CDA Journal - 082014 PDF
CDA Journal - 082014 PDF
CDA Journal - 082014 PDF
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/265332367
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Dan Jenkins
International Association of Physiologic Aest…
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TMD:
THE GREAT
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Daniel N. Jenkins, DDS, LVIF, CDE
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Aug. 2014 C D A J O U R N A L , V O L 4 2 , Nº 8
D E PA R T M E N T S
585 Periscope
588 Tech Trends
589 Dr. Bob/Snore and You Sleep Alone 501
F E AT U R E S
563 Physiologic Neuromuscular Dental Paradigm for the Diagnosis and Treatment of
Temporomandibular Disorders
PNMD paradigm acknowledges the primacy of physiology in shaping and controlling
anatomy in a functioning human body.
Prabu Raman, DDS, MICCMO, LVIM, FPFA, FACD
A U G U S T 2 014 495
C D A J O U R N A L , V O L 4 2 , Nº 8
CDA Classifieds.
JournaC A L I F O R N I A D E N TA L A S S O C I AT I O N
Volume 42, Number 8
August 2014
496 A U G U S T 2 014
Associate Editor C D A J O U R N A L , V O L 4 2 , Nº 8
A
bout a year ago, a California
dental school administrator
predicted that the “small, Overhead has always
single-practitioner family been a concern, but will it be
dental office” would soon
be a thing of the past. Put aside the the cause of our extinction?
corporate practices and the potential
large retail store shops. Since then, the
consolidated all-dentistry-under-one-roof
offices and dentist-owned-and-operated system instantaneously — and prefer to dentist finds a good fit in an associate
group practices have been popping up communicate via email.1 And according — someone who can manage a satellite
on my radar. They’re everywhere. And to the ADA, millennials will “shop office, provide quality care to patients
they’re multiplying. They’re burgeoning. around for better prices” as compared to and follow through on the brand that
Health policy experts at the other generations. Will a larger office, the name on the door is supposed to
American Dental Association with the ability to balance its bottom represent. And if we could bottle the
maintain that the dental economy line and provide treatment and lower good-fit associate formula, wouldn’t we all
is “in transition.”1 Of course, we costs, be better able to cater to this aspire to start our own group practice?
can all acknowledge the burst of generation? The ADA reports, “When The ADA’s Healthy Policy Institute
consumerism in our practices. Patients owner dentist salaries are included as a notes that dentists who are 65 years of
are increasingly developing a new cost, practice expenses average about age and older are choosing this group
mindset and approach to managing 90 percent of gross billings.”1 Overhead practice model, second only to those who
their health. I think it’s a good thing. has always been a concern, but will are 35 years of age and younger. Larger
Patients have a right to choose who it be the cause of our extinction? practices buy mass supplies at a cheaper
provides their care and how, and they The ADA Health Policy Institute cost; thus, services can be provided at a
deserve to understand why the care is has been tracking the recent increase of lower cost to the office. And the patient
needed. Because we are a small office, group practices throughout the country. can receive dental treatment at a lower
we are flexible to such demands. We They are not only growing in quantity, cost as well. It may be cheaper or easier
take our time. We discuss our findings but also modernizing in “character and for the large group practice to provide its
and reasons for diagnoses with patients structure.” The ADA has proposed employee benefits and retirement plans.
at great length. We have the luxury six classifications, including dental The economies of scale tilt the scale in
of ensuring that our patients see the management organization affiliated favor of many dentists choosing to expand
same familiar practitioner at every group practices, insurer-provider group their single-practitioner practices into
appointment. You know what you’re practices, not-for-profit group practices, a larger corporation with more dentists,
going to get when you come to one of our government agency group practices, more patients and perhaps more revenue.
single-practitioner offices. How would hybrid group practices and dentist- Our colleagues in medicine are facing
an office with a multitude of dentists owned and -operated group practices.1 the extinction of the single-practitioner
seeing many patients with production We all know a successful general offices at a much higher rate. Accenture
goals looming over its head manage the dentist who has branched out to open recently reported “a significant drop in
transition our profession is facing? several satellite offices. Sometimes a physicians who practice independently,
And then there is the new generation turnkey group of associates sees the from 57 percent in 2000 to 39 percent
of patients. Millennials may have patients, while the name-on-the-door in 2012.”2 The overwhelming majority,
more casual feelings about their health owner dentist handles the marketing almost 90 percent, reported the top
care system. But they also want access and business aspects of the offices. Yet, grounds for this transition were business
to the doctor and their health care sometimes we get lucky. The owner costs and expenses. As one physician
A U G U S T 2 014 497
A U G . 2 0 14 ASSOCIATE EDITOR
C D A J O U R N A L , V O L 4 2 , Nº 8
in Minnesota noted, “The only way doctors unwound the relationships and cities and suburbs may be targeted by
to survive … is having big pockets went back to running their own offices.” a slew of corporate and group practices
behind you, and that’s joining a hospital Many questions arise. How do we trying to run us out of town. But from
or joining an insurance company.”3 survive extinction? Since single-dentist what I’m told, our profession has a history
Another physician cited the economic offices make up a large portion of CDA of resiliency. We are nimble. We adapt.
barriers (especially compensation and membership, will organized dentistry take We will determine how to make the most
reimbursement) in recruiting new brilliant on the responsibility of preventing our of our individuality and set ourselves
physicians and retaining the super-star extinction? In fact, it’s actually ironic. apart from the dinosaurs (or the giant
physicians who were proven valuable A Guardian article explains that larger group practices). I have a feeling that we
members of their medical team. Many animals “tend to suffer the most in mass won’t just survive. We will figure out a
articles blame these financial issues on extinctions because they usually have way to thrive in what may be a different
the changes mandated by the Affordable specialized … requirements. Plants are dental world in the coming years. ■
Care Act, pointing to the increases for hardier.”5 The article goes on to provide
independent medical practice overheads tips on surviving mass extinction, two REFERENCES
and changes in the reimbursement system. of which can perhaps be applied to our 1. ADA Health policies resources center: A Profession in
Transition and A Proposed Classification of Dental Group
Yet studies show that the transition single-practitioner dental offices: Be a Practices.
from a single-practitioner medical generalist and be good at surviving stress. 2. Number of Independent Physicians Decreasing. www.rwjf.
practice to a salaried employee of a We must have an ability to provide diverse org/en/blogs/human-capital-blog/2012/11/number_of_
independen.html.
hospital is not always positive. An patients with a variety of services and 3. “The business of dentistry continues to face challenges as
article on forbes.com cites “ample “keep going through bad times or be able well.” www.mprnews.org/story/2011/05/14/independent-
evidence” that this transition actually to move into a new environment and medical-practice.
4. Hospitals Are Going on a Doctor Buying Binge,
decreases employees’ productivity.4 survive.” Though we may be smaller, we and It Is Likely to End Badly. www.forbes.com/sites/
Evidently, this is not medicine’s first have large patient populations and know scottgottlieb/2013/03/15/hospitals-are-going-on-a-doctor-
day at this rodeo. The rapid and large-scale how to be efficient with our resources. buying-binge-and-it-is-likely-to-end-badly.
5. www.theguardian.com/science/lost-worlds/2012/sep/20/
hospital acquisitions of medical practices Only time will tell if the dental dinosaurs-fossils.
happened in the 1990s. The Forbes administrator was right about our
article attests, “The hospitals and practice extinction. Perhaps many of our practices The Journal welcomes letters
management companies that went on will become like the ivory-billed We reserve the right to edit all
buying binges … mostly failed. The woodpecker or the little dodo bird. Our communications. Letters should discuss
an item published in the Journal within
the past two months or matters of general
interest to our readership. Letters must be
Reminder for Members to Create New no more than 500 words and cite no more
than five references. No illustrations will
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498 A U G U S T 2 014
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Impressions C D A J O U R N A L , V O L 4 2 , Nº 8
A U G U S T 2 014 501
A U G . 2 0 14 IMPRESSIONS
C D A J O U R N A L , V O L 4 2 , Nº 8
Dog Breed
d May Unlock Discovery on Cleft
Clefft Palate
Palates
Nova Scotia Duck Tolling Retrievers may hold the key to learning more about cleft
palates, a birth defect that affects approximately one in 1,500 live births in the U.S.
Researchers at the University of California, Davis, School of Veterinary Medicine
Gum Disease Bacteria have discovered a genetic mutation that causes cleft palate in this dog breed.
The genome-wide study of Nova Scotia Duck Tolling Retrievers, published in
Selectively Disarm Immune the PLOS Genetics journal, found that the dogs that have the mutation also have
System a shortened lower jaw, similar to humans who have Pierre Robin sequence.
The human body is composed of “This discovery provides novel insight into the genetic cause of a form of cleft
roughly 10 times more bacterial cells palate through the use of a less conventional animal model,” said Professor Danika
than human cells. In healthy people, Bannasch, a veterinary geneticist who led the study. “It also demonstrates that
these bacteria are typically harmless. dogs have multiple genetic causes of cleft palate that we anticipate will aid in the
But, when disturbances knock these identification of additional candidate genes relevant to human cleft palate.”
bacterial populations out of balance, This is the first dog model for the craniofacial defect. Cleft palate is not commonly
illnesses can arise. Periodontitis, a severe understood, so this is could lead to a breakthrough in research for humans.
form of gum disease, is one example.
According to the Mayo Clinic, cleft lip and palate “occur when tissues in the baby’s
In a new study, University of
face and mouth don’t form properly. Normally, the tissues that make up the lip and palate
Pennsylvania researchers show
that bacteria responsible for many fuse together in the second and third months of pregnancy. But in babies with cleft lip and
cases of periodontitis cause this cleft palate, the fusion never takes place or occurs only partially, leaving an opening (cleft).”
imbalance, known as dysbiosis, with a The findings of the study can be found at plosgenetics.org/article/
sophisticated, two-pronged manipulation info%3Adoi%2F10.1371%2Fjournal.pgen.1004257.
of the human immune system.
Their findings, reported in the
journal Cell Host & Microbe, describe
the mechanism, revealing that the
periodontal bacterium Porphyromonas another, exacerbating periodontitis. Toll-like receptor-2, or TLR2.
gingivalis acts on two molecular pathways In this study, the researchers Inoculating mice with P. gingivalis,
to simultaneously block immune cells’ wanted to more fully understand the they found that animals that lacked
killing ability while preserving the molecules involved in the process by either of these receptors, as well as
cells’ ability to cause inflammation. The which P. gingivalis causes disease. animals that were treated with drugs that
selective strategy protects “bystander” “We asked the question, how could blocked the receptors, had lower levels
gum bacteria from immune system bacteria evade killing without shutting of bacteria than untreated, normal mice.
clearance, promoting dysbiosis and off inflammation, which they need to Blocking either of the two receptors
leading to the bone loss and inflammation obtain their food,” said senior author on human neutrophils in culture
that characterize periodontitis. At George Hajishengallis, DDS, PhD. also significantly enhanced the cells’
the same time, breakdown products The team focused on neutrophils, ability to kill the bacteria. Microscopy
produced by inflammation provide which shoulder the bulk of responsibility revealed that P. gingivalis causes TLR2
essential nutrients that “feed” the for responding to periodontal insults. and C5aR to physically connect.
dysbiotic microbial community. The Based on the findings of previous For more information, see the
result is a vicious cycle in which studies, they examined the role of complete study in the June 11, 2014,
inflammation and dysbiosis reinforce one two protein receptors: C5aR and issue of Cell Host & Microbe.
502 A U G U S T 2 014
C D A J O U R N A L , V O L 4 2 , Nº 8
A U G U S T 2 014 503
Practice Support
Expert Analysts
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quick pra c tice
manag emen t
question, bu t who
can I ask tha t
I trust ?
CDA members have access to Practice Support Analysts
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Always just a phone call or email away, they have the
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A U G . 2 0 14 IMPRESSIONS
C D A J O U R N A L , V O L 4 2 , Nº 8
“It would be a
substantial advance
Light Coaxes Stem Cells to Repair Teeth in the field if we can
A Harvard-led team is the first to in regenerative medicine, such as wound regenerate teeth rather
demonstrate the ability to use low-power healing, bone regeneration and more. than replace them.”
light to trigger stem cells inside the The team used a low-power laser
DAVID MOONE Y , P H D
body to regenerate tissue, an advance to trigger human dental stem cells
they reported in Science Translational to form dentin, the hard tissue that
Medicine. The research, led by Wyss is similar to bone and makes up the
Institute Core Faculty member David bulk of teeth. They also outlined the
Mooney, PhD, lays the foundation precise molecular mechanism involved A number of biologically active
for a host of clinical applications in and demonstrated its prowess using molecules, such as regulatory proteins
restorative dentistry and, more broadly, multiple laboratory and animal models. called growth factors, can trigger stem
cells to differentiate into different cell
types. Current regeneration efforts
require scientists to isolate stem cells
Oral Cancer-fighting Patch in the Works from the body, manipulate them in a
The Ohio State University and the University of Michigan have signed an agreement laboratory and return them to the body
with Ohio-based Venture Therapeutics Inc. to develop and commercialize a pharmaceuti- — efforts that face a host of regulatory
and technical hurdles to their clinical
cal technology targeted at the treatment of precancerous oral lesions. These lesions are
translation. But Mooney’s approach is
currently managed by invasive surgery, and approximately a third recur after surgery.
different and, he hopes, easier to get
Previously published data show that about 30 percent of the higher grade into the hands of practicing clinicians.
precancerous oral lesions progress to oral cancer, specifically oral squamous cell “Our treatment modality does not
carcinoma. This type of cancer is particularly devastating to patients because treatment introduce anything new to the body, and
entails removal of facial and mouth structures essential for esthetics and function. The lasers are routinely used in medicine
National Cancer Institute estimates that 42,440 Americans will be diagnosed with oral and dentistry, so the barriers to clinical
cancer and more than 8,390 oral cancer-related deaths will occur in 2014. translation are low,” he said. “It would be
Precancerous oral lesions can be seen and touched by patients, and this easy a substantial advance in the field if we can
access to the lesion allows the use of local delivery formulations in an oral patch to regenerate teeth rather than replace them.”
directly treat the disease without causing adverse side effects. In a laboratory version of a dentist’s
“This type of collaboration, involving multiple university partners with strong office, the researchers drilled holes
in rodents’ molars, treated the tooth
industry support, is increasingly essential to expedite the discovery, development
ind
pulp that contains adult dental stem
delivery of more targeted cancer therapies. There is no routine
and de
cells with low-dose laser treatments,
cancer, and today it takes the collective minds across disciplines, applied temporary caps and kept the
institutions and industry to move the field forward,” said Michael
institu animals comfortable and healthy. After
Caligiuri, MD, director of The Ohio State University Comprehensive
Cali about 12 weeks, high-resolution X-ray
Cancer Center.
Can imaging and microscopy confirmed
“Ultimately, these collaborations can be the catalyst for new, more
“U that the laser treatments had triggered
ective cancer treatments, leading to better outcomes, faster responses,
effectiv the enhanced dentin formation.
fewer side effects and more hope for cancer patients everywhere,” Next, the team aims to take this
Caligiuri said.
Cal work to human clinical trials. For more
information, see the study in the journal
Science Translational Medicine, May 2014.
A U G U S T 2 014 507
A U G . 2 0 14 IMPRESSIONS
C D A J O U R N A L , V O L 4 2 , Nº 8
O
H NH2
1 Me N
Gln Trp Val Ile (D)
Tyr
Asp
S
Trp
S
Promising New Target for Gum Disease Treatment Identified
Sar Nearly half of all adults in the U.S. around a tooth, promoting the buildup of
N-Me
suffer from periodontitis, and 8.5 microbes, and one in which the disease
Ala His Arg N percent have a severe form that can occurs naturally in aging mice, mimicking
Ile
H
O
raise the risk of heart disease, diabetes, how it develops in aging humans.
arthritis and pregnancy complications. “Without the involvement of a
University of Pennsylvania different complement component,
The results, researchers have been searching for the C5a receptor, P. gingivalis can’t
Hajishengallis ways to prevent, halt this mean and colonize the gums,” said George
reverse periodontitis. In a report Hajishengallis, DDS, PhD, a professor
said, “provide published in the Journal of Immunology, in the School of Dental Medicine’s
proof-of-concept they describe a promising new target: a Department of Microbiology. “But
component of the immune system called without C3, the disease can’t be
that complement- complement. Treating monkeys with sustained over the long term.”
targeted therapies a complement inhibitor successfully Building on this finding, the
can interfere with prevented the inflammation and bone researchers tested a human drug that
loss associated with periodontitis, blocks C3 to see if they could reduce the
disease-promoting making this a promising drug for signs of periodontal disease in monkeys,
mechanisms.” treating humans with the disease. which, unlike mice, are responsive to
Earlier work by the Penn team had the human drug. They found that a
shown that the periodontal bacterium drug called Cp40, a C3 inhibitor that
Porphyromonas gingivalis can hamper the was developed for the treatment of the
ability of immune cells to clear infection, rare blood disease paroxysmal nocturnal
allowing P. gingivalis and other bacteria hemoglobinuria (PNH) and ABO-
to flourish and inflame the gum tissue. incompatible kidney transplantation,
The researchers wanted to find out reduced inflammation and significantly
which component of the complement protected the monkeys from bone loss.
system might be involved in contributing According to the researchers,
to and maintaining inflammation in this study represents the first time,
the disease. Their experiments focused to their knowledge, that anyone has
on the third component, C3, which demonstrated the involvement of
occupies a central position in signaling complement in inflammatory bone loss
cascades that trigger inflammation and in nonhuman primates, setting the stage
activation of the innate immune system. for translation to human treatments.
The team found that mice bred to The results, Hajishengallis said,
lack C3 had much less bone loss and “provide proof-of-concept that
inflammation in their gums several complement-targeted therapies
weeks after being infected with P. can interfere with disease-
gingivalis compared to normal mice. C3- promoting mechanisms.”
deficient mice were also protected from For more information, see the
periodontitis in two additional models of study in the Journal of Immunology
disease: one in which a silk thread is tied published online first May 7, 2014.
508 A U G U S T 2 014
This year, be inspired.
CDA Presents The Art and Science of Dentistry is one of
the most anticipated dental conventions in the U.S., thanks
in part to the dynamic exhibit hall. With new product
launches and hundreds of exhibiting companies, this is the
place to be inspired by the latest innovations in dentistry.
CDA Presents. So much more than you imagined.
The Spot — The Smart Dentist Series, Free Lectures in the Educational Theater
Pilates Respond- Practice Latest Tripartite Ethical
and Yoga ing to Transition Trends Leadership Dental
Stretches Online Hoover in Dental Opportuni- Profes-
Proper Reviews Benefits ties sionals
Posture Corum Milar LDC Repre- Ryan
Kagan sentative
7 AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
CDA Presents Schedule-at-a-Glance
Express Lectures — Speakers New to the Podium
7 AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
7 AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
CDA Presents Schedule-at-a-Glance
Moscone South (MS) * Repeated Course Friday Exhibit Hall Hours
The Spot — The Smart Dentist Series, Free Lectures in the Educational Theater
Manuals What Can Managing Dental Interna-
and a Consul- Patient Benefits tional
Policies tant Do Conflicts Milar Volunteer
Thomason for Your Alvi Rollofson
Practice?
Perry
7 AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
CDA Presents Schedule-at-a-Glance
Lectures (continued)
7AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
7 AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
CDA Presents Schedule-at-a-Glance
Moscone South (MS) * Repeated Course Saturday Exhibit Hall Hours
9:30 a.m.—4:30 p.m.
Saturday, Sept. 6, 2 014
InterContinental (IC)
Dugoni School (DS)
> Continued Course
The Spot — The Smart Dentist Series, Free Lectures in the Educational Theater
Regulatory
Compli-
ance
Pichay
7AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
CDA Presents Schedule-at-a-Glance
Lectures (continued)
7AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
Nuts-and-bolts Treatment
Planning
Melkers, MS 101
Top Tips for Clinical Success Anterior Esthetic Techniques
Brady, MS 101 and Materials
Brady, MS 101
Imaging Frontiers Applied Imaging
Hatcher, MS 310 Hatcher, MS 310
Dental Implants: From Basic Dental Implants
to Advanced Warshawsky, MS 200-212
Warshawsky, MS 200-212
Practice Transition Practice Assessment
Perry, IC Grand Ballroom B Perry, Thomason, IC Grand
Ballroom B
I'm A Dentist – Now What? Financial Planning for Dentists
Wiederman, MS 302 Wiederman, MS 302
Smart Patient Management Forensic Odontology
Glazer, MS 308 Glazer, MS 308
Basic Social Media/Online Advanced Social Media/
Reputation Online Reputation
Zuckerberg, MS 303/305 Zuckerberg, MS 303/305
Treatment for the Medically Guide to Clinical Protocols
Complex Patient Glick, MS 309
Glick, MS 309
MICRA
Davidson,
MS
274/276
Esthetic Dentistry Update
Kugel, MS 307
7AM 8 AM 9 AM 10 AM 11 AM Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM
The Art
and Science
PRESENTS of Dentistry Exhibitor Listing
3M ESPE ........................................ 1719 Columbia Dentoform ......................... 926 Engle Dental Systems ....................... 1528
A. Titan Instruments ......................... 2038 Common Sense Dental Products ........ 2208 eRECORDS Inc ................................. 620
Accutron Inc ................................... 1012 Community Medical Center ................ 512 eRelevance Corporation................... 2408
Acteon North America ..................... 2120 ContacEZ, Ultimate Interproximal eServices ....................................... 2126
A-dec ............................................ 1110 Solution ..................................... 2210 Essential Dental Systems................... 1308
Air Techniques Inc ........................... 1012 Convergent Dental .......................... 2310 EXACTA Dental Direct ........................ 805
Airway Management......................... 402 Cosmedent Inc ................................ 1516 EZ 2000 Inc ................................... 1328
ALCO Professional Supplies ............. 1441 Cowsert Dental Supply .................... 1426 E-Z Floss......................................... 1514
All Computer Systems ........................ 842 Crescent Products ............................ 2302 Flight Dental Systems ......................... 715
AllPro ............................................ 1830 Crest Oral-B ................................... 1202 Flyingdocs.org (Los Medicos
AMD Lasers ...................................... 404 Crown Seating ............................... 2206 Voladores) .................................. 2435
American Eagle Instruments ................ 722 Crystalmark Dental Systems .............. 1836 Forest Dental Products Inc................. 1012
AM-Touch Dental ............................. 1540 CustomAir ........................................ 926 Fortune Management....................... 1137
Angie’s List ..................................... 2304 Danville Materials LLC ..................... 2115 Fotona, Lasers4Dentistry .................... 706
Apteryx Inc ...................................... 627 Darby Dental Supply LLC.................... 725 Fundation ......................................... 628
Aseptico ........................................ 1418 Datacon Dental Systems ................... 1627 Garfield Refining Company .............. 1106
Aspen Dental .................................. 2402 Demandforce .......................... 913, 2138 Garrison Dental Solutions ................... 811
Associated Dental Dealers ................ 1426 DenMat ......................................... 1319 GC America Inc .............................. 1102
ATS Dental ..................................... 1426 Denovo Dental Inc ........................... 1428 Gendex/NOMAD/SOREDEX/
Axis Dental..................................... 1808 Dental Board of California ................. 514 Instrumentarium ........................... 1814
Bank of America Practice Solutions...... 918 Dental USA ...................................... 522 Giggletime Toy Company ................. 1701
Beaverstate Dental Systems .............. 1518 DentalEZ Group ................................ 926 Glidewell Laboratories ..................... 1532
Belmont Equipment .......................... 1420 Dentalree.com .................................. 526 Global Dental Relief .......................... 414
Benco Dental .................................... 832 Dentaltown .................................... 2240 Global Surgical Corporation ............ 1717
Berkeley Free Clinic & Suitcase Clinic .. 534 DentalVibe ..................................... 2141 Glove Club..................................... 1609
Beyes Dental Canada ...................... 1942 DentalXChange — EHG................... 1013 Good Time Attractions ....................... 838
Bien-Air Dental................................ 2202 Dentaprox ...................................... 2328 Great Lakes Orthodontics ................. 1512
Bioclear Matrix Systems by Dentazon (DXM) ............................... 606 GuaranteedCelebrity.com ................. 442
Dr. David Clark ............................. 718 DENTCA ........................................ 2040 GumChucks at Oralwise Inc ............. 2337
BioHorizons ................................... 1939 Dentegra Insurance Company........... 1538 Handpiece Express............................ 601
BIOLASE ........................................ 1614 Denti-Cal .......................................... 825 Hartzell & Son, G. .......................... 1401
Biotec Inc ....................................... 1425 DentiMax Practice Management ......... 516 Hawaiian Moon ............................... 613
Bisco Dental Products ...................... 1620 Dentist’s Advantage ......................... 1615 HealthFirst ...................................... 1703
BQ Ergonomics ....................... 719, 2238 Dentrix........................................... 2126 Henry Schein Dental ........................ 1926
Brasseler USA ................................. 1002 Dentrix Ascend ............................... 2126 Henry Schein Merchandise/Exclusives .1925
BrightLine Medical Inc ....................... 518 DENTSPLY Caulk ............................. 1402 Henry Schein Orthodontics............... 1933
Broadview Networks ....................... 2142 DENTSPLY International.................... 1402 Henry Schein Practice Management
Burkhart Dental Supply .................... 2102 DENTSPLY Maillefer......................... 1402 Solutions .................................... 2126
CadBlu .......................................... 2316 DENTSPLY Professional .................... 1402 Henry Schein Professional Practice
California Dental Assistants Association...635 DENTSPLY Prosthetics....................... 1402 Transitions .................................. 2036
California Dental Hygienists’ Association . 633 DENTSPLY Raintree Essix .................. 1402 Henry Schein ProRepair ................... 2135
California Dentists’ Guild ................. 1431 DENTSPLY Rinn ............................... 1402 Heraeus Kulzer ............................... 1212
CareCredit ..................................... 1017 DENTSPLY Tulsa Dental Specialties .... 1402 High Level Medical ......................... 2313
Carestream Dental .......................... 1312 Denttio Inc ........................................ 626 High Speed Service......................... 1426
Cargill ............................................. 941 Desco Dental Equipment .................... 726 Hiossen Inc..................................... 2232
CariFree .......................................... 836 Designs for Vision Inc .............. 819, 2022 HR For Health ................................... 604
CDA Endorsed Programs ................... 802 DEXIS Digital X-Ray ......................... 1802 Hu-Friedy ....................................... 1502
CDA Foundation ............................... 802 DiaGold/GoldBurs.com/MDT ............ 622 Hunter Dental ................................... 726
CDA Member Benefits Center ............. 802 Diatech .......................................... 1330 i-CAT/Imaging Sciences ................... 2016
CDA Mobility Center ......................... 802 DigiDent Dental Art Technology ........ 2311 ICW International ........................... 1012
CDA Practice Support ........................ 802 Digital Doc LLC ............................... 1742 Infinite Therapeutics ......................... 2421
CDA Well-Being Program ................... 508 Digital Practice Xperts Inc ................... 432 Infinite Trading ................................ 2405
Centrix Inc ..................................... 1837 DMG America ................................ 1527 Institute for Advanced Laser Dentistry ... 831
Citibank Commercial Bank Healthcare DOCS Education............................... 729 Instrumentarium............................... 1814
Practice Finance Group................ 2419 Doral Refining Corp. ....................... 1405 Integrity Practice Sales ...................... 642
ClearBags ...................................... 2306 DoWell Dental Products ................... 1941 Invisalign/iTero ............................... 2301
ClearCorrect .................................... 940 Dr. Fresh LLC .................................. 2215 Isolite Systems................................. 2214
Clinician’s Choice Dental Products Inc. ..1738 Dr. Fuji........................................... 2341 Ivoclar Vivadent Inc ........................... 826
Coast Dental .................................... 937 DryShield ......................................... 735 J. Morita USA Inc ............................ 1510
Cochran Dental .............................. 1426 Easy Dental .................................... 2126 KaVo ............................................. 1720
Colgate ......................................... 1702 Ecoclean ........................................ 2241 KaVo Kerr Group ............................ 1714
Coltene .......................................... 1631 Endo Technic .................................. 1715 Keating Dental Arts ........................... 815
Exhibitor Listing
Kerr Corporation............................. 1808 Philips Sonicare and Zoom Staples Advantage ............................ 917
Kettenbach LP ................................. 1637 Whitening .................................. 1432 Star Dental Supply Inc ..................... 2303
Kilgore International Inc ................... 1621 PhotoMed International ...................... 701 StarDental ........................................ 926
Kohan Group ................................... 712 Physics Forceps — Golden Dental Sultan Healthcare ............................ 1602
Komet USA ...................................... 703 Solutions ...................................... 618 Suni Medical Imaging Inc................. 1437
Kuraray America Inc........................ 1832 Planmeca CAD CAM Division........... 1936 Sunstar Americas ............................ 1604
L.A.K. Enterprises Inc ....................... 1618 Planmeca USA Inc ........................... 1636 Supply Doc Inc ................................. 605
Lares Research ................................ 1414 Porter Instrument Co. Inc .................. 1425 SurgiTel/General Scientific Corp. ...... 2220
LED Imaging ..................................... 426 Posca Brothers Dental Lab Inc ........... 1342 SW Gloves .................................... 2137
Lester A. Dine Inc ............................ 1625 PracticeSquare.................................. 739 SybronEndo ................................... 1808
Livionex Inc ...................................... 840 PractiCure ..................................... 2204 Symphony Metals............................ 1612
LocalMed ....................................... 2332 Preventech...................................... 1617 TDIC ................................................ 802
Loma Linda University School of PreXion Inc ..................................... 2336 Tech West Inc ................................. 2212
Dentistry....................................... 511 PRO-Craft Dental Laboratory............... 603 TeleVox ............................................ 721
LumaDent ............................... 502, 2425 Professional Practice Sales ............... 1407 The Auxiliary of The Gideons
MacPractice ..................................... 521 Professional Sales Associates Inc ....... 1012 International ................................. 536
Magic Massage Therapy ................... 742 Proma Inc....................................... 1425 The Digital Dentist ............................. 820
Main Street Hub................................ 504 Prophy Magic ................................. 1220 The QDr........................................... 617
Marus Dental .................................. 1916 Prophy Perfect .................................. 818 Tokuyama Dental America Inc ............. 616
MassMutual...................................... 619 ProSites............................................ 919 ToothPyk.com.................................... 615
Maxdent Dental .............................. 1426 Pulpdent Corporation....................... 1317 Top Quality Manufacturing Inc ............ 731
Medi-Cal EHR Incentive Program ........ 634 PureLife Dental .................................. 914 Tri Hawk International........................ 531
Medidenta ..................................... 1222 Q-Optics & Quality Aspirators .......... 1218 Trojan Professional Services Inc .......... 816
Medtrainer Inc ................................ 2406 Quality Dental ................................ 1426 U.S. Bank Small Business Banking ....... 501
Meisinger USA LLC.......................... 1012 Quintessence Publishing Co. Inc ....... 1205 U.S. Dental Tennis Association .......... 2433
Meta Biomed Inc .............................. 632 R & D Services Amalgam Separators....1635 UCSD Student-Run Free Dental Clinic......436
Microcopy ..................................... 1302 Radiation Detection Company ............ 714 UCSF School of Dentistry ................... 507
MicroDental Laboratories ................... 702 RAMVAC ......................................... 926 Ultimate Creations Inc ...................... 2415
Midmark Corporation ...................... 1626 Renue Dental .................................... 841 Ultradent Products Inc ...................... 1726
Milestone Scientific.......................... 1237 Reputation Impression ........................ 710 Ultralight Optics ....................... 732,1842
Millennium Dental Technologies Inc ..... 827 Reputation.com Inc .......................... 2307 Universal Orthodontic Lab ................ 1039
Miltex, an Integra Company ............. 1526 RF America .................................... 2116 University of the Pacific, Arthur A. Dugoni
MIS Implants Technologies Inc .......... 1740 RGP Inc ......................................... 1336 School of Dentistry ........................ 505
Modular and Custom Cabinets (MCC)1012 Ribbond Inc .................................... 1613 Univet Optical Technologies ............... 506
Mydent International........................ 1040 Rose Micro Solutions ..... 705, 1042, 2422 USAF Health Professions .................... 416
MyRay ............................................. 610 Royal Dental Group & Porter USC Distant Learning (Online Masters
Neoss ............................................ 2330 Instrument Co.............................. 1425 Program) ...................................... 510
Nevin Labs ....................................... 926 Ruiz Dental Seminars ....................... 1141 USC Ostrow School of Dentistry.......... 509
NOMAD ........................................ 1814 Schumacher Dental Instruments ........... 625 ValuMax International ...................... 1542
NSK Dental LLC .............................. 2226 SciCan Inc ..................................... 2110 Vatech America ................................ 736
OCO Biomedical .............................. 631 Scott’s Dental Supply ....................... 1242 Vector R & D Inc................................ 938
Officite .......................................... 2315 SDI (North America) Inc ................... 1038 VELscope by LED Dental ..................... 717
OraBrite......................................... 2042 Second Story Promotions ................... 716 Viade Products Inc .......................... 1037
OraHealth Corp. .............................. 637 Septodont ........................................ 720 Viive.............................................. 2126
OraPharma ...................................... 814 Serenity Sedation Dental Network ....... 630 VOCO America Inc ......................... 1238
Orascoptic ..................................... 1708 Sesame Communications ................. 1139 Warren’s Professional Service ........... 1426
Ortho Classic ................................ 2339 Shark Supply ................................. 2334 Water Pik Inc .................................. 1520
Ortho-Tain Inc ................................. 1608 SharperPractice .............................. 2326 Wells Fargo Practice Finance ............ 1138
OSHA Review Inc ........................... 1015 Shofu Dental Corporation................. 1326 Western Dental Services Inc ............... 807
Otto Trading ........................... 520, 2320 Sinsational Smile Inc.......................... 611 Western Practice Sales ....................... 809
PACT-ONE Solutions ........................ 1241 Sirona Dental Inc ............................ 1226 White Towel Services ...................... 2322
Palisades Dental ............................. 1828 Sky Dental Supply ........................... 1041 XDR Radiology.................................. 621
Paperless Dentists ............................ 2242 SmileOnU ....................................... 636 Yaeger Dental Supply ...................... 1426
Parkell Inc ........................................ 602 SML – Space Maintainers Laboratories .... 1513 Yelp ................................................. 609
Parnell Pharmaceuticals Inc .............. 1239 Snap On Optics...................... 422, 2401 Yodle ............................................. 1340
Patterson Dental Supply Inc .............. 1026 SoFi .............................................. 2414 Zeiss Multimedia ............................... 741
PBHS Inc ........................................ 1338 SolmeteX .......................................... 935 Zimmer Dental .................................. 817
PDT Inc./Paradise Dental Solutionreach ................................. 1838
Technologies ............................... 1641 SOREDEX ....................................... 1814
Pearson Dental Supply ....................... 822 SOTA Imaging ................................ 1935
Pelton & Crane ............................... 1916 Springstone Patient Financing ............. 728
PeriOptix, a DenMat Company......... 1707 SS White ....................................... 1826
introduction
C D A J O U R N A L , V O L 4 2 , Nº 8
GUEST EDITOR
T
Daniel N. Jenkins, wenty-five hundred years ago, on this CR position, a TMD patient in
DDS, LVIF, CDE, holds a Hippocrates recorded in his pain has often had teeth reconstructed
fellowship and instructs in
sixth book of Epidemics his to maintain CR. Keeping in mind that
Physiologic Neuromuscular
TMD at the Las Vegas observation, which confirmed many people have achieved pain relief
Institute for Advanced traditional thought of the and function from this CR position,
Dental Studies. He is a time, that many people with severe you might ask, “Why?” In fact, there
certified dental editor of headaches also had crooked teeth. are probably successful cases with
the American Association
Over the centuries, while the tooth- every other CR position and TMD
of Dental Editors and
Journalists, editor of the headache connection was accepted, philosophy. Otherwise, why would dentists
Tri-County Dental Society, there did not seem to be a consistently keep treating patients by using those
book review editor of successful treatment. With the advent approaches? (Although, at a recent TMD
Cranio: The Journal of pharmacological pain medications debate, one presenter admitted that she
of Craniomandibular
in the 20th century, head pain was had TMD and has not been successful
and Sleep Practice and
immediate past-president of treated by drugs, thus treating the in curing it with her own philosophy.)
the International Association symptoms and not the cause. Since TMD pain is transmitted to the
of Comprehensive the patient’s primary goal is pain relief, brain by nerves. Among the many TMD
Aesthetics (IACA), ADA drug therapy was deemed a success by philosophies I have studied or reviewed,
designated champion for
the patient — at least for a while. pain by nerve transmission is accepted.
evidenced-based dentistry
and a board member of Most dental students are taught The controversy arises over what causes
the American Alliance of a centric relation (CR) philosophy the pain and what is to be done about
TMD Organizations. Dr. regarding TMD. While there are more it. Relieving TMD pain is only a short-
Jenkins has a private dental than 25 accepted definitions of CR, term goal; treating the cause to keep it
practice in Riverside, Calif.
the most common one taught in dental from recurring is the long-term goal. I
Conflict of Interest
Disclosure: Dr. Jenkins schools in the U.S. is that the proper have relieved many TMD patients of
holds a fellowship and position of the condyles of the mandible their pain within a few minutes simply
instructs in Physiologic is in the uppermost and most posterior by having them close lightly on a cotton
Neuromuscular TMD at position in the glenoid fossa. (Thus, it roll with their anterior teeth — but
the Las Vegas Institute for
fits into place like a puzzle piece.) Based that is not a long-term solution.
Advanced Dental Studies.
Video for this article is available in the e-pub version of the Journal, available at cda.org/apps.
A U G U S T 2 014 519
C D A J O U R N A L , V O L 4 2 , Nº 8
Temporomandibular Disorders:
A Human Systems Approach
James Fricton, DDS, MS
A B S T R A C T The face and associated cranial, oral and dental structures are among
the most complicated areas of the body, contributing to an array of common
orofacial disorders that include temporomandibular disorders (TMD), orofacial
pain disorders and orofacial sleep disorders. This paper presents a broad, inclusive
approach to diagnosis and management of TMD that reflects both conceptual
models of human systems in understanding chronic illnesses as well as systematic
reviews of treatment for successful management.
AUTHOR
T
James Fricton, DDS, MS, Pain and Fibromyalgia and he face and associated cranial, personal expression and, thus, can deeply
has devoted his career to Advances in Orofacial Pain
oral and dental structures are affect an individual’s psychological and
patient care and research and TMJ Disorders and
in temporomandibular and is serving as president of among the most complicated functional status.7 A national poll found
orofacial pain disorders. the International Myopain areas of the body, contributing that adults working full time miss work
He is a senior researcher at Society. to an array of orofacial disorders, because of head and face pain more
the HealthPartners Institute Conflict of Interest including temporomandibular disorders often than for any other site of pain.5
for Education and Research Disclosure: None reported.
(TMD), orofacial pain disorders, The high prevalence, personal impact
and treats patients at the
Minnesota Head and Neck orofacial sleep disorders, oral lesions, and poor access to care for these problems
Pain Clinic in Minneapolis. dental disorders and oromotor disorders. have led to an expanded role for dentistry
He is professor emeritus Orofacial pain disorders are the most in providing solutions. However, because
in the Department of common of these problems and can dentists focus most of their patient
Diagnostic and Surgical
cause symptoms of orofacial pain, jaw care on treatment of the dentition and
Sciences in the School of
Dentistry at the University dysfunction and chronic head and related structures, it can be a challenge to
of Minnesota. Dr. Fricton neck pain, with a collective estimated understand the broader scope of diagnosis
has published and lectured prevalence of at least 20 percent of and management of these conditions.
extensively, is the author the general population (TA BLE 1 ).1-7 To Treatment of TMD, like many pain
of TMJ and Craniofacial
complicate matters, oral and craniofacial conditions, is often singular and can
Pain: Diagnosis and
Management, Myofacial structures have close associations with vary according to the clinician’s favorite
the functions of eating, communicating, theory of etiology. Clinicians tend to see
seeing and hearing, and they form the what they treat and treat what they see.
basis for appearance, self-esteem and Clinicians who see a stress etiology treat
A U G U S T 2 014 523
human systems
C D A J O U R N A L , V O L 4 2 , Nº 8
TABLE 1
Worry,
Initiating Factors anxiety
Trauma
Habits Muscle-tensing,
Repetitive strain Stress
protective posture
Short-term
Acute TMD Pain
Poor sleep, Musculoskeletal
Protective Factors Risk Factors diet, exercise strain
Body: health, resilience Decreases Increases Body: comorbid conditions
Lifestyle: sleep, diet, posture risk risk Lifestyle: poor sleep, diet, hurried
Emotional: positive emotions Emotional: anxiety, anger, depression Musculoskeletal
Social: social support Social: stressful, abuse, secondary gain Pain
Spiritual: positive belief/faith Spiritual: negative belief, catastrophizing
Mind: self-efficacy, understanding Mind: misunderstanding, confusion
Environment: organized, protective Environment: chaotic, injury prone Poor understanding,
Depression
unrealistic expectations
Chronic TMD Pain
Long-term
Helplessness, Unsuccessful
FIGURE 1. Multiple protective and risk factors play a role in the progression from acute to chronic TMD pain. hopelessness treatment
Secondary gain,
catastrophizing
continuation of the cycle, while negative order changes are the basis for significant
feedback leads to its discontinuation. improvement of a condition to create a new
This is often referred to as a self-reflexive paradigm for the health of the individual. FIGURE 2 . Positive and negative feedback cycles
or “circular causation” relationship. Small first-order compensatory changes play an important role in sustaining a person’s illness
Positive and negative feedback cycles made by a patient in response to TMD over time.
play an important role in sustaining a pain, such as reducing use of the jaw,
person’s illness over time (FIGURE 2 ). taking an analgesic or other self care, not only treatment of the TMD pain
Patients with an illness often fall into the can improve the illness if it is an acute as noted, but also working with a team
recursive cycles that perpetuate the illness. self-limiting problem, at least in the short to identify all comorbid conditions
Contributing factors to an illness, such term. However, these compensatory and contributing factors and helping
as repetitive strain, depression or poor changes may also allow a more complex the patient make major changes to
sleep, are elements that sustain the cycle. illness to fall into a long-term chronic factors that may be perpetuating the
Several types of change can influence cycle (FIGURE 2 ). If a clinician can help long-term cycles. These changes could
these cycles (FIGURE 3 ). First-order change a patient make higher order changes by include managing a comorbid medical
is based on “reinforcement” of existing understanding the multiple elements in condition such as fibromyalgia, addressing
elements that promote maintenance or the cycle and changing those keystone stressful or abusive relationships and
escalation of the existing cycle and its factors that perpetuate it, the illness changing poor work situations. In
related illness. A second-order change may change more readily. Integrative this way, healthier, positive feedback
involves a “revelation” that makes a care strategies that encourage second- cycles are set up that do not perpetuate
significant change from within the order change within an existing cycle the factors that drive the illness.
system through multimodal education, include splints, physical therapy and Chaos theory was first popularized by
training and treatment that lead to a new behavioral management of oral habits, Lorenz (1963) in a paper on the theories
state. This change may either be toward sleep and muscle tension. This strategy of diverse weather patterns entitled
improved health or escalation of the illness, works quite well for simple to moderate “Does the Flap of a Butterfly’s Wings in
depending on the direction of change in cases, but more complex patients may Brazil Set off a Tornado in Texas?” He
the element. Finally, a third-order change is need a more robust intervention. In presented evidence that small differences
based on “enlightenment,” which produces those cases, transformative care strategies in initial conditions of a system might
a change from outside to achieve a new encourage third-order changes that can yield widely diverging outcomes within
level of existence distinctly different from lead to the most dramatic long-term dynamic systems. Chaos theory suggests
the original structure. Second- or third- results. Third-order change involves that “it’s the little things that matter
A U G U S T 2 014 525
human systems
C D A J O U R N A L , V O L 4 2 , Nº 8
Severity of pain
Second-order change Strain
multilevel problem by
“Revelation” 6 Injury
single clinician
4
Transformative care for complex 2
Third-order change Acute Chronic Intractable
problem with life issues by
“Enlightenment” 0
interdisciplinary team
01 2 3 4 5 6 7 8 9 10 12 14 16
Pain onset Months since onset
FIGURE 3 . Three levels of change match the three levels of care for increasingly FIGURE 4 . Multiple contributing factors can each play a small role at the early
complex patients. stages of a chronic illness, but when combined they will accelerate the condition
dramatically.
the most.” When applied to health and we repeatedly do is supported by much the contributing factors in each realm.
disease, it suggests that multiple risk research in achieving health and wellness. The physical diagnosis is the physical
factors can each play a small role at early These theories explain the diverse problem that is responsible for the chief
stages of a chronic illness. However, when results of placebo-controlled clinical trials complaint and associated symptoms. The
these factors are combined, they will for TMD pain and other pain conditions orofacial pain disorders noted in TA BLE 1
accelerate the condition dramatically. which suggest that many different are included in this definition of the scope
As FIGURE 4 illustrates, an illness interventions, from splints and medications of dental practice because they have
begins with initiating factors such as to physical and cognitive-behavioral characteristics that involve the oral cavity,
acute physical injury of the muscles and therapies and even injections and surgery, maxillofacial area and/or the adjacent and
joints. In most cases, this pain is transient can all be used to alleviate TMD pain.21-39 associated structures. Contributing factors
and resolves without complication or The effect of each of these interventions include those that initiate, perpetuate or
persistence. However, if a sufficient number beyond the placebo effect may be small, result from the disorder but in some way
of contributing factors are present, even but they are all significant. Furthermore, by complicate the problem.
though small, the balance can shift from combining these concepts in a multimodal These risk and protective factors
healing of acute pain to delayed recovery integrative model of care that is based are diverse and involve the seven
and chronic pain (FIGURE 2 ).44-50 Various on a human systems approach, the small realms of our lives:40-63 the physical
underlying neural mechanisms, such as effects of multiple interventions employed (physiologic, genetic, molecular);
peripheral and central sensitization and at the same time can result in the greatest lifestyle (repetitive strain, posture,
wind-up, play a role in this process that is positive outcomes. Thus, the evaluation lifestyle, eating, sleep); emotional
difficult to predict. Likewise, the presence and management approaches proposed (depression, fear, anxiety, anger); social
of protective factors and early intervention in this paper follow these principles. (relationships, abuse, secondary gain);
in multiple factors will have the greatest cognitive (attitudes, understanding,
impact in resolving the condition. Principles of Evaluation honesty); spiritual (faith, beliefs,
Behavioral medicine, then, suggests The principles of HST can be applied purpose); and environmental (accidents,
that specific behavioral interventions to the evaluation of patients with TMD pollution, disorganization, hygiene).
such as exercise and oral habit reversal by employing an inclusive problem list, Specific risk factors for chronic pain
can help restore health and wellness. determining the complexity of the case and may include peripheral factors such as
It complements theories on positive following the decision tree for increasing repetitive strain, oral and postural habits,
psychology that focus on building health, the potential for successful management. central mediating factors such as anxiety
strength and positive virtues as much as on Determine the Problem List. HST and depression, and comorbid conditions
correcting illness, problems and vices.16,17 expands the traditional “problem list” to such as fibromyalgia, somatization and
The Aristotelian idea that we are what include both the physical diagnoses and catastrophizing. Protective factors
526 A U G U S T 2 014
C D A J O U R N A L , V O L 4 2 , Nº 8
TABLE 2
deliver or recommend.21-39 They include the habit, learns how to correct it (i.e., The most serious complication is major
both reversible and irreversible treatments. what to do with the teeth and tongue) and irreversible changes in the occlusal scheme
Reversible treatments designed to knows why it is important to correct it. (open bites) that occur because of long-
encourage healing in the muscle and When this knowledge is combined term use of partial coverage splints such as
joints include self care, behavioral with a commitment to conscientious the anterior bite plane and the posterior
therapy, splints, medications and physical monitoring, most habits will change. coverage splint. Splints should not be
medicine. Irreversible treatments include Progress in changing habits should designed to move teeth orthodontically
joint surgery and permanent occlusal be addressed at all appointments. during treatment of a TMD.
treatments. To determine whether the In some cases, patients may have Pharmacotherapy. The most commonly
problem is self-limiting, self care should significant psychosocial problems that used medications for pain are classified
be initiated first. If the problem does accompany a TMD and may benefit from as nonnarcotic analgesics (nonsteroidal
not resolve within a few weeks and medication or counseling by a mental anti-inflammatories), narcotic analgesics,
there is evidence of progression and/ health professional. Prior to initiating muscle relaxants, tranquilizers (ataractics),
or persistence, treatment can proceed treatment, a decision should be made as sedatives and antidepressants.37-39
if pain and/or locking is severe enough Analgesics are used to allay pain, muscle
to affect functioning or quality of life relaxants for muscle tension and nocturnal
and the patient desires treatment. Each activity, tranquilizers for anxiety, fear and
type of treatment is discussed briefly. enhancing sleep and antidepressants for
Information about self care pain, depression and enhancing sleep.
Reversible Treatments Opioid analgesics have their own
Self Care. A key determinant should be provided to all problems because of the potential for abuse
of successful management of any patients and in some cases and should be used sparingly and only with
musculoskeletal disorder involves is the only strategy needed. patients who have intractable chronic pain,
educating the patient about the disorder no psychiatric conditions and no history
and the necessity of compliance with of chemical abuse. If prescribed, clinicians
the self-care aspects of management, need to follow specific opioid prescribing
including exercise, habit change and standards such as use of pain contracts,
proper use of the jaw (TA BLE 2 ).30,31 to whether the psychological distress is urine toxicology testing, suspension of
Information about self care should be the primary problem. If this is the case, medications with violation and other
provided to all patients and in some treatment of the psychological problem guidelines found at fsmb.org/pdf/2004_
cases is the only strategy needed. is best accomplished first and as an issue grpol_Controlled_Substances.pdf.
Behavioral Therapy. Approaches separate and apart from the TMD. Despite the advantages of medications
to changing maladaptive habits and Intraoral Splints. Splint therapy can for pain disorders, problems can occur
behaviors should be addressed and be effective alone or in combination because of their misuse. For this
presented as an integral part of the overall with other treatments for each stage of reason, an important goal of treatment
treatment program for all patients with temporomandibular joint (TMJ) internal for most patients is to eliminate the
TMD and poor oral habits.32,33 Behavior derangements and myofascial pain.22 need for medications long term. With
modification strategies are the most Although there are many useful types of chronic pain patients, termination
common techniques used to change splints, four are commonly used for TMD: of current medications should take
habits. Although many simple habits the full-arch stabilization splint, the precedence over prescribing additional
will change when the patient is made anterior repositioning splint, the anterior ones. Problems that can occur from
aware of them, changing persistent habits bite plane and the posterior bilateral use of medications include chemical
requires a structured program facilitated partial coverage splint. Complications dependency, behavioral reinforcement
by a clinician trained in behavioral that can occur with the use of any splint of continuing pain, inhibition of
strategies. Habit change using a habit include caries, gingival inflammation, endogenous pain relief mechanisms,
reversal technique can be accomplished mouth odors, speech difficulties and/or side effects and adverse effects from
when the patient becomes more aware of psychological dependence on the splint. the use of polypharmaceuticals.
A U G U S T 2 014 529
human systems
C D A J O U R N A L , V O L 4 2 , Nº 8
Physical Medicine. The use of physical of available techniques, the potential for ■ Prior unsuccessful treatment with a
medicine techniques follows the same complications, the frequency of behavioral nonsurgical approach that includes
orthopedic and physical therapy guidelines and psychosocial contributing factors and a stabilization splint, physical
as the evaluation and treatment of any the availability of nonsurgical approaches therapy and behavioral therapy.
musculoskeletal condition.23 Many exercises mandate that TMJ surgery be used only in ■ Prior management of bruxism, oral
and modalities are available to help reduce selected cases that meet specific criteria. parafunctional habits and other medical
pain and tenderness and increase range The decision to treat a patient surgically or dental conditions or contributing
of motion. Exercises are recommended to depends on the degree of pathology present factors that will affect surgical outcome.
stretch, strengthen and relax muscles, to within the joint, the success or failure of ■ Patient consent after a discussion
increase joint range of motion, to enhance appropriate nonsurgical therapy and the of potential complications, goals,
muscle strength or to develop normal extent of disability that the joint pathology success rate, timing, postoperative
arthrokinematics. They are prescribed creates. A discussion of individual management and alternative
in order to achieve specific goals and techniques is beyond the scope of this paper approaches, including no treatment.
are changed or modified as the patient and can be found in the current American These conditions maximize the
progresses. Once the patient has reached the potential for a successful outcome but
goals of the treatment, a maintenance level cannot guarantee it. Patients with
of exercise is recommended to assure long- factors such as fibromyalgia, depression
term resolution of the patient’s problems. or resistant nocturnal bruxism present
In some cases of structural joint problems, Irreversible treatments with a complexity that has a poor
limited range of motion and inflammation, prognosis. In addition, a full knowledge
ultrasound, iontophoresis, phonophoresis, involve risk and should of complications and the reasons for
superficial heat, cryotherapy and massage be used only if specific surgical failure can help clinicians make
have been found helpful. Electrotherapies criteria are met. this decision. Once this information is
such as electrogalvanic stimulation and available, a realistic discussion of the
transcutaneous electrical stimulation have prognosis, the patient’s expectations
also been shown to be useful. Muscle and and any complicating factors can help
joint injections may also be recommended. a patient make a correct decision about
However, these modalities typically have Association of Oral and Maxillofacial surgery. Postoperative physical and
short-term effects and need to be used with Surgery (AAOMS) position paper on behavioral therapy should be integrated
exercises to maintain the improvement. For TMJ surgery. Surgical management may into the overall surgical management.
this reason, they should be used only until vary from the closed surgical procedure Permanent Dental Stabilization.
there is no longer a change in objective (arthroscopy) to an open surgical procedure Permanent dental treatment may be
signs and/or improvement in pain. (arthrotomy), depending on the degree of needed for some patients to provide
disk deformity and degenerative changes. stable occlusal support and function
Irreversible Treatments Each of the following criteria, adapted from for the dental and temporomandibular
In most cases, TMD problems the AAOMS criteria, should be fulfilled structures.40 These treatments include
improve with self care in combination before proceeding with TMJ surgery: occlusal adjustment, restorative dentistry,
with reversible treatments that ■ Documented TMJ internal fixed or removable prosthodontics and
encourage the natural healing processes derangement or other structural joint orthodontics with or without orthognathic
of the muscles and joints. Irreversible disorder with appropriate imaging. surgery. If needed because of poor
treatments involve risk and should be ■ Evidence suggesting that symptoms stability of the dentition, permanent
used only if specific criteria are met. and objective findings are a result treatment is recommended only after
This applies to both TMJ surgery and of disk derangement or other pain has been reduced and normal
permanent dental stabilization. structural joint disorder. jaw function restored. The criteria for
Surgery. TMJ surgery has become an ■ Pain and/or dysfunction of such using secondary dental treatment to
effective treatment for structural TMJ magnitude as to constitute a maintain comfort and function of the
disorders.34-36 However, the complexity disability for the patient. temporomandibular structures include:
530 A U G U S T 2 014
C D A J O U R N A L , V O L 4 2 , Nº 8
A U G U S T 2 014 531
human systems
C D A J O U R N A L , V O L 4 2 , Nº 8
3. Lozada-Nur F, Miranda C. Oral Lichen Planus: Pathogenesis 24. Bussone G, Grazzi L, D’Amico D, Leone M, Andrasik F. 39. Ekberg EC, Kopp S, Akerman S. Diclofenac sodium as an
and Epidemiology. Semin Cutan Med Surg 1997; 16:290- Biofeedback-assisted relaxation training for young adolescents alternative treatment of temporomandibular joint pain. Acta
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among patients with temporomandibular disorders. J Orofac
Pain 2005; 19(4): 291-300.
irst, I want to thank the guest what is known and what is practiced,
56. Velly AM, Look JO, Carlson C, Lenton PA, Kang editor, Dr. Jenkins, for his and to improve patient care based upon
W, Holcroft CA, et al. The effect of catastrophizing and innovative approach in this informed decision making.” Systematic
depression on chronic pain — a prospective cohort study of
temporomandibular muscle and joint pain disorders. Pain
issue, and the three contributing reviews of randomized clinical trials
2011; 152(10): 2377-83. authors, Drs. Gelb, Simmons (RCTs) are considered the highest
57. Jensen MP, Romano JM, Turner JA, Good AB, Wald LH. and Raman for their thoughtful and quality of scientific validation because
Patient beliefs predict patient functioning: further support for
a cognitive-behavioural model of chronic pain. Pain 1999;
engaging comments on their diverse they measure both the quality of RCTs
81(1-2): 95-104. approaches to managing TMD. It is only and the power of combining outcomes
58. Jensen MP, Turner JA, Romano JM. Changes in beliefs, through this type of knowledge exchange from multiple studies (FIGURE ).
catastrophizing and coping are associated with improvement in
multidisciplinary pain treatment. J Consult Clin Psychol 2001;
and discussion that we will be able to With this in mind, systematic reviews
69(4): 655-62. improve the broad understanding and of RCTs employing placebo-controlled
59. Jensen MP, Turner JA, Romano JM. Correlates of care of TMD patients. After reviewing clinical trials for TMD pain have
improvement in multidisciplinary treatment of chronic pain. J
Consult Clin Psychol 1994; 62(1): 172-9.
the three authors’ responses to each demonstrated the efficacy of many different
60. Jensen MP, Turner JA, Romano JM. Self-efficacy and of the papers, some general as well as interventions, including intraoral splints,
outcome expectancies: relationship to chronic pain coping specific comments are warranted. self care, exercise, medications, physical
strategies and adjustment. Pain 1991; 44(3): 263-9.
61. Turner JA, Whitney C, Dworkin SF, Massoth D, Wilson L.
Evidence-based dentistry is the therapy, transcutaneous electroneural
Do changes in patient beliefs and coping strategies predict conscientious, explicit and judicious use stimulation, cognitive-behavioral
temporomandibular disorder treatment outcomes? Clin J Pain of the best and most current evidence therapies, injections and TMJ surgery.
1995; 11(3): 177-88.
62. Turner JA, Holtzman S, Mancl L. Mediators, moderators,
in making decisions about the care of Each addresses one or more of the many
and predictors of therapeutic change in cognitive-behavioral each patient. As Turpin1 stated, “The factors involved in the etiology of TMD,
therapy for chronic pain. Pain 2007; 127(3): 276-86. purpose of using the evidence-based depending on the individual diagnoses
63. Jensen MP, Nielson WR, Turner JA, Romano JM, Hill ML.
Changes in readiness to self-manage pain are associated
approach is to close the gap between and characteristics of the patient.
with improvement in multidisciplinary pain treatment and pain
coping. Pain 2004; 111(1-2): 84-95.
64. Grzesiak RC. Psychologic considerations in
temporomandibular dysfunction. A biopsychosocial view of
symptom formation. Dent Clin North Am 1991; 35(1): 209-26.
65. Epker J, Gatchel RJ, Ellis E 3rd. A model for predicting
chronic TMD: practical application in clinical settings. J Am
Systematic
Dent Assoc 1999; 130(10): 1470-5. Reviews
66. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis E
Filtered Information
3rd. Efficacy of an early intervention for patients with acute Critically Appraised
temporomandibular disorder-related pain: a one-year outcome Topics [evidence
study. J Am Dent Assoc 2006; 137(3): 339-47. syntheses and guidelines]
67. Bell IR, Caspi O, Schwartz GER, Grant KL, Gaudet TW,
Rychener D, Maizes V, Weil A. Integrative Medicine and Critically Appraised Individual
Systemic Outcomes Research. Issues in the Emergence of Articles [article synopses]
a New Model for Primary Health Care. Arch Intern Med
2002;162(2):133-140. Randomized Controlled Trials(RCTs)
68. Mann D. Moving Toward Integrative Care: Rationales,
Models, and Steps for Conventional-Care Providers. J Evid
Unfiltered Information
Cohort Studies
Based Complementary Altern Med October 2004 vol. 9 no.
3 155-172.
69. Fricton J, Hathaway K, Bromaghim C. The interdisciplinary
Case-controlled Studies/Case Series/Reports
pain clinic: outcome and characteristics of a long
term outpatient evaluation and management system. J Background Information/Expert Opinion
Craniomandib Disord, 1(2):115-122, 1987.
THE AUTHOR,James Fricton, DDS, MS, can be reached at FIGURE . The hierarchy of scientific evidence.
frict001@umn.edu.
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human systems
C D A J O U R N A L , V O L 4 2 , Nº 8
Response to Dr. Gelb’s critique patients in clinical practice. He states, is still of paramount importance. Safe
Dr. Gelb recognizes the importance of “This is where the proverbial rubber dental treatment is also important
the concept that should be the basis for meets the road,” and provides an because dental treatment can cause
all TMD evaluation and treatment: TMD important rationale for an evidence- TMD injuries if the mouth is opened
is a chronic illness with a multitude of based approach. What works for the few too wide or for too long a period.12-14
contributing factors. His innovative paper patients who accept a specific treatment
shows how protection of the airway is one approach by a single dentist must also Conclusion
such factor that is paramount to survival work for many patients who receive I believe that most clinicians who
and can play a role in the development the same treatment by other dentists. care for patients with TMD realize that
and subsequent management of TMDs. In this regard, systematic reviews there is both an art and a science to TMD
Likewise, many other contributing of RCTs employing occlusal treatment treatment. The art is important when
factors complicate TMDs and are as as a primary treatment for TMD, patient complexity requires recognition of
important for survival. Examples include including occlusal adjustment, the multitude of contributing factors and
the patient with a closed TMJ lock as a restorative dentistry, orthodontics and formulation of a personalized approach
result of an assault who now has post- orthognathic surgery, either have not that also maximizes the outcomes of
traumatic stress disorder (PTSD), or the had sufficient clinical trials or have not evidence-based treatments. Although
patient with masseter pain from being demonstrated consistent efficacy.2-11 we are dentists first and are well trained
sexually abused who is now depressed Although individual patients may to treat the teeth and occlusion, we
and suicidal, or the patient with temple improve after these interventions, the need to recognize that when managing
headaches from the anxiety of being a results of studies of larger populations are a chronic illness, we must understand
single working mother of two children, inconsistent. Because of these negative and manage the whole patient, even if
or the patient with jaw pain caused by findings and the readily available it involves bringing in other clinicians
severe nocturnal bruxism due to the side TMD treatments that have scientific with expertise we may not have.
effects of antidepressant medication for support for their efficacy and, with Furthermore, there is still a place for
ADHD. These types of patients exist the exception of surgery, encourage empirical experience-based approaches
in all TMD clinics and the many other natural healing and repair with fewer to TMD, because we cannot always
contributing factors need to recognized adverse events, occlusal treatments rely on science-based approaches that
and managed as with any chronic illness. are currently not recommended as only estimate what strategies work best.
a primary treatment for TMD. But, as Isaac Asimov states, “There
Response to Dr. Simmons’ critique These recommendations do not is a single light of science, and to
Dr. Simmons astutely points out that mean that occlusion has no relevance brighten it anywhere is to brighten it
there is no “one-size-fits-all” approach to to TMD or that dentists should ignore everywhere.” Let’s continue to bring
TMD. Both the specific TMD diagnoses occlusion. For all dental patients, science to the treatment of TMD.
(muscle, joint or both) and the list occlusion is critical in providing Note: For those interested in
of contributing factors (behavioral, orthopedic support for stability, understanding the strategies and
cognitive, emotional, social, comorbid comfort and function of the teeth paradigms of a human systems approach
conditions, etc.) must be identified for and is essential to eating, appearance, to chronic pain, including TMD, the
each patient. Then the judicious use of communication and personal expression. University of Minnesota in coordination
these evidence-based interventions as Furthermore, patients with TMD often with the International MYOPAIN
part of an interdisciplinary and integrated need dental treatment as part of normal Society (myopain.org) offers an
approach to care for an individual patient dental care. This is particularly true online MOOC course on the topic at
will result in the greatest positive outcome. when malocclusion does not provide coursera.org/course/chronicpain. ■
adequate orthopedic support because REFERENCES
Response to Dr. Raman’s critique of missing teeth, dental or skeletal 1. Turpin DL. Consensus builds for evidence-based methods.
Dr. Raman also wisely points out imbalances or gross interferences. Am J Orthod Dentofacial Orthop 2004;125:1-2.
2. Fricton J. Current Evidence Providing Clarity in
that the crucial step for any TMD Thus, providing sound evidence- Management of Temporomandibular Disorders: A
philosophy is its actual application for based dental care to these patients Systematic Review of Randomized Clinical Trials for Intraoral
Appliances and Occlusal Therapies. J Evid Based Dent
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Pract March issue, vol. 6, issue 1, pp 48-52, 2006. repositioning onlays in the treatment of temporomandibular interdisciplinary pain clinic: outcome and characteristics of a
3. Forssell H, Kirveskari P, Kangasniemi P. Effect of occlusal joint disk displacement: comparison with a flat occlusal splint long-term outpatient evaluation and management system. J
adjustment on mandibular dysfunction. A double-blind study. and with no treatment. Oral Surg Oral Med Oral Pathol Craniomandib Disord 1(2):115-122, 1987.
Acta Odontol Scand 1986;44(2):63-9. 1988;66(2):155-62. 14. Juhl GI, Jensen TS, Norholt SE, Svensson PJ. Incidence
4. Tsolka P, Morris RW, Preiskel HW. Occlusal adjustment 9. Kirveskari P, Le Bell Y, Salonen M, Forssell H, Grans L. of symptoms and signs of TMD following third molar
therapy for craniomandibular disorders: a clinical Effect of elimination of occlusal interferences on signs and surgery: a controlled, prospective study. J Oral Rehabil
assessment by a double-blind method. J Prosthet Dent symptoms of craniomandibular disorder in young adults. J 2009 Mar; 36(3):199-209.
1992;68(6):957-64. Oral Rehabil 1989;16(1):21-6.
5. Vallon D, Ekberg E, Nilner M, Kopp S. Occlusal 10. Kirveskari P, Jamsa T, Alanen P. Occlusal adjustment and
adjustment in patients with craniomandibular disorders the incidence of demand for temporomandibular disorder
including headaches. A three- and six-month follow-up. Acta treatment. J Prosthet Dent 1998;79(4):433-8.
Odontol Scand 1995;53(1):55-9. 11. Wenneberg B, Nystrom T, Carlsson GE. Occlusal
6. Vallon D, Nilner M, Soderfeldt B. Treatment outcome in equilibration and other stomatognathic treatment in patients
patients with craniomandibular disorders of muscular origin: with mandibular dysfunction and headache. J Prosthet Dent
a seven-year follow-up. J Orofac Pain 1998;12(3):210-8. 1988;59(4):478-83.
7. Karppinen K, Eklund S, Suoninen E, Eskelin M, Kirveskari 12. Huang GJ, Drangsholt MT, Rue TC, Cruikshank DC,
P. Adjustment of dental occlusion in treatment of chronic Hobson KA. Age and third molar extraction as risk factors
cervicobrachial pain and headache. J Oral Rehabil for temporomandibular disorder. J Dent Res 2008 Mar;
1999;26(9):715-21. 87(3):283-7.
8. Lundh H, Westesson PL, Jisander S, Eriksson L. Disk- 13. Fricton J, Hathaway K, Bromaghim C. The
Oral Health
INSTITUTE FOR
IOHWA.ORG
Education and Collaboration Resource for
Advancing Innovation in Oral Health Care
A U G U S T 2 014 535
You are the reason people stand tall in front of the class,
grin widely for the camera and never cover their mouths
in shame. You are the champion of the smile and all the
possibility it represents. The confidence you help instill in
your patients is one reason why CDA supports and protects
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ara therapy
C D A J O U R N A L , V O L 4 2 , Nº 8
Temporomandibular
Joint Orthopedics With
Anterior Repositioning
Appliance Therapy and
Therapeutic Injections
H. Clifton Simmons III, DDS
AUTHOR
T
H. Clifton Simmons III, College of Dentists, the he American Association of Informed Consent
DDS, received his dental International College of Dental Research (AADR) defines Informed consent is paramount for the
degree from the University Dentists, the American temporomandibular disorders TMD orthopedic dentist. Some dentists
of Tennessee College of Academy of Craniofacial (TMDs) as a group of musculo- have less than optimum formal education
Dentistry in 1977. He Pain, the American
is currently an assistant
skeletal and neuromuscular in the assessment, diagnosis and treatment
Academy of Orofacial Pain,
clinical professor in the the Academy of General conditions that involve the temporo- of TM disorders2 but we are legally liable
Oral and Maxillofacial Dentistry, the Tennessee mandibular joint (TMJ), the masticatory in most states for diagnosing and treating
Surgery Department at Dental Association and muscles and all associated tissues.1 these disorders.3 This makes for an
Vanderbilt University School the Academy of Dentistry environment where the dentist providing
of Medicine, an assistant International. Dr. Simmons
professor at the University is president of the American
Definition of TMD Orthopedics TMD orthopedic care must make sure that
of Tennessee College of Board of Craniofacial Pain, TMD orthopedics is the assessment, his or her patients have a clear concept of
Dentistry and has a private president of the Tennessee diagnosis and management of orthopedic the treatment that is proposed for them
practice. Dr. Simmons is a Dental Association and disorders of the TMJ with the goal and the research supporting that care.
diplomate of the American editor of the Journal of of returning the joint and associated Patients have the right to decide
Board of Craniofacial Pain the Tennessee Dental
and the American Board
structures to the highest level of between conservative and invasive care
Association.
of Orofacial Pain. He is Conflict of Interest function and least pain achievable, in treating disorders of the body.4-6 Dental
a fellow of the American Disclosure: None reported. with physiologic normal as the goal. patients may decide whether they want
A U G U S T 2 014 537
ara therapy
C D A J O U R N A L , V O L 4 2 , Nº 8
to have a tooth extracted or to have all associated tissues.” Weldon E. Bell, therefore displace the disk from a normal
endodontic care. Cancer patients decide DDS,16 said, “A good understanding of the physiologic position to an abnormal
whether they want care or not. Proper basic principles of orthopedics should be pathologic position. Displacement of TMJ
informed consent requires that patients fundamental to everyday dental practice. It disks is the causation of TMJ internal
are informed of treatment methods that is prerequisite to the rational management derangements.7 This would exclude
are available for their disorder.4 There is of temporomandibular disorders.” Most normal function and occlusal dental
adequate peer-reviewed, evidence-based TMDs are an orthopedic disorder, with conditions from causation of internal
literature to support orthopedic anterior magnetic resonance imaging (MRI) derangements of the TMJ. It would also
repositioning appliance (ARA) care showing anatomic abnormality in the exclude parafunction of the mandible
for some TMD patients.7-12 If informed TMJ in greater than 80 percent of TMD as causation of TMJ disk displacement,
consent does not include informing patients.9,17 In one recent study, 88 percent as this is not defined as a macrotrauma
an appropriate group of patients about of 58 consecutive TMD patients seen in a event. There are six ligaments (Okeson
TMD orthopedic ARA care, then proper referral-based practice had abnormal MRIs includes the joint capsule in ligaments)
informed consent has not been attained. when read by an oral and maxillofacial in or associated with each human TMJ.7
The author spends three hours MRI results were obtained on 30
conducting a history, examination infants and young children from age 2
and consultation with each new TMD months to 5 years. None of the 60 joints
orthopedic ARA care patient to ensure “A good understanding that were examined had a displaced TMJ
that there is clear informed consent before disk.23 Therefore, humans are not usually
anything more than emergency care is of the basic principles born with a TMJ internal derangement.
provided. TMD orthopedic ARA therapy of orthopedics should Isberg et al. described an arthrokinetic
is complex care, and dentists should seek reflex in the muscles of mastication
education and clinical training before be fundamental to associated with disk displacements.
attempting to provide these services everyday dental practice.” “Continuous muscle activity was provoked
to patients.13 Successful ARA therapy by disk displacements and ceased when
depends on the knowledge and skills of the disk position was normalized on
the clinician and it has limitations.14 mouth opening, only to occur again
The author has developed a three- radiologist.9 Many TMDs are the result every time the disk became displaced
page consent form for initial active of injury to ligaments, muscles, tendons, on mouth closure.” These findings were
TMD orthopedic ARA care and, nerves, vascular or joint structures.18-21 in line with those previously published
when needed, an additional three-page Wiesel and Delahay’s textbook, on limb joints, which indicated that
consent form for more durable, long- Essentials of Orthopedic Surgery, states joint derangements are a cause of
term occlusal care and retention. that ligamentous injuries occur as muscle hyperactivity.10,21 Farrar reported
a result of acute macrotrauma and that the evidence was “conclusive and
Human Orthopedic Fundamentals represent a macrotrauma process. In irrefutable” that TMJ displaced disks
The American Academy of contrast, injuries to tendons can be produced the symptoms of myofascial
Orthopaedic Surgeons’ definition both acute and chronic processes. pain dysfunction.24 There is literature to
states that this specialty’s scope of Chronic tendon overload represents the support that recapturing a TMJ disk can
practice includes the diagnosis, care and classic microtraumatic injury in sports relieve symptoms of the arthrokinetic
treatment of musculoskeletal disorders, medicine. These injuries occur at the reflex.25 Relieving abnormal muscle
including the body’s bones, joints, sites of high exposure to repetitive tensile activity can relieve pain of muscle origin.
ligaments, muscles and tendons.15 The overload.22 Macrotrauma is defined as Cyriax, in his Textbook of Orthopaedic
AADR defines TMDs as those that either an impact blow or hyperextension Medicine,11 states that muscle spasm
“encompass a group of musculoskeletal of a joint system.21 The conclusion should not be treated as a primary disorder
and neuromuscular conditions that can be drawn that a macrotrauma when there is a concomitant joint
involve the temporomandibular joints event is required to tear the ligaments disorder. He maintains, “If arthritis or a
(TMJs), the masticatory muscles and that hold the TMJ disk in place and degree of internal derangement can be
538 A U G U S T 2 014
C D A J O U R N A L , V O L 4 2 , Nº 8
abated, the protection given to the joint turned this area of care over to the ■ Use injection techniques to
by the muscles becomes unnecessary.” dental profession. As testimony to this, diagnose and treat TMDs.7,12,34-37
Cyriax also states, “No structure of the Campbell’s Operative Orthopaedics, fourth ■ Use physical medicine to treat
body is so quickly altered by influences volume, 11th edition (4,899 pages) and TMDs,7,12,38 and, when indicated,
outside itself as muscle. Once a muscle Wiesel and Delahay’s textbook, Essentials provide long-term reversible
has wasted considerably, even though of Orthopedic Surgery22 (615 pages) do not and irreversible occlusal care
no disease of the muscle itself has ever have the words “temporomandibular” for orthopedic TMDs.3,7,39,40
occurred, it may never regain full bulk.” or “TMJ” in either of their indexes. It TMD orthopedic dentists may
A TMJ with a disk displacement (internal is now the responsibility of the dental treat sleep apnea13,41 and dental
derangement) may cause abnormal muscle profession to provide orthopedic care malocclusions,39,42 but these disorders are
activity (contraction) around the joint. for the only joints that the medical not classified as TMDs. TMD orthopedic
The abnormal muscle activity may then community does not treat. Many TMDs ARA care that is peer reviewed and
cause the patient to experience muscle are orthopedic disorders and orthopedic evidence based is clearly available for
pain through trigger points, headache, care for some TMDs is appropriate.16 some TMDs.25,43-48 The American Dental
neck ache, autonomic phenomena such Association (ADA) publication Dental
as dizziness and disequilibrium, fatigue Practice Parameters for Temporomandibular
in craniofacial muscles and mandibular (Craniomandibular) Disorders3 supports
dysfunction. The question for the TMD It is now the responsibility most of the procedures described in
orthopedic dentist is, “Why is that the above definition of an orthopedic
muscle in a state of continuous activity, of the dental profession to TMD dentist. The ADA Council on
contraction, splinting or spasm?” provide orthopedic care for Dental Care Programs40 also supports
Knowledge of the anatomy and a most of these procedures. Dentofacial
systematic approach are the fundamentals the only joints that the medical orthopedics is a part of mainstream
of palpation.26 A widely accepted method community does not treat. orthodontic care utilizing functional
to determine muscle tenderness and pain is appliances and Herbst appliances.39
by digital palpation. A healthy muscle does
not elicit sensations of tenderness or pain Value of Normal Disk Position
when palpated.7,27 While tenderness of a Hall49 stated that data now support
particular structure may be present in the The TMD Orthopedic Dentist the assumption that a normal TMJ
majority of individuals, tenderness should An orthopedic TMD dentist disk position assists in alleviating pain,
not be present in a healthy, optimally is a dentist who may: prevents the gross degenerative changes
functioning structure. Consequently, ■ Treat TMDs by utilizing orthopedic of osteoarthritis and promotes growth of
while tenderness may be “the norm” for appliances to reposition the mandible the mandible. Based on these data, he
that individual, it is not truly normal and to diminish the load on the TMJ.7,30,31 believes there is a strong argument for
indicates a subclinical dysfunction. So the ■ Reposition the mandible to including disk recapture as an important
conclusion can be drawn that palpated attempt to recapture displaced goal of any treatment for the painful
normal structures should not elicit pain. TMJ disks that are reducing.7-9 joint with a displaced disk that reduces.
For proper orthopedic evaluation, ■ Reposition the mandible to place the Nickerson,50 using Boering’s 30-
joint motion must be assessed and condyle in a more physiologic position year study of the natural course of TMJ
measured.26 The consensus among a to diminish an arthrokinetic reflex degeneration,51 showed that reestablishing
large group of TMD authorities is that (protective muscle splinting).10,11,21 normal disk position protects the joint
mandibular normal opening range is 40-50 ■ Manipulate the mandible to from degenerative joint disease and
millimeters, and the normal left and right reduce TMJ disks that may have osseous breakdown leading to occlusal
lateral movements are 8-12 millimeters.28 been reducing and now are collapse and facial distortion. Nickerson50
TMD care was covered in orthopedic acutely nonreducing.7,12,13 stated that under certain conditions
medicine and surgery textbooks until the ■ Manipulate the mandible to mobilize there is a relationship between TMJ
1980s,11,29 when physicians and surgeons the TMJ condyle and/or disk.7,32,33 disk displacement and masticatory
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FIGURE 1. Normal TMJ anatomy (adapted from FIGURE 2 . Abnormal TMJ anatomy — TMJ disc FIGURE 3 . Awake mandibular orthopedic
Lundh and Westesson). displacement with reduction (adapted from Lundh repositioning appliance.
and Westesson).
musculoskeletal pain. He suggested that and 45 joints with disks recaptured Occlusal changes are possible from
there is positive value to having the disk with ARA, yielding a 3-D recapture displacement of the TMJ disk.7,13,49,50
in a load-bearing position, and that the rate of 85 percent. Recapture or When the patient is awake, the reflex
primary focus in treating patients with improvement in disk position was to swallow (deglutition) occurs once per
disk displacement with reduction should achieved in 91 percent of reducing, 28 minute59,60 and causes the maxillary teeth
be an attempt to recapture the disk. percent of nonreducing and 63 percent to index into a mandibular orthopedic
Schellhas et al.20 used MRI to show of all joints with internal derangements. appliance (FIGURE 3 ) that is constructed
the negative effects of disk displacement No disk status was worsened. to cause the mandibular condyle to return
of the TMJ in children. They found to a more physiologic position in the
that children with retrognathia and TMD Orthopedic ARA Therapy Care glenoid fossae. Over a period of one to
mandibular asymmetries usually have Treatment of most human disorders two months, the patient adapts to the
advanced degrees of TMJ derangements usually has as the goal a return to a new swallowing occlusal index in the
with characteristic shifts toward the more normal physiologic state. TMD orthopedic appliance. Patient symptoms
most deranged joint. They proposed orthopedic ARA therapy’s goal is to are usually relieved in three to six months
that in the growing facial skeleton, return the mandibular condyle and by the normalization of the contents
internal derangement of the TMJ the contents of the TMJ to the most of the TMJ,25,61 which reduces the
either diminishes or stops condylar normal physiologic orthopedic condition protective muscle splinting (arthrokinetic
growth, resulting in facial distortion. attainable. Imaging is necessary for reflex)10 that may have caused the pain
Lundh and Westesson52 discovered that proper bite positioning53-55 and has shown the patient was experiencing. Research
recapturing a displaced disk effectively recapture with MRI in 85-96 percent of has shown that the muscles associated
eliminated pain and dysfunction in patients with disk displacements with with the TMJ sense where the condyle
patients in whom a normal relationship reduction.8,9 Lundh and Westesson is positioned more than they sense
between the disk and the condyle can be showed normal anatomy of the TMJ in where the disk is positioned.25,62
established. In their study, ARA therapy their TMJ dissection videos (F I G U R E 1 ) Lundh and Westesson62 felt that
was deemed superior to either flat plane as the reference for normal, and others replacement of the disk onto the condyle
appliance therapy or to no treatment. have validated this.56-58 F I G U R E 2 shows may not be absolutely necessary and that
There is adequate literature to abnormal TMJ anatomy demonstrated a protrusive change in condylar position
support the value of having the TMJ as disk displacement with reduction. may be sufficient to give relief of
disk in a normal anatomical and Some patients with disk displacement symptoms in some cases. During sleep
load-bearing position, and there are with reduction start as shown in patients swallow only three times per
definite negative consequences to F I G U R E 1 , with teeth in maximum hour63 so they need an appliance similar
having a displaced TMJ disk. intercuspation, and through macrotrauma to that popularized by Farrar43 (F I G U R E 4 )
A study by Simmons and Gibbs9 become as shown in F I G U R E 2 , with that does not rely on swallowing to
included 53 joints with disk reduction teeth in maximum intercuspation. compensate for the injured ligaments of
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TABLE 1
TABLE 2
Untreated Cohort of TMD Patients Versus Patients Treated With ARA and
Therapeutic Injections
TMJ scale domains 45 untreated patients 100 treated patients
Percent improvement Percent improvement
Pain report (PR) 30.3 68.2 Regeneration of Mandibular Condyles
Pain palpation (PP) 8.8 76.4
From ARA Therapy and Long-term
Retention
Perceived malocclusion (MO) 14.7 37.2
Several of the long-term follow-
Joint dysfunction (JD) 14.2 76.2 up patients showed regeneration
Range of motion limitation (RL) 19.0 56.9 of the mandibular condyles as a
Non-TM disorder (NT) 5.1 55.1 result of their ARA therapy, durable
Psychological factors (PF) 13.1 43.7
occlusal care and long-term retention.
FIGURES 6A–B and 7A–B show one
Stress (ST) 8.8 37.5
of these regeneration cases.
Chronicity (CN) 18.2 23.5
Global score (GS) 24.3 64.1 Retention of Orthodontic Care and
This yields a statistical significance of <0.001. Condylar Position
Joondoph79 devoted a complete
chapter in a textbook to his findings that
recaptured with ARAs. That yields a 3-D lock) at pretreatment initial MRI. Three postorthodontic treatment results after
initial disk recapture rate of 80 percent disks recaptured from the nonreducing ARA therapy completely relapsed over
(20/25) in this patient population.9 group to a normal position by ARA time (four years). In a recent study by
All MRIs were read by a board- therapy and long-term retention. This Lenz and Harris,80 orthodontic relapse
certified oral and maxillofacial radiologist yields a 25 percent (3/12) recapture was 50 percent of dental correction
(S. Julian Gibbs, DDS, PhD). Twelve of disks that were disk displacement and 115 percent of skeletal correction
joints retained the recapture of disk without reduction prior to treatment. at 10 years posttreatment in a group of
at long-term MRI evaluation, for a 60 When the three new recaptures from the dental students who were treated by
percent (12/20) retention of initial displacement without reduction group their hometown orthodontists. Lenz and
TMJ disk recapture in this patient are added to the final count of recaptures, Harris state that there is little to suggest
population and a long-term recapture the total is 18 disks recaptured long long-term stability of an orthodontic
rate of 48 percent (12 recaptured disks term (12 retained from initial recapture, result. Aggressive lifetime retention
long term/25 joints with reducing disks three new recaptures from reducing appears to be the only predictable method
before treatment). Some of these patients group and three new recaptures from of permanently retaining orthodontic
had experienced significant trauma to nonreducing group) of the 28 joints (25 corrections.73 The author’s cases in this
the mandible since finishing care. reducing and three nonreducing), for a report were all aggressively retained by a
At long-term follow-up, six joints recapture rate of 64 percent (18/28). maxillary anterior retaining appliance to
had new recapture of the disks that were Four patients had the six surprise be worn during sleep for the rest of the
not recaptured initially. Three of the disk recaptures. All of these patients patient’s life. Proper aggressive lifetime
six were displacement with reduction were compliant and reported that they retention solves ARA case relapse.
and three were displacement without wore their maxillary ARA almost every
reduction before treatment. Three disks time they slept following completion Conclusions
that recaptured long term from the of more durable occlusal care. In Katzberg and Westesson’s opinion,58
reducing group that did not recapture Subjective percent improvement protrusive appliance therapy, followed
initially, added to the 12 disks that statements were signed by each of by permanent alteration of the dental
initially recaptured, equals 15 disks that the 20 patients who had a long-term occlusion to match the therapeutic
recaptured long term. This raises the MRI. The average subjective symptom position, is an effective method of
long-term recapture rate of this patient relief in this group was 94.5 percent of diminishing symptoms related to disk
population to 60 percent (15/25) of presenting symptoms relieved. Eight of displacement with reduction. Okeson7
disks recaptured from the reducing the patients reported that 100 percent states that when occlusal therapy is
group. Twelve joints out of 40 had disk of their presenting symptoms were gone indicated to resolve the symptoms of a
displacement without reduction (closed- at an average of 10 years’ follow-up. TMD, the specific treatment goals are
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REFERENCES
1. Greene CS. Managing the care of patients with
temporomandibular disorders: a new guideline for care. J Am
Dent Assoc 2010;141(9):1086-8.
2. CODA. Accreditation Standards for Dental Education
Programs. In: ADA, editor; 2013.
3. ADA HoD. Dental Practice Parameters for
Temporomandibular (Craniomandibular) Disorders. J Am Dent
Assoc 1996;October.
4. Glick M. Informed consent: a delicate balance. J Am Dent
Assoc 2006;137(8):1060, 62, 64.
5. CNA. An Informed Consent Primer. Dental Expressions
FIGURE 6A . MRI — right TMJ, 1/28/95, 42 years FIGURE 6B . MRI — left TMJ, 1/28/95, 42 years Chicago: CNA HealthPro-NP; 2005.
3 months old. 3 months old. 6. Schloendorff v. Society of New York Hospital 105 N.E. 02;
1914.
7. Okeson JP. Management of Temporomandibular Disorders
and Occlusion. 6th ed. St. Louis: Elsevier Mosby; 2008.
8. Simmons HC 3rd, Gibbs SJ. Recapture of
temporomandibular joint disks using anterior repositioning
appliances: an MRI study. Cranio 1995;13(4):227-37.
9. Simmons HC 3rd, Gibbs SJ. Initial TMJ disk recapture with
anterior repositioning appliances and relation to dental history.
Cranio 1997;15(4):281-95.
10. Isberg A, Widmalm SE, Ivarsson R. Clinical, radiographic
and electromyographic study of patients with internal
derangement of the temporomandibular joint. Am J Orthod
1985;88(6):453-60.
11. Cyriax J. Diagnosis of Soft Tissue Lesions. 8th ed. Bailliere
Tindall; 1982.
12. Pertes RA, Gross SG. Clinical Management of
Temporomandibuar Disorders and Orofacial Pain. Chicago:
Quintessence Publishing Co.; 1995.
13. Simmons HC 3rd. Craniofacial Pain: A Handbook for
Assessment, Diagnosis and Management Chattanooga:
Chroma Inc.; 2009.
FIGURE 7A . MRI — right TMJ, 4/29/06, 53 years FIGURE 7B . MRI — left TMJ, 4/29/06, 53 years 14. Simmons HC 3rd. Guidelines for anterior repositioning
6 months old. 6 months old. appliance therapy for the management of craniofacial pain
and TMD. Cranio 2005;23(4):300-5.
15. Surgeons AAoO. American Academy of Orthopaedic
determined by an occlusal appliance then ARA should be the appliance of Surgeons — Background; 2011.
16. Bell WE. Temporomandibular Disorders: Classification,
that has successfully diminished the choice for this patient population. Diagnosis and Management. 2nd ed. Chicago: Year Book
symptoms. If an intraoral appliance has Orthopedic care is appropriate for Medical Publishers Inc.; 1986.
diminished the signs and symptoms, some TMDs. ARA therapy for TMJ 17. Westesson PL. Reliability and validity of imaging
diagnosis of temporomandibular joint disorder. Adv Dent Res
a similar occlusal condition may be internal derangements was successful 1993;7(2):137-51.
introduced by irreversible occlusal therapy. in long-term recapturing disks in 18. Pullinger AG, Seligman DA. Trauma history in diagnostic
Simmons and Gibbs25 concluded a reducing and nonreducing joints in groups of temporomandibular disorders. Oral Surg Oral Med
Oral Pathol 1991;71(5):529-34.
1997 paper by stating that if the largest this patient population at a rate of 19. Laskin DM. Etiology and Pathogenesis of Internal
category in a consecutive complex 64 percent. ARA therapy for TMJ Derangements of the Temporomandibular Joint. Oral
chronic TMJ pain population is disk internal derangements was subjectively Maxillofac Surg Clin North Am 1994:218-22.
20. Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal
displacement with reduction, and 85 successful in relieving symptoms long derangements of the temporomandibular joint: effect on
percent of these will recapture when term in reducing and nonreducing facial development. Am J Orthod Dentofacial Orthop
the condyle is placed in the Gelb 4/7 joints in this patient population at an 1993;104(1):51-9.
21. Bertolucci LE. Trilogy of the “Triad of O’Donoghue” in
position (physiologic normal), and average rate of 94.5 percent. Based on the knee and its analogy to the TMJ derangement. Cranio
symptomatic relief following ARA therapy the evidence presented in this study, 1990;8(3):264-70.
has been shown by both subjective the orthopedic TMD dentist utilizing 22. Wiesel SW, Delahay JN. Essentials of Orthopedic Surgery.
3rd ed: Springer; 2007.
and objective criteria in patients ARA therapy may now regenerate 23. Paesani D, Salas E, Martinez A, Isberg A. Prevalence
with other categories of disk disorder, TMJ condyles in some patients. ■ of temporomandibular joint disk displacement in infants and
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Airway Centric
TMJ Philosophy
Michael L. Gelb, DDS, MS
AUTHOR
T
Michael Gelb, DDS, and Orofacial Pain Program he airway guides the development floating hyoid, high narrow palate,10
MS, is an innovator in and a clinical professor in of the nasomaxillary complex, retruded constricted maxilla4 and
sleep apnea, painful TMJ the Department of Oral mandible, temporomandibular maxillomandibular retrognathia as well as
disorders and other head Medicine and Pathology
and neck pain disorders. Dr.
joint (TMJ) and, ultimately, enlarged tonsils, adenoids and tongue. In
at New York University
Gelb has studied breathing- College of Dentistry.
the occlusion of the teeth.1-5 addition, current orthodontic technique11
related sleep disorders Conflict of Interest Occlusion is driven by the airway, and and nightguard fabrication may compress
(BRSD), specializing in Disclosure: Michael Gelb, malocclusion and facial morphology are condyles and narrow pharyngeal
how they relate to fatigue, DDS, MS, is the co-inventor compensation for a narrowed airway. airspace.12 Environmental factors, such as
focus and pain, and their of the Airway Centric
potential adverse effects.
Airway Centric (AC) TMJ philosophy feeding patterns, dietary characteristics,
medical device and is the
He received his dental chairman and CEO of Gelb
explains this important paradigm shift trauma, pacifier use, digit sucking, mouth
degree from Columbia Technologies LLC. Historical based on new research, with an emphasis breathing and swallowing habits, are also
University School of Dental portions of this content are on prevention of sleep disordered associated with malocclusion.13 Airway
and Oral Surgery and a from previously published breathing (SBD), temporomandibular narrowing and SDB lead to alterations in
master’s degree from the material.
State University of New
disorders and neurobehavioral the nasomaxillary complex and mandible
York at Buffalo School of disorders5,6 (FIGURES 1 and 2 ). as well as to further malocclusion.14
Dental Medicine. He is the The airway governs our ability to The dentist plays a key role in airway
former director of the TMJ breathe and achieve a restful, oxygenated, health, as 90 percent of obstruction
restorative night’s sleep, as well as occurs behind the maxilla and mandible
to perform optimally during the day. in the region of the soft palate, tongue
Epigenetics7 and phylogenetics8 have and lateral fat pads.15 The ear, nose and
made humans susceptible to airway throat specialist (ENT) and orthodontist
collapse because of a variety of factors, are also essential to establishing nasal
including a descending epiglottis,9 a and pharyngeal airway patency.
A U G U S T 2 014 551
airway centric
C D A J O U R N A L , V O L 4 2 , Nº 8
EAR 2 1
5 4
3
7 6
Gelb 4/7
FIGURE 1. Closed airway. FIGURE 2 . Airway Centric philosophy. FIGURE 3 . Gelb 4/7 position.
Any TMJ or occlusal philosophy must History of Centric Relation Dentistry to “flatten” profiles and supposedly give
also include a nighttime component to My introduction to centric relation more stable results (FIGURE 5 ). Ron
address parafunction or bruxism because and the TMJ dates back to 1965 when Roth, DDS, and Robert Williams, MS,22
of the shearing forces to the joint12 and I viewed the images my father, Harold applied the CR concept to orthodontics
increased tension of the cervical and Gelb, DDS, used for his lectures. It is now in ensuing years. Over the next 40 years,
masticatory muscles. Sleep bruxism is 49 years later, and the Gelb 4/7 position the gnathologists and Tweed orthodontists
classified as a parasomnia or stereotyped (FIGURE 3 ) has serendipitously evolved contributed to a more retruded jaw
movement disorder16 with obstructive into the AC philosophy and the Gelb position with fewer teeth (FIGURE 5 ). This
sleep apnea as a leading risk factor. 4/7 Bite, Balance, Breathing method. jaw position was taught and utilized in
Other etiologic factors are autonomic A little more history: In 1930 the American dentistry from 1930-1995 and
sympathetic cardiac activation, sleep fathers of gnathology, Harvey Stallard, is still taught in some parts of the country.
arousal, neurochemicals, comorbidities PhB, PhD, DDS, Charles Stuart, DDS, To dentists such as Bill Farrar, DDS,
(SDB) and psychosocial factors. and Beverly B. McCollum, DDS, followed Barney Jankelson, DDS, and Harold Gelb,
SDB, defined as mouth breathing, Bonwill’s mechanical occlusion theory20 this made no sense. The condyle wars
snoring, upper airway resistance and translated the movement of the in the 1970s pitted gnathologists such
syndrome (UARS), hypopnea and jaw to an articulator. The gnathologists as L.D. Pankey, DDS, Peter E. Dawson,
apnea, leads to sleep fragmentation developed a jaw position called centric DDS, and the Society of Occlusal Studies
and decreased stage-three restorative relation (CR), which is the most retruded against Gelb, Farrar, Jankelson and John
sleep. Decreased stage-three, or delta superior position of the joint (FIGURE 4 ). Witzig, DDS. Witzig taught the European
slow wave, sleep has been linked to Some dentists referred to this jaw position school of functional orthodontics
fibromyalgia17 and increased chronic pain. as rearmost, uppermost or terminal popularized by Laszlo Schwartz, DDS,
Any TMJ or occlusal philosophy hinge. The focus at that time was on and Christine Frankel, DDS, which used
must address airway patency while the teeth and the occlusion and the way the Gelb 4/7 position in nonextraction
managing pain and dysfunction, the teeth fit together and contacted in expansive orthodontics. Witzig was the
identifying contributing factors18,19 right and left lateral excursions. Other expert witness in a landmark legal case
and alleviating perpetuating factors. articulators were developed to support involving a four-bicuspid extraction
The teeth are the last piece of the occlusal philosophies over the next patient who required TMJ surgery
AC paradigm. The airway is the first, 80 years, and include the Artex, Sam, following extraction orthodontics. The
followed by joint and muscle and, lastly, Panadent, Whip Mix and Denar. patient received more than $1 million,
the occlusion and anatomy of the teeth. These gnathologists were revered and a substantial settlement at the time.
Prevention of temporomandibular were inducted into the USC Dental Hall In the 1980s Dawson, along with the
disorders (TMD), malocclusion and of Fame. Around the same time, Charles authors of the glossary of prosthodontic
neurobehavioral and neurocognitive H. Tweed, DDS, had just graduated terms,23 realized that the gnathologists had
issues6 is the goal of AC TMJ philosophy from Angle’s School of Orthodontics no biologic or physiologic evidence for a
and requires early identification and rejected nonextraction theory as retruded centric position. They followed
and early intervention, although producing faces that were too protrusive.21 Gelb, but with a more conservative
intervention can occur at any age. He began extracting permanent bicuspids anterior-superior position (FIGURE 6 ).
552 A U G U S T 2 014
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mandibular orthopedic repositioning position would also retrude the tongue profound effects on stage-three restorative
appliance (MORA) (FIGURE 7 ). The and palate and lead to a collapsed sleep, which is necessary for repair and
NYU appliance covered the cuspids, airway. Gelb and Farrar were the first regeneration of musculoskeletal tissue, as
which prevented intrusion and allowed to go against the grain and maintain well as on rapid eye movement (REM)
for cuspid guidance, and placed acrylic a forward position for an open airway sleep that is needed for well-being
around the linguals of the lower during the day and at night. and memory consolidation. SDB also
anteriors for stability. Both appliances Most of the TMJ/TMD research of profoundly affects tissue inflammation,
worked best with occlusal indexing, the last 30 years has been measuring hypoxia and reperfusion, oxidative stress
which defined the new occlusion the wrong variables. With the advent and endothelial dysfunction, all of which
and gave increased proprioception of PSGs we can easily measure impact the TMJ, muscles of mastication
while swallowing. Gelb and Gelb electrical activity of the heart and general well-being of the patient.
recommended a Farrar antiretrusion with an electrocardiogram (EKG), AC philosophy takes dentistry into
appliance at night for those patients electrical activity along the scalp the field of medicine and empowers
with clicking or intermittent locking.43 with electroencephalography (EEG), the dentist or physician to treat apnea,
Farrar27 utilized a position very electrical activity produced by muscles hypopnea, upper airway resistance
similar to the Gelb 4/7 in accordance with electromyography (EMG), syndrome and snoring and, in doing so,
with arthrography to reposition the heart rate variability (HRV), CO2 to improve overall health and wellness.
jaw and maintain that position at and O2 saturation, as well as apnea, AC TMJ is a new philosophy in
night with the Farrar antiretrusion hypopnea, upper airway respiratory dentistry. The airway now trumps
appliance.27 Not only did Farrar prevent symptoms, arousals of the brain and everything else in dentistry or medicine.
jaw clicking and locking during sleep, body position with sound and video. Along with sleep and breathing, the
he, along with Gelb, serendipitously I propose that these objective airway is hierarchically the most
fabricated the first oral sleep appliances. physiologic measurements have already important function for humans. Ideal
When the mandible retrudes to a shown the efficacy of mandibular health, wellness and brain development
retrognathic, or slack-jawed, position positioning appliances over the last depend on an open pharyngeal airway,
during supine sleep, the tongue and 20 years, with multiple position nasal breathing and restorative sleep.
soft palate also retrude and collapse papers published by physicians, sleep This requires a partnership between
the airway. Nightguards traditionally specialists and researchers.44 the ENT, pulmonologist, lactation
fabricated in a terminal hinge-retruded Sleep deprivation and SDB have consultant, myofunctional therapist,
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further down in the oropharynx. Humans an adverse effect on the size of the hypotonia and secondary changes in
were no longer obligate nose breathers, nasomaxillary complex, mandible and maxillomandibular growth. Other
and with increased demands, mouth pharyngeal air space.10 The same changes children develop difficulty with nasal
breathing was born. This trend of mouth are seen in children who display habitual breathing when tonsils and adenoids
breathing, downward migration of the mouth breathing and who are at risk of develop between ages 2 and 8, which
tongue base and descent of the hyoid is SDB. Harvold54 stated, “Elimination of leads to chronic mouth breathing and
associated with changes in mandibular nasal airway interferences followed by SDB. Parents may report noisy breathing
posture to retrognathic. The increase in changes from oral to nasal respiration in infants rather than frank snoring.52
mouth breathing is also associated with may result in improvement of certain Bonuck found habitual snoring in 9.6
less time spent with the tongue to the aspects of facial and dental deviations.” percent to 21.2 percent of children six
palate, narrowing of the maxilla and A key aspect of the AC TMJ months to 6.75 years of age. At age
increased facial height.50 The downward occlusal philosophy is, therefore, 6, 27 percent were habitual mouth
and backward rotation of the maxilla establishment of nasal breathing with breathers. Snoring increased significantly
and mandible is a powerful predictor of ideal development of the maxilla. between 1.5 and 2.5 years in a study
SDB51 as well as TMJ and malocclusion. of 11,000 children older than 6 years.
A variety of researchers, clinicians SDB causes abnormal oxygen and CO2
and anthropologists has identified an The downward and levels, interferes with restorative sleep
underdeveloped maxilla as the root cause and disrupts cellular and chemical
of malocclusion and naso-oropharyngeal backward rotation of homeostasis. The fragmentation of
constriction. Identification of mouth the maxilla and mandible stage-three restorative slow-wave brain
breathing is therefore recommended activity by disruptive sleep or hypoxia
as early as the first year of life.52 is a powerful predictor of can result in issues with decision-making,
The animal model of OSA is SDB as well as TMJ ambition and emotional regulation.56
the English bulldog that suffers from The AC TMJ philosophy starts
brachiocephalic syndrome. Since the
and malocclusion. prenatally with the mother’s nutrition
1950s the bulldog has been bred with a and airway. Our goal is for a full-term
thicker neck and pushed-in snout. This pregnancy with ideal development
brachiocephalic “retropositioning” results AC in Children of the palate and maxilla. At birth,
in a retruded maxilla and mandible similar Pediatric sleep disorders result in we advocate for at least two months
to the description of human evolution disrupted, inefficient and inadequate of breast-feeding,57 and preferably
above. This bony malformation reduces sleep and may affect brain development six months or a year if practical.
oral volume and pharyngeal space. The and cause neuronal damage.1,6 Even This confers a reduction in SDB. A
bulldog often exhibits pseudo class-three habitual snoring is an indicator of a poor suck may result from hypotonia
occlusion, crowded teeth, pinched nostrils number of health problems in children, from birth and result in SDB.
and a large tongue that protrudes from the including poor physical growth, Frenum attachments may need to be
mouth. Most bulldogs expire from heart emotional and behavioral problems, surgically released if they interfere with
disease or cancer secondary to the effects neurocognitive impairment and tongue movement or breast-feeding. Nasal
of brachiocephalic airway narrowing decreased academic performance.55 breathing is of paramount importance
and subsequent systemic inflammation, It is accepted that an apnea–hypopnea for growth and development. If a child
oxidative stress and hypoxia.53 index (AHI) greater than 1 is abnormal has nasal obstruction due to allergy, it
Egil Harvold, DDS,54 converted in a child. Nasal airway obstruction is must be addressed as early as possible.
rhesus monkeys to mouth breathers by particularly significant in infants and Many premature infants are born with
obstructing nasal breathing and observed young children who are obligate nose high narrow maxillas, which predispose
increased face height, posterior rotation breathers. Many premature infants them to mouth breathing, the first sign of
of the mandible and malocclusion. In are born with high narrow palates an airway disorder. With mouth breathing,
growing animals in which the nasal and are mouth breathers from birth.10 the tongue cannot assume proper rest
airway is gradually occluded there is These children also display orofacial posture against the premaxilla, resulting in
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narrow, constricted, high-vaulted palates Narrow maxillas also predispose to Most jaws today do not have room for
and poor maxillary growth. It can also TMJ disorders, growth abnormalities all 32 teeth, as evidenced by the number
result in a poorly developed nasal airway, and SDB. Sixty percent of facial of children and young adults who require
increased facial height, a retrognathic growth is attained by age 6 and 90 wisdom teeth extractions. Comparing
mandible, shorter maxilla and mandible, percent by age 11 or 12; therefore, early the wide U-shaped skulls from the
larger tongue, longer and thicker soft intervention is particularly warranted Smithsonian and the Museum of Natural
palate and an inferiorly placed hyoid bone. in children with SDB. Occupational History with today’s skulls indicates that
Tonsils and adenoids tend to therapy and myofunctional therapy the maxilla has significantly retruded.
hypertrophy between ages 2 and 8; however, with special orofacial exercises during Epigenetic factors include
before that, by six, 18 and 30 months of feeding and chewing in the first two environmental pollutants, obesogens,
age, snoring and sleep apnea are already years of life may lead to improvement sugar in our diet and pesticides. These
present, which predict neurobehavioral in facial anatomy, repositioning of the factors are also thought to have caused
disorders at age 4 and 7. Children in one tongue and development of a normal the sudden dramatic increase in
study who were symptomatic in infancy nasomaxillary complex and mandible.10 attention deficit hyperactive disorder
were 20 to 60 percent more apt to exhibit (ADHD), obesity, diabetes, heart disease
neurobehavioral disorders by age 4, and and a spectrum of other disorders.
40 to 100 percent more likely by age Abnormal nasomaxillary growth is
7. Symptoms included hyperactivity,
The maxilla can thought to be responsible for SDB and
misconduct and peer difficulties. These be developed very TMD. AC philosophy addresses the
attention and executive function early in childhood following vital pathologic processes:
deficits persisted into adulthood.58 ■ Oxidative stress — results in
Early SDB may lead to permanent and has a huge impact free radical production.
prefrontal cortex change, causing on improving nasal ■ Systemic inflammation — associated
attention and executive function problems with the release of inflammatory
even if the SDB improves. In other words,
breathing and SDB. cytokines, tumor necrosis factor alpha
SDB’s effects may be irreversible.6 (TNF-alpha), interleukin 6 (IL6).
Our knowledge of brain changes ■ Intermittent hypoxia — oxygen
encourages intervention as early as It is encouraging to realize that early desaturation is followed by reperfusion,
the first year of age. The trend today interdisciplinary intervention may prevent often hundreds of times per night.
is adenotonsillectomy (AT), palatal SDB and subsequent pathologic sequelae. ■ Endothelial dysfunction — reflects the
expansion and myofunctional therapy health of the blood vessel wall and the
as early as age 3.5. AT resolved only 51 Development of the Maxilla ability to vasodilate. It is the risk factor
percent of OSA in nonobese prepubertal Epigenetic factors are thought to have of risk factors for cardiovascular disease.
children.1 Children who snore in dramatically changed the development ■ Autonomic deregulation — thought
early childhood tend to have lower of the jaws.5,7 Robert Corrucini, PhD, has to be a major contributing factor
academic performance independent also attributed crowded teeth and small, in the development of cancer and
of AT later in development.10 History narrow jaws to the soft consistency of cardiovascular disease.
of either SDB or behavioral sleep the diet. Kevin Boyd, DDS, a pediatric Lack of quality sleep increases pain and
problems in the first five years led dentist, points to the dietary changes lowers immune function while increasing
to increased likelihood of special following the industrial revolution TNF-alpha, IL6 and interleukin 8 (IL8).61
educational need at age 8 in one study.59 and lack of breast-feeding as a cause Most chronic diseases are greatly
The maxilla can be developed very for the shrinkage of the maxilla.7 influenced by the airway and breathing.
early in childhood and has a huge Seminal work by Weston Price, DDS, Opening the airway with the AC TMJ
impact on improving nasal breathing has demonstrated that malocclusion philosophy allows normalization of
and SDB. In adults with narrow palates, occurred in primitive tribes within endothelial dysfunction and reduces
adequate nasal breathing is often two generations of the introduction oxidative stress, systemic inflammation
impossible even with nasal surgery. of an industrialized diet.60 and intermittent hypoxia. This is often
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C D A J O U R N A L , V O L 4 2 , Nº 8
the missing link for the treatment headache and dysfunction related to Anterior Posterior
of fatigue, obesity, ADHD, diabetes growth and development, parafunction Epigenetics has predisposed to
and cardiovascular disease. or past trauma. In patients who present predominantly retrognathic bites
AC treatment will help determine the with TMD, pain or dysfunction, with forward head posture. As we
final TMJ, muscle and occlusal position. the appropriate appliance design is reposition the mandible forward, we
The TMJ will be decompressed and chosen in combination with physical work with physical therapists who use
the pharyngeal airway will be open. therapy, medication, Botox injections, the Alexander Technique, Feldenkrais
craniosacral therapy, chiropractic Method, Pilates and Gyrotonics to
Nighttime Philosophy or osteopathic manipulation. Lower strengthen the core and achieve ideal
Therapeutic jaw position at night appliances are preferred during the day posture, like that of a dancer or actor.
is dictated by the airway first and TMJ to help articulation. The NYU and lower As we bring the jaw forward, the
second. Because bruxism is associated with stabilization appliances are recommended head goes back over the shoulders. Our
brain arousal and is thought to be related for six to 12 weeks of daytime wear and philosophy is to decompress the jaw joints
to SDB, a sleep study is required for any then as needed during physically and bilaterally by anterior repositioning of
patient with excessive daytime sleepiness the mandible. Criteria for repositioning
(EDS), snoring, witnessed apnea, high include recapturing the disk when
blood pressure (HBP) or narrowed airway. possible, alleviating joint noise when
Home sleep studies or PSG are both Our philosophy is possible, achieving ideal facial esthetics,
adequate, depending on comorbidities maintaining minimal bite opening
and the information required. to decompress the during the day and maintaining natural
A positive sleep study will usually jaw joints bilaterally anterior guidance when possible.
necessitate an oral appliance to maintain by anterior repositioning I tell my patients that I am putting
an open airway, sometimes combined their chins back to the middle of their
with continuous positive airway
of the mandible. faces. When phonetics and ramus
pressure (CPAP), nasal surgery and height discrepancy support moving
positional therapy. Treatment duration the mandible back to the center while
could be three to six months followed alleviating joint compression and
by a sleep study to ensure efficacy. emotionally stressed periods. These might reducing joint noise, it is done. The
Bite changes can be expected, include exercising, playing competitive mandible often migrates to the short
particularly for patients with class- sports, studying for and taking tests, ramus side, which is the high eye side.
two division-two malocclusions or and putting in intense days at work.
retruded maxillas. At a three-week Beauty
follow-up visit, the dentist monitors Vertical Dimension Nonsurgical facelifts were talked
the list of chief complaints related Most patients have lost vertical about in the ’80s and ’90s. Today we
to pain and dysfunction. Criteria for dimension or have compressed are able to restore full lips and reduce
success require alleviation of pain and temporomandibular joints. In long-face nasolabial folds, but more important,
dysfunction complaints as well as of patients, we want to decompress the increase the oxygenation of the skin
EDS, noisy breathing and OSA. joint without opening vertical more and open the eyes. There is a glow and
than necessary. In anterior open bites, sense of life that was missing. Part of
Daytime Philosophy we always establish anterior guidance the transformation is the reduction
Oral appliances are often used during by providing anterior contact. in pain and stress on the body. More
the day as well to address daytime In dental school, we were taught that important perhaps is the healing effect of
complaints, which require habit control one could not open the vertical dimension restorative sleep, decreased inflammation,
and TMJ or muscle rehabilitation, of occlusion. We now know that the hypoxia and oxidative stress.
particularly for patients who need body will reestablish freeway space, and In approximately 10 percent of adult
cognitive behavioral therapy. Many often the vertical needs to be added to cases and 100 percent of children’s
patients who present with SDB also have at night to maintain an open airway. cases, orthodontics, such as palatal
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expansion, is required. Smile lifts, as ■ Normal spinal curvature achieved Upper airway resistance and SDB
popularized by Larry Rosenthal, DDS, with Alexander Technique, are also linked to a retruded short
from NYU and Aesthetic Advantage, Feldenkrais Method, Pilates, yoga. maxilla and retrognathic mandible,
are often needed because of the ■ Lips together, teeth apart. which predispose to TMD headache
preponderance of narrow maxillas. Dr. ■ Chest up. and cervical postural change.
Rosenthal and I have restored several ■ Belly in, engage abdominals. The Airway Centric TMJ and
cases after TMJ and AC stabilization. occlusal philosophy will result
TMJ in a condylar position between
Occlusal Philosophy ■ Absence of clicking, popping, locking. concentric and Gelb 4/7 during
Many patients have anterior open ■ Decompressed in the range the day and Gelb 4/7 to the middle
bites secondary to condylar degeneration concentric to Gelb 4/7. of the eminence at night.
or perimenopausal changes in the joint. ■ Full range of motion or a measured Robert M. Ricketts, DDS, stated,
In those cases, we always establish opening of 36-54 mm. “Respiration and mastication are
anterior guidance, typically bringing biologically inseparable. It would appear
the mandible forward to decompress the Face that normal nasal breathing is conducive to
joint and open the airway. Whenever ■ Shape — favors horizontal growth. normal growth of the maxilla and normal
possible, the appliance establishes ■ Lips — full and symmetrical. development of the occlusion of the
canine guidance. I use a modified Gelb ■ Skin tone — glowing. teeth.”63 The influence of gnathology and
appliance for daytime, covering the ■ Eyes — open and alive, not orthodontics in the ’30s and ’40s led to the
cuspids and placing acrylic behind the showing too much sclera. concept of treating just the teeth instead
lower anterior teeth to prevent shifting. ■ Profile — good vertical of the face or the patient as a whole.
Gnathologic principles can be used and strong lower jaw. Ricketts also wrote, “We talk about
if the jaw is in the right position. the oral cavity as if it is independent of
Slight posterior open bites are Teeth the development of the first branchial
acceptable and often preferred. We want ■ Smile lift or palatal expansion arch and independent from respiration.
the majority of force in the premolars to fill buccal corridors. Biologically, the functions of mastication
and anterior teeth. A slight posterior ■ Support airway and TMJ. and respiration have been connected with
open bite discourages parafunction. ■ Cuspid rise. the same set of muscles and the same set
In 10 percent of cases, some form ■ Anterior coupling. of nerve paths. We can’t separate them.”63
of dentistry is required following ■ OK to have lighter contact posteriorly Final occlusal restorations cannot
my treatment plan, which often or slight posterior open bite. be completed until SDB is successfully
involves physical therapy, trigger point managed over a six-month to one-year
injections and Botox injections. Conclusion period. There will be occlusal changes
A small upper airway and stunted based upon the initial position of the
Criteria for Success nasomaxillary complex predispose nasomaxillary complex, mandible,
humans to SDB.8 Early intervention pharyngeal air space, hyoid bone
Airway is essential to prevent and correct and craniofacial morphology.
■ Open day and night. anatomic abnormalities, which will The dentist should recognize and
■ Improved SDB or AHI; respiratory also prevent SDB and resultant address TMJ and airway disorders prior to
disturbance index (RDI) decreased emotional and behavioral problems, restorative dentistry, as TMJ and airway
by at least 50 percent. neurocognitive impairment, decreased treatment may result in occlusal changes. ■
■ Improved EDS. academic performance and poor REFERENCES
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associated with hypoxia, oxidative children. Indian J Med Res 2010 Feb; 131(2): 311-320.
Posture (standing, seated and supine) stress, disrupted sleep and endothelial 2. Linder-Aronson S. (1969) Dimensions of face and palate in
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■ String pulling up the back of dysfunction,62 all precursors to obesity, 14:187-200.
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Dr. Raman
Publications, 1982.
Drs. Fricton, Gelb and Simmons’ well-written papers contribute to the knowledge
28. Katzberg RW, Westesson PL. (1993) Diagnosis of the base for dentists.
Temporomandibular Joint. Philadelphia: W.B. Saunders Co. Dr. Gelb nicely summarizes the history of TMD treatment approaches. His
29. Mehta NR, Forgione AG, Rosenbaum RS, Holmberg R.
Airway Centric approach is very congruent with the PNMD approach. TMD treatment
(Jan. 1, 1984) “TMJ” triad of dysfunctions: a biologic basis of
diagnosis and treatment. J Mass Dent Soc 33, 4, 173-6. guided by objective physiologic measurements such as real-time electromyography
30. Gelb H, Arnold GE. Syndromes of the head and neck of (EMG) and computerized mandibular scanning (CMS) is the foundation of PNMD.
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Arch Otolaryngol 1959; 70:681-691.
31. Simmons HC 3rd, American Academy of Craniofacial
do EMG and CMS.
Pain. (2009) Craniofacial Pain: A Handbook for Assessment, Dr. Gelb states that anterior repositioning appliances are superior to neuromuscular
Diagnosis and Management. Chattanooga, Tenn: Chroma Inc. (NM) splints. NM orthotics are constructed to a mandibular position where all
32. Westesson PL, Lundh H. Temporomandibular joint disk masticatory and cervical muscles are unstrained. Craniocervical physical therapy to
displacement: arthrographic and tomographic follow-up after 6
months’ treatment with disk-repositioning onlays. Oral Surg Oral address cervical restrictions and recapture of any displaced disks is done before taking
Med Oral Pathol 1988; 66(3):271-278. PNMD bite relation. This position is determined by the real-time physiologic parameters
33. Simmons HC 3rd, Gibbs SJ. Initial TMJ disk recapture with of EMG. The resulting changes to the condylar position vary on an individual case as
anterior repositioning appliances and relation to dental history.
recorded by CT scans. Often it is down and forward in the fossa. It can also be more
Cranio 1997; 15(4):281-295.
34. Simmons HC 3rd, Gibbs SJ. Anterior repositioning appliance downward on one joint. So his claim that an arbitrary anterior positioning of the mandible
therapy for TMJ disorders: specific symptoms relieved and is more efficacious than a physiologic NM orthotic appliance is illogical. The referenced
relationship to disk status on MRI. Cranio 2005; 23(2):89-99. studies seem to compare flat plane appliances.
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joint disks using anterior repositioning appliances: an MRI study.
Dr. Gelb describes moving the mandible back to the center using phonetics and ramus
Cranio 1995; 13(4):227-237. height. Is this any less subjective than “romancing the mandible”? While acknowledging
36. Lundh H, Westesson PL, Kopp S, Tillstrom B. Anterior the utility of clinical judgment and subjective factors such as phonetics, EMG of muscles of
repositioning splint in the treatment of temporomandibular joints
mandibular and cervical posture gives real-time objective data on the physiology rather
with reciprocal clicking: comparison with a flap occlusal splint an
untreated controlled group. Oral Surg Oral Med Oral Pathol than using anatomical landmarks.
1985; 60(2):131-136. I respect the contributions of Dr. Harold Gelb. Dr. Michael Gelb states that the Gelb
37. Anderson GC, Schulte JK, Goodkind RJ. Comparative 4/7 position correlates with the physiologic normal position for the TMJ condyle in the
study of two treatment methods for internal derangement of the
temporomandibular joint. J Prosthet Dent 1985; 53(3):392-397.
fossa and that the Airway Centric philosophy will result in a condylar position between
38. Simmons HC 3rd. Guidelines for anterior repositioning concentric and Gelb 4/7 during the day and Gelb 4/7 to the middle of the eminence at
appliance therapy for the management of craniofacial pain and night. Focusing on the relative position of the condylar head in the fossa to an idealized
TMD. Cranio 2005; 23(4):300-305.
position within the fossa misses on two counts:
39. Simmons HC 3rd. Orthodontic finishing after TMJ disk
manipulation and recapture. Int J Orthod 2002; 13(1):7-12. ■ Morphological changes of the condyles — bending, breaking, flattening and other
40. Summer JD, Westesson PL. Mandibular repositioning can compensatory changes make the position of such a condyle different from an
be effective in treatment of reducing TMJ disk displacement. A
long-term clinical and MR imaging follow-up. Cranio 1997; undamaged condyle within the same fossa.1
15(2):107-120. ■ Anatomical appearance shows the current condition of the structures that have
41. Kurita H, Kurashina K, Baba H, Ohtsuka A, Kotani A, Kopp resulted in response to the forces over time. It is akin to looking at the rearview mirror.
S. Evaluation of disk capture with a splint repositioning appliance:
clinical and critical assessment with MR imaging. Oral Surg Oral Physiologic parameters — such as electrocardiogram (EKG), apnea–hypopnea index
Med Oral Pathol Oral Radiol Endod 1998;85(4):377-380. (AHI) and EMG give current data on the function of the organism. Function changes
42. Manzione JV, Tallents R, Katzberg RW, Oster C, Miller the form just as oral breathing changes maxillary shape.
TL. Arthrographically guided splint therapy for recapturing the
temporomandibular joint meniscus. Oral Surg Oral Med Oral 1. Hatcher DC. Progressive Condylar Resorption: Pathologic Processes and Imaging Considerations. Semin Orthod
Pathol 1984; 57(3):235-240. vol. 19, no 2 (June), 2013: pp 97-105.
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repositioning therapy. In: Bledsoe WS Jr., ed: Intraoral
Orthodontics. Baltimore: Williams & Wilkins, 1991.
44. Kushida CA, et al. American Academy of Sleep. (Jan. 1,
2006) Practice Parameters for the Treatment of Snoring and
Obstructive Sleep Apnea With Oral Appliances: An Update for
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CDA Store
Disorders and Special Educational Need at 8 Years: A
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Khalyf A, Tauman R. (Jan. 1, 2010) Sleep measures and morning Shop online
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THE AUTHOR, Michael Gelb, DDS, MS, can be reached at mgelb@
gelbcenter.com.
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C D A J O U R N A L , V O L 4 2 , Nº 8
Physiologic Neuromuscular
Dental Paradigm for the
Diagnosis and Treatment of
Temporomandibular Disorders
Prabu Raman, DDS, MICCMO, LVIM, FPFA, FACD
AUTHOR
T
Prabu Raman, DDS, a past president of the he diagnosis and treatment of improvements occur in any arena with
MICCMO, LVIM, FPFA, International Association of temporomandibular disorders a change in the basic paradigm.1 The
FACD, has practiced Comprehensive Aesthetics, a
dentistry in Kansas
(TMD) is the most confusing physiologic neuromuscular dentistry
past president of the Greater
City, Mo., since 1983, Kansas City Dental Society subject in dentistry. Many factors (PNMD) paradigm offers such a
with an emphasis on and serves as an HOD contribute to this confusion; significant improvement in how the
neuromuscular dentistry/ delegate, member of the chief among them is a simplistic view dental profession views and treats
temporomandibular Council on Dental Education of this disease that relates it only to TMD. It acknowledges the primacy of
dysfunction, esthetic and Licensure of the
dentistry-complex restorative
temporomandibular joints (TMJs) or physiology in shaping and controlling
American Dental Association
dentistry, neuromuscular and as a trustee of the attributes it to a single etiology. Another anatomy in a functioning human
functional orthodontics and Missouri Dental Association. factor is the lack of TMD training body. A guiding principle of PNMD
sleep breathing disorders/ He earned his dental in predoctoral dental education. is, “If it has been measured, it is a fact.
oral appliance therapy. He degree from the University TMD encompasses a group of If it has not been measured, it is an
is a fellow of the American of Missouri, Kansas City,
College of Dentists and a
musculoskeletal and neuromuscular opinion.” As such, physiologic data
School of Dentistry.
fellow of the Pierre Fauchard Conflict of Interest conditions that involve the masticatory such as electromyography (EMG)
Academy. Dr. Raman is Disclosure: None reported. system, the dentition (occlusion), the of the jaw and neck muscles drive
TMJs and all associated tissues. Quantum diagnostic and clinical decisions.
Video for this article is available in the e-pub version of the Journal, available at cda.org/apps.
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SMV View
FIGURE 3 . Pretreatment sEMG scan of mandibular and cervical posture muscles FIGURE 4 . Comparison of muscle recruitment at rest versus effort needed to bring
at rest versus at light occlusion. LTA = left temporalis anterior, LMM = left medial teeth into just light occlusion prior to chewing. RTA and LTA posture the mandible and
masseter, RSM = right sternocleidomastoid and RDA = right digastric anterior. bring it through space into occlusion.
recorded with pulse oximetry. nerves) were pulsed for 60 minutes by ultra- same act of bringing the teeth into
■ Palpation of TMJ, jaw and cervical low-frequency transcutaneous electroneural occlusion was almost effortless with
muscles was performed and recorded. stimulation (ULF-TENS). Every muscle the orthotic (FIGURES 7 a n d 8 ).
■ Severe tenderness was noted at left innervated by these nerves was pulsed While this objective measure of
shoulder trapezius and bilateral lateral for 0.5 second every 1.5 seconds so they improvement is encouraging, the most
pterygoids; moderate tenderness was would contract and relax, essentially important measure is that all of Dana’s
noted at bilateral medial pterygoids, massaging each of these muscles to improve symptoms resolved 70 percent within
right posterior scalene and bilateral oxygenated blood flow, eliminating waste 30 days, far exceeding her expectations.
stylomandibular ligaments; mild products such as lactic acid from the Therefore, she chose the option of
tenderness was noted at left temporal muscles to reestablish a biochemical and orthodontically moving her teeth, guided
tendon, right levator scapula, physiologic optimum. A repeat EMG by the physiologic metrics to permanently
right neck trapezius, left posterior showed even lower recruitment of these change her mandibular alignment. One
scalene, right anterior scalene, right muscles, denoting relaxed muscles. From year later, she is currently undergoing
sternocleidomastoid muscle (SCM), this optimal physiologic condition, the true physiologic neuromuscular orthodontics
bilateral occipital, bilateral middle magnitude of the mandibular discrepancy and remains 90 percent symptom-free.
scalenes, bilateral posterior TMJ was revealed when the patient brought The improvement in Dana’s quality of life
space and bilateral joint capsules. her teeth into light occlusion requiring and that of her family is immeasurable,
Cone beam CT evaluation of the 7X on the right side and 12X on the according to her and her husband.
TMJs was within normal limits with left temporalis (FIGURES 5 and 6 ). Dentists who choose to treat TMD
slight reduction of joint space. It was Once the 3-D relationship of the patients should acknowledge that TMD
negative for condylar deformation or mandible to maxilla was diagnosed, is multifactorial.33-36 They should use
deterioration (FIGURES 1 and 2 ). a temporary anatomic fixed orthotic objective measurements of physiology37
A Myotronics K7 evaluation system was constructed of Integrity resin to supplement anatomical data such as
was utilized. The patient’s resting EMG, (DENTSPLY, Milford, Del.) on the radiographic imaging and subjective
shown on the left half of the image, mandibular arch to allow for physiologic reports in the diagnosis and treatment.
was within the norms noted on the left economy of the posturing muscles. TMJ radiographic imaging does not
margin. However, the effort it took for The patient functioned with this fixed make a diagnosis of etiology in and of
her temporalis muscles just to bring the orthotic that she could not remove but itself. Qualified medical professionals
teeth into occlusion, shown on the right that could be removed by the dentist interpret imaging records and those data
half of the image, increased 5X on the if the treatment was unsuccessful in facilitate the overall diagnosis. Similarly,
left and 8X on the right side compared symptom resolution. At a follow-up surface EMG studies provide objective
to resting posture (FIGURES 3 and 4 ). visit seven days after delivery, the clinical information about masticatory
Her cranial nerves V, VII and XII mandibular function was again objectively muscle status, which a properly trained
(trigeminal, facial and spinal accessory evaluated and coronoplastied. The dentist interprets to aid in his or her
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FIGURE 5 . Post ULF-TENS treatment sEMG scan of mandibular and cervical FIGURE 6 . Comparison of muscle recruitment at rest versus effort needed to just
posture muscles at rest versus at light occlusion reveals the actual level of mandibular bring teeth into light occlusion prior to chewing.
discrepancy to maxilla.
diagnosis. The bioelectronic devices teeth in light habitual occlusion,45 the mandibular position of presenting
commonly known as neuromuscular maximum clenching46 and contraction habitual occlusion and the physiologic
measurement devices are used to frequency of muscles that indicate neuromuscular mandibular position
provide the diagnosing clinician with muscle fiber types and fatigue levels.47 is the starting point of therapy.60
much expanded, precise, objective The utility and reliability of sEMG is A neuromuscular dental treatment plan
measurements and clinical information to well established in research literature.48-50 requires minimal or no treatment when the
reach an accurate diagnosis. The role of ■ Computerized jaw tracking studies dentist’s diagnosis so indicates. Provisional,
these instruments in reliably documenting of mandibular movement.51 reversible treatment that accommodates
and providing objective data is well ■ Electrosonography (ESG) recordings chewing and speaking is used first to
documented in numerous studies.38-40 of TMJ sounds during function.52 confirm the efficacy of therapy, validate the
As dentists, our training and license ■ Cone beam CT views or corrected planned treatment and to further refine the
to practice limit us to the orofacial tomograms of the TMJs in habitual mandibular position before any permanent
region. At the outset, it is necessary to occlusion, maximal opening alteration of the teeth is done. Because
determine whether the primary etiology and maximal protrusion. mandibular posture is a function of the
of the patient’s complaints is related to ■ Static posture and gait analyses to overall posture, as the posture improves,
a discrepancy of mandibular posture. If identify postural compensations. the mandibular posture may change as well
so, a comprehensive gathering of data is ■ ULF-TENS of muscles of mastication until stability is achieved. The patient and
needed to facilitate an accurate diagnosis. and cervical posture through dentist have the option of discontinuing
These may include the following: neurally mediated pulses.53-57 orthotic therapy if there is inadequate
■ Comprehensive history, including ■ Determination of the physiologic improvement. Objective measures, similar
medical and dental history. neuromuscular mandibular position to the pretreatment diagnostic series,
■ Thorough examination of the within a neutral zone when muscles are used to evaluate progress. Treatment
dentition and periodontium. of mastication and cervical posture progress needs to be evaluated partly
■ Diagnostic photographs of the are optimally unstrained.58 Objective, through subjective reports, as has been
dentition, face and posture. real-time EMG measurements of the done traditionally. However, because there
■ Palpation of the muscles of mastication, posture muscles guide the clinician are inherent inaccuracies involved in
TMJs and cervical muscles. in diagnosing this position.59 There is subjective reports, objective measures are
■ Range of motion records of mandible universal agreement on comfortable, needed, as well. This is akin to a physician
and upper cervical spine.41 unstrained masticatory muscles as a using electrocardiogram recordings or blood
■ Surface electromyographic (sEMG) requisite for a healthy stomatognathic pressure readings for diagnosis as well as
studies of muscles of mandibular and system. PNMD protocols actually evaluating the efficacy of treatment and
cervical posture.42 These may include measure physiologic data to confirm this, not just relying on how the patient feels.
sEMG measurements of muscles of rather than just relying on subjective Only when there is substantial
mandibular posture at rest,43,44 with measures. The discrepancy between improvement in both subjective and
A U G U S T 2 014 567
pnmd
C D A J O U R N A L , V O L 4 2 , Nº 8
FIGURE 7. One week post PNMD fixed orthotic treatment sEMG scan of posture FIGURE 8 . Comparison of muscle recruitment at rest versus effort needed to bring
muscles at rest versus effortless occlusion proves that the mandibular discrepancy to teeth into light occlusion prior to chewing shows that temporalis anterior muscles
maxilla has been corrected through the PNMD orthotic. needed little effort. This correlates with symptom resolution.
objective measurements of treatment treatment needs and preferences.”63 A the treatment needs and preferences
progress, thus proving the validity of the dentist’s clinical expertise and a patient’s of patients who choose treatment
craniomandibular position, should any treatment needs and preferences are options after being fully informed of the
stabilizing steps that involve irreversible equally as valid as literature support. In consequences of all options — including
changes even be considered.61 These their JADA editorial, Glick and Meyer letting their disease continue without
include orthodontic movement of teeth, acknowledge, “In reality, a lack of clinical any intervention. All caring practitioners
restorative treatment of some or all teeth research or insufficient clinical evidence can support this approach that respects
and prosthetic replacement of missing is the rule rather than the exception the patients who seek our care. ■
teeth. No matter which option is chosen, in dentistry and medicine.” They also REFERENCES
objective data are used as a guide by the state, “Scientific plausibility — or ‘prior 1. Covey SR. The 7 Habits of Highly Effective People.
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proven by the reversible orthotic therapy. evidence, including prior probabilities, as with headache. Cephalalgia 2003 Feb;23(1):35-8.
Each of these options has corresponding building blocks for new data. These prior 4. Kim DS, Cheang P, Dover S, Drake-Lee AB. Dental otalgia. J
Laryngol Otol 2007 Dec;121(12):1129-34.
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society of patients with Meniere’s disease after treatment of
patient’s prerogative to make the decision providers must continually seek to improve temporomandibular and cervical spine disorders: a controlled six-
on the options, including the option of the quality of patient care through sound year cost-benefit study. Cranio 2003 Apr;21(2):136-43.
no treatment, once all the consequences professional judgment based on provider 7. Bjorne A, Berven A, Agerberg G. Cervical signs and symptoms
in patients with Meniere’s disease: a controlled study. Cranio 1998
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with Meniere’s disease: a three-year follow-up. Cranio 2003
In discussions of evidence-based the experience of thousands of patients Jan;21(1):50-60.
dentistry (EBD), the greatest importance is whose TMD symptoms were successfully 9. Visscher CM, Lobbezoo F, de Boer W, van der Zaag J, Naeije
placed on literature citations. As defined at resolved through a comprehensive M. Prevalence of cervical spinal pain in craniomandibular pain
patients. Eur J Oral Sci 2001 Apr;109(2):76-80.
the 2008 ADA Evidenced-based Dentistry approach for evaluation and treatment. 10. D’Attilio M, Epifania E, Ciuffolo F, Salini V, Filippi MR, Dolci
conference, “Evidence-based dentistry is an PNMD protocols are indeed guided by M, Festa F, Tecco S. Cervical lordosis angle measured on lateral
approach to oral health care that requires evidence-based dentistry65 in line with the cephalograms; findings in skeletal class II female subjects with and
without TMD: a cross sectional study. Cranio 2004 Jan;22(1):27-
the judicious integration of systematic ADA’s position of considering the clinical 44.
assessments of clinically relevant scientific expertise of thousands of private-practice 11. Makofsky HW. “The influence of forward head posture on
evidence, relating to the patient’s oral and dentists around the world who successfully dental occlusion.” Cranio 2000 Jan;18(1):30-9.
12. Cunali PA, Almeida FR, Santos CD, Valdrighi NY,
medical condition and history, with the treat TMD patients daily. Even more Nascimento LS, Dal’Fabbro C, Tufik S, Bittencourt LR. Prevalence
dentist’s clinical expertise and the patient’s important, this approach considers of temporomandibular disorders in obstructive sleep apnea
568 A U G U S T 2 014
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A U G U S T 2 014 569
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C D A J O U R N A L , V O L 4 2 , Nº 8
How does the neuromuscular dentist treat an acute disk displacement without
reduction or intermittent acute displacement without reduction? If a practitioner is 31. Bakris G, Dickholtz M, et al. Atlas vertebra realignment an d
solely focused on the muscles, how is a TMJ internal derangement treated? achievement of arterial pressure goalin hypertensive patients: a pilot
Care of the TMD patient is broken down into assessment, diagnosis and management.7 study. J Hum Hypertens 2007, 1-6.
32. Schieppati M, Nardone A, Schmid M. Neck muscle fatigue
Diagnostic tests, beyond range of motion, anatomic site palpation and diagnostic affects postural control in man. Neuroscience 2003;121(2):277-
anesthetic blocks, have a minimal role in determining who needs TMD care.1 The 85.
diagnosis of the TMD patient is properly based upon history (82 percent); then confidence 33. Vignolo V, Vedolin GM, de Araujo Cdos R, Rodrigues Conti
PC. Influence of the menstrual cycle on the pressure pain threshold
in the diagnosis is added with examination (9 percent) and testing (9 percent).8 of masticatory muscles in patients with masticatory myofascial
This paper is supportive of neuromuscular dentistry as the method of diagnosing pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008
and treating TMDs. Any significant opening of the mouth through muscle pulsing with Mar;105(3):308-15.
34. Benoliel R, Sharav Y. Craniofacial pain of myofascial origin:
TENS or other method causes anterior repositioning of the mandibular condyles in temporomandibular pain & tension-type headache. Compend
their fossae. The reviewing author believes that this technique accomplished its goals Contin Educ Dent 1998 Jul;19(7):701-4, 706, 708-10 passim;
because of the underlying repositioning of the condyles to a more physiologic orthopedic quiz 722.
35. Nowlin TP, Nowlin JH. Examination and occlusal analysis of
position in the fossae. This anterior repositioning of the condyles may have caused the the masticatory system. Dent Clin North Am 1995 Apr;39(2):379-
muscles associated with the joint to sense that the joints were more normal and therefore 401.
the muscles to reduce in contraction and the pain and dysfunction diminished. 36. Lima AF, Cavalcanti AN, Martins LR, Marchi GM. Occlusal
interferences: how can this concept influence the clinical practice?
I would like to thank Dr. Raman for participating in this journalistic endeavor. Eur J Dent 2010 October; 4(4): 487–491.
His patients appreciate his care in relieving their pain and dysfunction. 37. Cooper BC. The role of bioelectronic instruments in
documenting and managing temporomandibular disorders. J Am
1. Simmons HC 3rd. A critical review of Dr. Charles S. Greene’s article titled “Managing the Care of Patients with
Dent Assoc 1996 Nov;127(11):1611-4.
Temporomandibular Disorders: a new Guideline for Care” and a revision of the American Association for Dental
38. Hickman DM, Cramer R. The effect of different condylar
Research’s 1996 policy statement on temporomandibular disorders, approved by the AADR Council in March 2010,
positions on masticatory muscle electromyographic activity in
published in the Journal of the American Dental Association September 2010. Cranio 2012;30(1):9-24.
humans. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2. Lund JP, Widmer CG, Feine JS. Validity of diagnostic and monitoring tests used for temporomandibular disorders. J
1998; 86(1):2-3.
Dent Res 1995;74(4):1133-43.
39. Hugger A, Hugger S, Schindler H. Surface electromyography
3. Lund JP, Widmer CG. Evaluation of the use of surface electromyography in the diagnosis, documentation, and
of the masticatory muscles for application in dental practice. Current
treatment of dental patients. J Craniomandib Disord 1989;3(3):125-37.
evidence and future developments. Int J Comput Dent 2008;
4. Cecere F, Ruf S, Pancherz H. Is quantitative electromyography reliable? J Orofac Pain 1996;10(1):38-47.
11(2):81-106.
5. Cyriax J. Diagnosis of Soft Tissue Lesions. 8th ed: Bailliere Tindall; 1982.
40. Cooper B, Kleinberg I. Establishment of a temporomandibular
6. Isberg A, Widmalm SE, Ivarsson R. Clinical, radiographic and electromyographic study of patients with internal
physiological state with neuromuscular orthosis treatment affects
derangement of the temporomandibular joint. Am J Orthod 1985;88(6):453-60.
reduction of TMD symptoms in 313 patients. Cranio 2008;26(2)
7. Simmons HC. Craniofacial Pain: A Handbook for Assessment, Diagnosis and Management. Chattanooga: Chroma
104-117.
Inc.; 2009.
41. D’Attilio M, Epifania E, Ciuffolo F, Salini V, Filippi MR,
8. Zakrzewska JM. History Taking. In: Zakrzewska JM, Harrison SD, editors. Assessment and Management of Orofacial
Dolci M, Festa F, Tecco S. Cervical lordosis angle measured on
Pain. 1st ed. London: Elsevier; 2002.
lateral cephalograms; findings in skeletal class II female subjects
with and without TMD: a cross sectional study. Cranio 2004
Jan;22(1):27-44.
Dr. Gelb 42. Jankelson RR, Adib F. Literature Review of Scientific Studies
The physiologic neuromuscular dental paradigm puts a premium on the Supporting the Efficacy of Surface Electromyography, Low
Frequency TENS, and Mandibular Tracking for Diagnosis and
muscular and reduces the significance of the TMJ, articular disk and airway. Treatment of TMD. Myotronics 1995.
The TMJ is objectively measured with MRI and cone beam CT and the airway 43. Riise C, Sheikholeslam A. The influence of experimental
with a polysomnogram and home sleep testing. The physiology of the airway affects interfering occlusal contacts on the postural activity of the anterior
temporal and masseter muscles in young adults. J Oral Rehabil
the growth and development of the face and with it the mandible and TMJ. 1982 Sep;9(5):419-25.
Dr. Raman states, “Occlusal disharmony can result in hyperactivity and a 44. Biasotto-Gonzalez DA, Fausto Bérzin F. Electromyographic
disturbed pattern of muscle contractions, leading to muscular pain and joint study of patients with masticatory muscles disorders,
physiotherapeutic treatment. Braz J Oral Sci vol. 3, num. 10, 2005,
overload.” AC looks at airway first, TMJ and myofascial second and occlusion pp. 516-521 Braz J Oral Sci, vol. 3, no. 10, July/September
third. Occlusal disharmony is not the driver in AC TMJ philosophy. 2004, pp. 516-521.
When considering the actual interdigitation of the teeth, it is not “the effort” 45. Li J, Jiang T, Feng H, Wang K, Zhang Z, Ishikawa T. The
electromyographic activity of masseter and anterior temporalis
needed by the muscles to bring the teeth into occlusion that is crucial, but more during orofacial symptoms induced by experimental occlusal
important, the efforts of the individual to breathe and maintain an open airway that highspot. J Oral Rehabil 2008 Feb;35(2):79-87.
affects the autonomic nervous system, oxidative stress and systemic inflammation. 46. 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
continu es in sidebar on 571
intercuspal position. J Oral Rehabil 1983 May;10(3):207-14.
47. Thomas NR. The Effect of Fatigue and TENS on the EMG Mean
570 A U G U S T 2 014
C D A J O U R N A L , V O L 4 2 , Nº 8
572 A U G U S T 2 014
Call CPS To Get The Most Out
Of Selling Your Dental Practice
888.789.1085
www.practicetransitions.com
576 A U G U S T 2 014
SELL YOUR PRACTICE . . . . .
LEE SKARIN
3. Bank financing or Seller financing, with proper agreements to adequately protect
the Seller and make the deal close - realistically and expeditiously.
6. Lease negotiations.
Your calls are invited. Put our thirty years of experience to work for you!
818.991.6552
Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461
J A N U A R Y 2 014 577
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Making your transition a reality.
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25 Years in 40 Years in 36 Years in 33 Years in 42 Years in 35 Years in 35 Years in 26 Years in 25 Years in 11 Years in
Business Business Business Business Business Business Business Business Business Business
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GR $528K. #CA109 HUNTINGTON BEACH: General patients. ‘12 GR $515K on 32 hr/wk. EZ 4 Ops in a professional building near
Dentistry, est. 18 years. Spacious suite with Dental, Pan. #CA558 freeways. SoftDent, est. 40+ years. 2012 GR
COALINGA: General Dentistry, 1,100 sq. 6 Ops, 3 equipped, 3 plumbed. #CA155 of $740K with $220K Adj. Net. #CA135
ft., 3 Ops, remodeled in 2011. 1,000 active POWAY: General Dentistry, 4 Ops in a
D
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patients. #CA564 INDIAN WELLS: General Dentistry/TMJ 1,100 sq. ft. suite, Dentrix, Digital x-rays, SOUTH COUNTY SAN DIEGO: General
Practice, 4,000 sq. ft. suite. 6 Ops. ‘11 GR and intra-oral camera. Est.1985. 2013 GR Dentistry Practice & Building. 1200 sq. ft.
COASTAL ORANGE COUNTY: General $350K+ on 1 doctor-day/wk. #CAM530 of $720K, $241K Adj. Net. #CA139– on a main street. Est. 38 years, 4 Ops. 2013
Dentistry, $500K spent on 4 new high-end GR of $310K on 150 days worked. #CA148
Ops. Dentrix and Dexis, Digital Pan. Close LA MESA: General Dentistry, 3 Ops, 2,000 REDLANDS: General Dentistry, 3 Ops,
to the ocean - dream location! 2013 GR of sq. ft. in a prof. building. GR of $396K in Established 48 years. $364K GR on 3 doctor THOUSAND OAKS: FACILITY ONLY
$511K. #CAM566 2012 with $155K Adj. Net. Practice utilizes days and 3 hygiene days per week. #CA160 – Move-in ready 4 ops in 1,325 sq. ft.
Dentrix, Laser, and Digital X-Rays #CA127 Modern design, Dentrix with 4 workstations,
EASTERN SIERRAS: General Dentistry, RIDGECREST: General Dentistry Practice equipped business of¿ce, and sterilization
1,650 sq. ft. w/ 4 Ops. ‘12 GR $521K. Low LONG BEACH: General Dentistry, 8 Ops, & Building. 1,500+ sq. ft. building, 4 Ops. area. Great start-up location or satellite
52% overhead. #CA528 6 Equipped. Associate-run practice with Small practice grossed about $175K in ‘12. of¿ce. #CA137
$1.2MM GR and 8 days of hyg/wk. Dentrix/ #CA523
FOLSOM/EL DORADO HILLS – PRICE
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TUSTIN: General Dentistry, 3 Ops and
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Dexis. #CA152 – In Escrow
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Building with emphasis on Implants. 5 Ops,
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1,200 sq. ft., 4 Ops. 2012 GR. of $405K. MORENO VALLEY: General Dentistry, Adj. Net. #CA131
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Dentrix, Laser, Digital X-rays, and Intra-oral 5 Ops in a busy retail center near freeway. est. over 50 years. 2012 GR of over $500K.
cameras. #CA103 2013 GR of $291K with $121K Adj. Net. #CA120 VICTORVILLE: General Dentistry,
Est. 14 years. #CA151 3 equipped Ops plus 3 add’l plumbed in
FREMONT: 3,000+ Sq. Ft. suite, 10 Ops. S. LAKE TAHOE: General Dentistry, 1,450 2,150 sq. ft. est. 34 years, SoftDent. 2013
Digital X-rays, Pan. 4,000 active patients. NEWPORT BEACH: PRICE REDUCED- sq. ft. of¿ce w/5 Ops and 1 add’l available. GR of $313K and $147K Adj. Net. #CA149
PPO/HMO, ‘12 GR. $1.2MM w/ Adj. Net General Dentistry, 3 Ops, newer, high-end Avg. GR over last 3 years $733K. #CA134
Inc. of $300K. #CA553 equipment, 2012 GR of $350K on 3½ days/ – In Escrow WALNUT CREEK: PRICE REDUCED
wk. #CAM534 - Prosthodontic Practice.3 Ops and full
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lab. 2013 GR $399K and $143K Adj. Net.
3 equipped. Dentrix, Digital X-rays, GR NORTH EAST BAY – PRICE REDUCED 4 Ops in a 1,350 sq. ft. suite in a coastal #CAM540
$236K+ as of 12.11.13 on 8 days/month. $77K: General Dentistry, 7 Ops. in 2,324 sq. location. Dentrix. #CA119
#CA128 – In Escrow ft. Dental Mate software, Intra-oral Camera, WEST LOS ANGELES: General Dentistry,
SACRAMENTO: General & Specialty 4 Equipped Ops, 1 add’l plumbed. Great LA
GREATER ROSEVILLE/ROCKLIN/ Pano X-ray, Digital X-ray. 2012 GR $885K. Dentistry. Stand-alone, leased of¿ce w/2
Building to be sold with practice. #CA108 location on the west side with GR of $342K
LINCOLN: General Dentistry, 1,887 sq. ft., suites, GP and Specialty, approx. 4,000 sq. on just 2 doctor days/week. #CA117
2 equip. Ops (3 add’l plumbed). 3 days NORTHERN CALIFORNIA: Periodontal ft. combined, GP has 4 Ops, Specialty has
hygiene, Eaglesoft. 2013 GR $350K+. Practice. 5 Ops with equipment for right or 6 equip. Ops w/3 add’l plumbed. Dentrix, YORBA LINDA: General Dentistry,
#CA154 left-handed provider. Eaglesoft software. Intra-Oral, Digital X-ray, Pano. 2013 GR 4 Equipped Ops, 1 add’l plumbed in a
$1.3M. #CA157 prof. building. Est. for 30+ years. 4 days of
D
2013 GR $890K+. #CA153
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GREATER SACRAMENTO: Orthodontic hygiene. EagleSoft, digital, and paperless.
Practice. Like-new 2,300 sq. ft., 6 chairs. NORTHERN CALIFORNIA: Endodontic SAN BERNARDINO: General Dentistry, 2013 GR $914K, $301K Adj. Net. #CA146
220 active patients phase 1. #CA551 Practice. 3 Ops (1 add’l plumbed) in 1,200 4 Ops, 30+ years goodwill, street sign, – In Escrow
sq. ft.. 2 Microscopes. Digital. 2013 GR average GR $265K the last 3 years, Dr. is
GREATER SACRAMENTO – PRICE retiring. #CA150 YORBA LINDA: General Dentistry, 5 Ops,
REDUCED $50K: General Dentistry $319,865. #CA158
laser, Intra-oral camera, and digital X-rays.
Practice & Condo. 1,300 sq. ft. in prof. bldg. NORTH OF SACRAMENTO: General SAN CLEMENTE: General Dentistry, 3 hygiene and 3 doctor days/wk. #CAM531
w/4 Ops. Eaglesoft. ‘13 GR $679K. #CA138 Dentistry, 5 Ops in 2,050 sq. ft. 2012 GR 3 Equipped Ops, 2 Add’l plumbed. Est. for – In Escrow
$1.2M+. Dentrix, Intra-oral Cameras, Digital 10 years. PracticeWorks, digital x-rays and
X-ray, Imaging System, Pano. #CA106 Pano. #CA129
F
ollowing are answers to questions X-rays at no cost to the patient. Practices of copying X-rays and postage if the
asked in recent months by dental that offer free X-rays as a new patient patient requests receipt by mail.
practices. A Guide to Dental incentive should be aware that denying ■ Electronic copy: The fee may not
Practice Act Compliance is available a patient access to his or her records exceed the actual labor and material
on cda.org/practicesupport. may lead the patient to file complaints costs of fulfilling the request. If the
with the Dental Board and the U.S. practice maintains patient treatment
A new patient has been trying to obtain Department of Health and Human records electronically and the patient
a copy of his radiographs from another Services, which enforces HIPAA. requests an electronic copy, the
dental practice. The other practice is asking Allowable charges are: practice must provide a copy in an
the patient to pay $50 for the copy because ■ Paper copy: No more than 25 cents electronic format agreed upon by
the patient took advantage of an offer for per page or 50 cents per page for both the patient and the practice.
free X-rays. Can the practice do that? copies made from microfilm. All Labor cost may not include day-
No. A dental practice may not charge reasonable costs, not exceeding actual to-day maintenance of the records
a patient more than what state or HIPAA costs, incurred by the dental office to system. Many practices forgo charging
laws allow for copies of the patient provide the copies may be charged a fee if they transmit the records
record, even if the practice provided to the patient. This includes the cost directly to another dentist.
A U G U S T 2 014 579
A U G . 2 0 14 R E G U L ATO RY C O M P L I A N C E
C D A J O U R N A L , V O L 4 2 , Nº 8
580 A U G U S T 2 014
WHAT CLIENTS ARE SAYING:
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Dentist • Attorney • Broker She was very ethical and kept me informed every step of
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San Diego Dentist
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$130k HN-197 EAST LODI FOOTHILLS: Two practices for one great price!! Call
DG-232 SANTA CRUZ: Large, well-established Medical/Dental Prof com- today for details! $595k
plex! 1,063 sf w/ 3 ops REDUCED ! $330k HN-242 YOSEMITE (Charts Only): Increase your Patient Base! Procure
500+ charts for only $75k
NORTHERN CALIFORNIA HN-268 CALAVERAS COUNTY: “Main Street” charm & picturesque views of
Central Sierra Foothills. 2,000 sf w/4 ops + 2 add’l $250k
EG-198 SACRAMENTO: Tucked in well established “Pocket Area” in high- HN-280 NORTHEASTERN CA: “Only Practice in Town” 900 sf w/ 2 ops $110k
ly desirable corridor. 1,112 sf w/3 ops Now Only $95k HN-290 PLACERVILLE: Embrace the lifestyle and build your success
EG-237 ROCKLIN: State-of-the-art, top-of-the-line equipment. 1,000 sf w/ story here! FFS. Office ~ 1,400 sf w/ 4 ops, $210k
2 ops. Plumbed for 2 add’l REDUCED! $230k
EG-283 ROSEVILLE: With a philosophy & focus on providing the best dental CENTRAL VALLEY
treatment! Visibility & loca on are unsurpassed! 1,008 sf w/ 4 ops $228k
EG-285 SACRAMENTO: Seller re ring! 40 years Goodwill! 2 ops. ~ $200k IC-277 STOCKTON & TRACY: 2 Quality FFS Practices $600k
in collec ons/yr $125k IG-067 STOCKTON: Fully computerized, paperless, digital. 5,000 sf w/10
ops REDUCED! Now ONLY $360k
Our extensive buyer database and unsurpassed exposure allows us to offer you a …
Be er Candidate Be er Fit Be er Price!
ASK THE BROKER
Why isn’t there an MLS type service for dental
practices like there is for home sales? It seems
like I need to contact every broker to find all
the practices that are for sale.
CENTRAL VALLEY CONTINUED Believe me, I felt the same way when I was a young dentist. I
even thought I might be able to change that when I started
IG-292 TRACY: 1,300 sf w/ 4 ops . Collected $200k + in ‘13 $129k
IN-193 MODESTO Facility: Recently remodeled! High foot traffic!
brokering practices. However, now that I have been doing
2,300 sf w/6 ops $49k (unequipped) practice transitions for 15 years, I understand why the system will
IN-205 STOCKTON Facility: Desirable professional corridor. Newly probably not change. It is a specialized niche market and too
remodeled. 1,565 sf w/ 4 ops $169k equipped or $69k w/o small to be able to duplicate what can be done in large real estate
equipment markets. Without boring you with a detailed explanation of the
IG-247 ATWATER: 1,090 sf w/ 3 ops. State of the Art & Top of the
Line! REDUCED! NOW ONLY $550k
intricacies of the dental brokerage business, let’s just say that
IN-297 MODESTO: 1,980 sf w/ 4 ops. PR: $475k / RE : $425k there is a lot more time and expense behind the scenes to bring a
JN-251 FRESNO: Dedicated to delivering the highest quality of practice to the market and feel confident that the practice is fully
care! 1,565 sf w/ 4 ops $140k exposed to all possible buyers.
JN-254 FRESNO: “Retro-vintage-designed”. All this practice needs
is you! 2,159 sf w/ 4 ops $140k So what does this mean for buyers? Since there is no “MLS”
JN-259 FRESNO Facility: Newly Remodeled! 1,197 sf w/ 3 ops + 1 system in place for dental practices, buyers need to contact every
add’l. Seller Motivated! $45k active dental practice broker in their local area. Having no
JG-261 TULARE CO: Seller willing to stay for transition! 730 sf w/ “MLS” system in place is also part of the reason that the brokers
3 ops $325k
JG-278 GREATER VISALIA: Runs like a well-oiled machine! 1,500
are routinely agents of the seller only, as the seller chooses the
sf w/ 4 ops $320k (Real Estate Also Available) broker that is responsible to do the “heaving lifting” of obtaining
JN-295 VISALIA: Practice & Real Estate 2,000 sf w/ 5 ops PR: all the necessary reports and documents to evaluate the practice.
$185k RE: $300k While a good broker may spend the majority of their time in a
transition guiding buyers and facilitating steps that buyers need to
SPECIALTY PRACTICES
accomplish, brokers are almost always the agent of the seller.
DC-246 PLEASANTON Pediatric: Highly Motivated Seller! Pediatric Therefore, buyers need to understand that they will eventually
Practice/Facility Only. 1700 sf w/ 4 ops. Plumbed for additional need to lean on their own accountant, attorney or practice
ops. Practice $325k or Facility only $250k consultant to help guide them through the process.
I-7861 CENTRAL VALLEY Ortho: 2,000 sf, open bay w/ 8 chairs.
Fee-for-Service. $370k In addition, Sellers need to understand that it IS important to
I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5 chairs/bays & choose wisely when they hire a broker. There may be a big
plumbed for 2 add’l $180k difference between brokers when it comes to experience and their
EN-203 SACRAMENTO Oral Surgery: Highly efficient office. 3,000
sf w/ 4 ops ONLY $235k
credentials. Just as in dentistry, one usually gets what they pay
GN-284 CHICO Ortho: Warm, caring and well established! 900 sf for. An experienced broker is much like an experienced dentist.
w/ 2 ops + 1 add’l. $75k We don’t really know when we start a process whether it will go
BC-230 CENTRAL CONTRA COSTA Perio: Loyal patients @ 2 loca- smoothly or have a complication or two along the way. The
tions! $650k
EG-225 SACRAMENTO Ortho: Well-maintained, single-story Medi- economic and legal landscape is always changing and a broker
cal/Dental complex. 1,200 sf w/ 4 chairs $95k with experience should be able to navigate those changes more
DN-229 EAST BAY Endo: Strong referral & patient base.. High foot effectively. It is not as easy as one might think to change brokers
traffic. 975 sf w/ 2 ops REDUCED! $225k
once the practice has been exposed to the market, so it is
DG-264 SAN JOSE Ortho: $300-400k in build-outs alone! 1800 sf
w/ 5 chairs. ONLY $270k normally not a good idea to try the discounted route first,
GN-304 NORTHERN SACRAMENTO Pedo: Well established, highly thinking you can simply change if it doesn’t work out. It also just
esteemed. ~ 1,800 sf w/ 4 ops $595k makes sense that more exposure should translate into more
DN-293 LIVERMORE Perio: Specialty of Periodon cs, Dental Im-
plantology and Oral Medicine. ~2,200 sf w/ 5ops + 1 add’l. PR:
buyers, which could translate into either a better price, a better fit
$650k RE: TBD for the practice, or both!
We are a proud member of: Timothy G. Giroux, DDS is currently the Owner & Broker at Western Practice
Sales and a member of the nationally recognized dental organization, ADS Transitions.
You may contact Dr Giroux at: wps@succeed.net or 800.641.4179
“MATCHING THE RIGHT DENTIST
TO THE RIGHT PRACTICE”
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions
Periscope C D A J O U R N A L , V O L 4 2 , Nº 8
IMPLANTS
A U G U S T 2 014 585
A U G . 2 0 14 PERISCOPE
C D A J O U R N A L , V O L 4 2 , Nº 8
IMAGING
Image quality of different CBCT scanners under high- and low-resolution protocols utilizing various fields
of view (FOV). Four observers scored the resultant images.
Pauwels R, Beinsberger J, Stamatakis H, et al. Comparison of spatial
and contrast resolution for cone-beam computed tomography Results: There was a high intra-/inter-observer agreement
scanners. Oral Surg Oral Med Oral Pathol Oral Radiol 114: 127- for contrast and spatial resolution scoring. Image quality, as
35, 2012. reflected by perceived contrast and spatial resolution, varied
considerably among the various scanners and among the
Clinical problem: Cone beam computed tomography different imaging parameters utilizing the same scanner.
(CBCT) is widely used in various aspects of everyday dental
practice. Several CBCT scanners are commercially available Conclusions: CBCT devices are generally suitable for
and are tailored toward various applications. How could these imaging high-contrast structures at moderate spatial
scanners be evaluated and compared with each other? resolution. Certain exposure protocols improve visualization
of lower contrast structures or fine details.
Aim: To systematically and objectively evaluate
the spatial and contrast resolution for various CBCT Bottom line: Different CBCT scanners produced images
scanners at various clinically relevant settings. of varying spatial and contrast resolution. Optimization of
exposure parameters is important to achieve diagnostic
Method: A customized phantom was constructed and rod patterns images while delivering as low as reasonably achievable
of various densities and line-pair grids were inserted into the (ALARA) radiation exposure to the patient.
phantom. Thirteen commercially available CBCT scanners and
one multislice CT scanner were utilized to image the phantom — Sanjay M. Mallya, BDS, MDS, PhD, and Sotirios Tetradis, DDS, PhD
586 A U G U S T 2 014
Specialists in the Sale and Appraisal of Dental Practices See PPS at
Serving California Dentists since 1966 CDA Booth
How much is you rpractice worth??
Selling or Buying, Call PPS today! 1407
NORTHERN CALIFORNIA SOUTHERN CALIFORNIA
(415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732
Raymond and Edna Irving Thomas Fitterer and Dean George
Ray@PPSsellsDDS.com PPSincnet@aol.com
www.PPSsellsDDS.com www.PPSDental.com
California DRE License 1422122 California DRE License 324962
PHENOMENAL SAN FRANCISCO EAST BAY OPPORTUNITY
2013 Produced $2.4 Million, Collected $2 Million & realized Profits of $1.1+ Million
SOLD
Success here is contrary to basic tenet which is “build a strong Hygiene Department.” Such a theme maintains the patient foundation with each year yielding
another harvest as a result of renewed insurance benefits and watches that now need to be addressed. This practice believes that the “real opportunity” is how
new patients are handled and immediately tending to their neglected oral health. This location is a “goldmine” guaranteeing a continuous high volume flow of
new patients each month with little competition.
6061 LODI Beautiful 5-op office. Digital and paperless. 16+ years left on ANAHEIM $30K/mth part-time. 6 ops, $30K invested in digital x-ray. FP $225K.
Lease. ANAHEIM Near Highway 91 & Harbor. Gross $300K+. FXOOPULFH $250K.
6060 CONCORD Practice has impressive history. Revenues have ANAHEIM HILLS GrossHV $400. Buy 50% now & remaining 50% when
topped $900,000 per year. Office was recently remodeled. Lease expires in 1.5 years.
6059 MODESTO Long established. 2013 collected $283,000 with APPLE VALLEY – HESPERIA GrossHV $700 DQGNets apprx $350.
Profits of $146,600. Nice foundation to build upon. 8ops. Full Price $595,000.
6058 MODESTO On 2-day week, produced $522,000 and collected BAKERSFIELD AREA Gross $400K. FP for practice & building $265,000.
$404,000 for 12-months ending 3/31/14. Profits totaled $211,000 in BAKERSFIELD GrossHV $800. Nets $400+. 5 Ops. Should do $1
2013. Owner unable to spend more time here and knows practice
Million. FXOOPULFH$500,000.
would be better served by full-time DDS.
BAKERSFIELD – SOUTH Practice & RE. 5-ops DQGapt. FP $250,000.
6056 STOCKTON 3-op practice averages 9 New Patients per month.
Collected $368,000 in 2013 with Profits of $178,700. Near CORONA – NORCO AREA GrossHV $90/mth. 8-op building. FXOOPULFH
Sherwood and Weberstown Malls. . for SUDFWLFHDQGEXLOGLQJ1,850,000.
6055 VACAVILLE Strong reputation. 3-days of Hygiene. 3-ops. 2013 HEMET Absentee Owner. GrossHV $50-to-$60K/mth. Partnership available
collected $568,000 on 3-day week. Profits totaled $240,000. for $300,000.
6054 TRACY Great launching pad waiting for opportunistic buyer. Best HEMET Grosses $650K part-time. Will do $1 Million. 10 op. FP $585,000.
SOLD
location. Beautiful 4-Op office. Digital and paperless. Part-time HMO 3 Practices gross $6 Million. $52,000 cap checks/mth. One includes RE.
management collected $189,000 in 2013. Will do well with HUNTINGTON PARK 98% Hispanic. Gross $600K. Low overhead. 4-ops.
full-time attention. Full Price $125,00. INDIO 4,600 sq.ft. building. First practice in Indio. Across from City Hall.
6053 SAN FRANCISCO’S SOUTH BAY – PEDO PRACTICE Long LANCASTER Hi identity location only. 2-ops. FXOOPULFH$55,000.
SOLD
established. 2013 tracking $660,000 in production, $650,000 in
collections and $255,000 in Available Profits. Great staff.
NEVADA Resort Area. Grosses $600 on 3-days. Beautiful office.
PASADENA AREA Grosses $950 part time. Did $1 Million+ with more
6052 BERKELEY Trendy north side shopping area. Very strong
SOLD
foundation. 2,000 active patients. 4-days of Hygiene. Beautiful hi
time. Hi identity building also For Sale.
REDLANDS Bank Repo managed by Internet Marketing DDS. 4-ops.
tech office with great curb appeal. 2012 collected $590,000. Lots of
work referred out. GrossHV $30/mRQth. FXOOPULFH$285,000.
6051 FRESNO’S FIG GARDEN VILLAGE AREA Not a Delta RESORT AREA NORTH OF BAKERSFIELD Seller grosses $1,500,000
Premiere practice. Collected $430,000 in 2013 on 3.5 day week. on 24 hour week.
6050 MERCED 2013 trending $360,000. Very profitable. Refers Endo, RIVERSIDE GrossHV$860. Can do $1.50LOOLRQ. Digital 10 ops in hi
SOLD
OS & Perio. Not a Delta Premiere Practice. Great foundation to identity center near Walmart. FXOOPULFH$800.
build upon. Full Price $125,000. SAN DIEGO Four practices grossing $4 Million.
6048 SALINAS Great opportunity for the ambitious, Ideal for two SAN FERNANDO VALLEY Part-time $300. Will do $500.
SOLD
Dentists. 10 days of Hygiene per week. 2012 collected $1.1 Million. Building also available.
2013 tracking $1.2 Million. Practice did well during Great Recession. SAN FERNANDO VALLEY – BEST HISPANIC LOCATION 7 Ops. 70
6047 STOCKTON Best location outside Brookside Community on West QHZSDWLHQWVPRQWK. $2 Million location. Practice $1 Million, RE $1.75 Million.
SOLD
March Lane. 2013 collected $535,000. Attractive 3-Op office. SAN FERNANDO VALLEY HMO Grossing $1.6 Million.
Package sale includes condo. SAN JUAN CAPISTRANO Modern 4-ops in prestigious Plaza.
SOLD
6046 PINOLE Collected $500,000 in 2012. 4-days of Hygiene produced
$178,600. Beautiful office. Refers Endo. Lots of Goodwill here.
SOUTH ORANGE COUNTY BEACH CITY Gross $950K in 2013. 5-ops.
SOUTH ORANGE COUNTY SHOPPING CENTER $415 investment
6043 EL SOBRANTE 3-day practice collected $184,000 in 2013. 3-ops. with $2 Million gross upside.
Building optional purchase. Full price $50,000.
SANTA ANA Hi identity center. 3 ops, low overhead, GrossHV $200.
TORRANCE Gross $300+. Serves Palos Verdes. 3-ops.
**FOUNDERS OF PRACTICE SALES**
years of combined expertise and experience! TORRANCE - GARDENA Conservative DDS. Successor will do $600
3,000+ Sales - - 10,000+ Appraisals first year. FXOOPULFH$185.
**CONFIDENTIAL** VICTOR VALLEY Conservative DDS nets $350 on $700.
PPS Representatives do not give our business name when returning your calls. YUCCA VALLEY Location only. 800 sq.ft., 2-ops.
Tech Trends C D A J O U R N A L , V O L 4 2 , Nº 8
Notifyr (Arnoldus Wilhelmus Jacobus van Dijk, $3.99) Nest Protect (Nest Labs, $99)
Notifyr is a remarkable app for iOS that brings mobile device Nest Labs recently unveiled the latest addition to its offering of
notifications to the Mac. Users already familiar with Notifications connected home devices with the debut of Nest Protect, its smoke
Center for the Mac will be impressed with its seamless integration. and carbon monoxide detector. Two different models are offered
Users must install two applications: one for iOS available from the — one for hard-wired thermostats and one that runs on regular
App Store and one for Mac available from the developer’s website. batteries — and the installation requires only four screws. A few
Users follow instructions to pair their iOS devices to their Macs via clicks of the Nest Protect itself painlessly syncs it to the Nest app
Bluetooth LE (low energy) when launching the app for the first time. on a user’s smartphone or tablet. Operationally, the Nest Protect
The app must be continually running in the background in order to is the height of minimalism; because it’s a smoke detector, it sits
send notifications to the Mac. Anytime an iOS device is in range of in the background and requires no interaction, other than the
its paired Mac, the app will send all notifications that appear on recommended regular testing to ensure it is functioning properly.
the iOS device to Notifications Center on the Mac. Notifications According to Nest, the majority of U.S. home fire deaths occur in
from any iOS app (e.g., Instagram, Snapchat, WhatsApp) are homes with no smoke detectors or, worse yet, smoke detectors that
supported. The Mac application counterpart is a Preference Pane have had their batteries removed (presumably from the annoying
that allows a user to toggle notifications on or off from individual low-battery warning we have all heard chirping late at night on our
iOS applications, which is useful to eliminate repeat notifications old smoke detectors). Nest wants to fix this with its Protect, which
from apps that both Mac and iOS share. Many users will find notifies users of low battery warnings via their smartphones.
Notifyr to be easy to use and extremely useful. For Mac users with
— Blaine Wasylkiw, director of online services, CDA
iOS devices, this app makes it simple to have one central location
for viewing notifications across all devices.
Instagram update (Instagram, Free)
— Hubert Chan, DDS
Those who wanted to be more artsy with their photos now have a
chance, using the updated version of Instagram. Traditionally, users
UpTo (Rock City Apps, Free) were only able to select from the 19 photo filters in the app (you
know, amaro, mayfair, earlybird and the rest). But now, the filters are
This new calendar app for iOS and Android devices provides a
customizable, allowing more photo editing. Though no new filters
unique way to combine personal and business events into one
were added, there is now an option to use a slider to determine
interactive spot. UpTo functions as a traditional calendar that also
how much of a filter to use. Users can also try new features such as
allows users to “follow” other people or organizations. Once those
brightness, contrast, warmth, saturation, highlights, shadows, vignette
accounts are being followed, the user can add their events to his
and sharpen, among others, to further edit their photos. These new
or her own calendar. The app has two layers. The front layer is the
features also operate using a slider function.
user’s existing calendar. The back layer, which can be accessed
via a simple pinch of the screen, is the events from other calendars — Blake Ellington, Tech Trends editor
the user follows. If users find an event interesting, they can add it to
their main calendar. These events include movie and music releases,
upcoming concerts in their city and more. Users who belong to a Would you like to write about new technology?
club or group can also create a separate calendar for that group Dentists interested in contributing to this section should contact
and then share it with other members. Push notifications are also a Tech Trends Editor Blake Ellington at blake.ellington@cda.org.
feature for events.
— Blake Ellington, Tech Trends editor
588 A U G U S T 2 014
Dr. Bob C D A J O U R N A L , V O L 4 2 , Nº 8
The following Dr. Bob column was originally printed in the August 1998 issue of the Journal.
considerably sharper than the first. This man (women do not snore as they do not without breathing at all, followed by an
tableau has become a nocturnal ritual, sweat as they do not grow hair in their explosive snort to make up for lost time.
leaving me with enough contusions to ears) lies flat on his back, mouth open, My research shows this to be a
qualify for abused spouse protection. from which arises a line of little “z’s” phenomenon known as sleep apnea that is
I decided to do some research on terminating in a balloon containing a log considered by students of sleeping disorders
snoring to buttress my position. Centuries being cut by a saw. The descriptive words to be a serious problem. Having always
ago, it seems, snoring was thought to be for this act look something like “snor-r-f,” been the type of person who will face his
the result of demons within the skull “bla-a-ff” and sometimes “y-o-on-n-k.” problems whenever there appears to be no
trying to get out at night. To test the Meet the new breed of snorer. Contrary other way out, I have sent away for a device
validity of this theory, snorers frequently to the stereotype, I can demonstrate the known as an oral proprioceptive stimulator.
had their skulls clove by dedicated ability to snore while lying on my side, This is a plastic appliance to be worn in
researchers; and, sure enough, the snoring mouth clenched shut while thinking the palate at night and resembles a flipper
stopped as the demons escaped. that I am wide awake. If I apparently without teeth, but with a movable flap
More recent studies have shown that can’t distinguish between being awake or at the distal of the soft palate that pushes
snoring is the direct result of breathing; and asleep, I may have a problem more serious the base of the tongue down while the
scientists discovered that if you could stop than just snoring. Besides my sounding wearer attempts to keep his dinner down.
a snorer from breathing long enough, the like an International Harvester during The theory behind its operation is
problem would disappear. Also disappearing the height of the season, my bride claims something I don’t have time to understand,
is the stereotype of the typical snorer: a that occasionally I go for long minutes nor the capacity to do so. I bought it as
an antisnoring machine; and although
the jury is still out, I think the portents
are good. My wife says she thinks it may
be working. She came in from the other
Bring in a new member, get $200. room and woke me up to tell me this. I
was pleased, as you can imagine I would
Refer a new member to CDA and receive double be, to be awakened at 2 a.m. with this
kind of information. As it turns out, being
the reward, a $100 check from CDA and a aroused periodically is not a bad idea if
$100 American Express gift card from the ADA you wish to avoid one other nocturnal
for every referral. Simply share with your peers problem, that of drowning in your sleep.
why you love being part of the 25,000 My salivary glands, which seem to be the
last of my glands to show the ravages of
dentists who are working to make the time, are producing upwards of 50 gallons
profession stronger. of saliva every night in a frantic effort to
wash out the appliance before morning.
For details visit cda.org/mgm I think young people who are out
tomcatting around all night, when they
Dr. Rockwell referred a new CDA member. have the natural ability to sleep straight
ADA campaign ends September 30. The total awards possible per
through from 10:30 p.m. until 9 a.m.,
calendar year are: $500 from CDA, and $500 in gift cards from the would do well to listen to the laments
ADA. Members may decline the gift card and the ADA will contribute
$100 to the ADA Foundation.
of their elders who can never remember
having had this blessing once. Grab as
many zeds as you can while you’re young,
kids, there will be plenty of time at
night later to consider other pursuits like
wondering if there is any Alka-Seltzer in
the cabinet or trying to determine what
time the luminous dial on the clock says
without finding your glasses first. ■
590 A U G U S T 2 014
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