a measured perspective. They were never shown how it is possible to objectively measure involuntary jaw movements, how it is different than habitual voluntary jaw movements (especially in cases that have muscle dysfunction, pain and temporomandibular dysfunction problems). Most clinicians never knew there is a difference.
Recognizing the difference with measured instrumentation in a scientific manner unveils the hidden secrets to proper occlusion, muscle health and proper TMD diagnosis. Without this realization TMD problems will continue to be misdiagnosed and be mistreated.
When the dental profession no longer is able to find a reasonable and scientific basis for the suffering patient’s complaint these patients are often relinquished to the waste heap of our dental and medical profession as either crazy, time consuming and or psychologically impaired. Could it be that in actuality the dentists were never trained to know and learn what they didn’t know?
Neuromuscular (NM) instrumentation has been recognized by the FDA and ADA as scientifically valid. “The ADA Council on Scientific Affairs Acceptance of K7/EMG Electromyography, K7/CMS Jaw Tracking and K7/ESG Electro-sonogram is based on its findings that the products are effective for measuring physiologic or anatomic parameters of the temporomandibular musculoskeletal complex, when used as directed.” (June 16, 2005.) Many TMD leaders and occlusal teachers in the past have strongly criticized and fought against the NM approach mainly because of the present dental occlusion establishment, culture and cherished dogmas. A majority of dentists lacked the understanding and experience in the clinical use of these newer measuring technologies. The FDA have evaluated neuromuscular measuring instrumentation and found them to meet each of the criteria for scientific validity and found them to be effective aids in the diagnosis and treatment of TMD.
Many scientific discoveries are still being made and led by new occlusal paradigms. Scientists adopt new instruments and are open to look in new places for better clinical answers. Even more importantly, during revolutions, scientists will seek new and different ways when looking for better answers with familiar instruments in places they have previously looked before. An increased appreciation and understanding of the GNM occlusion concept have developed causing many fellow colleagues to take the deep dive into learning TMD science and occlusion. They chose to discover things they never fully realized existed and now realize is possible clinically. This has been my experience and realization from my personal research and clinical investigations.
Clayton A. Chan, D.D.S. – Founder/Director
Telephone: (702) 271-2950
Leader in Gneuromuscular Dentistry