My article On Centric Relation prompted the following comment/question from a reader. My response to her situation was in-depth enough that I decided to publish it as a stand-alone article. I hope you find the information beneficial.
Hi Dr. Halligan! I am interested in your viewpoint with NM’s tandem K7 and TENS philosophy. It has not worked for me and I’ve seen MANY different NM dentists – an ICCMO, then LVIM, and one considered above LVIM – a dubbed “GNM” (gneuromuscular dentist – gnatho-neuromuscular). Anyhow, my experience is this – they supposedly relax your muscles, as you’ve mentioned, using the TENS for an hour, then afterwards- they use the K7 (jaw tracking) device to “track the path” of what they believe is the best bite and do the whole bite registration bit to create a new bite according to the K7 AND TENS. So, its not only TENS they use, it’s also the K7 (they use it together – the TENS is on full blast when they began to refine the splint they’ve made). Would you mind providing your expertise and explain why the K7 is/is not reliable?
Thank you kindly!
You pose a very difficult question. After all, if you ask a neuromuscular (NM) dentist why using TENS and K7 does not work, he or she will tell you that it does work. So, if I tell you where I believe the limitations lie, then understand that it’s my opinion.
First of all, can you and I agree that the technique is unreliable? You have seen many NM dentists. ICCMO (International College of Cranio-Mandibular Orthopedics) people, LVI (Las Vegas Institute) people, etc. And so far nothing has worked for you.
Therefore, logically, we must assume that something is missing.
Let’s address problems one at a time.
First, what about TENS? Try entering, “Do TENS machines really work?” on your browser. You’ll find some comments from the public giving the devices mixed reviews. TENS seems to work for some, but not for others. However, studies done by credible medical researchers give TENS a rather poor score. The theory of why TENS should work is related to the device’s ability to interfere with conduction of pain signals at the neural level. It turns out that this doesn’t really work well or predictably.
If someone is using TENS and it’s working, I wouldn’t recommend stopping. But for the majority in actual medical research studies, the procedure does not help.
The NM dentists though insist that they are using TENS for a different purpose. They will tell you that TENS relaxes muscles. And to that I say, “Sometimes. But certainly not predictably.”
I have seen people with severe muscle contraction pain actually become much worse with the use of TENS. Why? I actually think it’s simple. The pain of chronic muscle contraction is due to the build-up of lactic acid in the muscle fibers. So think of a fatigued, over-worked muscle full of pain inducing lactic acid and now just imagine sticking some electrodes on that sore muscle and forcing it to contract once a second for 40 minutes to an hour. Ouch. The muscle needs rest, not forced overtime.
A TENSed muscle is just as likely to become more painful and more tense. Not the result you want, but the result you have probably experienced as you made the rounds of all those NM dentists.
The Myotronic evaluation system includes electromyography—the use of surface EMGs (SEMG) to measure muscle tension. Well, muscle physiologists tell us that SEMG is not reliable and that to really measure muscle activity you need to use needle EMGs. Just what our patients want, right? Stick needles with electrodes attached into the sore muscles—yes, dentists would have lots of volunteers for that.
But let’s assume that SEMG, though not as accurate as needle EMG, is at least a fair indicator of muscle tension. When I examine a patient, I often find that the medial pterygoid muscle is the sorest muscle of all, and you can only access that muscle inside the mouth. How about the lateral pterygoid? That’s the muscle usually responsible for pain immediately behind the eye. It lies deep to the cheek bone. How are you going to measure its activity? These muscles have been monitored with needle EMG but not objectively in any other way.
So surface EMGs, even assuming they work, are only applied to surface muscles: Masseters, temporal muscles, sternocleidomastoid, and so on. And those muscles only tell part of the story.
But I have one more observation. Over the years I’ve had the experience of seeing patients who were already wearing oral appliances made by neuromuscular dentists. The NM dentist in each case has told the patient, “I know you’re better because electromyography shows that your muscles are more relaxed.” And why are they seeing me? Because they feel the NM approach is not working. In one case, the patient even brought in print-outs of the SEMG results before and after orthotic placement. And the muscles really did calm down somewhat. For that patient, I made a new orthotic based on x-ray findings, i.e. I placed the condyles in an anterior-superior position in the glenoid fossae and verified that with x-rays. After a week I suggested she go back to the NM dentist and have him check with SEMG again. The dentist found that now the muscles had incredibly calmed much, much more. And then he found out that it wasn’t with his orthotic.
I have already mentioned that in a meeting with Dr. Chris Stevens in Wisconsin he stated that he uses NM principles to take a bite registration, and then takes a tomogram (x-ray) of the result to see if the joint position looks reasonable and if not adjusts or retakes the bite registration. I believe that to be an important step.
So, one missing link? I think it’s joint imaging and the proper reading of those images. Recently I attended a course in 3D cone beam CT interpretation given by a well known expert in head and neck x-ray technology, Mr. Richard Greenan. And that course was given at LVI. I think that’s a favorable sign. If the NM crowd would also recognize the importance of structure and actually work to correct that structure, I believe NM dentistry would enjoy better results.
Proper joint positioning combined with ideal vertical dimension and left-to-right corrections is not easy to accomplish. Personally, I start with x-ray findings. And then it’s a matter of the art and science in working to achieve the best result for each person.
I know that it’s tempting for dentists and patients alike to believe that a couple of machines attached to electrodes and sensors can find that sweet spot for them almost automatically and every time. Why is it that the techniques are unreliable and unpredictable? Well, there are many who say NM dentistry is entirely predictable and is the answer. You’ve already proven that it just isn’t so.
Another approach is needed. So, in your case, what’s missing? Have cone beam CT images of the joints been done? If not, find someone who will do that. How about thorough neck and back exam? Are there cervical problems causing some of the pain? Have you seen an ENT or a neurologist? How about a good evaluation of the occlusion? I think T-scan is the best tool available for this (See my article, The Wonders of T-Scan: It’s Amazing What You’re Missing). I was gratified to see that LVI has now begun to advocate and teach the use of T-scan in their programs.
For you personally, the NM approach has not worked. I would recommend you go to www.aacfp.org on your computer and check the referral area for someone with lots of experience in or near your town. That isn’t necessarily a 100% guarantee of success, but it will let you see another approach. In my opinion some of the best practitioners treating TMD world-wide are a part of this organization and it is where I recommend you explore next.