Neuromuscular Occlusion
A
Pioneer Against Pain
by William G. Dickerson, DDS
Through a series of questions and answers, a
practitioner with expertise in neuromuscular occlusion explains why this
field contains information every dentist should know something about.
In an effort to inspire
dentists not to give up hope and to try to achieve the success they have
always wanted, I have been asked to do a series of interviews with
successful individuals. The goal is to give some insight into the thinking
of those who have persevered and find out how and why they are successful.
This interview is with Dr. James F. Garry, a general dentist practicing in
Fullerton, Calif.
Dr. Dickerson: How did you develop a
practice that is so different from the average practice? Why did you do it
and have you found it difficult?
Dr. Garry: The difficulty in developing a
practice that is so different from the average is the unjust criticism by
fellow colleagues with little or no clinical experience in the application
of the technology. However, I can honestly say that my difficulties have
been minimal compared to the tremendous clinical success I have had in
treating symptomatic and asymptomatic patients to an optimal neuromuscular
position. My practice has exploded with patients in pain from all over the
world - patients who have been treated unsuccessfully for orofacial pain,
or who have had full-mouth reconstruction that has failed.
Dr. Dickerson: I'm sure you had no idea what
you were getting into when you went in this direction. What has been the
most surprising thing in your professional journey?
Dr. Garry: First, learning that I could
document optimal craniomandibular relationships utilizing biomedical
electronic instrumentation. Imagine having the ability to relax muscles of
mastication, verify relaxation with electromyographic recordings, and
record, with precision, the physiologic rest position from which occlusion
can be established along a myotrajectory path of closure 1 to 1.5 mm from
physiologic rest.
Second, the rapidity of pain resolution and
the stability of occlusion.
Third, the resolution of medical symptoms
that are not recognized by most dentists as often arising from a
craniomandibular disorder, such as otalgia, subjective hearing loss,
fullness in the ear, retro-orbital pain, vertigo, tinnitus, cervicalgia,
migraine-type headaches, tearing of the ears, etc. When medical treatment
for these symptoms has failed, neuromuscular alignment of the mandible to
the cranium is often successful.
Dr. Dickerson: Who or what has been the most
inspirational in your professional career?
Dr. Garry: The most inspirational colleague
I have ever had the honor of knowing was Dr. Bernard Jankelson. He is the
father of neuromuscular dentistry, as well as a teacher, inventor, and
practitioner of prosthodontics. He pioneered computerized diagnostics as
an aid in the diagnosis and treatment of craniomandibular disorders. He
taught me that if you could measure it, it is a fact, and, if you can't
measure it, it is an opinion.
He stood alone among his fellow colleagues
for years, professing the need for dentists to become physiologists of the
head and neck. He utilized surface electromyographic recordings (sEMG) to
document muscle activity at rest and in function; utilized
ultra-low-frequency TENS to facilitate relaxation of all masticatory
muscles; developed jaw tracking instrumentation to measure, analyze, and
display mandibular movement in multiple dimensions; and developed
sonography to record joint sounds. These are the same technologies used
for comparable purposes in medical diagnosis and treatment. The
measurement devices have the ADA scientific council seal of acceptance and
FDA regulatory clearance.
Dr. Dickerson: Did you immediately use
neuromuscular techniques when you began your clinical practice?
Dr. Garry: When I graduated from the
University of Southern California in 1954, there was no neuromuscular
technology. In fact, computers had not been invented. I was taught to push
the mandible to the most retruded position from which unstrained lateral
movement could be made. This propelled me into pedodontics for 20 years to
avoid retruding the mandible. Twenty-seven years ago, my sister developed
severe head and neck pain resulting from equilibration of her teeth by a
good friend of mine, and was treated with several splints. His inability
to relieve her pain forced me to seek another mode of treatment.
This changed my life.
I met Dr. Jankelson, who insisted I take his
course on neuromuscular occlusion. I told him that I was a pedodontist and
had no need to learn neuromuscular dentistry. He asked me if I wanted to
be a "mechanic" or a "physiologist of the head and neck" for the rest of
my life. What could I say? So my staff and I sat through one week of the
most exciting, informative dental course I had ever taken. Thirty dentists
and their staff members were in attendance; 15 of those dentists had
severe TMJ pain and had been treated previously without success. Dr.
Jankelson smiled and said, "I will have each of you out of pain by the end
of this week." I thought to myself, "I'm in another voodoo course!"
Dr. Jankelson performed a comprehensive
history, evaluated radiographs supplied by the dentists present, and
proceeded to use biomedical technology as an aid to his diagnosis and
treatment. By the end of the week, every dentist treated was asymptomatic,
as Dr. Jankelson had promised. So, 27 years ago, I went from a pedodontist
to a general practitioner with an expertise in neuromuscular occlusion. My
bonus was that I had my sister asymptomatic within 24 hours.
Dr. Dickerson: Many conventional
occlusionists believe that you cannot open the vertical of a patient. Some
have stated that, when restoring to the proper vertical by opening the
existing bite, it will always return to its original vertical. I know you
have been doing this for a very long time. Is that a problem with these
cases that require opening the vertical?
Dr. Garry: It is extremely important to
understand that patients continually lose vertical over the years as a
result of attrition. Many adversaries state that vertical dimension should
never be altered. I have more than 4,000 patients over a period of 27
years whom I have increased vertical to a neuromuscular position and, to
my knowledge as of this interview, have not had a single relapse. To the
delight of my patients, the cosmetic improvement is immediate.
The neuromuscular dentist uses known
physiologic phenomena to better deliver an occlusal result that is
optimally synergistic for teeth, TMJs, and masticatory muscles.
Masticatory muscle activity is recorded by sEMG prior to relaxation.
Relaxation is achieved utilizing ultra-low-frequency stimulation and
verified by sEMG. Relaxation and decompression are elemental to all
therapeutic paradigms for treatment of the musculoskeletal system.
Dr. Dickerson: Since the physiological rest
position is the ideal place to start a restorative process, what is the
best way to determine that position, in your opinion?
Dr. Garry: The best way to establish a
physiological rest position is to relax the muscles of mastication with
ultra-low-frequency TENS, verify relaxation with sEMG recordings, and
electronically track the change of mandibular posture from a pathologic
position to a physiologic rest position. This position is repeatable and
consistent. Dr.
Dickerson: So, once the physiological rest position is acquired, how does
the dentist determine where the occlusion should be built?
Dr. Garry: As I stated earlier in this
interview, occlusion should be built 1 to 1.5 mm from the physiologic rest
position along the myotrajectory. The myotrajectory is established by
pulsing a patient with a low-frequency TENS unit from physiologic rest
position upward 1 to 1.5 mm. The TENS unit has two purposes - to relax the
entire masticatory musculature verified by sEMG and to propel the mandible
through space along a myotrajectory path.
Dr. Dickerson: What do you say to those who
are absolutely sure the bimanual-manipulation technique of CR position is
the right position? Can you say that about myocentric?
Dr. Garry: To those dentists who employ
bimanual manipulation to establish CR, I plead with you to verify what
happens to masticatory muscles with sEMG recordings. You must not induce
muscle tension when manipulating the mandible. Remember that a pathologic
position does not always result in clinical TMJ symptoms. We can be in an
accommodative pathologic position without clinical symptoms.
A few years ago, I was lecturing at White
Memorial Hospital in Los Angeles and made the statement that 80 percent of
all head and neck pain was muscular. At the end of my lecture, an elderly,
short woman came to the podium and stated that she had enjoyed my lecture;
however, my percentage of muscle pain was not correct and stated that it
should be at least 90 percent. I asked her if she was a physician and she
confirmed that she was. I asked her what her name was and she smiled and
said, "My name is Janet Travell." I told her if I had known she was in the
audience, I would have acknowledged her as she has been my idol since I
read her textbook titled "Myofascial Pain and Dysfunction - The Trigger
Point Manual." She was President Kennedy's personal physician and an
adorable human being. We became close friends over the years and shared
our experiences.
I tell you this relationship so you can understand why I am vehement on
documentation. Know what you are doing to muscles when you manipulate the
mandible. Don't leave a patient in an accommodative pathologic position.
Dr. Dickerson: If you could give advice to a
young dentist starting out on his or her journey, knowing what you know
after all these years of practice, what would it be?
Dr. Garry: Don't be satisfied with the
status quo. Continue to improve your clinical skills. Investigate new
technologies, and don't condemn modalities that are unfamiliar to you.
Dentistry can be exciting and rewarding. I have been in dentistry for 50
years; I entered USC in 1950 and I am still practicing full-time.
Dentistry is my hobby; make it your hobby. Why should you or I retire?
Dr. Dickerson: Thank you for your insights
on this controversial subject. I appreciate you not ever giving up against
all that was stacked against you. Nothing has excited me in dentistry, not
even esthetics, as much as neuromuscular dentistry. It has changed my life
and the lives of hundreds of dentists who have come through our occlusion
programs. Thanks for being one of the great pioneers in this area.
This article originally appeared in Dental Economics April, 2001
Author(s) : William Dickerson
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