you wake up...
...do you feel fabulous?
Dr. James P. Boyd, developer of the first medical device to be cleared by the FDA for both the prevention of medically diagnosed migraine pain and TMJ Syndrome, discusses the most important and most over-looked aspect of the diagnosis of chronic migraine and TMJ symdrome (TMD).
When you wake up, do
you feel fabulous?
Their "morning headaches" are
somehow manageable, and therefore in their mind, not
worthy of including in their complaints to their
health care provider. Unfortunately,
unless this critical component of their condition is
acknowledged and resolved, effective prevention and
management of their chronic headache and jaw
condition is unlikely.
Many have seen plenty of
doctors for their headaches or TMD problem.
The headache doctors asked specific questions
regarding the degree of pain that alters their
normal function like, "When do you get your worst
headaches...", and "What makes your headache
worse?", or "How many times per week/month do you
have a migraine?". Rarely, if
ever, is a chronic headache sufferer asked, "Exactly
when DON'T you have any degree of headache,
even the slightest?".
A trek from dentist to dentist
results in numerous explanations as to why they're
miserable, each with their own passionate treatment
plan (but no guarantees) as they've been told
they're "one of the more difficult cases out
there". Most commonly, the sufferer is told
that they have "a bad bite", or a
"malocclusion". If only the patient's
occlusion were as the practitioner deemed
appropriate could the patient experience relief.
The biggest obstacle in
successful management of a TMD (temporomandibular
disorder) is the lack of a complete
diagnosis. Too often, a patient is told they
have a "malocclusion", with treatment consisting of
a certain type of splint (or orthodontic treatment),
so that their "misalignment" can be corrected.
In order to understand the implication of what
"malocclusion" is, one must fully understand
dentistry's concept of occlusion.
OCCLUSION vs. OCCLUDING
Consider the definition of
dentistry. What is it that a dentist is
responsible for? Obviously the health of the
teeth, gums and the bone that support the
teeth. He's also aware of how the teeth
function during mastication, that is, chewing.
Each tooth has individual responsibilities.
The front incisors cut through food, the canine
teeth can grab and tear, and the molars crush
things. The teeth are shaped and
designed to contact and chew food. It's amazing how
accommodating people can be less than a full set of
When the jaws are pressed
together, the alignment of contacts of the opposing
teeth is called the occluding scheme, or the
"occlusion". During chewing (their purposeful
function) teeth may glance off each other but never
stay "in occlusion" for more that a fraction of a
One of the biggest concerns of
dentistry is the presence of a "malocclusion".
The hypothesis is that if the teeth are not aligned
against each other in an optimal manner, then
problems may arise. Here's the big problem
with that. There has not been one scientific
study to show that malocclusion can cause
symptoms. Researchers would have to be able to
assemble hundreds of people with varying occlusions
and be able to determine who was be symptomatic without
interviewing them. It's just not
possible. We've all seen people with crooked,
misaligned teeth, yet they may be completely pain
free, and those with beautifully aligned teeth who
are absolutely miserable. The variable isn't
the patients occlusion, it's the degree of their
Dr. Boyd on dentistry's assumptions of occlusion:
Dr. Boyd's insight on the muscular nature of occluding:
Teeth are not supposed to be
"in occlusion" for more than a fraction of a second
to begin with. Once the teeth come together,
there are four variables that can determine whether
or not signs and symptoms arise: Frequency
(how often the person occludes their
teeth); Duration (the length of
time their teeth remain occluding); Intensity
(the force of the muscle contractions; and Position
(the relationship of the lower jaw to the upper jaw,
that is, centered, out forward, off to one side).
The most important of those
four variable is INTENSITY and POSITION. It
doesn't matter very much if one hardly ever occludes
their teeth (low frequency), or if they do, it's not
for very long (short duration). If, however,
the intensity is significant and/or the lower jaw is
off to one side during the occluding, then
considerable signs and symptoms may arise (for
example, jaw clenching off to one side can cause
and/or perpetuate considerable TMJ pain).
Clenching vs. Grinding
Dr. Boyd: Insight on the variability of bruxism:
|As you might have
seen in the above video, there is that difficult
presentation where the patient suffers from both
headache/migraine and TMD/jaw-joint pain, with only a
moderate degree of tooth wear. It's no
coincidence that chronic headache/migraine and TMDs
are closely related, as they are controlled by the
same cranial nerve...
RELATING MIGRAINE AND JAW CLENCHING
Here's an analogy:
Imagine a woman coming home from a hard day at work,
where for several days, she's been assigned
difficult, stressful tasks. These tasks are not
abnormal to her, but their length and intensity are
more than "normal". She does not address or
consider the effect they might be having on
her. She comes home and discovers her checking
account is overdrawn and the plumbing is backed
up. She enters the kitchen and is asked by her
children, "Where's dinner?"
For any normal person, being
asked, "Where's dinner?" would not illicit an
intensely stern and aggressive reply. Only if
you understood what she's been going through would
you understand why she "snaps" with a stern,
aggressive, irritated response. Her response
isn't caused by any abnormal circumstance,
but by an excessive degree of normal
So how does this relate to the
occurance of chronic headache/migraine pain and
jaw-clenching? Both migraine and jaw disorders
are considered disorders of the Trigeminal
nerve system. The Trigeminal gets it
name from its three sensory divisions that bring
information to the brain; from the scalp, the
face/sinuses, and jaw. Neurologists who treat
migraine are concerned with the first two divisions,
which bring in information (sensations) from the
scalp/forehead and sinuses. The current
hypothesis in the cause of chronic migraine is that
there must be some kind of negative (or "noxious")
information coming in from these two divisions, such
that the system becomes fatigued or irritable, thus
becoming susceptible to a "trigger" which launches a
painful attack along those same sensory nerves.
By the way, that's the
hypothesis of Botox for prevention of chronic
migraine. By injecting Botox into certain
nerve endings of the scalp, neck and shoulders that
deliver information to the brain, the Botox will
reduce the information flow, thereby reducing the
But what of the remaining third
division of the Trigeminal? The third
division, the mandibular (jaw) has two
roles. Not only does it receive sensory
information from everything in your mouth and
delivers it to the brain, it carries "motor"
information from the brain to the muscles of
chewing, and most importantly for our concerns, the
large clenching muscles that cover the temples (the
Now consider our analogy woman
again, but this time, everything at her work is
great. In fact, everything in her life is
wonderful: work, home, finances, social
life...except for her chronic headaches and
migraines. Every night, without her or her
husband's knowledge, she clenches her jaw while
asleep. Not grinding her teeth, but clenching
her jaw. She therefore is making no
grinding noises and there is no wearing away of her
teeth, or, she's clenching with her jaw over to one
side, causing considerable stain on her jaw joint
(which then becomes painful and/or damaged).
In fact, her teeth are beautiful and her dentist has
assured her that she's not grinding her teeth at
all! However, her jaw clenching muscles have
been working very, very hard. Her teeth are
being compressed and crushed into their own sockets
(her teeth are sometimes sensitive to cold), and her
jaw joints are very sore (they may make clicking
sounds, or lock closed). The sensory component
of the Trigeminal nerve is essentially bombarding
her brain with noxious (negative) input.
So now, not only does her
chronic jaw clenching cause her to wake with a
degree of headache (or stiff/sore neck, shoulders
and/or jaw), she has become far more susceptible or
irratable to her migraine triggers. So how
does one tell if they might be a chronic jaw
The table above is from a 1997
study, "Waking and
sleeping temporalis EMG levels in tension-type
headache patients", where researchers compared temporalis
(clenching) activity during sleep of chronic
tension-headache sufferers to non-headache
controls. Interestingly, researchers ignored the
sleeping data altogether (showing headache patients
clenching 14x more during sleep), and determined that
the slightly elevated recordings of daytime
tension was due to the pain the sufferers were in
and not significant enough to be causative.
There are two simple questions
to ask in an interview of a headache/migraine
patient that tend to identify the probability of
nocturnal jaw clenching.
Question 1: On a scale of 0-10, with 10 being the worst discomfort above the shoulders that you could imagine (includes neck, jaw, sinus, headache or migraine pain), and 0 being no pain at all, how many mornings per week do you wake with a ZERO, that is, you feel fabulous?
That last part needs to be
emphasized. To anyone else, not having pain
upon waking is normal. Sure, you can still
feel tired, but a lack of pain isn't
remarkable to the normal person. For the
chronic headache and migraine pain sufferer, some
degree of pain/discomfort above the shoulders is
normal. For them, having no discomfort at all
would be, well, fabulous. Perhaps
unintentionally, the chronic headache and migraine
pain sufferer avoids that acknowledgement.
So when asked the above question, most chronic migraine sufferers will hesitate with their reply, and then begin to rationalize their answer before they provide it. They'll begin by stating, "Well, when I get my really bad headaches...", or, "Nobody ever really feels fabulous", or some justification as to why it's "within normal limits" for them to have discomfort upon waking. The practitioner must press on, and confirm how many mornings per week that the patient wakes with ZERO pain.
Experienced practitioners will soon find that being completely pain free every morning upon waking is quite rare for the chronic migraine sufferer. The practitioner can remind the sufferer that waking daily with, say, liver pain or kidney pain is certainly not normal, and so it is with chronic headache pain. The most effective migraine prevention treatment plan cannot be provided to its fullest extent if their entire presentation is not understood.
Question 2: On those days that you don't wake with a ZERO (that is, you have "a number"), what's the average "number" that you have?
Now the practitioner will have
a clearer picture of the patient's condition and
likelihood of the presence of nocturnal jaw
clenching. For example, waking 5 days per week
with a level 4 headache, to some chronic sufferers,
is not worthy of reporting. They have
learned that they must deal with their discomfort
and reserve their complaints for the degree of
migraine pain that alters their daily lives.
They are wary of being labeled "drug overuse"
patients, because in some practitioners minds,
constant headache, especially upon waking, could only
be due to medication overuse. Chronic jaw
clenchers will wake "with a number" more times than
not, with the intensity varying, depending on the
intensity of clenching the night before.
Although waking with a 4 to a 6 wouldn't be unusual,
waking with an 8 or 9 does not surprise them
(while waking with 0 would be very
surprising). To them, it's something that
happens, and if they can get on with their day, they
try to ignore it.
The chronic migraine sufferer
may eventually succumb that their worst headaches
and migraine attacks are far more important to try
and manage than their chronic "normal discomfort"
existence. Besides, no one has been able to
diagnose and alleviate their normal discomfort,
anyway. However, to the practitioner,
this information is critical in the assessment of
the cause and/or perpetuation of their patient's
This is not to suggest that
chronic nocturnal masticatory parafunction (i.e.,
intense jaw clenching) is the cause of chronic
headache or migraine pain (while can certainly be
the cause of TMJ pain and damage). On the
contrary, it is better considered as being a primary
complicating factor and/or perpetuating influence on
chronic headache and migraine pain. Better
stated, habitual nocturnal jaw clenching cannot, by
itself, cause chronic headache or migraine pain, but
chronic headache and migraine pain cannot be
completely managed and prevented in
the presence of undiagnosed and uncontrolled
nocturnal jaw clenching. In fact,
without controlling nocturnal jaw clenching,
traditional medical attempts at migraine prevention
may fail altogether.
So how is jaw clenching
controlled? In order for clenching to achieve
pathologic intensities, the back molars and/or
canine (fang) teeth must come into contact with
either each other, or with an object sandwiched
between them. Some people use a common "nightguard"
to protect their teeth from clenching.
Unfortunately for the headache/migraine patient who
clenches, the nightguard allows them to clench more
intensely with it than without it. If the
nightguard is intended to alleviate TMJ problems,
the sufferer's jaw may be shifting to clenching
positions that the practitioner had not anticipated,
thereby not only being unsuccessful, but sometimes
making the condition worse.
NTI therapy uses an NTI device,
which is a far smaller mouthpiece that fits only on
either the upper or lower front teeth. By
preventing the molars (or canines) from engaging
anything, clenching intensity cannot achieve
pathologic levels. At first one might be
concerned that when using an NTI device that their
clenching intensity would damage their front
teeth. However, since the back teeth cannot
touch, clenching intensity remains low and tolerated
by the front incisors.
Following the first month of NTI therapy, the practitioner can re-ask the two questions above. Although the patient might first proclaim, "I'm still having headaches" (as if no improvement had occurred), the practitioner may discover that the patient is now waking less frequently "with a number" and that the level of that number has been reduced. Continually using the two questions above is a handy tool to follow a patient's progress.
By the way, NTI stands for
Nocioceptive Trigeminal Inhibition.
Essentially, the name implies that negative sensory
input (nocioception) to the brain via the trigeminal
nerve is inhibited by the presence of the device
(which prevents high intensity jaw clenching).
How well does it work? In
the clinical trials submitted to the FDA, 82% of
migraine suffers experienced a 77% reduction in
migraine pain events. In 2000, the FDA cleared
the NTI device "For the prevention of TMJ
syndrome", then in 2001, was then cleared "For
the prevention of medically diagnosed migraine
pain". Note that the NTI does "cure" migraine,
it reduces (sometimes to zero) the pain events and
intensity. (In this follow-up
study of patients who's chronic daily
headaches were deemed "severe and disabling", 65%
had a 71% average reduction in their morning
headache days, while 75% reported a significant
improvement in the quality of their lives).
Using an NTI can greatly enhance a sufferer's
on-going migraine prevention therapy. This
study (PO384) showed that adding an NTI to
Depakote (a medication approved by the FDA for
migraine prevention) provides result far superior to
either method alone.
If the NTI is so effective, why
hasn't it been enthusiastically embraced by the
medical community? The problem is the design
of the initialstudy that was submitted to the
FDA. When a drug is tested, it is compared to
a placebo, that is, a similarly shaped sugar
pill. The placebo will always produce the
desired effect to some degree. The goal is to
statistically have the test drug outperform
the placebo. For example, Botox was recently
approved by the FDA for the prevention of chronic
migraine. When compared to the injection of
water (the placebo), Botox patients had 1.5 more
"headache free days" per month. The
advertising doesn't tell you that that means placebo
patients had 16.5 headache days per month while
Botox patients had 15.
Unfortunately, there is nothing can be put into one's mouth that cannot produce sensory information, therefore, the NTI cannot be compared to a placebo mouthpiece. Even with 82% of migrainuers reporting a 77% reduction in their migaines, without "placebo controlled" studies, the efficacy of NTI therapy for migraine prevention is not seen as credible in medicine.-James P. Boyd, DDS
Developer of the NTI therapeutic protocol. (more on Dr. Boyd)
To find a dentist near you who fabricates the NTI in-office, CLICK HERE
Dentists who uses a professional lab to fabricate the NTI device, CLICK HERE
|More from Dr. Boyd on his
background and experience in headache management:
I had been a daily headache sufferer for 12 years, from my senior year in high school in 1977, through 1989, four years out of dental school. Each day I woke with a degree of headache, ranging from a 3 to a 6. For the first few years out of dental school, it was rarely in the low ranges. I consumed nearly a dozen Excedrin tablets per day. Occasionally, it would get out of control, and the nature of the pain would change from squeezing and throbbing to a degree where I was nauseous. Later I leaned those were migraines. (continued below)
|Dr. Boyd on Good Morning
American, September, 2001:
|As an undergraduate
college student, I had been a "TMJ" patient. My
jaw would make loud popping sounds as I chewed, and
occasionally would locked closed upon waking in the
morning. I was treated with a "splint", a horse-shoe
shaped acrylic device that covered my upper
teeth. It seemed to help for a few days, but I
eventually got used to it and my headaches
returned. I learned that if I only used in for a
night or two, then went without it for a night or two,
then back to wearing it, I wasn't as bad.
Three years out of dental school and my head was pounding all day long. The really frustrating part was that my dental practice emphasized "TMJ treatment", yet I was unable to help myself. The splint I had used while in college helped some patients, but many seemed just like me. No matter what I tried, their headache symptoms persisted.
In 1988 I recalled a lecture I had been to a few years prior, given by one of the experts in Temporomandibular Disorders (the proper name for TMJ). He had said that for the patient in "muscular distress" (meaning clenching like crazy), to place an anterior midline mound on the patient's splint (in dentistry, that's called a "deprogrammer"). Allow the patient to become comfortable over a few days, then remove the addition. Practically in desperation, I added a small elevated mound at the front midline of my splint, so that when I closed my mouth, only the edges of my lower front teeth contacted the mound. No other teeth touched anything.
For me, it was nothing short of miraculous. The next day I woke without a headache. Although it creeped back somewhat later in the day, it was nothing like I was used to. The next three days was the same lack of the usual morning headache. Things were going great until the end of the week when I woke with a type of headache that I was completely unfamiliar with. Pain behind my eyes and at the base of my skull. I assumed this was why I had been instructed to remove the mound after a few days...apparently, it would eventually backfire. However, as I assessed myself while biting on the splint, I discovered that my jaw had "learned" to shift forward enough to avoid the mound! I had learned to clench my back teeth by shifting my jaw forward, thereby also changing the presentation of my headache.
So I began my personal education of the variability of jaw clenching activity. It's not the same for everyone. It's as if the jaw clenching activity looks for a way to maintain itself, doing whatever it takes (like moving way off to one side, forwards, backwards, whatever) to accomplish the goal of making the patient miserable. A simple mound on a splint would fail miserably in most sufferers, as their jaw would shift to clench elsewhere, usually making the patient feel worse. So over the years, dentists had already learned that a deprogrammer should not be used for more than a few consecutive nights. No one really knew why, just that the relief just didn't seem to last. But I wasn't just the dentist. I was the patient, so I set about "enhancing" the deprogrammer. The shape of the mound changed, anticipating the extremes of jaw movements, allowing for a continuous midline contact on the lower teeth no matter where the jaw went. As it turned out, the enhanced design was so unique I received several U.S. and International Patents.
Using an NTI device is certainly not without its precautions. Unlike a medication, the efficacy of an NTI device is directly related to the practitioner's ability, knowledge and insight. The jaw clenching activity may alter its patterns, making the patient present as a "new patient" each time they're seen by their dentist, so he has to be on the lookout. The jaw joints are like no other in the human body. Unlike a common hinge joint, the jaw joint allows the lower jaw to move up, down, forwards, backwards, side-to-side. It's actually the jaw muscles that dictate any one position. In some people, after using an NTI device, their jaw musculature's posture changes, after having been chronically tensed for years. Their jaw musculature "normalizes". As the patient's symptoms improve and the jaw muscle tension changes, the relationship between their upper and lower jaw may change, with the patient sometimes noticing a difference in their bite. The majority of the time the change in this small minority of patients is practically unnoticeable. However, there are cases where the change of the jaw's relationship has necessitated the patient to have orthodontics done to regain a bite relationship that is more agreeable to them. These changes occur in the presence of an improvement of symptoms. Although symptom reduction/elimination is the desired outcome, each patient and their practitioner must weigh their risks vs. benefits. In this published study of 90,720 NTI devices delivered, only 1.6% of the practitioners reported undesired changes in their patient's bite.