When 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?

Seems like a silly question, doesn't it?  If I had to boil it down to one concept that has made the NTI therapeutic protocol so successful at migraine and TMD prevention, is the acknowledgement that most chronic sufferers don't (or won't) admit that upon waking in the morning, having some degree of discomfort above their shoulders is completely "normal" for them.  Not just headache or even full blow migraine...it could be the facial/forehead and back-of-the-neck combination pain, sore and stiff jaw, or "sinus" headache.  (TMJ syndrome sufferers typically acknowledge that mornings are not their best).

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. 


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 teeth! 

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 second.

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 occluding.

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   
Once the teeth are occluding, which is made possible by the muscles that can only elevate (close) the jaw, either the elevator muscles maintain the closed jaw and occluding teeth, or they relax and allow the jaw-opening muscles do their job (separate the teeth and lower the jaw).  If the elevator muscles remain contracting, thereby keeping the teeth in occlusion, and then the jaw-openers go to work, a conflict occurs.  There is a jaw-opening muscle (the lateral pterygoid) on both sides of the jaw.  When they work alternately while the jaw is still being closed, grinding of the teeth occurs.  The intensity of the on-going closure dictates the degree of resistance the jaw-opening muscles encounter as the teeth rub/grind across each other.  The more intense the on-going closure, the more pressure and force there is on the teeth during grinding.  Sometimes, the intensity of closure (clenching) can be so great that the jaw-openers cannot move the jaw at all, resulting in an inability to grind the teeth.  This patient's teeth may have no wear on them, as it's grinding that damages/wears the teeth.  The clencher, who can be profoundly symptomatic, my have beautiful and perfectly aligned teeth.  
On the other hand, if the on-going closure is relatively mild, the minimal resistance on the teeth allows for much less effort by the lateral ptergoids, which can result is considerably worn teeth in a person without any pain complaints. 
Unfortunately, the term "bruxism" is used to include both grinding and clenching of the teeth.  However, in the absence of any tooth wear, dentists don't diagnose bruxism, because they don't see evidence of grinding, when it's the degree of clenching that causes the symptoms. 

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...


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 circumstances. 

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 sufferer's "triggerability".

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 temporalis muscles). 

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 clencher?

Tension-type Headache sufferers clench 14x more during sleep that asymptomatic controls.

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 condition.

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

If your dentist is not an NTI provider and is interested in becoming one, he can log-on to:
www.NTIdevices.com and click on Try NTI,
or go to www.KellerLab.com and call to arrange for the first complimentary case.

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.