“Customized mandibular orthotics in the prevention of concussion/mild traumatic brain injury in football players: a preliminary study”

Prof Dave Singh

It’s an American paper, so it refers to American Football, not “soccer”, but it’s interesting nonetheless I think, especially as I make appliances very similar to this for a number of Premiership footballers (soccer players) and the main benefit for them seems to be a reduction in pelvic strain and hamstring injuries.

Here’s the abstract:

Abstract

Background/Aim: It is accepted that sports mouthguards decrease the incidence of dental injuries in athletes, but the value of oral orthotics in the prevention of concussion/mild traumatic brain injuries in footballers remains contentious. However, previous investigations have primarily studied non-customized mouthguards without dental/temporo-mandibular joint examinations of the subjects. Therefore, the aim of this study is to determine whether the use of a customized mandibular orthotic after temporo-mandibular joint assessment reduces the incidence of concussion/mild traumatic brain injuries in high-school football players.

Materials and methods: Using a longitudinal, retrospective design, data were collected from a cohort of football players (n = 28) over three seasons using a questionnaire. The mean age of the sample prior to the use of the customized mandibular orthotic was 17.3 years ± 1.9. Prior to deployment, dental records and temporo-mandibular joint evaluations were undertaken, as well as neurocognitive assessment, including history of concussion/mild traumatic brain injuries. After establishing optimal jaw position, a customized mandibular orthotic was fabricated to the new spatial relations.

Results: The mean age of the sample after three seasons was 19.7 years ± 2.0. Prior to the use of the customized mandibular orthotic, the mean self-reported incidence of concussion/mild traumatic brain injuries was 2.1 ± 1.4 concussive events. After the deployment of the customized mandibular orthotic the number of concussive events fell to 0.11 ± 0.3 with an odds ratio of 38.33 (95% CI 8.2–178.6), P < 0.05.

Conclusion: The preliminary results of this study suggest that a customized mandibular orthotic may decrease the incidence of concussion/mild traumatic brain injuries in high school football athletes, but a comprehensive study is required to confirm these initial findings. Furthermore, additional research is necessary to indicate the possible mode(s) of action of a customized mandibular orthotic in the prevention of concussion/mild traumatic brain injuries.

Link to full paper HERE - you might need to log in or register with Dentinal Tubules to read this.

“Evidenced Based TMD: Paradigms for a New Decade”

http://goo.gl/x4aPm

Programme:
Wednesday February 22, 2012
7:00 – 8:00 AM: Registration and Continental Breakfast
8:00 – 8:20 AM: Opening Ceremony
8:20 – 8:30 AM: Introductions
Panel 1: Orofacial Pain: Mechanisms and Treatment Considerations
8:30 – 9:15 AM: Evidence: What is the Value? – Peter Baragona, DMD
9:15 – 10:00 AM: Orofacial Pain: Looking at the Big Picture – Jeffrey Okeson, DMD
10:00 – 10:30 AM: Break with Exhibitors
10:30 – 11:15 AM: Glia as the “Bad Guys” in Dysregulating Pain & Opioid Actions: Clinical Implications – Linda Watkins, PhD
11:15 AM – 12:00 PM: Psychological Considerations in the Management of TMD: Red Flags – Charles Carlson, PhD
12:00 – 12:15 PM: Morning Panel Discussion
12:15 – 1:30 PM: Lunch
Panel 2: Occlusion, TMJ Imaging, and Arthrocentesis
1:30 – 2:15 PM: Functional Occlusal Assessment: The 3 Ps –John Kois, DDS, MS
2:15 – 3:00 PM: Intracapsular Disorders: Imaging Considerations – Gerhard Undt, DMD, MD
3:00 – 3:30 PM: Break with Exhibitors
3:30 – 4:15 PM: Arthrocentesis: A Technique for the Treatment of Adhesive TMJ Disorders – Steven Shall, DDS and Matthew Lark, DDS
4:15 – 4:45 PM: Afternoon Panel Discussion
6:30 – 8:30 PM: President’s Reception
Thursday February 23, 2012
7:00 – 8:15 AM: Registration and Continental Breakfast
7:15 – 8:15 AM: New Member Breakfast
8:15 – 8:30 AM: Introductions
Panel 3: Sleep and Medical considerations of Orofacial Pain
8:30 – 9:15 AM: The Efficacy of Hard Splint in Treating TMD: Results of a Systematic Review – James Fricton, DDS
9:15 – 10:00 AM: Medical Conditions Posing as TMD – Donald R. Tannenbaum, DDS
10:00 – 10:30 AM: Break with Exhibitors
10:30 – 11:15 AM: Daytime Bruxism and the TMD/OFP Patient – Alan G. Glaros, PhD
11:15 AM – 12:00 PM: Sleep Medicine and The Dentist – Dennis R. Bailey, DDS
12:00 to 12:15 PM: Morning Panel Discussion
12:15 to 1:45 PM: Lunch and AES Membership Meeting
Panel 4: The Restoraive TMD Connection
1:45 – 2:30 PM:
TMD Related Topics – Frank Spear, DDS, MS
2:30 – 3:15 PM: Advanced Implant Reconstruction for the Parafunctional Patient – Ricardo Mitrani, DDS, MSD
3:15 – 3:45 PM: Break with
:45 – 4:30 PM: Is Occlusion Dead or Just Sleeping it Off? , Dr. Jeffrey Rouse
4:30 – 5:00 PM: Afternoon Panel Discussion
5:00 – 5:15 PM: Closing Remarks

There is a discussion of the myths around whether one can or cannot increase or decrease VDO and a very useful chart (Table 2) showing the effect that a change in height at the molars will have on position of the incisors and the incisal pin of the articulator. There are also several very interesting case presentations, including the use of occlusal equilibration alone to close down a significant anterior open bite. Please read the article and comment below if you have any questions of observations.

I might put a few similar cases of my own up if there’s sufficient interest, or if you have some photos and a case report you are prepared to share and have discussed please send them to me and I will publish them on here for you.

Andy

Yorkshire Post article

Please let us know if you have anything planned in your practice for Migraine Awareness Week – seems like a great opportunity to get the message across to the general public.

Fractured teeth and restorations, sensitivity and acute pain, loose teeth, abnormal wear, bone loss. Difficulty chewing, atypical facial pain, TMJ breakdown and the list goes on. There are those (including myself) who believe this condition is directly related to frequent headaches, neck and shoulder pain, tinnitus, vertigo and more. An impressive list of important disorders – and the likely cause of these many problems is…? Of course the answer is occlusion.

This very important subject is rarely, if ever, taught at undergraduate level and yet it underpins the dynamics of many dental problems, as well as perhaps being the prime driver behind a range of medical problems that our medical colleagues frankly don’t have a clue as to how best to manage. Sadly I am consistently astonished at the epidemic of untreated occlusal disease I discover amongst my patients. I am of the firm opinion that there are more than a few within our profession unaware of a problem that affects a substantial proportion of the patient problems they encounter on a daily basis. I find this disturbing and I think it is high time that something was done about it: training on occlusion deserves to be a mandatory area of study. Occlusal disease has a marked detrimental impact on patients and to practice dentistry without a knowledge of occlusion is like driving a car whilst wearing a blindfold. I regard it as appalling that a proper appreciation of occlusion is not a core subject for all dentists, therapists and hygienists.

Dentistry as a profession has moved far away from the days of carpentry and I view myself as an oral physician as much as a surgeon. With the latest technology such as lasers and CADCAM along with a modern proactive evidence based preventive approach to practice there has never been a more interesting time to be a dentist.

The future for dentistry in the UK ought to be very bright, notwithstanding the current difficult financial circumstances we are in one of the few areas in the economy which can confidently predict year on year growth for the foreseeable future. Properly informed patients tend to make good health choices and select according to value rather than price.  Opportunity for growth in private practice is immense and for anyone thinking of leaving the NHS behind them the future looks very bright. Clinical outcome however is key and for that reason such a basic problem as occlusal disease really should be confronted by the profession as a matter of urgency. Now is the time to put our house in order and to lead rather than be led by the lawyers! 

Mark Cronshaw

The UK’s leading dental laser trainer, Mark practises at Amery Dental Practice, Cowes Isle of Wight

https://www.facebook.com/#!/PPDMagazine

http://www.ppdentistry.com/

 Loss of cervical tissue around teeth has been linked to the presence of excessive occlusal loading.

These are known as abfraction lesions, defined as “Loss of tooth structure, usually in a wedge-shaped pattern in the cervical area of the tooth, attributed to flexure and fatigue in an area away from the point of loading (usually cervical).” The true aetiology of these has been called into question, with some recent research purporting to show that a toothbrush and abrasive dentifrice are required for them to develop. 

A case I saw this week seems to contradict such an assertion – this aesthetic case need a little gingival recontouring around the anteriors:

…. so I started to work on the lateral first and look what has appeared! This photo was taken moments after removing the gingival tissue, and it hasn’t been touched by a bur: 

Now, this looks suspiciously like an abfraction lesion to me, and it has has been subjected to significant occlusal loading palatally from a deep overbite Class II div 2 situation for many years. Is this final proof that such things really do exist – it can’t possibly be toothbrush abrasion since this is the first time it’s ever seen the light of day. Any other ideas, or do you think I have found something significant?

https://www.surveymonkey.com/s/CXW9BBR

Should take no more than a few minutes and will help highlight possible need for better support and education in this increasingly important field.

Many thanks.
_________________
Andy Lane

It turns out that Dr Glassman’s interest in the field was first encouraged by attending a Niles Guichet course, just like the majority of lecturers for SDS Occlusion! Interviewed at his specialist clinic in Pennsylvania, Dr. Glassman described how his interest was first aroused in this specific aspect of dentistry.

“Quite early in my career I had an adult female patient suffering upper right bicuspid pain with no obvious odontogenic cause, and which did not respond to orthodox dental procedures, which included endodontic therapy. At about that time I was advised of a course to be taken by Dr. Niles Guichet explaining how occlusal interferences can provoke excessive muscular activity. Our knowledge has moved on since then, but Dr. Guichet’s course confirmed my desire to learn more about the causes and treatment of craniofacial pain, joint dysfunction, chronic pain, headaches, and sleep disordered breathing.”

Despite the increasing understanding within the dental profession of bruxism, sleep apnoea and migraines there is still much to learn, and Dr. Glassman is concerned that these topics are not being adequately covered in dental training. “Although more practitioners are making the connection between bruxism, migraine and joint dysfunction, the mechanics are not understood and nocturnal and diurnal parafunction are often not diagnosed. I feel that dentistry should be the accepted initial gateway for patients with sleep abnormalities, but the current limitations in dental training, allied to the unresolved controversies surrounding occlusion and joint position, as well as a persistent adherence to dogma, are precluding this. Only by investigating new areas will dogma be defeated.”

Dr. Glassman has published many clinical and academic articles, hosts courses and seminars for dentists and has recently won the AACP’s coveted Haden-Stack Award, which is presented annually to the member who is deemed to have made the most significant contribution to advancing the understanding of TMD while promoting the AACP. In demand as a speaker worldwide, Dr. Glassman is not afraid to court controversy by challenging accepted attitudes and treatment practices. “ It is,” he states, “self-evident that many hundreds of patients have improved following considered, conservative dental therapy when other forms of medicine have failed. It is vital to find practitioners with the appropriate skills, not merely the right qualifications. We must also find ways of coordinating care between the healthcare professions in the best interests of the patient, to avoid the present scenario when rivalry between the disciplines, as a consequence of attitudes established during training, leads to a competitive arena with the patient being offered contrasting therapies or opinions.”

“We need to consider and evaluate therapy guidelines for conditions such as TMD and bruxism with an open mind, and not be hidebound by dogma or emotional adherence to a fixed ‘belief system.’ While this is not an exact science, and hard evidence for conclusions is sometimes lacking, we must always depend on science to underpin the therapies we adopt. To successfully treat chronic pain and dysfunction a more flexible model is required. Both we as clinicians, and our patients, expect successful outcomes from dental treatment based wholly on science, but success in this area is less certain. We need to acknowledge our failures as well as our successes, and always accept that whatever we do we cannot improve on or second guess the science involved.”

As one of dentistry’s latter day pioneers, Dr. Glassman’s October lecture will undoubtedly “muddy the waters of truth with the stick of enquiry,” and some attendees are likely to find themselves re-evaluating long established habits of mind. Dr. Glassman himself is keenly anticipating the event. He concluded the interview by stressing the importance of progress and of “facing the truth about occlusion and bruxism and the role of dentistry in sleep medicine.” He complimented S4S for so radically raising the awareness of bruxism and sleep medicine among dentists. “I’m proud to have been invited to launch Bruxism Awareness Week, and London is my favourite city in the world!”

CLICK HERE TO BOOK YOUR PLACE

I’m amazed what a difference having extra knowledge of occlusion has made. I have treated many hundreds of patients since finishing the course but one in particular jumped out at me. The patient in question has had undiagnosed occlusal problems for years. The SDS questionnaire flagged up the problem. Past dental history revealed a bridge which had failed four times in ten years and numerous broken teeth. On examination he has very large bony exostosis, abfractions, Masseteric hypertorphy and classic violin strings through his Temporalis which were excrutiating to touch. Absolute barn door case, straight out of the notes. Amazingly he’s been a patient at the practice for 20 years and it had never been picked up. As you said on the course, you can only see what you know. After a stabilization splint and a decent bridge made in CR he’s got no pain and is pleased as punch with me as a dentist. He is a GMP for a living and values the holistic approach that we’ve taken to his treatment. He has since recommended other patients to the practice.

It frustrates me that there is such a big black whole in undergraduate occlusion teaching. I now don’t like looking at work that I’ve done before the course as I can see my own mistakes even though I considered myself a good dentist. I have older dentists who’ve been qualified for years telling me that occlusion is a waste of time. I truly believe it is not and am very grateful to you and Higgy for changing my career. CM

If you’d like to change your career in a similar way please book on our next POISE course, 12th/13th November 2012 at ACE in Wakefield, you won’t regret it! Call Jemma on 01457 821800 or email: jemma@sds-ipso.com

This prestigious event will be held at the Royal College of Physicians in London on 24th October 2011.
S4S are sponsoring the event and have agreed to provide all our SDS Occlusion Blog subcribers with a special booking package which includes your place at the event and a Kit of 5 NTI splints (worth £105.00) all for a 20% discounted rate of £280.00 (normally £350).
 
To take advantage of this offer book online HERE, select the “special offer booking package”, use discount code “CWK” and mention which kit you would like in the “order notes”.  Alternatively you can call S4S on 0114 250 0176.