Wednesday, October 21, 2009

Orthotic Managment, Clenching and BNS 40 TENS

Clayton A. Chan, DDS Response

QUESTION:Has anyone had experience with their patients using the BNS-40 at home? I just got one to give to a chronic headache pt for home use. The patient is a 49 yr. old female with a 25 year history of headaches, usually 2-3 per week, and she reports she clenches every night. I made her an orthotic and have done 3 adjustment appts. I am considering having her TENS with the BNS-40 every day for two weeks then run more scans and another adjustment for the orthotic. I'm doing this because therapy with the orthotic has given only slight impovement in her condition. Does anyone have alternate methods/protocols they might offer?



The chronic paining clencher is one of the more challenging type of cases the clinician will face. Although the use of the BNS-40 Myomonitor TENS is known to be an effective means to relax the masticatory muscles the treating clinician must also recognize that there are other factors involved beyond delivering an orthotic and relaxing muscles. The true clencher will usually show hypertrophy of the masseter muscle extra-orally, a well developed dental arch without depression of the Curve of Spee, and an unfaceted dentition with good anatomic morphology.

The reality is that many patients are a combination bruxer-clenchers. The typical bruxer shows a significant faceting and wear of the dentition, bicuspid drop-off with depression of the Curve of Spec, inadequate arch development with lingual inclination of the lower posterior teeth.

Regardless of whether a patient is a clencher or bruxer there exists an heighten noxious proprioceptive input feeding into the CNS-reticular loop, resulting in a greatly accentuated motor hyperactivity. This means that occlusal therapy must be successfully controlled to reduce the noxious influences which in turn reduces the level of bruxing/clenching in most of our patients. The clencher appears to have a more patterned or engrammed central nervous system component to their noxious occlusal habit. Biofeedback is often a helpful adjunct for the chronic clencher.

Here are a few pointers to consider:

  1. Make sure your orthotic is properly designed to accommodate lateral cuspid rise and posterior disclusion.
  2. Anterior contact and posterior disclusion is an absolute requirement for these kind of cases (something most NM teachings overlooked).
  3. Protrusive contacts must be properly balanced.
  4. Retrusive contacts must be balanced, but not eliminated (especially in the supine laying down positions – night time wear).
Bottom line is that proper micro occlusal coronoplasty application must be implemented to get a proper result. The patient must be able to chew and function normally with a properly adjusted orthotic, if not the patient will not be comfortable and wear the appliance. Any interferences during functional jaw movements that remain will trigger unresolved clenching challenges and the patient will not resolve to the next level.
It has been my clinical experience that patients that present as so called “clenchers” will present with:
  1. Anterior open bite tendency – They may appear with normal occlusion with seemingly higher Golden Vertical values in the anterior region, but in reality are previous ortho or post surgical cases.
  2. Arches appear well developed, but don't let that decieve you.
  3. Posterior teeth contact in lateral excursive movements contributing to mandibular jaw torque (culprits to clenching. Relieve posterior interferences, if left the patient will continue to clench).
  4. Inadequate disclusion of the posterior teeth during protrusive movements.
  5. Maxillary arch can be retrognathic relative to an optimized NM position and trajectory when evaluating with K7 Scan 4/5, an optimized TENs bite and or cephalometrics.
Common Clenching Symptoms Relating to the Bite - Dentist Need to Know
The following headaches can and should be resolved by the dentist:
  1. Temporal headaches
  2. Masseter facial pain
  3. Tenderness and pain at the posterior lower border/corner of the jaw.
  4. SCM tenderness
  5. Cervical neck pain and tenderness
  6. Pain in the occipital region
  7. Pain on top of the head
  8. Shoulder pain
  9. Numbness and tingling in the arms, hands and fingers
Note: No matter how long you TENS and how many Myotrodes you place if you don't fix the bite to proper physiologic parameters, the dentist will be confused and will continue to search for the unobvious.
I believe that clenching problems can be resolved with effective a comprehensive craniomandibular cervical structural approach which goes against what most literature and teachers may say, relinguishing this problem to the CNS emotional psychosomatic stressor department rather than acknowledging the physiologic somatopsychic issue.

We know we can help you!
If you have further questions please don't hestitate to contact me at: clayton@claytonchan.com
Clayton A. Chan, D.D.S.

Neuromuscular Dentistry