A Measured Approach – Predictability and Reliability
A “50 year old technology that is achieving slow but sure acceptance, because of its predictability and reliability…” Where has this dental profession been?
In 1986 the American Dental Association Council on Scientific Affairs, after in the ADA’s own words the most intensive scrutiny ever given, granted the ADA Seal of Acceptance to all of Myotronics products. This included the Myomonitor, Jaw Tracking and EMG. The Jaw Tracking, Electromyography (ESG) and Electrosonography ESG presently have the coveted ADA Seal of Acceptance after the scientific validity of the instrumentation was again reviewed several years ago by the ADA Scientific Council. What does that mean? The instrumentation does what it is intended to do PREDICTABLY and RELIABLY.
Neuromuscular instrumentation is “Standard of Care” in Italy. As you may know, most dentists in Italy are MD’s with a dental specialty. Really helped to have doctors with strong neurophysiology backgrounds. They were used to measuring! Virtually every dental university in Japan and Italy have instrumentation.
If one will go to the Myotronics website (www.Myotronics.com) one will also see that all the instruments have FDA 510k approval. Again, this is a most rigid process requiring predictability and reliability of the device to do what the manufacturer claims.
This is the danger of flippant statements on websites indicating that instrumentation has not achieved acceptance. There are thousands of pages of scientific documentation supporting the safety, efficacy, and reliability of these instruments. The data was necessary to pass the ADA Scientific Council and FDA scrutiny. It represents the work of hundreds of researchers throughout the world. It is a most compelling collection of data and documentation. If the reader is not aware of this voluminous scientific work such statement may keep a colleague from exploring technologies and techniques that can help their patients.
The genesis of neuromuscular dentistry began with the collaboration of Dr. Bernard Jankelson and H.H. Dixon, MD, a world famous muscle physiologist, at the University of Oregon Medical School in 1965. Dixon demonstrated that fatigued muscle restores its energy with light, free motion (we now call that the myopulse) below 1.0hz, in a biphasic wave at millamperage at around 100 volt. When a bilateral stimuli is delivered at 0.67hz through the coronoid notch it initiates a neurally mediated contraction of all muscle supplied by the Facial and Trigeminal nerve. The Myomonitor is designed to facilitate MUSCLE RELAXATION. The first Myomonitor was developed, based on Dixon’s parameters, in 1970. The paper by Williamson (1986) showed the affect of succinyl choline and subsequent Naloxone reversal on Myomonitor mediated contraction which affirmed the studies of Choi (1977), Fuji (1977), Jankelson et al (1975) etc.
There also appears to be some confusion regarding the intent and use of the Myomonitor. The Myomonitor measures nothing. The scientific literature supports the Myomonitors efficacy to facilitate muscle relaxation prior to occlusal diagnosis and treatment.
The studies involving use of the Myomonitor (Low frequency TENS), Jaw Tracking, Electromyography (EMG) and Sonography (ESG) all involve issues of human anatomy, physiology, neurophysiolgy. To my knowledge that airplane (the human body) still functions following the same universal laws that it did 50 years ago, 100 years ago, 1000 years ago etc. Quickly, let’s review the purpose of instrumentation.
Myomonitor (Low Frequency TENS) facilitates relaxation. Many studies have shown increased circulation, increased lymphatic drainage, and restoration of normal aerobic muscle function in fatigued muscle following Myomonitor therapy. i.e. Lasagna/Orlandi(1982) etc. Also remember that as the muscle goes from anaerobic to aerobic metabolism that 32 high energy phosphate molecules (ATP) necessary for normal muscle function (used at actin/myosin ATP binding sites) is available as opposed to only 4 ATP being hydrolyzed in the anaerobic (muscle spasm) state. That’s why it is so necessary to have a modality to intervene in the pain/spasm cycle since it is often a self perpetuating cycle in patients with occlusal pathology. One of the most elemental premises of neuromuscular dentistry is that the clinician should restore masticatory muscles and the TMJ to optimal function prior to establish a final occlusal position. Build the teeth (28 gears) into the most relaxed, functional position for joints and muscles. Then the muscles aren’t going to fight the gears, nor is derangement of the condyle/disk going to perpetuate. Happy muscles make for happy patients and dentists.
The Computerized Jaw Tracking, EMG and ESG are all measurement modalities. Jaw Tracking was first introduced in 1975, EMG in 1980 and ESG in 1985. EMG- measures muscle electrical activity at rest and in function. This is an objective expression of the Goldman-Nerst transmembrane equation that expresses the electrical and chemical properties of skeletal muscle. I think you would agree that objective data to evaluate muscle status before, during and after therapy is clinically useful. Over 300 supportive EMG studies were submitted for FDA and ADA approval processes. Not much argument there!
Jaw Tracking records three dimensional mandibular position relative to the maxilla . It’s impersonal, unemotional. Just tells you where the jaw is. Wouldn’t you like to have that in you clinical cockpit? Forget your occlusal philosophy. Wouldn’t it be great to know your patient’s jaw position displayed in three dimensions on the computer. In addition, real time EMG will give simultaneous information as to how the muscles are responding at that particular occlusal position. I know it has been a Godsend to me and my patients.
Electrosonography (ESG) simply detects, records quantifies and displays temporomandibular joints sounds. The doctors hearing acuity is not a factor. Don’t know about you, Rick, but I’m getting up there and sure wouldn’t want to depend upon my hearing to identify joint sounds. All it does is record joint sounds. Now, that’s not too radical is it?
Is is always a great honor to correct misconceptions. Ultimately there is only one common goal. Better patient care. I came from a rigid gnathologic background in the 1960’s. I studied with and knew most of the gurus–Charley Stewart, Peter K Thomas etc. They spent time in my office in the late 60’s and 70’s. Great gentlemen. But, centric relation never made sense. As that old country western song goes, “Lookin’ for love in all the wrong places”. Problem is we have been looking for mechanical solutions to neurophysiologic problems. Scientifically we should start from generic anatomic and physiolgic laws and build our occlusal paradigm from them.
I’ll close with Dr. Bernard Jankelson’s favorite comment (lifted from Chief Justice Cardoza)
“IF YOU CAN MEASURE IT IS A FACT, OTHERWISE IT IS AN OPINION.”
– Robert R. Jankelson,DDS
(January 12, 2000 3:21 PM)
All doctors are welcome to attend our Occlusion program at OCCLUSION CONNECTIONS to understand the technology and techniques involved in Gneuromuscular occlusion. I invite dialogue and any questions you may have regarding these issues.