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Oral Medicine

How Effective Is the Neuromuscular Occlusion Approach in diagnosing and treating TMD?

This summary is based on the Rapid Response Report developed by the Canadian Agency for Drugs and Technologies in Health:  Neuromuscular Occlusion Concept-based Diagnosis and Treatment of Tempromandibular Joint Disorders: A Review of the Clinical Evidence 

Full Report (PDF)

Key Messages

Diagnosing TMD:

  • The use of electromyograms (EMG) is not supported by evidence.
  • There is insufficient evidence to determine the diagnostic value of kinesiography.

Treating TMD:

  • Electrical stimulation is not supported by evidence.
  • The efficacy of occlusal splints is uncertain.


Temporomandibular disorder (TMD) is a group of clinical problems involving the chewing muscles, the temporomandibular joint (TMJ), and related structures. Symptoms may include headache, muscle and joint pain, difficulty chewing, and TMJ clicking or stiffness. TMD may be diagnosed using a clinical examination called the Research Diagnostic Criteria for TMD that groups people into three categories depending on the results of the examination and their symptoms (muscular, disc displacement in the TMJ, or arthralgia/osteoarthritis/osteoarthrosis).

The term dental occlusion refers to the way in which the teeth come together. Neuromuscular occlusion (NMO) considers the entire system that controls the positioning and function of the jaw — the teeth, muscles, and joints ―and seeks a balanced relationship between them. This is done through various means including transcutaneous electrical nerve stimulation (TENS), electromyograms (EMG), computerized mandibular scans, electrosonography,and kinesiography. Using these techniques, the rest position of the jaw is determined and is then used as a reference to establish the ideal mandibular position. The dental occlusion is then altered or adjusted to produce the new mandibular position. This can be achieved by surgery, an occlusal splint (an appliance that stabilizes the occlusion in a particular position), or other means.


Various studies related to the diagnostic values of the electromyography in TMD patients showed that the technology produced a wide range and inconsistent values of specificity and sensitivity that prevent its adoption as a diagnostic test for TMD. The EMG indices were not consistently different between TMD patients and the healthy controls. Furthermore, the EMG indices correlated poorly with the clinical signs and symptoms of TMD, such as pain and function.

Other studies on the electrical stimulation of muscular muscles showed that the use of contingent electrical stimulation was not different from the use of placebo in changing the clinical outcome or the electromyographic evaluation.

Follow-up: What further information would you like on this topic? Email us at jcdaoasis@cda-adc.ca

JCDA-OASIS is working closely with the Canadian Agency for Drugs and Technologies in Health to provide you with the latest clinical information.

Readers are invited to comment on this initial response and provide further insights by posting in the comment box which you will find by clicking on “Post a reply“ below. You are welcome to remain anonymous and your email address will not be posted .


  1. Clayton Chan March 12, 2013

    This is totally politically focused and an attempt to disparage technological advancement which was already battled at the ADA and FDA years ago and won. Why do such bitter academics continue to try to stir the profession in such unconscionable manners which will place our dentists and their patients many years behind with these false and unfounded claims. Those who are responsible for writing such need to be stopped and exposed once again for their callous disregard for truth, history and what has already been clarified repeatedly with the American Dental Association and failed attempts for those perpetuating the Orofascial bio-psychosocial agenda to the treatment of temporomandibular joint disorders.

    The examination of these articles shows a pattern of these authors who continue to claim having the best and latest evidence on the subject. In fact, Dr. Greene and his cohorts attempt to game the system by positioning themselves as self appointed judge and jury to what is acceptable evidence while consistently purposely ignoring the mountainous levels of evidence supporting NMD and its instrumentation. Dr. Greene’s false and seriously biased misleading and opinionated statement which stated, “In addition, it has become accepted widely among pain experts in the medical and dental professions that these types of pain conditions must be managed within a biopsychosocial framework, in which behavioral approaches supplement conservative medical care” is so far removed from the truth and reality of matter.

    Not all pain experts widely agree with Dr. Greene’s position, in fact this is purposeful disregard for the fact that the majority of pain experts belong to the American Alliance of TMD Organization a larger group comprising of 9 organizations national and state groups with TMD treatment interests formed in opposition to the TMD/orofacial pain specialty application initiatives. They recognize that a patho-bio-physiologic/ neuromuscular/occlusal model is an effective and reasonable approach to manage the TMD pain conditions.

    The American Alliance of TMD Organizations is comprised of the following 9 organizations:
    • The American Academy of Gnathological Orthopedics
    • The American Academy of Pain Management
    • The American Association of Functional Orthodontics
    • The American College of Prosthodontics
    • The American Equilibration Society
    • The American Prosthodontic Society
    • The American Society of Temporomandibular Joint Surgeons
    • The International College of Cranio-Mandibular Orthopedics
    • The Society of Occlusal Studies

    These 9 organizations oppose the psychosocial model that Dr. Greene and his associates are advocating as a Standard of Care. Dr. Greene and his coharts of psychosocialists do not align with the perspectives of these ADA recognized organizations and TMD experts. Vigilance is always necessary if professional freedom is to continue. Political underpinings continue with this small group who house themselves under the Academy of Orofacial Pain organization who deny occlusal causality for TMD. They attempt to posture TMD as a psychosocial disease caused by emotional stressors. The 1996 National Institute of Dental Research Consensus Conference clearly defined the biomechanical versus the psychosocial paradigm schism.

    I hope the publishers and editors allow another side of this story be published to counter and balance these false and outrageous claims being stated as detrimental to all those dentists and patients who believe there is another side.

    1. Dr. Pasquale Duronio March 12, 2013

      The politics of Dentistry is so interesting. It took over 10 years, at the beginning of my career, to come up with an effective way to treat TMD. The list of experts that I heard speak is too long to list. Most of them had an agenda and were totally invested in their treatment regimen. What I discovered in all those years was that all the “experts” had an 85% success rate, according to them. What I was looking for was the treatment for the other 15%. Eventually I learned that I had to be able to use all of their treatment regimens. What worked for most people didn’t work for all but I did learn that eventually you could find something that helped. The problem with TMD is that some of my patients had to try 3 0r 4 different treatment modalities to eventually find the right one. That can be a very expensive process for the patient.

      I have had patients that have been helped by massage therapy, chiropractic therapy, acupuncture, biofeedback, electric transcutaneous point stimulation, occlusal adjustment, orthodontics as well as 6 different types of splint designs. I wish I could predict which one would be successful at the very beginning of treatment, but, unfortunately, there are always some patients that don’t fit the treatment that I would like to have succeed. I think it’s about 15% of my TMD patients.

      When it comes to Dentistry and healthcare in general I follow the advice I once received from the great Dr. Weldon Bell, “Think for yourself. The teacher might be wrong”.

      1. Brian Barrett March 15, 2013

        Folks will think that I have nothing better to do but those that know me will understand that I do enjoy a debate and can usually argue either side in an attempt to try and come up with some logical conclusion with the joint effort. It is interesting to note that you have found of all the different treatment modalities proposed over the years that none really fits everyone and you have to adapt to individual patients. I too in the beginning was trying all over the map different ways to help these poor folks and as you have stated they are costly to patients especially when you try many. I used to say we can try this – or we can try that and I won’t charge you a lot cause I am not sure it will work. Guess what – as with you I found that 85% could be helped with one type of treatment or another – then about 20 years ago, reading scientific literature two findings and recommendations really jumped out and made sense. The first was that 85-90% of people suffering with TMD pain got better if you did nothing at all – spontaneous recovery they called it and there are dozens of studies that document those statistics. When combined with the recommendation to only use reversible treatments and that basic tenet of all treatment ” do no harm” I then treat them all with my explanation of what may be going on and a bite plane or absolutely nothing and – I do find that 85% get better – less costly as well.

        1. Bruce Greenstein March 19, 2013

          Where to begin?

          I am not a Canadian citizen and do not have any knowledge of the governing bodies that rule on legitimate, evidence-based therapies to improve the lives of patients seeking care.

          I also do not understand how any one entity can draw conclusions that would affect the lawful practice of dentistry based upon 15 studies when there is a plethora of articles written by dedicated clinicians dating back at least 50 years. A report from an agency such as this should most definitely include a significantly larger sample of tests and research with detailed measurements and information on the processes employed.

          What kind of training did the researchers have in the area of NM bites or K-7 use?

          Who monitored the patient compliance with treatment modalities?

          What standards were set for determining maximum medical improvement?

          Was it subjective from the patient’s perspective and/or were there objective measurements to support the pre- and post-treatment positions of the mandible, jaw movements and sounds?

          Reading this report left me with a feeling of concern as to who and what motivated the claims made in the conclusion section. With an organization that has the word “Drugs” in its title, it is not so far-fetched to question possible agendas in putting forth this report.

          The NM approach to health of the entire body is well accepted in other medical modalities such as physical therapy post-surgery for knees, shoulders, etc. as just one quick example.

          Am I to believe that my own posture, whether one hip is higher than the other or shoulder lower than another, is the result of a day or week’s stress?

          Pharmaceuticals alone will come to my rescue?

          Should I inject something into a joint or the back of my head?

          Perhaps surgery?

          From personal experience, I can report that determining a “centric relation” position is not only a subjective exercise, it is also entirely unpredictable and challenging to find from patient to patient. Why manipulate someone into position rather than let the nervous and musculoskeletal systems self-correct by aligning posture and bite on the same page? Or, should I just create a splint in the patient’s current habitual biting position irrespective of the manner in which the head sits on the spine and the relationship with the rest of a quite possibly crooked body?

          Ultimately, EMGs DO NOT diagnose anything – they are merely tools employed in a medical professional’s arsenal which includes many other modalities, from radiographs to questionnaires to clinical examinations and more. It is the DOCTOR who diagnoses a disorder based upon signs and symptoms and a well-documented, supported collection of data.

          Over the course of 24+ years of practicing dentistry, I have had the privilege to learn from renowned clinicians all over the world and all over the spectrum (gnathologists, centric relationists, NMists!) It is interesting to note that while some of the “Hatfields” and “McCoys” continue their feuds, the best data, techniques and concepts from those worlds continue to seek each other out and meld themselves into a truly objective and REPEATABLE method of improving the quality of life for our patients.

          I remain excited about the future despite those who wish to control it!

          Bruce Greenstein DMD

  2. Brian Barrett March 12, 2013

    I will preface my comments by stating that I am not a researcher, I practice dentistry. I also am not very good at assessing research that others have done, so when it comes to reading scientific papers I am never really sure if the methodology, results and conclusions that authors come up with are valid. In this day of evidence based treatment it is important that someone can, at least indicate for me those that are properly done.

    I understand that CADTH is The Canadian Agency for Drugs and Technologies in Health, an independant, not for profit organization jointly funded by Canada’s federal, provincial, and territorial government. They will review various topics and provide decision-makers, , with the evidence, analysis, advice, and recommendations they require to make informed decisions in health care.

    The individuals there are not usually medical or dental professionals byt research specialists, statisticians, and evaluators that have no preconceived ideas as to the outcome of their research or bias. When I read the report it appeared they did not specifically try and find out what works or why or which treatment should be done or the “best” diagnosic methods . They did not study different camps to see whose beliefs one should follow nor did they end up picking sides. What they did review was all the studies carried on over the last number of years related to the topic under discussion to see if they were done according to accepted scientific criteria as they do for all their reports.

    Their conclusion is what it is – not based on the fact that Charles Green or Clayton Chan is correct or better than the other. What it is – based on their review of all the studies done on neuromuscular occlusion, that very many did not meet the criteria as properly designed studies and those that did – had such a variation of results that the conclusions did not prove anything. They didn’t even suggest that the findings were set in stone, just that to this point in time all of the studies done have yet to prove the point they were trying to make. I would suggest that anyone really interested in this field mount a properly designed, double blind study of a large enough group and see what happens.

    In any event as practicing dentists, unless one happens to be well trained in the evaluation of scientific work we are very lucky to have a non-partisan, independant group such as this CADTH to help us find out way through the weeds. They have absolutely no vested interest or prior beliefs to cloud any of their findings and will simply tell it like it is

    1. Paul Belzycki March 25, 2013

      I have been in practice for 32 years. I have seen a lot of quackery come and go. It is my belief that most dentists are driven more by financial gain rather than what is best for the patient. I believe Dr. Barrett wrote the following:

      85-90% of people suffering with TMD pain got better if you did nothing at all… with the recommendation to only use reversible treatments and ” do no harm” I then treat them all with my explanation of what may be going on and a bite plane or absolutely nothing and – I do find that 85% get better – less costly as well.

      I concur wholeheartedly with this finding. But that doesn’t make the NeuralMuscular folks from Las Vegas any money. And when you start throwing porcelain veneers and onlays on teeth that don’t really need it, it is all about money.

      Before all this computer stuff, I knew of colleagues that would use Applied Kinesiology. The quackery where muscle testing is done by pushing down on the arm of the patient with various thicknesses of tongue depresses. Today, we disguise the quackery with sophisticated digital imaging. But it’s all still lies and deceit. And it’s easy for a dentist to deceive patients. You just have to deceive yourself first. The rest is easy!

      There is even a dentist down the street from me that waives a Crystal over the patient’s head as a guide to therapy. That dentist makes the claim of being a Healer. Took a weekend course!

      Besides the statement “above all do no harm” one should remember that there is “nothing more dangerous than a dentist back from a weekend course given in a hotel conference room, or pseudoscientific institutes of study”.

  3. Clayton Chan March 13, 2013

    In this 37 page document it is evident that the drafters of this work clearly they have done a lot of work, but the reviewers ‘ bias is quite evident. They have selected a group of references that lack many supportive studies. Two of the Cooper studies were included, but yet they rejected Cooper’s studies because it did not meet their selection criteria.

    They violated their own tenet of “clinical evidence”, considering the conclusions that were reached in the Key Findings of page 2 “The use of electrical stimulation is not supported by the current evidence”. They based this on two studies by Monaco, et. al. and Jadidi et. al.

    Everyone should read the attached abstracts of these two studies and decide whether they can reach such a conclusion.

    It has been noted that in Jadidi’s study, they used an “electrical square wave pulse train”. They did not use a low frequency TENS indicated for relaxing muscles. It is no surprise that muscle tension was not reduced/relaxed. In Monaco’s study, the conclusion was clear and definite made by the investigators that “Significant differences were observed in the TENS group…and EMG values of masticatory muscles of both sides were significantly reduced”. The drafters of this document obviously overlooked these findings and didn’t report them in a fair and balanced way.

    There are many TENS studies that they overlooked but the only study they produced that used a Myomonitor (Monaco’s study) indeed substantiates the efficacy of TENS in reducing muscle tension!!

    I am sure there are other interesting surprises in the other studies that will become unveiled as readers analyze and study this document more thoroughly.

    1. Brian Barrett March 13, 2013

      With all due respect I do not believe that they intended to say that TENS was not a useful pain releving modality to reduce pain in muscles – I understood the point was -“”With regards to the clinical efficacy of TMD treatment based on the electrical stimulation of muscular muscles, data was limited to one randomized-controlled trial and two non-randomized trial. Results from the randomized-controlled trial showed that the use of contingent electrical stimulation was not different from the use of placebo in changing the clinical outcome or the electromyographic evaluation. The non-randomized trial reported contradictory results between the electromyographic and kinesiographic evaluations.

      I read this to mean that basing the type of treatment on the results of electrical stimulation was not shown to be accurate. They then went on to suggest how the errors in the studies could be addressed.

      “Further development of these methods by establishing discriminative values that correlate with the clinical signs and symptoms of TMD may enhance their acceptance in clinical practice.””

      ON performing a search of the CADTH site there is a separate document on efficacy of treatments and laser, biofeedback, and electromyography are noted as effective compared to some others.


      I guess from all clinicians treating these folks there is no doubt patients who fell through the cracks and when treated by different treatments – get better. We as scientists have to remember that getting better is not proof that the treatment worked – it is just stating a fact that in this patients case – they got better.

      The arguements over this topic have gone on for nearly 40 years that I can recall and the most sensible advice I recieved was – do no harm and do nothing that can not be reversed.

      1. Clayton Chan March 14, 2013

        With further more detailed analysis of what they are reporting, they violated their own tenet of “clinical evidence” and proper balance reporting by creatively and purposely eliminating what data and information they desire to report (cheering picking the literature) or construing as evidence to their summary findings based on their biased methods of ruling out what they feel is valid to convey their message….to cause the reader to conclude… “The diagnostic accuracy values of EMG were reported in two studies; both studies reported a wide range and inconsistency values.”

        What is in questions about this kind of research is on what physiologic bases do they establish the terms of sensitivity and specificity of their methods? Do they come up with their own and establish that as the standards to the rest of the community who are familiar with this technology and its proper clinical use?

        In the Efficacy Studies section page 5, the reporters did not properly acknowledge the conclusions of the Monaco et al. study accurately or completely. It actually states: “Significant differences were only observed in the TENS group for masticatory muscles of both sides; one-way analysis of variance revealed that sEMG values of masticatory muscles of both sides in he TENS group were significantly reduced.”…but rather the researchers prefer to report: “….The evaluation was based on EMG and kineseographic indices without any clinical outcomes.” (The researchers did not disclose the actual effects of this 60 min. TENS application on sEMG and kinesiographic activity in this TMD patient study. Why did they chose not to report this?

        Another example of an obvious error in this report is that the researchers site the Jadidi et al study on page 7 in the Efficacy Studies section, but don’t disclose that this study used an “electrical square wave pulse train (450 ms)” biofeedback stimulator type unit rather than a low frequency TENS which is indicated specifically for relaxing muscles. It is not surprising that muscle tension was not reduced/relaxed using that kind of biofeedback modality in that study, thus the researchers are again cheering picking their literature studies to convey a wrong message about EMG and TENS efficacy and or the researchers are not clearly distinguishing the differences between electrical square wave pulse biofeedback stimulators vs. ultra low frequency TENS. They are not the same. It’s like comparing apples to oranges…thus their reported conclusions and results of this study puts in it all in question as to it’s reliability, sensitivity and specificity of their conclusions of this literature research study to which adds doubt and little confidence to the readers as to accuracy of this “Rapid Response Report”.

        1. Clayton Chan March 15, 2013

          A further note to the editors of JCDA:
          On this very page above (http://www.jcdablogs.ca/2013/03/11/tmd/) with all do respect, it states something very untrue, in fact very misleading the following.
          The title above says KEY MESSAGES:
          • Treating TMD: “Electrical stimulation is not supported by evidence”.

          When reading through this Rapid Response Report that most of the findings are related to use of electromyography as a diagnostic test for TMD. But no where do I see any evidence in this CADTH research report/study to support the JCDA’s false and misleading front page statement that “Electrical stimulation is not supported by evidence.” – We are talking TENS Stimulation…..but where is the evidence in this report that show electrical stimulation is not supported by evidence?

          • Diagnosing TMD: “There is insufficient evidence to determine the diagnostic value of kinesiography”.

          There seems to be very little amount given to showing evidence against Kineseography – 1 short paragraph in the CADTH report page 8-9. That is all? There appears to be a lack of complete understanding about kineseography in this report and the referenced study by Manfredini et.al., in that the report only addresses the max. opening, left and right deflections and freeway space movements. Anyone that uses kineseography during an evaluation recognizes antero-posterior (AP) dimensions are also critical parameters in the diagnosis of TMD. It was obviously overlooked, or excluded in the selection criteria of this very limiting report. This is a significant aspect to TMD/kineseographic evaluation which they fail to address or never studied. Therefore the author presents some very misleading conclusions. The report stated on page 9 under Efficacy Studies – “The kinesiographic evaluation showed that TENS treatment was associated a statistically significant difference between groups in terms of the vertical evaluation; however, these differences were not provided for the anterior/posterior index or the ratio of vertical/ anterior-posterior indices.”
          Why not?
          It seems there is something missing here before the author’s draw their conclusions about Kineseography? It seems that this report recognizes that TENS works and is of statistical significance! Very different that what is advertised and promoted above.

          It is unfortunate to see JCDA Blog page advertise misinformation like this as the KEY MESSAGE attempting to disparage the Neuromuscular Approach. These marketing points on this pages do not reflect or accurately depicted the content of the CDATH report. As a reader, dentist who practices, teaches with these kind of technologies and treats patients with TMD issues it seems that these false misleading propagandizing statements on this JCDA blog page are used to purposely diminish the NM Approach and technologies publicly. This is misleading investigative journalism.

  4. Vishal Sharma March 13, 2013

    Dear editor of the JCDA,

    Thank you for posting the editorial review on the usage of Neuromuscular Occlusion in diagnosing & treating TMD. As a younger dentist looking to better educate myself, such that i can provide my patients with the best possible care, I have found the information on TMD disseminated in dental publications to be widely varied, & at times immensely contradictory. Although I very much appreciate the author’s efforts in their publication, I feel it is in the best interests of our profession to, with all due respect, point out some very relevant shortcomings that I see in the article.

    Now, I would like to qualify my position. Athough I have taken a variety of courses on TMD treatment approaches, I would readily admit that I am certainly not an expert in the area. But I am a concerned & engaged member of our profession.

    The paper identifies a variety of studies that refute the efficacy of EMG’s in diagnosing TMD in patients & controls. I was not aware that EMG’s provided a diagnosis of disorder. My understanding of EMGs & Kinesiography is that it provides a clinician with numerical information & data that requires interpretation from an appropriately educated clinician. I would assume that the criteria for a diagnosis of TMD would still center around a proper medical & dental history, clinical evaluation including, but not limited to an evaluation of the dento-gingival structures, proper muscle palpation, range of motion (either with machinery, or ruler), joint sonography (with or without the aid of equipment), radiographic (or tomographic) evaluation & further interviewing of the patient. My further understanding is that once a complete analysis has taken place, & a TMD diagnosis is made, EMGs could provide a clinician with baseline numerically objective data to show whether EMGs are altered after therapy ‘in the TMD patient’. I’m unclear as to how EMGs in control patients, who do not have TMD, are pertinent in determining that “this approach is not based on solid evidence”. The author, it seems, may have missed the point on what EMGs are utilized for in Neuromuscular Occlusion.

    Without getting into the same detail regarding a TENS machine, I would respectfully suggest that the author may have again missed the point in reaching their conclusions from their review of the literature. The TENs device, from my understanding, is just one instrument that could be used to help ‘deprogram’ a patient who has been diagnosed with TMD. The author seemingly suggests that a TENS is a primary modality of treatment in the Neuromuscular based therapy of a TMD patient. I believe this not entirely accurate. This ‘deprogramming’ is not necessarily immediately therapeutic, from my understanding, but is intended to inhibit proprioceptive feedback that only takes the mandible back to the theoretically pathological maxillo-mandibular relationship that contributed to a patient’s TMD.

    I would respectfully ask two things of our CDA Journal. The first is to include the name of authors & their credentials in the future. The second is to consider being slightly more judicious in their decision to publish articles that dangerously criticize dental treatments as “not supported by the literature” when those articles may have completely misinterpreted the treatment protocols for which they are condemning. Young dentists, who are trying to determine what treatments are best for their patients, may just benefit from a more balanced, fair assessment.

    Thank you for your time,


    Vishal Sharma, DMD
    Calgary, AB

  5. Norman Thomas March 14, 2013

    While I have not read the complete paper on the above obviously skewed reportI would respectfully point out that the stated research does not correctly cover the known research findings on the effect of TENS on the electromyography frequency raw data nor is there any reference to the findings of Thomas NR (1990)”Pathphysiology of Head and Neck Musculoskeletal Disorders: The effect of fatigue and TENS on the EMG m,ean power frequency” in Frontiers of Physiology vol 7:162-170 that was supported by a grant from MRC Canada and has been confirmed by Eble et al at Frieberg University Germany. I have not been sent the original paper on the subject matter but from muy research experience the question is a non issue and has been adequately answered in the scientific literature including the International Journal of Dental Research and the “Literature Review of Scientific Studies Supporting the Efficacy of Surface electromyography ,Low Frequency TENS and Mandibular Tracking from Occlusion Evaluation and AIDS in the Diagnosis &Treatment of TMD by Jankelson RR and Adib F (2009) pub by Myotronics Noramed inc Norman Thomas PHD;DDS:MB.BSC;FRCD;Certs Oral Path and Med;MedAc(Alta) :Professor Emeritus University of Alberta Canada

    1. Brian Barrett March 15, 2013

      Dr. Thomas:

      Sir with all due respect here I am a lowly private dentist trying to treat patients and I appreciate your dedication and interest in this field – However once again – with respect to your work at U of A how should I compare your opinion with that of these colleagues from there published in that often quoted journal JADA which states that Electromyography is of no use in diagnosing TMD ??


      You also quote the International Journal of Dental Research and then I read a position statement by the International Association of Dental Research and The American Association of Dental Research which is contrary to what you have said.


      And again – who has the credibility and backing so that I – as a lowly GP can believe “THE SCIENCE” –

      1. Norman Thomas March 19, 2013

        Thank you Dr Barrett. I am also a licensed dental practitioner who began his journey over fifty years ago as a dental technician who understood the simple concept of the sanctity of the neutral zone (Wilfred Fish; U.K : Beresin USA) which is fundamental to sound dental and medical practice.When the barrier of the neutral zone is unrespected as we are taught in dental school and where we also resort to telling the patient to remove their dentures at night and to wear retainers to prevent collapse and pathology then we may just begin to see with the eye of common sense that oral pathology,systemic morbidity and death from chronic disease and sleep apnea ensues because of our wide neglect for the neutral zone. Now as a specialist treating oral pathology and systemic illness I practice neuromuscular dentistry and my patients are alive and well because I practice safe dentistry. Have no doubt Doctor that neuromuscular dentistry is founded upon the physiological researches of several Nobel lauretes and I respectfully advise you that you also once learned about the importance of aerobic biochemistry and the efficient and economical production of 36 molecules of ATP for every molecule of sugar combusted (Krebs’ cycle) as opposed to anerobic glycolysis in which only 3 molecules of energy producing ATP are produced per sugar molecule(Embden Meyerhof pathway) . Dentures and dentition in the neutral zone is the aim of neuromuscular dentists who save lives daily.I see the skewed article under present discussion as a return to the status quo where your patients and mine are expected to suffer as an acceptable ageing phenomenon because of simple loss of common understanding of what we learned in the physiological and biochemistry lab now long forgotten.. That is why we now understand that sleep apnea is increasing in our patients because we dentists neglect the very simple aerobic antidotes to anerobic destruction because there is encroachment of the dentures/dentition on the tongue and soft tissues. In fact it is commonplace to hear dental students being taught to tell their students to remove their dentures at night thus promoting apnea and anerobism.As a practicing oral physician I see the daily effects of dentures and dentition that extend beyond the neutral zone as you must as a general dental practitioner.The morbidity and death should alarm us. I understand your confusion. You are correct .A group of American and Canadian Professors contrary to published research issued a statement in the Canadian Dental Journal denigrating neuromuscular dentistry. That statement was rebutted by several of us in a follow up letter to the Journal of the Canadian Dental Journal which you clearly did not read. You read only the false and unsupported criticism and what’s more you believe it though it is based upon false premises. Norman Thomas Certified Specialist in Oral Medicine and Pathology. Chancellor and President of the International College of Craniomandibular Orthopedics; Director of Neuromuscular Research LVIADS USA;Professor Emeritus U.of Alberta,Canada

  6. Steven Cload March 14, 2013

    Prior to publication of the article it would be appreciated if a dentist trained in Neuromuscular therapy was able to review the paper and comment on the findings. Many dentists just read the abstract and conclusion or findings.With this paper they would beleive neuromuscular dentistry to be of no use and simply voodoo.

    I have been a member of the Canadian dental association for over 20 years and do not believe I have ever seen a paper or review “ How effective is the CR approach in diagnosing and treating TMD” Why? Because it’s the holy grail of many dental academics who refuse to question this ancient treatment protocol of distalising the mandible and then refuting any other approach using the argument of reproducibility. The irony being reproducing this condylar position is impossible which explains the use of the long centric position. We have all seen many poor cases of treatment based on CR therapy but do we see published papers on this? No we do not .
    Any research on TMD diagnosis and therapy will produce a multitude of varied and at times extremely contradictory opinions. If the unknown author of this research had given more information on the Rapid Response Report it would be obvious they have a bias towards a psych/social cause of TMD. You only have to read some of the patient questions, “are you feeling blue” ,”do you feel depressed”. There is no questions regarding the body posture such as neck pain, pain behind the eyes. To limit the diagnosis of TMD to the jaw joint area is in my opinion the problem with bias against neuromuscular dentistry. If the CR splint does not work then it must be in their head and give them some medication
    The author does not seem to understand that TEN’s is not a treatment protocol. It’s a technique to essentially relax musculature associated with the cranial nerves V,VII and XI and evaluate the change in mandibular position.
    EMG’s are again on not the sole piece of information used to make a diagnosis of TMD. They are part of a complete exam including but not limited to a full medical and dental history, clinical evaluation, joint sounds, radiographic analysis, postural examination, jaw tracking, signs and symptoms. I am also extremely confused as to how EMG’s in control patients are relevant. If the author understood the physiology of a human being there is a range of “normal “ for everything. There is no control. We are talking about individual muscle physiology in an individual. EMG analysis helps to see improvement in muscle physiology based on the patient’s body posture, mandibular posture relevant to the patient in questions starting point, not the other 6 billion people on the planet. The arguments related to specificity and sensitivity do not apply. Their specificity and sensitivity argument is useful for simple yes/no tests such as the PAP smear. But to expect a single test to rule out or rule in a complex, multi-etiology condition such as TMD indicates a fundamental ignorance of the nature of the condition by the authors quoted not to mention their lack of understanding of the physiological complexity of the condition. They use this argument to discredit Neuromuscular dentistry

    I find it ironic that the author also eliminated nearly six hundred research papers because of criteria they created to bias the results. Eliminating any study with bruxism in the patients is ridiculous. Is the author saying bruxism has no relationship to TMD. Even if they argue TMD does not cause bruxism as its psychological they cannot argue that bruxism will not affect the joint and musculature due to over use.
    ‘Evidence’ does not ONLY refer to published papers. There are hundreds of published papers that support what we do. There is a stair-step of ‘Evidence’ that includes “case reports”. There are thousands of case reports of patients who were successfully treated with NMD to relieve their years of debilitating symptoms.

    This anonymous author of this paper I would suspect is part of the bandwagon headed by Dr. Greene attempting to discredit a neuromuscular approach to treatment. I have personally treated many patients utilising a neuromuscular approach to TMD with amazing results and very grateful patients. I have seen two ladies today who are almost completely pain free but lived with a large bottle of Advil in their purses for years. On Monday I followed up on a completely pain free patient who had been treated over a 15 year period by numerous dentists placing CR splints that did not work. She was told it was all in her head. With 5 weeks of neuromuscular splint therapy she is pain free, able to go back to work full time and as she said, enjoy her vacation with her family now she is not in pain. Tell her neuromuscular therapy does not work.

    I would kindly ask that from now on the Canadian Dental association is far more judicial in vetting items it publishes in it journal that have an obvious bias both in the findings and the research criteria.

    My father-in -law is a highly regarded economic statistician working in his career for research institutes and government. He has often told me literature review are useless because the author no matter how hard they try to be independent will create a bias based on their selection criteria for the review and find the result they were pre-ordained to find based on the criteria. As he said to his superiors when they handed over research papers “ What do you want me to say they prove”

    Dr. Steven Cload

    1. Gary Henderson March 20, 2013

      Steven….do you think you could do a totally unbiased report on the various treatment modalities offered for TMD ? Of course not….. you will gravitate towards studies that support your thinking…confirmation bias. That’s the way it is. There is a lot of work being done to make studies relevant …. the discussion and conclusion in most studies are meaningless because the methods and materials are inadequate to answer the fundamental question that the study is asking. This has to change…. you obviously don’t believe in CR dentistry, but it is highly successful in hundreds of thousands of cases. Do you ever wonder why both CR and NM works in most cases? Do you ever wonder why NM doesn’t work in some cases ? Why CR doesn’t work in some cases. You believe what you want to believe, and you explain the mechanism of action with the knowledge that you already have. CR doesn’t work because the patients muscles weren’t TENS’d, so the starting point was wrong….. do you really believe that to be the case ? If you start with a standard that nobody in the world has ( a TENS’s resting muscle position), then it is easy to explain to someone why they’re in pain. What you should be trying to explain is why isn’t EVERYBODY in pain, since nobody is in that rest position ????

  7. Dr. Larry Stanleigh March 14, 2013

    I am very disappointed in the JCDA and the Editor for allowing this poorly prepared and researched report with obvious strong biases to once again be published in a CDA sponsored publication.
    The blogs here have been really well presented with the authors clearly identified and their goals well stated.
    The report listed above has no author listed, other than being part of a larger umbrella organization that is meant to guide the Provincial and Federal Government of Canada for policy and procedures.
    Ths report above is a veiled attempt to discredit the use of technology in the diagnosis and treatment of Temporomandibular Disorders, yet does so in a very poor way. Two examples of errors are in the comments about TENS being ineffective. Just to show how they violated their own tenet of “clinical evidence”, consider the conclusions reached in the Key Findings of page 2 “The use of electrical stimulation is not supported by the current evidence”. They based this on two studies by Monaco, et. al. and Jadidi et. al.
    In Jadidi’s study, they used an “electrical square wave pulse train”. They did not use low frequency TENS indicated for relaxing muscles, therefore the equipment tested is very different than the low frequency tens units in common use in Canada today. How can they be compared? It is no surprise that muscle hyperactivity was not reduced.
    In Monaco’s study, the conclusion was clearly made by the investigators that “Significant differences were observed in the TENS group…and EMG values of masticatory muscles of both sides were significantly reduced”. Yet, the anonymous author of the CADTH report has stated the Monaco study did not find differences in the use of TENS, but Monaco clearly indicates that there was a difference. If the anonymous author of this report is stating something different than the actual reference states, what other flaws are there in the remainder of the 37 page report?
    What is the goal with this report? What is the intention? why is the author anonymous? Why did the Editor of the JCDA allow this obviously flawed report to be published here? This reflects very poorly on the reputation of the JCDA by allowing biased, flawed and inaccurate reports to be given a public forum here. Even the CADTH has a lengthy disclaimer about this report on the front page of the report.
    I am deeply disappointed with this and concerned about the long term outcome of this kind of report and it’s effect on the way I practice dentistry if allowed to go unchallenged.

  8. Marke Pedersen March 15, 2013

    If the CDA is trying to create value for its membership,it has really done the opposite by using a “hurry- up and report ” approach to review a very important area of treatment for the general population.The first disclaimer in the report implies CADTH will do a fast review,with quick decisions being made and will then not accept responsibility for its findings and these findings may accept or reject the hypothesis. If the CDA wants to be seen as a credible resource for the profession nationally ,due diligence must take place before it allows inaccurate ,biased articles and reviews to be published with their name on them. When does CDA membership become voluntary for dentists in British Columbia? Yours truly. Marke Pedersen

  9. Brian Barrett March 15, 2013

    I can’t be spending all this time debating what many obviously feel is not even worth getting into either because they agree with the CADTH report or can’t be bothered which is too bad. We will never come to any conclusions until some day there is a preponderance of true science that is indisputable. That said there will still h those that will believe what they want to believe because it is like religion = those that believe do NOT need any evidence and for those that don’t believe NO evidence will ever be enough. Maybe the earth is flat as the sun moves around us. Been fun gentlemen – keep up the research.

    1. Clayton Chan March 16, 2013

      The preponderance of evidence, it is there and has been in the medical and dental literature available to all who are of an inquisitive mindset to learn more about the bio-physiologic and neuro-muscular sciences – objective measuring technologies like EEG, EKG, EMG, CMS, ESG, A growing number of dentists have been searching for serious answers to clinical issues. Many clinicians who deal with complex issues of TMD and occlusal problems have seriously searched for clinical answers for years related to resolving TMD pain problems as well as searching for logical and reasonable answers to our occlusal dilemmas we all face daily in clinical practice. But now no longer!

      Thanks to the large body of science and evidence that validates the efficacy of these objective measuring technologies that have given us the confidence to stand up for what we know is right and what is misleading. We are not fooled easily any more! The science and literature has been produced by serious clinicians and researchers who have dedicated their lives and their time to develop studies as well as taken the time to publish their findings on these topics of TENS, EMG and kineseography for years, while most of the dental profession has ignored most of this research, not published in the typical dental marketing journals we all know so well. As a clinical and researching community of dentists with a serious focus on analysis we recognize we cannot simply ignore all this work and sweep it under the table and pretend it does not exist, because each is a significant part of the whole.

      At a more in depth level, governing boards and committees of the FDA comprised by well educated individuals of the sciences, medicine, dentistry, engineer, neurophysiology have scrutinized and analyzed the data and literature science on these matters of validity and efficacy to assist dentist with aids in the diagnosis and treatment of TMD problems. The FDA is the United States regulatory agency who has recognized that these technologies are safe and effective for use within the dental profession to keep patients from harm. They have very stringent parameters that must be fulfilled to meet their approval, but it did pass! The America Dental Association (ADA) with their regulatory committees and boards have also scrutinize the evidence and science, not causally or superficially, but have also done their job to make sure dentists within the profession as well as the consumer are safe and will not be harmed, thus granting TENS, EMG, CMS and ESG it’s ADA “Seal of Acceptance”. They analyzed and scrutinized the scientific literature.

      The FDA and or ADA doesn’t propogandize false statements that have been noted on this site about NM Approach diminishing the NM science with false statements. They have learned the history and also recognized the politics as well as the science.

      Read more on Neuromuscular Dentistry Politics at: http://occlusionconnections.com/Neuromuscular_Dentistry/neuromuscular-dentistry-politics/

      How is it possible for any research to be recognized as notable and scholarly if it does not recognize the complete body of research and science that has been analyzed and scrutinized by so many with dedication and intensity on this subject of EMG, TENS and kineseographic technology from a bio-physiologic perspective (not just with 15 or so papers and narrowing it down to 1 or 2)! This topic of neuromuscular dentistry is huge. It has continued to grow and develop in numbers because it makes sense, not like some want to misrepresent it as. It has amazingly come to the forefront of notable levels that the dental profession can no longer ignore its validity. It may not fit everyone’s paradigm of TMD and occlusion understanding, but this is the reason why objective measurements are valued within the neuromuscular dental community, to raise the bar with credibility – to help remove the subjective bias when we treat our TMD patients and occlusal problems.

      To read more on the Efficacy of Surface Electromyography in Dentistry – http://nmdfacts-emg.blogspot.com/

      To read more on the Efficacy of Low Frequency TENS in the Diagnosis and Treatment of TMJ/ MSD – http://nmdfacts-tens.blogspot.com/

      To read more on the Efficacy of Mandibular Tracking in the Diagnosis and Treatment of TMJ/MSD – http://nmdfacts-mandibulartracking.blogspot.com/

      The objective of this CADTH report was not achieved because numerous clinical studies published in established peer reviewed journals by neuromuscular dentists/academicians were excluded. Further, the reviewers distorted and misrepresented the findings of many of the 15 studies that were reviewed and commented on. Of the total of 596 articles that were identified in the initial review, only one article was selected (Silva, et. al. ref. 28) to assess the efficacy of “occlusal splints prepared using the EMG values as a reference of ideal occlusion”.

      It seems obvious that something is dramatically wrong!

      Clayton A. Chan, DDS
      Las Vegas, NV

      1. Gary Henderson March 22, 2013

        I would guess, Dr. Chan, that these reports and studies are totally objective and unbiased ?

  10. Curtis Arling March 15, 2013

    Evidence based treatment is an interesting subject. What one practitioner or researcher considers conclusive can often be refuted by another, as noted in the above responses. This leaves a practicing dentist is a situation where they are forced to sift through the available arguments to determine how they can best proceed and help their clients.

    In dental school I was trained in CR techniques, but didn’t feel confident treating TMD issues with the level of knowledge I had. In searching to upgrade my education I was exposed to neuromuscular training and currently treat clients using neuromuscular techniques. While I’m not an expert at deciphering the voracity of scientific technique, the fact that there are definable, measurable criteria that can assist in evaluating the course of treatment, is helpful to me. In few, if any, other TMD treatment paradigms, is this level of information available. While I believe that there is rarely one cause for TMD and as such, adjunctive modalities are often required to help sufferers, in my hands the success rate using neuromuscular techniques has proven its usefulness.

    To the best of my knowledge, the effect of ultra low frequency TENS on muscle tonicity has been well established in the medical and dental scientific literature. Rehashing old statements or choosing to exclude valid finding seems unhelpful. As always, I maintain an open mind, but until someone can show me a treatment method that has better, measurable, verifiable results, the value to me of neuromuscular techniques will remain.

    Dr. Curtis Arling
    Calgary, Alberta

  11. Kent stringham March 15, 2013

    I find it interesting that someone is trying so hard to discredit the whole of neuromuscular dental theory. I can’t imagine trying to perfect a full mouth restored to a new bite without using a scan 8 on Myotronics K 7 to view the chewing efficiency in real time. Nor would I want to find the first contact without the data given by scan 12, which shows which muscles fire first. I would hate not knowing if the dyskinesia was improved when viewing the open and close cycles. I can’t imagine not knowing that the muscles are all firing evenly after removing interferences with scan 11? inmy neuromuscular training I have learned about anterior guidance, occlusal equilibration and occlusal schemes which have helped me with every crown and filling I have placed since. I have learned how to palpate muscles and evaluate clicks, pops and joint dysfunction. I also used these principles in partial and full dentures ,MADs, partial and full mouth reconstructions.. They haven’t steered me wrong in the last 12 years and I can’t imagine practicing without utilizing all these skills. The article argues academics and posturing but the dentists who use it and the patients who benefit from it don’t care what these un-named detractors think.

    Dr Kent Stringham

  12. Dr. Andrea Stevens March 16, 2013

    When speaking of diagnostic testing, the first thought in my head is of a patient I saw this week in my practice. A gentleman in his 60’s, I suspected lack of vitality in a tooth due to an obvious color change. Using EndoIce (a diagnostic modality I learned to use while in dental school at Temple University in 1990), I tested a tooth mesial to the tooth in question. No reaction. I tested the next mesial tooth…no reaction. I tested the tooth I was initially concerned with…no reaction. Hmmm…3 root canal treatments needed? NO…more EndoIce applied…and all three teeth reacted normally. What is my point? CLINICAL JUDGEMENT. The point that the published article failed to make is that despite whatever diagnostic tools we choose to use in our individual practices, we also use our CLINICAL JUDGEMENT to make a diagnosis, not one modality, not a computer, not even only one radiograph!

    When diagnosing a TMD, my dental colleagues responding thus far to this blog have agreed that a large number of factors are taken into consideration before making a diagnosis and a treatment plan. When it comes to the point of treatment planning, many patients suffering from TMDs have been self-medicating or doctor-medicating for a very long time to mask and “deal with” the symptoms. In fact, many of these patients have been given zero hope of recovery from their symptoms.

    What exactly is it about the subject of treating TMD that makes the CDA so anxious to discredit a modality that has been clinically successful for so many dentists and their patients in Canada, US, Australia, and other countries? I wonder if the CADTH would like to interview the dozens and dozens of patients successfully treated with the techniques of neuromuscular dentistry in my practice over the last 7+ years, or the likely thousands of patients treated in the offices of my peers around the world. Perhaps the CADTH would like to remove the appliances that have allowed patients in my practice and the practices of my peers to finally improve years of significant discomfort. I suppose it would be better, then, to follow like sheep and encourage these patients to continue taking significant amounts of medication, missing days from work and school, utilizing disability insurance…and to what end?

    How terrible that the CDA seems to be encouraging a lack of evolution of treatment in this arena. Is TMD the ONLY area of dentistry in which we are not moving forward, but staying still? Endodontics…moving forward. Periodontics…moving forward. Oral surgery…moving forward. Orthodontics…moving forward. But TMD…let’s just stand still. I agree with my colleague from BC…when does MY membership in CDA become optional? Because the CDA is certainly against my practice of treatments that ARE making a difference in the lives of my patients.

  13. Tony Pensak March 17, 2013

    As pointed out earlier in the post by Dr. Cload, it is reasonable to assume that the author’s conclusion, as a result of any literature review, is probably influenced by the bias of the author, whether intentional or not. In this particular case, the reader is in the bizarre position of not even knowing who the author is!

    When clinicians without post-graduate neuromuscular training weigh the evidence in attempting to determine the value of the neuromuscular approach to TMD management, it may be valuable to factor in the real-life clinical experiences of dentists that treat TMD in practice. With that in mind, I would like to invite any dentist reading this to answer the following question.

    Do you know of any dentist trained in the neuromuscular approach to the management of TMD, to have ever abandoned that philosophy?

    I personally know of dozens, if not hundreds, of dentists who have abandoned the ‘classic’ CR philosophy of occlusal rehabilitation, especially as it relates to the management of TMD’s, but know of not a single dentist who has ever been trained in the neuromuscular pardigm,, only to subsequently abandon it.

    Perhaps this will offer a glimpse into the value of neuromuscular dentistry on a clinical level.

    1. Gary Henderson March 20, 2013

      I know of a number of NM docs that have left that philosophy behind, one being my own dentist and friend for almost 30 years. The fact is that many different occlusal and joint positions philosophies work, whether CR, NM, 4/7 or an occlusion based on a phonetic bite a la the AACP. We also se many patients improve with a generic athletic mouthguard. If all the patients needed was a change in their joint position, rather than a specific joint position, then any position will do. The evidence shows that. The authors are not recommending one philosophy over another, they are looking at the evidence, discarding the studies that have methodological errors, and presenting their findings on NM dentistry only. If they reviewed studies on CR, or 4/7 dentistry, they would come up with the same results, I would think.

  14. Cliff Leachman March 20, 2013

    Nice to see that people will still speak the truth about this nonsense.
    atients need to know your after their wallets not helping out their dentistry!
    depressingg to see how many think this is a modality that actually works!
    phoney jig every-pocket and you should be ashamed of yourselves foe being so dumb as to believe this!

    1. Dr. Larry Stanleigh March 20, 2013

      Mr. Leachmen, it is very difficult to take your comment seriously when you cannot string a single sentence together that is not filled with spelling and grammatical errors. If you are a member of the general public, what experience and knowledge do you base your comments on?
      If you are a member of the dental profession, what evidence based methodology do you use to diagnose and treat TMD issues?
      I find it reprehensible that the JCDA has published an article with an anonymous author (and they even stated they are proud to be associated with this organization!), that has shown obvious bias, and most egregious of all, stated a conclusion by one of the references quoted that is the exact opposite of the original reference source. This is science at its worst and does not belong in a publication representing the Canadian Dental Association. There is a reason for peer review, and this report has escaped all the normal checks and balances that should have been in place.

      1. Cliff Leachman March 20, 2013

        If you believer in this neuromuscular fairy tale the you have already ignored ALL peer-reviewed science.
        This is another SCAM to get patients to accept dubious treatment based on numerous false assumptions. Using surface electrodes to measure muscle activity is the biggest joke I can think of and anyone who has tried to measure activity, me included , will tell you that.. Anyone who practises such nonsense should have their licenses pulled to protect the public. Opening someones bite based on this nonsense is CRIMINAL!
        Spelling mistakes due to my self-correcting iPad, but really what does that matter? I guess a lot when you have no feet to stand on
        I find it reassuring that the CDA hasn’t bought into this charade and thank them for dispelling this myth.

        1. Irfaan salyani March 21, 2013

          Dear cliff
          If you think that surface emg’s are a joke, why do you and society in general accept it as sound medical medical diagnostic tool in diagnosing a heart attack. If medicine was to be as foolish as dentistry in disregarding tools that could help us in diagnosing our patients, think how many people would have died of heart attacks. Think of how many people suffer with severe migraines and debilitating pain who have been successfully treated with neuromuscular dentistry, and continue to be pain free. Why would dentistry wish to send our profession into the dark ages.

      2. Paul Belzycki March 26, 2013

        A note for Larry.
        Your attack against Clif Leachman is a spurious agrument.
        The following is cut and past from Wikipedia:
        “argumentum ad hominem, is an argument made personally against an opponent instead of against their argument. Ad hominem reasoning is normally described as an informal fallacy, more precisely an irrelevance.

        Yes, “irrelevance”. Just like all the data from all the electronic gizzmos employed in the Neuromuscular Scam. But those gizzmos are expensive to purchase. And once one has them, one now must justify their use, i.e. convince oneself they are eficacious. So more courses and more money.

        These toys remind me of the electronic devises used by the Scientologist to determine something or other about the state of one’s soul. “Look, the meter reads that you need more cleansing or you won’t go heaven. Wish it weren’t so, but the meter is accurate.” Open the pocketbook.

        Since everyone else on this blog is using quotable quotes, I offer this. ” A man convinced against his will, is of the same opinion still”

        And here’s another one, ” there are small fibs, there are bigger lies, there is out and out deceit, and then there is the missuse of statistics.”

        Larry, I humbly apologize for any spelling and grammatical errors.
        And Larry, your big smiley photo is wonderful by the way.

  15. Clayton Chan, D.D.S. March 20, 2013

    A profound and noted motto often used by Bernard Jankelson’s (Father of Neuromuscular Dentistry also quoted Galileo Galilei’s basic postulates, “If it has been measured, it is a fact; if it has not been measured, it is an opinion.”

    One of the greatest contributions Neuromuscular Dentistry has made to the dental profession has been one of being the first to bringing focus to “Objectivity” through objective measurements (technology) of bio-physiologic responses of the masticatory system. (These techologies don’t have any realization if they measure NM or CR or any philosophy or TMD method/approach…they just measure and document). This has never been achieved with any occlusal/ TMD philosophy that I am aware until more recently over the past 45 years in dental history. This is what makes NM unique and different than all former teachings we all have received from dental school training.

    We dentist all often wondered why their lacks a confidence when it comes to the topic of occlusion and TMD, yet as dentist we keep practicing and doing what we were taught and told assuming things are right, but our TMD patients began to realize the teachings we all received and practiced were not good enough to answer and address the more challenging issues they were experiencing, such as why are there so many follow up occlusal adjustment visits after a crown or filling was placed (top 10-15% of the difficult cases in one’s practice), or why are my vaneers coming off, or why is their teeth breakage, gum recession or bone loss occuring beyond a lack of good hygiene care? How about why is their teeth sensitivities that go beyond endodontic issues? Why do patients complain of ringing in their ears or ear congestion feelings afte ra simple filing was redone? Could there be jaw/occlusal relationship problem that is being overlooked by our dental profession? Ignored….The patient has gone to see their ENT doctor and could’t find a reasonable cause for such. What about pressure behind the eyes? Is there a dental connection that most will pan off as some opthalmic problem unrelated to dentistry? What about headaches, facial pain, cervical neck issues? Does our profession ignore these issues, especially if our patients have been routinely visiting the physical therapist, massage therapist, chiropractors, etc with very little resolution that is resolving the problem, or our we just band-aiding the underlying problems with superficial splint therapies, injections, fancy passify words to our patients,etc. and not getting to the cause of these masticatory problems. (Of course in the busy every day dental practice most dentist wouldn’t want to ask too many indepth questions to their patients….because it will slow one down). This is what neuromuscular dentist have been questioning for years and wanting to find clinical answers to these kind of problems and more….our public faces challenges daily and are looking for answers.

    We realize after years of clinical practice, being good students of dentistry, reading the scientific literature and furthering our training with post graduate education that the answers given are not sufficient and adequate to meet the next level of patient concerns within the public arena. We can no longer take at face value what is being said or written in the literature. We realize what we are seeing in our dental practices with our patients and what is being taught in dental schools and post graduate CE is not adequate, always meeting the needs. Questions are being asked to challenge the present day paradigms.

    How does one objectively relate the maxilla to the mandible “physiologically”? That is a question few wet fingered clinicians can adequate answer with clinical objective proof.

    Upper splints, lower splints, soft, hard, flat plane, anatomical, anterior discluders, gelbs, botox, trigger point injections, etc, etc. are all attempts given by many great doctors attempting to find an answer to the orofacial/TMD pain occlusal dilemma’s including trying to under the clenching, grinding, clicking popping joints issues all in association with the masticatory system. These issues goes beyond any one particular occlusal philosophy. (We know within each of our hearts what goes on in our clinical practices). As dentist we are looking for better answer, that make sense, and gives us a better clinical result. Certainly we all have success, be we also know we all have failures and challenges. It is these failures and challenges that we are looking for answers beyond the clinical subjective educated guessing that goes on. That is not good enough for some of us. We are more detailed and specific…..

    NM approach identifies pain problems with objective measurements.
    NM identifies masticatory muscle problems with objective measurements.
    NM identifies joint derangement problems with objective measurements.

    Based on a comprehensive objective assessment combined with subjective comprehensive clinical examination, clinician’s should be able to make a multi-dimensional observation of signature patterns in jaw movements, positioning as well as muscle tonicity status confirming injury and or hidden pathologies objectively, not typically visualized on cursory manual palpation examination. These objective findings are incorporated in the clinician’s senses, exponentially enhancing his/her special visualization, interpretation and conceptual grasps of the functioning or dysfunctioning body parts related to the neuro-vaso-muscular masticatory cervical systems, while utilizing to the fullest the physical findings from the clinical examination of the patient.

    How can this be done without objective bio-physiologic tools that quantify and objectively measure?

    Neuromuscular Approach is just asking the tougher clinical questions (pushing the envelope of diagnosis, treatment, care and reason) to get better clinical answers that make logical sense to both the astute wet finger dentists and those whom we treat related to TMD, restorative and orthodontic care.

    Clayton A. Chan, D.D.S.
    Las Vegas, NV – Dentist

    1. Gary Henderson March 22, 2013

      That old canard that if you measure it, it is a fact is quite a interesting point. However, it depends on what you are measuring, and what relationship it has to what you want to find out. If you watch 2 basketball players with equal skill levels, one 7’6″ and one 5’6″ play one on one, the taller player will have an advantage and usually win….all other things being equal. If you then think you can find the tallest player in the NBA by looking at scoring statistics, you will end up with the wrong conclusion. ( You can also turn it around by looking at the heights of the players and assuming they are the top scorers). By using the assumption that height is more important than it actually is, you will miss the mark.

      It is the same with “TMD” and pain …… in order to measure jaw position and EMG levels, we must assume that they are important and the results obtained are directly related to a mercurial condition. We know that to be untrue…many people in the general population have the same “measurements” as “TMD” patients, yet are not affected to any degree. Our patient populations are very different …. they are seeking help. It’s the same as patients with back pain …. almost everyone has some form of deformity or imbalance, but not everyone has back pain.

  16. Cliff Leachman March 20, 2013

    This sounds like a response from a Wink Dinkerson graduate of Las,Vegas, he never let science get in his way either.
    It CRIMINAL what dentists will do to create work with proven BOGUS modalities. Opening someones bite based on surface electrodes is moronic at best, but if you haver VEGAS blinders on its the treatment plan of choice!
    Amway dentistry at best and no clinician worth his salt would even consider such nonsencse.
    Well done CDA, keep debunking these MYTHS and protect the public from money-grubbing, under-educated pseudo-professionals who are ruining the professions image and stature!

  17. Marke Pedersen March 20, 2013

    Au contrare Mr. Leachman. Most patients in the hands of a learned TMJ doctor that can effectively interpret data from many sources, save countless dollars by avoiding many root canals that the cause of which is undetermined.With this knowledge,dental treatments last and have a far greater success .There is far less bone loss in the mouth,far fewer broken – off teeth and far fewer implants necessitated. One should do ones homework before making such statements.I have been doing my homework for forty years Mr Leachman.

  18. Susan Go March 21, 2013

    I don’t understand why certain people are so adamant about discrediting the tools and methods of neuromuscular dentistry. If this modality was truly “ineffective”, it would die a natural death very quickly simply because patients will realize that it doesn’t work (and spread the word all over social media). The mere fact that there are so many paining patients who have benefited from it proves that it “does” work.

    Dr. Susan Go
    Delta, BC

    1. Gary Henderson March 21, 2013

      As do many other treatment modalities….. even ones that place the condyle in a different position than NM does. Even modalities that don’t touch the teeth….
      You must realize that there are not only dentists who claim success with different philosophies than yourself, but also chiropractors, physiotherapists, naturopaths….heck, I even had a lady in that said that ear candling was the best treatment she has had to date !! Therefore, if all these different modalities work, then the mechanism that we espouse is probably not the TRUE mechanism of action….

      1. Susan Go March 21, 2013

        If only one person says something works, it’s likely a coincidence. The more people validate a method, the more we should open our minds to the possibility that it is legitimate. Physios, chiropractors and podiatrists are, just like us— finally realizing that we cannot treat a single area of the body without expecting a ripple effect on the rest of the body.

        1. Gary Henderson March 21, 2013

          I’m glad you agree that there are many ways to treat “TMD” and pain concerns, and that NM dentistry is not the only way, but the way you choose to practice.
          However, i am disappointed that those that espouse NM dentistry do not understand that this is a systemic review of the NM literature, and there are very clear guidelines as to what constitutes a legitimate study. If your favorite study is not included, then there is a reason for that….and it is not the bias of the reviewers. It would be the bias of the study, or improper methodology. What it points to is that the NM literature is not well done….it does not point to any conclusion on the efficacy of the treatment. If they had studied CR dentistry, or the Gelb 4/7 position, they would find very similar results. The literature on TMD has, for a long time, been very poorly done. There is not really any consensus on what constitutes TMD ….even with the TMD-RDC.

          1. Susan Go March 23, 2013

            If you agree that NM dentistry is a legitimate and valid mode of reating TMD, then why are the tools of NM dentisry being criticized as not being effective?

        2. Paul Belzycki March 29, 2013

          Chiropractic. No, science, there are either.
          Question: How many chiropractors does it take to screw in a lightbulb?
          Answer: Just one. But there is the need to return 30 times.

          A dear friend and chiropractor, claimed that he had a 70% success rate in relieving pain due to TMJ problems by some form of manipulation over a series of appointments.
          I told him I achieve 98% relief of pain by doing nothing. So his intervention dropped the success rate by 25%. Tongue-in-cheek, to be sure, but a true story nonetheless.

          Regarding podiatrists. Several years ago I spontaneously developed plantar fasciitis in 1 foot. Out of frustration, I attended a friend and podiatrist and was fitted for orthotics. After two days, I now had pain in 2 feet. I should’ve known better. Removed the orthotics and did nothing more than rest and wore soft spongy running shoes. After several months, I woke up one day and the pain was spontaneously gone. Another true story.

          I do not have chronic back pain. Developed a backache due to muscle spasm as a result of going for a deep shot while playing squash. Told this to a chiropractor patient and was told one legs was probably shorter than another and the need for corrective orthotics. Ya sure! Within two weeks of rest the pain was gone.

          The “laying on of hands” does have its placebo effect.
          Just make sure you charge accordingly.

          1. Susan Go March 30, 2013

            Hello Paul. We all know that TMD is multi-factorial and that not one single mode of treatment can claim to be effective for all cases. This is precisely the reason why there should not be all this badmouthing of neuromuscular dentistry. Initial treatment oftentimes involves a removable orthotic which is used to relieve the patient’s symptoms. This stage is completely reversible because the patient can take this appliance in and out at any time to see if it really works. The patient can tell whether or not their quality of life is improved by wearing this orthotic. If they feel it is not helping them, they simply remove it and they are back to where they were. Only the patients who request a permanent restoration of their new bite positions will undergo orthodontic or prosthodontic reconstruction. The rest will live with a removable orthotic or try to wean themselves off. Not everyone is a 28 crown case.
            My main point is that , based on numerous patients’ testimonials, NM dentistry is a viable and legitimate treatment modality. If there are unscrupulous practitioners out there, THEY should be held accountable and not NM dentistry as a whole.

  19. Dr. Allan Winchar March 21, 2013

    As a practising dentist since 1975 and with a special interest in treating TMD patients since 1987, I wish to mention that I have tried various treatment modalities for TMD patients.
    Some treatments are more effective than other treatments and I have chosen to continue with those treatments that have given me the most success with my patients.
    Ultimately, the use of low frequency TENS has provided a level of success in combination with jaw kinesiology and EMG measurements, not for diagnosis of TMD, but rather an adjunct to my treatment protocol for my patients.
    I do not wish to discuss terminology of “scientific evidence” but rather be comfortable with dealing with my patients on a one-to-one basis and getting the best results for them with the knowledge and experience of using these treatment modalities to the best of my ability.
    In addition, I agree that the most conservative treatment is in the best interest of the patient but I let them decide the course of their long-term goals, if any.
    It is important for this committee to know that in February of 2007, Japan’s Health Ministry recognized that both surface EMG data and the diagnostic information provided by jaw tracking.was pertinent information to justify treatment for patients that participate in Japan’s National Health Insurance program.
    This “before and after” diagnostic information was implemented by Japan’s Health Ministry upon the recommendation of a consulting committee.
    All 29 dental universities in Japan utilize the data obtained from EMG and jaw tracking modalities and 2 of the universities ( Osaka Dental University and Okayama University) use the data of EMG and jaw tracking in their clinical training curriculum. In addition, 23 of the medical schools in Japan are utilizing this technology .
    Perhaps this committee should enquire to these Japanese universities and understand how important this neuromuscular approach to treating patients can benefit these chronic pain patients and realize how insignificant their review of the literature means to the lay person who is eternally grateful in receiving help for their clinical problem.
    Respectfully submitted,
    Dr. Allan Winchar

  20. Colin Hughes March 25, 2013

    This is an interesting topic and I would suggest that anyone venturing one way or another to do some critical thinking. Place the literature aside for a second. We know of many condyl positions and occlusals schemes advocated by many diffiretn gurus. The one assumption I have to make is that these techniques must work resonably well in that practiioners hands or not even an idiot would continue to do the same thing to help their sore patients. We need to accept placing the condylm more forward may be a reasonable thing for one practitioner and placing it in a relaxed CR may be reasonable for another person. Why would two competent people do different things to achieve the same result. A happy patient in the end.
    The issue I have is that one treatment nearly always ends up with a plan for a boat load of crowns as the initial phase of treatment. I did have the pleasure of working near an LVI for awhile. He or she is now gone. I saw some of the treatment plans and requested the records. Now one thing for sure the NM should take pride in their records. Miticulous openings excursions first contacts etc. and detailed quesionaire. With the patient in the chair I asked her how long she had her headaches. She said she didnt have headaches. hmmm. Then I asked her about her muscle pain. Again maybe some soreness once in awhile but nothing worth talking about. Had she had advice on some nsaid treaments or as a very smart poster before said give it time. Not really was her answer. So a very detailed inaccurate patient interview. Apparently we are so good sometimes we know patients are sore and they don’s.
    My point is yes the researchers are biased and so are we. I phoned the doc and talked about the headaches and muscle pain. What was the answer……she just doesnt know she has them.
    So 28 crowns which the patient didnt do. So now I am biased.
    To everyone, I have a couple decades under my belt. What do you think is happening in my office? Crowns and teeth snapping off every second patient? Shoot get rid of the interferences.
    just try non invasive, you will be surprised how patients heal.
    Colin Hughes

    1. Andrea Stevens March 25, 2013

      For all the commenters talking about how “NM treatment ALWAYS ends up in 28 crowns”…I beg to differ. Over a period of about 8 years I have been treating several dozen NM patients, and I would tell you that 28 crowns is not the only option for many patients. The large majority of MY patients are having conservative orthodontic treatment as their second phase of treatment. Many of these cases are finished for several years now and are remaining completely stable. I will also tell you that this rings true for many of my NM colleagues.

      And for those patients who would benefit from a reconstruction…the patients whose anterior teeth are 6 or 7 mm long, multiple root canals, abfractions, what would you suggest as treatment for these patients? What is left to adjust? Maybe just extract all the teeth and make dentures? At what vertical, the same 10mm the patient is before the extractions?

      I do believe that different modalities work in the hands of different practitioners, and this is what is working in my hands. What works in your hands may be different. Mostly what I see and hear are the practitioners bashing NM techniques have “heard” from someone else, or known an “NM dentist down the road” who “overtreated.” I also “know” and have seen patients of prosthodontists and other very experienced clinicians who really feel they are doing their best for their patients, but the cases are still failing. There will always be less-skilled clinicians, on any side of the occlusion fence…don’t blame the technique unless you are fully educated in it.

  21. Clayton Chan, D.D.S. March 27, 2013

    Dr. Henderson,
    Respectfully, EMG technology, computerized mandibular scanning (CMS), ESG technology just monitors, records and measures physiologic response, function and positioning. They don’t have an awareness of a particular philosophy or bias slant one way or the other toward “NM” or “CR” or whatever ones occlusal belief.

    Years ago, I was super skeptical about all these technologies. I am personally a very analytical person (one who questions just about anything until I find a logical and reasonable answer to clinical dentistry) and I am not so easy to be swayed by what others may say even if they don’t fully understand what these technologies are about. I rather investigate and discover for myself first hand and test things out myself in a complete and honest manner to find out for myself rather than take things second and third hand from others when it comes to clinical treatment, effectiveness of a particular tool, method or approach to dentistry.

    I am very aware of all the criticisms, false and misleading denigrating remarks/statements that get passed around over these passed 13 or so years as if I am to believe these individuals who choose to write these false statements as experts on NM and measuring technologies. I am very familiar with these technologies over these past 17 years. I am a trained gnathologist, (a former die hard in centric relation who practiced and treated with fully adjustable articulation- face bow instrumentation) as well as a fully trained laboratory technician and graduate of the Dental Technology Institute. Like others I question everything still to this day. I question even those who are making the critical statements on this blog….why because the mis-informed remarks others make don’t make a lot of sense to me.

    The reason I use these technologies in my practice is to find a better way than what we were taught in dental school. I want precision, accuracy; resolution and I don’t like wasting time with my patients, especially with those cases that present as complex TMD pain cases and rehabs that may have to be done over. I also treat in a very conservative manner. I don’t practice my dentistry or make my living just with a high speed hand piece, because I recognize there is more than one way to resolve muscle dysfunction problems, pain and joint derangement problems. But from my personal clinical use of these technologies in my practice I find them useful, diagnostic and it has saved me and my patients a lot of time, expense and most of all the information gleaned from the data recorded has significantly changed how I practice, make clinical decision (diagnosis) and how I treatment plan and carry out my dentistry. It has improved the quality of both my patients and my life totally.

    1) I don’t guess any more when I need to find a patient’s bite when it is required to work beyond the accommodated MIP or habitual CO bite position, e.g. when doing dentures, orthodontics, prosthetic/complex restorative.
    2) I find this technology very accurate and precise (of course dentist need to get trained and learn how to properly use it and interpret their data).
    3) It saves me time and gives me the confidence to know whether a case should be equilibrated (bite adjusted) or not.
    4) It helps me know when I need to add up on the bite and when I need to grind away if I do. It helps me know when the mandible should come forward, go back, be moved slightly to the left or right or whether the maxilla is retrognathic or prognathic.

    By the way, using these technologies sure has saved my patients from having me grind away a lot of enamel and dentin (How? Because I measured first before subjectively guessing how much to remove). I also practice orthodontics and I can find a physiologic jaw relationship for my debilitated occlusally compromised cases without having to prep down and place a full mouth of porcelain, neither do I have to manually manipulate someone’s jaws in a laying down position…..not like what some have been saying NM is about (It’s been many years now realizing that I haven’t had to touch someone’s mandible to take a bite registration – it’s really nice to know that AP relationship relative to habitual CO within 0.1-0.3 mm as to where is the better bite relationship to avoid all those unnecessary follow up adjustment visits to accommodate that patient to their acquired neuromuscular trajectory). Those who are speaking so adamantly anti NM really don’t know what they are talking about! What they are saying is only a repeat of what someone told them or else saying what they perceived as true without fully learning or understanding what NM technology is really about…and it is not about opening vertical dimensions of a patients bite or prepping 28 units for porcelain, or all about the money, etc. etc. That is not what I practice! I use this technology daily and put it to good use with effectiveness like any cardiologist does when evaluating ECG’s or EKGs to diagnose a myocardial infarction vs use of hand palpations and a stethoscope.

    Regarding Cost: How much do most dentists spend on their golfing, extra-curricular activities, sporting equipment – boats, jet skis, fancy cars, etc.? I am sure it’s a lot more than what some think this equipment costs. Who said this equipment is expensive…., relative to what? Of course, like anything it takes training and learning….and what is wrong with learning how to use EMG, CMS, TENS and ESG technology properly and apply it prudently and judiciously?… (Rather than spreading false and misleading information).
    The small investment I made in this technology and approach (Years ago) and the return on investment it has given me both clinically, intellectually, and the quality of life as a dentist has been way worth it! And it’s not because I prep a lot of teeth to meet monthly goals and production.

    Those that espouse a non-NM approach to dentistry do not understand that this was not a systemic review of the NM literature, but rather a very exclusionary approach to systematically convey on the JCDA site that NM Approach and its use of technology was not effective. This couldn’t be further from the truth and certainly not done my mistake. It was another failed attempt to sound scientific pretending to viewers that it was a legitimate study. Those who studied the details of this CADTH report realize it is not!

    Clayton A. Chan, DDS
    Las Vegas, NV
    http://www.occlusionconnections.com (Read More)

  22. Barry Cooper, DDS April 22, 2013


    April 22, 2013

    I am writing as a Past International President of the International College of Cranio-Mandibular Orthopedics and the author of Temporomandibular Disorders: A Position Paper of the International College of Cranio-Mandibular Orthopedics (ICCMO). J Craniomandib Practice. July 2011, 29(3): 237-244. I write as a practicing clinician, researcher, author and educator. I presently hold the academic post of Clinical Professor, Division of Translational Oral Biology, State University of New York, Stony Brook, NY.
    I am contacting you in response to the CADTH Rapid Response Report on Neuromuscular Diagnosis and Treatments: a Review of the clinical evidence report published January 11, 2013, which was re-published on-line by the Journal of the Canadian Dental Association, CDA Clinical Q&A March 11, 2013.
    This Rapid Reply Report represented itself as a limited literature search, which not only cited but discussed the ICCMO Position Paper that I authored (reference #4), but disallowed one of my published research studies: Cooper BC and Kleinberg I. Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients (reference #9). The article was rejected by the CADTH reviewers as were numerous others, based on the absence of randomization, and comparisons with control population treated by other means such as placebo, behavior therapy, physical therapy, occlusal modification based on both mandibular rest position identified and recorded using conventional methods, surgery, medications, etc. It must be noted that in a clinical practice, these other parallel treatments cannot be provided by an ethical dentist. Patients need experience-based proven successful treatment, not experimentation.
    CADTH performed a literature search of the English language journals published between January 1, 2007 and December 4, 2012 and identified 596 articles for review. After excluding 567 studies because they did not meet the selection criteria, a reference list of 29 studies was developed. Fourteen of the 29 studies were subsequently excluded and a total of fifteen studies were considered for the final review. The field of neuromuscular occlusion and its successful application in clinical dentistry and in research has been published in many scientific journals including non-English journals for decades; therefore limitation of this literature search to six years and only in English journals was incomplete. I have carefully reviewed the 15 articles selected by the CADTH reviewers and will discuss my observations noting the inaccurate conclusions of the reviewers.
    Regarding the Efficacy of Electromyography as an Aid in the Diagnosis of TMD
    CADTH report concluded that twelve of the fifteen studies on electromyography 1, 15-25 that investigated “the diagnostic values of electromyography” showed “electromyography produced a wide range and inconsistent values of specificity and sensitivity that prevent its adoption as a diagnostic test for TMD.”
    While sensitivity and specificity are important in their application to the determination of the effectiveness of some diagnostic procedures for certain disease states, they are not appropriate in the evaluation of the diagnostic and therapeutic procedures used in the treatment of temporomandibular disorders. TMD is a collective term, representing a group of multi-etiological and multifaceted disorders. No single diagnostic device or procedure can be applied thereto. Neuromuscular dentists are not using the EMG device as a stand-alone definitive diagnostic device that rules in or rules out TMD. An attempt by the authors of this Rapid Response to apply sensitivity and specificity criteria in the selection (inclusion/exclusion) and evaluation of published articles on TMD management is not appropriate. It demonstrates at best either a lack of understanding of the subject and what they are reviewing or at worst an ulterior motive “guided” by those who have been overt antagonists of the neuromuscular dental philosophy for decades. In fact, 8 of the 12 selected EMG studies 1, 17, 19-20, 22-25 had concluded that EMG was an effective aid to the dentist in reaching his/her diagnosis of TMD. As for the remaining four EMG studies, one EMG study 21 is irrelevant (muscle fatigue was studied but rest EMG and maximal EMG activation patterns, considered significant by neuromuscular dentists, were not studied. EMG study 18 was inconclusive (found significant difference between the control and patient group in rest EMG but not in maximal activity) and EMG Studies 15, 16 incorrectly rejected the use of EMG based on the application of sensitivity and specificity parameters.

    Regarding the Efficacy of Electrical Stimulators for TMD Treatment
    CADTH identifies two studies 26, 27 that evaluated “the efficacy of TMD treatment based on the [application of] electrical stimulation”. The reviewers reached the following conclusion from the review of Jadadi et al.’s study 27 “Results from the randomized-controlled trial showed that the use of contingent electrical stimulation was not different from the use of placebo in changing the clinical outcome or the electromyographic evaluation.”

    This conclusion is completely misleading. Jadadi’s study 27 objective was to investigate the effect of contingent electrical stimulation “on jaw muscle activity during sleep” and whether the application of “an electrical pulse train” upon detection of clenching/grinding reduced the number of episodes per hour of clenching/grinding in a group of TMD patients with bruxism. The results showed that the TMD/bruxism group that received the electrical stimulation had far fewer episodes of clenching/grinding per hour versus the placebo group.

    This study did not investigate the effect of TENS as used in the treatment of TMD patients. To conclude that “electrical stimulation was not different from the use of placebo in changing the clinical outcome”, in the context of the reviewers objective for this report, is misrepresenting the study design and the conclusions documented by the authors and is evidence of the reviewers’ agenda. Further, this study used an “electrical pulse train” which is a completely different modality than the ultra low frequency TENS device used in neuromuscular dental treatment. Additionally, application of the electrical stimulation to the patient during sleep is contrary to how a neuromuscular dentist applies the TENS to a patient in a seated upright position in the dental office.

    As to Monaco et al.’s study 26, the second study on the efficacy TMD treatment with muscle stimulation, the reviewers concluded “The non-randomized trial reported contradictory results between the electromyographic and kinesiographic evaluations.” The reviewers have included the above ambiguous statement and have misquoted the conclusions reached by the authors. This study’s authors concluded that after the application of the Myomonitor TENS “one-way analysis of variance revealed that SEMG values of masticatory muscles of both sides in the TENS group were significantly reduced, in comparison to the placebo and control groups.” Further, they stated that “the vertical component of the inter-occlusal distance was significantly increased”. However, the CADTH reviewers concluded in error that this study “reported contradictory results between the electromyographic and kinesiographic evaluations” because the study did not report on the change “for the anterior/posterior index or the ratio of anterior/posterior indices”. Table 2 of the study (P. 466) indeed includes data on these two parameters.

    In summary, of the two studies identified by the reviewers on the effect of electrical stimulation in the treatment of TMD, one was irrelevant and the second study by Monaco et al, a placebo-controlled study, strongly supported the efficacy of TENS in reducing muscle tension and increasing vertical inter-occlusal distance. Therefore, the statement in the Key Findings section of the report that “The use of electrical stimulation for the treatment of TMD is not supported by the current evidence” is false and contrary to the clinical evidence reported and documented in the Monaco et al.’s study. Even though Jadadi et al.’s study was irrelevant, its conclusions are contrary to the reviewers’ statements in the Key Findings and the Conclusions sections of the report.

    Regarding the use of occlusal splints prepared with EMG values for Treatment of TMD

    The reviewers concluded that “the use of occlusal splints prepared with EMG values reduced TMD pain; however, this result should be interpreted in light of the fact that it was obtained from uncontrolled trial, and the magnitude of pain reduction was not reported.” Of the total of 596 articles that were identified by the CADTH reviewers, only one article was selected (Silva, et al. 28) to assess the efficacy of “occlusal splints prepared using the EMG values as a reference of ideal occlusion”. Silva et al.’s study had a control group of asymptomatic subjects and concluded that “the use of the splint promoted balance of the EMG activities during its use, relieving symptoms. EMG parameters identified neuromuscular imbalance, and allowed an objective analysis of different phases of TMD treatment, differentiating individuals with TMD from the asymptomatic subjects”. Despite the authors’ clear conclusions regarding the efficacy of EMG derived occlusal splint treatment, the CADTH reviewers made this statement in the Key Findings section of the report: “No conclusions can be made on the efficacy of the occlusal splint on the neuromuscular occlusion concept”, presumably because this study, the only study identified by the reviewers that met their own selection inclusion criteria and which strongly supported the use of an EMG derived occlusal splint, did not use another “therapeutic modality” to treat a controlled group of patients. Again the study I conducted on 313 patients (reference #9), which was excluded by the CADTH reviewers, documented a significant beneficial therapeutic effect of TENS on lowering resting electrical activity and on the use of neuromuscular orthoses in the long term reduction of subjective symptoms and improvement in physiological parameters related to mandibular and masticatory muscle resting and functional activity.

    In summary, the statement that appears under the heading Key Findings of the CADTH report as follows:
    The available evidence does not support the use of electromyography as a diagnostic test for temporomandibular disorder. The use of electrical stimulation for the treatment of TMD is not supported by the current evidence. No conclusions can be made on the efficacy of occlusal splint based on the neuromuscular occlusion concept.

    These findings cannot be supported by the reported clinical evidence and the authors’ conclusions of the cited studies.”

    While I understand CADTH’s confidentiality regarding the committee authors of this report, I submit that it does raise the question of the qualifications of the committee and the objectivity of the person (s) who wrote the Conclusions and the Key Findings sections of the report.
    Without going further into the misguided application of “science” in this report, I offer CADTH my expertise to provide future consultations regarding temporomandibular disorder therapies along with your other consultants. Hopefully, my input to CADTH and that of other experienced clinicians can provide a more balanced and objective report on the diagnosis and treatment of TMD dysfunction, certainly the goal of publications of CADTH to its lay and professional readership.
    Failure to correct the grossly inaccurate information contained in the CADTH report and its unfounded and misleading conclusions has the potential, in fact, the certain result, of severely harming clinicians and patients in Canada, and elsewhere. Knowledgeable clinicians are aware of the extreme lengths to which a group of anti-neuromuscular/anti measurement instrumentation individuals have gone, for over two decades in order to impose their self-appointed “standard of care”. Given this history, the JCDA, at a minimum, has the ethical responsibility to disclose the names of all individuals engaged in authoring, endorsing, and approving the publication of this flawed report. This is an opportunity for JCDA and those involved in this report to engage in a discussion of the merits of the CADTH report and to correct it as they find necessary to maintain the integrity of the science and clinical knowledge in this field. I await your response.

  23. I have just seen this forum for the first time tonight. I will make a more complete reply in the future when time permits. I do think that it is important to note that neurouscular dentistry is a treatment concept. The diagnosis is not made solely from EMG or MKG but rather in combination with history, physical exam and subjective and objective findings. The gist of the anti-neuromuscular opinions is that objective findings are not relative to a diagnostic protocol. Evaluation of EMG and MKG is obviously suitable for research as is study of jaw movement and muscle function. There is no question that it supplies accurate objective diagnostic findings. It is obvious that the opposition to this technology has to do with the treatment protocols that neuromuscular dentists utilize. The first step of treatment is the Diagnostic neuromuscular orthotic. This is where objective findings are utilized to create a “physiologic” position that must successfully relieve subjective patient symptoms.

    I have been utilizing neuromuscular techniques for over 30 years. Chicago HMO was a large medical HMO that sent me all of their TMD patients who were recomended joint surgery in a 3 state area of Illinois, Wisconsin and Indiana for many years and paid my full fee for several years even though non-surgical treatment of TMD was specifically excluded from coverage. Chicago HMO did this because we showed them that we could reduce total medical expenditures through neuromuscular treatment. The medical director Dr Mitchell Trubitt told me we saved the insurance company a$250,000 on the first six patients who avoided TM Joint surgery. They were bought out by United Health Care who did not cover surgery and therefore said they would have no savings. This was a pennywise and pound fullish approch as evidenced by Shimshak.

    The articles by Shimshak published in Cranio Journal showed that patients who carried TMJ diagnosis had a 200-300% increase in medical costs (in all medical specialties except obstetrics) compared to non-TMJ patients. This research was done by looking at medical claims by a statitician.

    Neuromuscular Dentistry allows for physiologic treatment of a host of TMD problems including but not limited to internal derangements including disc displacement, complete of partial, problems with the articular surfaces of the temporal or mandibular bones, problems with the surface slickness or joint lubrication, problems that involve disc, capsule and lateral pterygoid muscles, extracapsular problems including postural and stomatognathic musculature. The diagnosis of these problems is made using diagnostic data icluding radiographs, which also cannot diagnose TMD. Does that mean we should abandon radiographs?

    I apologize for any gramatical errors or typos but having quickly scanned this discussion I felt obliged to make an immediate gut response. This is a discussion about money, but not just the money that can be made by individual dentists, but also the massive cash accumulated by consultants that deny claims, and those who profit from denying care to patients.

    I would like to submit for review my article on neuromuscular dentistry (http://www.sleepandhealth.com/neuromuscular-dentistry)

  24. Doug Chase April 24, 2013

    I would like to state that the unknown authors of the : Rapid Response Report as a literature review under the title of Neuromuscular Occlusion for Diagnosis and Treatment of Temporomandibular Joint Disorders: A review of the Clinical Evidence on 1/11/ 2013. provided a limited “selected ” 15 studies from over hundreds. The intent appears to promote conclusions from misinterpreted data by the authors to the use of data gathering instruments used by clinical dentists over many decades. The large number of articles internationally that support alternative care were ignored.

    The “study” smacks of politics and hidden agendas of those wanting a more “pure” view of their clinical care and to limit in the future other proven options. This is evident in not knowing the authors and their ignoring of decades of care and studies showing positive results with neuromuscular occlusion practice. I hope there is some review on how such publications are reviewed. Science needs to know not only what is said but by who so that a dialog can start.

  25. Dr. Tammarie Heit May 1, 2013

    When trying to develop policy, it is hoped that our CDA exercises common sense and considers the many neuromuscular dentists that create the orthotic using EMGs and TENs to help their patients with craniomandibular disorder.

    Consider the recent case in Alberta Sparrowhawk vs Zapoltinski filed January 13, 2012 in the Court of Queens Bench Alberta: The Honourable Madam Justice D.L. Shelley preferred the expert testimony from Dr. Martyn Thomas, a neuromuscular dentist, which helped decide in favor of the motorist whose TMJs were injured in a motor vehicle accident. Not only was the diagnostic and treatment process using neuromuscular dentistry compared and debated in detail by two experts-one neuromuscular and one using traditional TMD treatment methods, the law was ultimately changed to the benefit of the patient.
    A precedent is now set for Albertans that TMJ disorder is no longer considered a minor injury when it comes to the legalities of motor vehicle accidents. This is a HUGE deal in legal circles. It benefits all our chronic pain patients and should be celebrated by all dentists that help patients with TMD.

    All dentists that take care of chronic pain patients with TMD should be recognized-no matter what method they use to help their patient. It is a difficult task and those that take it on are very dedicated to the health and welfare of their patients. Let’s work together on this. The most important thing is the patient and their informed consent. A patient has a choice as to which doctor they go to and what treatment they accept.
    It is well documented and duly noted in the conclusion of the CADTH report that orthotics made with TENs and using EMG’s reduce people’s pain. It is simple: The laws of optimal anatomy prepare the body for optimal physiology. Just as x-rays allow us to look at bones, EMGs allow us to look at muscle. These two things work together. The clinical evidence reported in hundreds of case studies and series in the literature reflects this basic concept and the physics of the human body which is common knowledge in medicine. The ‘uncontrolled trial’ argument should be resolved with a controlled trial. Why not fund a big study to answer your questions, Canadian Dental Association? Universities? Do you guys want to know why there are so many dentists using EMGs and TENs and why they continue to do so for the past 40 years? Maybe it is successful. We should be searching for the answers as to why it is so successful.
    The problem just might be an ethical one-how does one treat someone with pain to a non-physiologic jaw position? Or not treat them at all?

    There are thousands of dentists practicing neuromuscular dentistry worldwide benefitting tens of thousands of patients. The International College of Cranio-Mandibular Orthopedics has been going strong since it’s inception in 1979 by Dr. Bernard Jankleson. Numerous court decisions have been won on the grounds of measureable evidence using neuromuscular dentistry.

    As a general dentist, I have a choice to help my patients the best way I know how. As a vigorous student of continuing education and research along with a multidisciplinary approach to help solve whatever the patient presents with, my general dentistry practice has evolved into over 80% TMD patients. It is because of the success of the neuromuscular approach I chose to engage the use of biomedical instrumentation and conebeam computerized technology as two very important tools in my diagnostic regime that my practice has developed it’s referral base. The diagnostic forces of this wonderful technology is very powerful and is being used by many non-neuromuscular dentists as well. I am blessed with referrals from other patients, general dentists and specialists both locally and internationally as well as general medical doctors and specialists in neurology. It can be a difficult task at times as the patients coming to my practice can be very complex ranging from clicking jaw joints to completely missing condyles, surgical cripples to people treated every which way to people never treated at all. It has been a huge practice management evolution. The approach is custom to the patient voiced desires, systematic and with measurable evidence before and after treatment so they can know their result.
    If the neuromuscular approach to diagnosis seems like a good idea to a patient with chronic TMD pain or makes sense to someone who wants to prevent the development of a TM disorder when considering major treatment such as orthodontics, then it is a match for a neuromuscular dentist.
    If not, and if some patients prefer the traditional ways of dealing with TMD then I am pleased to refer them to one of my esteemed colleagues who practices a different approach. It is about patient and doctor choice. Professionals are both ethical and respectful of their colleagues and patients. Our job is to inform patients of their condition and all their options along with risks and benefits.
    Just as I am uncomfortable with prescribing medications in the realm of medical specialists along with their side effects, other dentists might be uncomfortable with EMGs and TENs. We still must let our patients know of the other ways they can be treated.

    It is the choice of the patient and our hands must not be tied. We should be supported.

    This recent article has ‘put off’ many dentists because it is not transparent, appears biased and is inflammatory with how it is written. It is ‘rushed’ which make it seem scandalous. Some dentists on the blog are wondering if they can disassociate themselves from the Canadian Dental Association because of the ethics in question. Many of us wonder just who our representatives really are, where they came from and what sort of dental interests they have.

    Rather than promote one group’s agenda, why not spend the government money on a large, blinded study with controls using thousands of people available with TMD that looks for the answers to these burning questions. I, for one, would be a willing neuromuscular participant in such a study. This is more the way of our medical colleagues, is more scientific and brings us back to the basics.

    All successful treatments for the TMDs should be taught and researched in dental school. It is well established in the literature that orthotics made with EMGs and TENs are successful. This should be taught and researched in dental schools, too. This is how our profession advances. Only then will we be true ‘doctors of the mouth’.

    Dr. Tammarie Heit (DDS, MICCMO)
    Canadian Regent for The International College for Cranio-Mandibular Orthopedics

  26. Tammarie May 2, 2013

    The image I submitted is very big and it is my hope that you are able to make it small and in the upper left corner like my colleagues.
    Thank you kindly

  27. fred stange dds May 9, 2013

    I would like to comment on the article I read published by the Canadian Agency for Drugs and Technologies in Health.
    I am quite surprised after reading the article that your conclusion has been one that has a negative view of Neuromuscular Dentistry. Firstly because your own disclaimer says this: “Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed.”
    The body of evidence that you reviewed started with 596 articles, the final review utilized only 15 of those articles. I would say this is less than representative of the 30 plus years that such literature would span. To state that you have only reviewed a section of such a complicated yet intensely studied clinical situation is surprising to me. I did think more of the Canadian medical system than such shortsightedness.
    Secondly I myself am both a clinician and a patient of the Neuromuscular theory. I have many patients that I have helped out of a painful state using the Neuromuscular instrumentation. I have patients who were unstable and in pain brought to a comfortable place of stability. I have a patient who was deaf in one ear brought back to where she could and can STILL hear out of the affected ear. This patient had neurologists and ENT’s all point her to TMJ/TMD specialists, only I the neuromuscular dentist could help.

    I find it interesting that this article is without a specific author. I wonder if that author be examined if he or she would be found not to believe the neuromuscular theory in general. As I stated I myself am a patient and will tell you that no one person could “assume to subjectively find” the center of my TMJ system. As a matter of fact THAT theory is what put me into a place of pain to begin with.
    I believe that until enough time can be placed into a REAL review of literature or a REAL study and not some ad-hoc quick review of 6 papers that such a statement “that prevent its adoption as a diagnostic test for TMD” should be reserved for a clinician who has themself used the instrumentation and actually understands what results they are actually interpreting.

  28. Hayley Donovan May 21, 2013

    Awesome post. I really learned a lot from it. Thanks for sharing. Keep it up.

  29. I’m a Canadian dental consumer who personally suffered because of biased agendas of “experts” such as Dr. Greene who continue their political propoganda to blame TMD primarily on psychological illness, and deny that any form of muscular or dental treatments influence TMD.

    I find it interesting that given the supposedly high statistics of TMD in the general population, not a single one of these “experts” in the countless research articles and studies and literature reviewed, has ever mentioned personally experiencing any TMD symptoms themselves, or within their families or circle of friends. Are all of these “experts” and their families somehow immune to what is supposedly such a common condition among the general population? I don’t think so. What I think is that these “experts” know how to take care of their own and they see to it that their personal dental needs are very properly met in order to avoid developing TMD in the first place (excluding disease or trauma induced TMD such as MVA).

    If I’m correct, then what could be their motive for biased studies denying the association between TMD and occlusion? What are they afraid of? Consider this. Now that it seems approximately half the children in North America are or have been in braces, and for the past ten years or so orthodontics has been heavily promoted for adults as well, could the real reason for this denial be the increase in, or fear of dramatic increase in malpractice lawsuits for TMD being caused by sloppy specialists providing improper orthodontics, prosthodontics, oral surgery, or improperly devised splints?

    Twenty to thirty years ago, the dental industry began promoting revision of the occlusal and facial development of children as young as six or seven. If according to their current statistics that a large portion of our population now experiences TMD, I have to wonder what percentage of the population they studied had orthodontics 20 – 30 years ago?

    Every profession including the dental specialties, contains a mix of excellent, mediocre, and substandard practitioners. The way I see it, the only protection for this extremely lucrative industry where half of its client base are children being brought in by their parents for elective cosmetic procedures to improve their self esteem, is for “experts” such as Dr. Greene et al to publish studies denying that any association between TMD and occlusion exists. Imagine the legal repercussions and financial fallout on this very profitable industry if it was admitted that orthodontics improperly done could permanently injure your child, or if you learned that your TMD was caused by orthodontics you had 20 years ago? The famous Michigan orthodontic malpractice case in the late 80’s was a wake up call to the industry and you can be sure they sure don’t want an escalation of that circumstance in this day and age where having orthodontics is almost as common as brushing your teeth!

    As there are both good and bad dentists, not all splints are made equal. Just ask anyone who’s worn a bad splint and then received a proper one! A properly designed TMD splint that provides harmonious balance between the teeth, muscles, and joints can almost instantly and very dramatically improve your life and health, and no psychotherapy required!

    How easy it is to put out these biased “scientific” studies in order to label TMD patients as being primarily psychologically ill, and sluff them off to the shrink rather than acknowledging some accountability and taking the time to correct what is almost always a physical problem related to a dysfunctional stomatognathic system.

    I would suggest that in the interests of “evidence based” dentistry, Dr. Greene and his supporters should submit themselves and their families for a first-hand TMD study where for three or four months their occlusions would be altered by wearing an improperly designed splint, or by uneven bonded equilibrations of their teeth. Then when their headaches and myofascial pain are to the degree that they can hardly think or function or sleep, and their discs become displaced and it hurts them to eat, they should get psychotherapy and antidepressant medication to see if it helps. Only then will they perhaps admit that occlusion and TMD are related, and that for the majority of people the muscles, joints and teeth must be physiologically harmonious.

    Thank you to Dr. Chan, Dr. Cooper, Dr. Heit, and the other neuromuscular dentists who posted. Why do think this massive campaign of biased studies by Dr. Greene et al continues while common sense and countless relieved patients are discounted? I think they are terrified of neuromuscular dentistry because you are not only taking away business from other dental specialties, you are also “fixing” many of the people they have injured. It’s all about the money and liability. The general public is surely counting on you because it appears that few others are looking out for our best interests, including the Canadian Dental Association.

    1. Colette Boileau June 14, 2013

      I am very disappointed in my Association for publishing this anonymous report which is plagued with inaccuracies and gives dentists who do not see past the blatant biases the message that neuromuscular dentistry’s instruments do not work. It is tantamount to telling dentists that an apex locator does not measure pain related to pulpal necrosis. It lacks specificity and sensitivity, yet it is helpful when performing a root canal treatment. The K7 is not meant to measure pain, nor is it meant to diagnose TMD. It is simply another tool in our belt. Many dentists and more importantly many patients have been helped by the neuromuscular approach. Of that you can be sure.
      The CDA must find a more efficient and effective way of serving it’s membership. I, for one, will be reluctant to take the time to access further articles posted on this website. What would be the point?

  30. Current methods for treating TMJ and other types of head pain are frequently unsuccessful. Failure is to be expected until dentists correct their approach to treatment. The jaws can be viewed as part of an intelligent machine designed to break down food into a form suitable for digestion. Assuming (1) that something happens that causes head pain or a TMJ problem and (2) that the occlusion is in some way causing the problem to happen, the dentist must study the patient as they perform acts like chewing and swallowing when the teeth are in contact.

    After identifying the cause of the problem, the dentist must establish an occlusion that will enable the patient’s CNS to use the jaws to prepare food in a way that will not cause problems.

    As we all know, dentists never study patients during mastication to find out how it is affecting oral health. The three main reasons are:
    (1) They have never been told to do it and it has probably has never occurred to them to do it
    (2) They have no idea how to do it and would not know how to interpret any observations they made.
    (3) They have no idea what the characteristics of the occlusion should be.

    Learning how to study patients as they are chewing and how to interpret the findings is not simple. I was able to do it because a number of unusual things occurred. However when I finally was able to do it it usually enabled me to figure out what was causing the problem and what needed to be done to eliminate it. This of course did not mean that I could always do what needed to be done. The capability to study patients during mastication enabled me to do many other things that previously were not possible.

    1. Anonymous May 19, 2019

      Dr J. Longhorns, Thank you for posting and sharing your thoughtful and clinically relevant insights. As a retired and experienced periodontist what you have pointed out has tremendous meaning and significance to the next generation of dentists who and definitely relevant to day!

      To confirm and support your thoughts there have been some in the community of dentistry who have done due diligence measuring and quantifying our patients healthy chewing patterns vs unhealthy, aberrant swallow patterns vs healthy normal swallows, what is functionally normal jaw movement and recruitment patterns vs unhealthy dysfunction. All of these mentioned things you have also mentioned, seen and observed should be acknowledged in the everyday dental practice, but as you are aware have not been…. thus the periodontal restorative and implant prosthetic failures we have seen today.

      The great thing all in our profession can be excited about is that there are tools and technology that can confirm with accuracy and precision these diagnostic facts. If more leaders in our profession would acknowledge the inevitable credibility of hard facts and legitimate position computerized jaw tracking, electromyography science has provided to dentistry the patients and dental profession would greatly be enhanced to another level of sound and conservative diagnosis for effective treatment- health and stability for our patients.

      Today measuring technology like Myotronics K7 allows a dentist to further confirm and quantify how we in our profession defines healthy occlusal stability from unhealthy occlusal dysfunction. But dentist need to come to terms and accept the fact they cannot avoid progress has been made amongst those in the profession who continue to shine the light on what is and what has been proven clinically relevant.

      Thank you for your words of inspiration!

      Clayton A Chan, DDS

  31. When I read the comments of different contributors to this discussion One thing that struck me is the passionate desire of clinicians to help their patients.It is this that moved me an old retired periodontist to try to contribute some information that I feel might help.
    The last third of my contribution was not presented. This was probably because the monitor of the site felt it should not be published and so l would like to thank them for removing it.
    I would like to now tell you what l did that l feel qualified me to contribute. My thesis project as a postgraduate periodontal student was to measure the distance between the position of the jaws when the mouth was closed and the most retruded position of the jaw that I could achieve by forcibly retruding the jaw of dental students. The device I designed, built and used was fastened to the teeth and gave me measurements accurate to about a two-hundredth of a mm. Besides giving me an average overall figure, I was struck by the large range of values that I obtained. These values did not change when l repeated the procedure on successive days. This made me wonder what was causing the differences. l applied for a grant of about 80 dollars to cover the cost of an apparatus that l could make and use to answer this question. This request was rejected because by this time l was a periodontist and a part-time instructor in the periodontics department. I therefore decided to fund the study personally. Three Years later, I had what I believed was the answer. Since I do not know how long comments like I am making can be I will stop now .
    Next week I will tell you what I Learned and start to describe some of the other relevant experiments I performed and what they taught me.


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