Dr Tuckers Self Help Guide to the Diagnosis

Dr. Tucker’s Self Help Guide to the Diagnosis & Treatment of Temporomandibular Disorders Jeffrey Tucker, DC, DACRB 11600 Wilshire Blvd. #412 Los Angeles, CA 90025 310 -473 -2911 www. Dr. Jeffrey. Tucker. Metaehealth. com 1

WHAT YOU CAN LEARN IN THIS SELF GUIDE: • • To identify problems of craniomandibular function and appropriate self care. To determine if your jaw muscles are overactive and learn a corrective exercise treatment. To screen yourself for problems related to activity limitations with chewing, swallowing, speaking, respiration, and emotional expression. Learn specific nutritional recommendations. www. Dr. Jeffrey. Tucker. Metaehealth. com 2

DIAGNOSIS of Temporomandibular Disorders (TMD) TMD is a collective term for a broad range of disorders displaying a variety of signs – radiating pain in the face, neck, or shoulders; limited movement or locking of the jaw; painful clicking or grating when opening or closing the mouth; and a significant change in the way the upper and lower teeth fit together. Other common symptoms include headaches, earaches, dizziness, hearing problems, and difficulty swallowing. www. Dr. Jeffrey. Tucker. Metaehealth. com 3

The Jaw Symptom Questionnaire consists of the following questions: q q q q Does it hurt when you open wide to yawn? Does it hurt when you chew or use the jaws? Does it hurt when you’re not chewing or using the jaws? Is your pain worse upon waking? Do you have pain in front of the ear, or earaches? Do you have jaw muscle or cheek pain? Do you have pain in the temples? Do you have pain or soreness in the teeth? Do your jaws make noise so that it bothers you or others? Do you find it difficult to open your mouth wide? Does your jaw ever get stuck/lock as you open it? Does your jaw ever lock open so that you cannot close it? Is your bite uncomfortable? www. Dr. Jeffrey. Tucker. Metaehealth. com 4

Jaw Symptom Questionnaire • In my experience if a patient answers more than three of the above questions they will benefit by education, an antiinflammatory home care program including dietary changes, nutritional supplements, heat or ice applications, avoidance of mechanically stressful activities, and resting the jaw (practice the “lips apart and jaws relaxed” procedure). www. Dr. Jeffrey. Tucker. Metaehealth. com 5

“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache? ” Your Dentist can evaluate if you have the following: • Disorders of the teeth Atypical Odontalgia Silent draining abscess • Oral lesions Carcinomas of the oral cavity • Vascular lesions (see specific nutrition recommendations next slide) Temporal arteritis Facial migraine www. Dr. Jeffrey. Tucker. Metaehealth. com 6

General Nutrition for TM Disorders • EC Matrixx™ is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix. • Chondro-Relief Intensive Care — 3 -6 capsules daily with food. Joint & soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and ASU. • Inflavonoid Intensive Care — 3 -9 tablets daily with meals. For relief of minor pain. • E-Complex 1: 1 — 2 -4 softgels daily. 1: 1 ratio of alpha and gamma tocopheryls. www. Dr. Jeffrey. Tucker. Metaehealth. com 7

“Do I have a disorder of the mouth, face or Temporo- mandibular joints manifesting as neck pain or headache? ” • • Your Dentist can evaluate if you have the following: Disorders of the teeth Atypical Odontalgia Silent draining abscess Oral lesions Carcinomas of the oral cavity Vascular lesions (see specific nutrition recommendations next slide) • Temporal arteritis • Facial migraine www. Dr. Jeffrey. Tucker. Metaehealth. com 8

Headache: Vascular / Migraine Nutrition • In conjunction with Ultra. Inflam. X • NOTE: in all forms of headaches, sensitivities to certain food or environmental factors can be a significant entity to address. If determined to be, add to the outlined protocols Perimine. www. Dr. Jeffrey. Tucker. Metaehealth. com 9

Headache: Vascular / Migraine requires nutrition for Inflammation Management: Cleanse, Repair& Put Out the Fire • • A natural strategy should attempt to support the production of substances in the body that protect tissue integrity and relieve pain and inflammation. This goal can be achieved by targeted nutritional support: Key anti-inflammatory nutrients, such as: – – – • Potent antioxidant nutrients, such as: – • Magnesium, zinc, and vitamins C, B 3 & B 6 to support healthy essential fatty acid and eicosanoid metabolism Citrus bioflavonoids, such as: – • L-glutamine to protect the integrity of the gastrointestinal mucosa barrier Vitamin B 5 (along with zinc and quercetin) to promote GI healing Rice bran fiber to promote the growth of beneficial GI bacteria; decrease betaglucuronidase, mucinase, and nitroreductase activities; and increase bile excretion Eicosanoid-balancing nutrients, such as: – • Mixed carotenoids, zinc, manganese, selenium, rutin, rosemary, and vitamins A, C & E to reduce free radical generation GI-supportive nutrients, such as: – – – • Ginger to inhibit pro-inflammatory prostaglandin and leukotriene production Turmeric to scavenge nitric oxide production and inhibit pro-inflammatory prostaglandin production Quercetin to inhibit lipoxygenase, tumor necrosis factor alpha, and nitric oxide Hesperidin to inhibit arachidonic acid metabolism and histamine release, thus resulting in analgesic and anti -inflammatory activities Detoxifying nutrients, such as: – – N-acetylcysteine and sodium sulfate to promote sulfation in phase II detoxification activities (often compromised in inflammatory conditions) Limonene to induce glutathione conjugation and glucuronidation – 2 scoops of Ultra. Inflam. X includes all of the above. www. Dr. Jeffrey. Tucker. Metaehealth. com 10

Headache: Vascular / Migraine Nutrition • In conjunction with Ultra. Inflam. X • NOTE: in all forms of headaches, sensitivities to certain food or environmental factors can be a significant entity to address. If determined to be, add to the outlined protocols Perimine. www. Dr. Jeffrey. Tucker. Metaehealth. com 11

Migraine Headache: Preventive Maintenance supplements • Trancor — 4 capsules daily. Helps balance between the calming influence of GABA and the excitatory effects of glutamate. • Somnolin — 4 capsules daily (2 in the AM and 2 in the PM). After headaches are under control for 4 -6 weeks decrease by 1 pill per week until lowest dose is found that maintains the patient symptoms. Features a complementary blend of 5 -HTP, theanine, and targeted B vitamins. • EPA-DHA Extra Strength — 2 softgels 2 -3 times daily with meals. Essential fatty acids from cold water fish. Natural antiinflammatory documented to benefit migraine sufferers. www. Dr. Jeffrey. Tucker. Metaehealth. com 12

Migraine Headache At Onset: • Trancor™ - 4 capsules daily. Trancor is formulated to support a sense of tranquility in those who may feel worried or nervous by beneficially modulating the balance between the calming influence of GABA and the excitatory effects of glutamate. www. Dr. Jeffrey. Tucker. Metaehealth. com 13

“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache? ” Your Dentist or Chiropractor can evaluate you for the following: • Neurological lesions Atypical facial pain Typical trigeminal neuralgia Atypical trigeminal neuralgia Pre-trigeminal neuralgia Tic douloureux See specific nutritional recommendations next slide www. Dr. Jeffrey. Tucker. Meta 14 ehealth. com

Specific nutritional recommendations: Atypical facial pain, Typical trigeminal neuralgia, Atypical trigeminal neuralgia, Pre-trigeminal neuralgia, Tic douloureux • Ceralin Forte® — Three capsules daily. Ceralin Forte is formulated to provide wellrounded support for brain and nerve protection, addressing multiple pathways involved in neurological health. • Wellness Essentials™ For Men/Women formula — 2 packets daily. Key Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition. www. Dr. Jeffrey. Tucker. Metaehealth. com 15

“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as neck pain or headache? ” Your Physician can evaluate you for the following: • Disorders of the eyes Eye strain Acute glaucoma • Disorders of the ears Ear pain (otalgia) (specific nutrition recommendation) www. Dr. Jeffrey. Tucker. Metaehealth. com 16

Ear pain of unknown origin. General Treatment Strategies: • Assume problem has a dietary component until proven otherwise. • Eliminate all dairy products for at least three weeks. • Eliminate refined sugars and “junk food. ” • Address food intolerance (begin with most simple and inexpensive). • eliminate foods that are on the “common offenders” list, or • perform elimination/provocation (E/P) testing • if E/P is unsuccessful you may wish to proceed to serum Ig. G, Ig. E or Ig. M—invasive and costly but very useful. • Eliminate trans fatty acids from diet. • Decrease omega-6 intake while increasing omega-3 intake. • Reduce intake of meat and eggs unless person is malnourished. • Address biomechanical problems with Chiropractor i. e. TM dysfunction. www. Dr. Jeffrey. Tucker. Metaehealth. com 17

“Do I have a disorder of the mouth, face or Temporomandibular joints manifesting as a disorder of the nose and throat? ” § Chronic nasal airway obstruction (CNAO) or § Sinusitis - Signs and Symptoms q Tenderness to palpation, swelling, redness, and opaque transillumination of involved sinuses q Fever, chills: suggest expansion of the infection beyond the sinuses q Nasal congestion and serous or mucopurulent discharge (usually yellow or green) q Malaise q Headache and/or dizziness that changes with position and is worse lying down or bending over q History of upper respiratory infections, dental problems, nasal allergies, or injury to the area q Nasal mucosa is red and swollen, and the exudate may be seen in the turbinates corresponding to the infected sinus(es) www. Dr. Jeffrey. Tucker. Metaehealth. com 18

Sinusitis Acute Nutrition Management • • • Sinuplex - Features a unique, ephedra-free blend of vitamin C, quercetin, nettle root extract, bromelain, and N-acetylcysteine. Supports healthy sinus, nasal, lung, and respiratory function. May help support healthy eicosanoid synthesis. Ingredients are carefully selected and manufactured with advanced processing technologies to preserve the potency and stability of delicate components such as bromelain. NOTE: If patient has a history of antibiotic use, add Ultra. Flora Plus to the protocol. Advanced Probiotic Nutrition with Immunoglobulins www. Dr. Jeffrey. Tucker. Metaehealth. com 19

Chronic Sinus Condition Management • Perimine — 1 -2 tablets twice daily with food. Patented, Flavonoid. Rich Perilla Seed Extract. Perimine features a patented extract of Perilla seed (Perilla frutescens), a unique herb that supports a healthy immune response in individuals who may be sensitive to certain food or environment factors. Dried Perilla seed and leaves have both historical and modern applications in Traditional Chinese Medicine to alleviate chest fullness, support healthy mucus secretion, and promote healthy breathing. • Sinuplex — 2 -4 tablets daily as needed. Healthy sinus and lung support. • Nazanol— 1 -2 tablets 2 -3 times daily (based on severity of condition) on empty stomach. Natural, stimulant-free herbal support for healthy sinus, nasal and lung function. www. Dr. Jeffrey. Tucker. Metaehealth. com 20

“Do I have a disorder of the cervical spine (neck) or headache manifesting as pain in the orofacial or TM apparatus area? ” Ask your Doctor to rule out: • Vascular lesion Carotidynia Thomboangiitis obliterans (Buerger’s disease) • Neurological lesions Neck-tongue syndrome • Arthritic Disease RA, SLE, AS, Psoriatic arthritis (see nutritional recommendations) www. Dr. Jeffrey. Tucker. Metaehealth. com 21

Core Nutritional Support Protocol for RA, SLE, AS, Psoriatic arthritis • Ultra. Inflam. X® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to address underlying inflammation. • Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet • Lacto. Flam. X™ — 1 capsule daily Lacto. Flam. X features L. plantarum 299 V — a strain-identified probiotic that has been specifically shown to support the integrity and healthy function of the muscosal lining. • EPA-DHA 6: 1™ Enteric Coated — 2 softgels three times daily. EPA-DHA 6: 1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions. • Iso D 3™ — 1 tablet three times daily. Vitamin D 3 with Isoflavones. Iso D 3 is designed to support optimal metabolism of vitamin D to its active form. If there is a soy sensitivity use: • D 3 1000™ — 2 microtablets three times daily. High potency vitamin D 3 — the most bioactive form of supplemental vitamin D. www. Dr. Jeffrey. Tucker. Metaehealth. com 22

“I have been diagnosed with a Temporal muscle tendinitis” • • Perform corrective exercise stretches in this presentation. Nutrition: EC Matrixx™ is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix. www. Dr. Jeffrey. Tucker. Metaehealth. com 23

SELF TEST: MANDIBULAR FUNCTION MOVEMENT PATTERN • Seated or standing in front of a mirror. 1. Slowly open & close mandible. 2. Qualification: Pass/fail You fail if your mandible (lower jaw) protrudes on initial phase of opening. Follow the exercises in this presentation. www. Dr. Jeffrey. Tucker. Metaehealth. com 24

Normal Opening Three fingers width www. Dr. Jeffrey. Tucker. Metaehealth. com 25

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General Signs & Symptoms of TMD q Pain on opening q Trismus (limitation of mouth opening) or deviated jaw mobility q Joint noises (clicking, popping, grinding) q Pain on chewing q Tenderness or pain felt in the jaw joint or muscles, or both q Pain felt in the area of the ear, temples, or cheeks q General Signs & Symptoms of TMD, con’t q Ear “fullness” q Subjective hearing loss q Change in occlusion q Abnormal wear of the teeth q Headache (most common presentation are frontotemporal & suboccipital) q Muscle hypertonicity q Hypertrophy of the jaw muscles q Tinnitis q Dizziness q Neck pain q Upper trapezial pain q Upper extremity pain & paresthesia q Difficulty swallowing Steigerwald, D. P. , Whiplash and Temporomandibular Disorders: An Interdisiplinary Approach to Case Management. Keiser Publishing, San Diego, CA. , 1992 www. Dr. Jeffrey. Tucker. Metaehealth. com 27

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Major Categories of TMDS • Muscle Disorders (treat with corrective exercises & nutrition) Muscle pain Protective muscle splinting (trismus, bracing, guarding) Myospasm Myositis Myofascial pain (trigger point activity) Contracture Hypertrophy Dyskinesia (muscle incoordination) Dstonia Bruxism These disorders are treated by a Rehabilitation Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical www. Dr. Jeffrey. Tucker. Meta 29 treatment for the above symptoms. ehealth. com

Nutrition for Muscle Disorders • EC Matrixx™ is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix • Muscle Spasm Remedy is a high quality, handmade homeopathic remedy designed to relieve muscle aches, spasms, or pain. • Chondro Relief Intensive Care — 3 -6 capsules daily with meals. Comprehensive joint & soft tissue support, with MSM, Green Lipped Mussel, Hyaluronic Acid, and ASU. • E-Complex 1: 1 — 1 softgel 2 times daily with food. E Complex-1: 1 is a unique, natural vitamin E supplement that features a 1: 1 ratio of alpha- to gammatocopherol; this ratio more closely resembles the tocopherol profile found naturally in vitamin E-rich plants. • • Avoid caffeine, menthols. Dietary Suggestions: Anti-Inflammatory Diet www. Dr. Jeffrey. Tucker. Metaehealth. com 30

Major Categories of TMDS • Ask your Doctor which Temporomandibular joint disorders do you have: q Disc displacement or internal derangement q Arthralgia q Capsulitis or synovitis q Arthritis disease (systemic) q Degenerative disease (osteoarthritis) q Traumatic articular disease (sprain or strain, fracture) q Disc displacement without reduction (closed lock) q Disc displacement with reduction q Subluxation of the condyle q Dislocation of the condyle These disorders are treated by a Rehabilitation Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less non-surgical treatment for the above symptoms. www. Dr. Jeffrey. Tucker. Metaehealth. com 31

General Nutrition for TM Disorders • EC Matrixx™ is a mechanism-specific formula designed to support healthy connective tissues by supporting the extracellular matrix, a key structural component of connective tissues such as tendons, ligaments, and cartilage. Features berberine and tetrahydro iso-alpha acids (THIAA), which have been shown in laboratory research to influence MMP-13, an enzyme involved in the maintenance of connective tissue structure. THIAA has also been shown to beneficially influence multiple cellular signaling processes related to connective tissue health. Supports biochemical processes that influence the health of the extracellular matrix. • Chondro-Relief Intensive Care — 3 -6 capsules daily with food. Joint & soft tissue support with MSM, Green Lipped Mussel, Hyaluronic Acid and ASU. • Inflavonoid Intensive Care — 3 -9 tablets daily with meals. For relief of minor pain. • E-Complex 1: 1 — 2 -4 softgels daily. 1: 1 ratio of alpha and gamma tocopheryls. www. Dr. Jeffrey. Tucker. Metaehealth. com 32

Major Categories of TMDS: Inflammatory disorders Continuous pain that is increased with function • • Core Nutritional Support Protocol Ultra. Inflam. X® Plus 360 — 2 scoops twice daily. Multi-mechanistic support with key nutrients, phytonutrients, and selective kinase response modulators (SKRMs) to address underlying inflammation. Follow either the Modified Elimination Diet or the Anti-Inflammatory Diet • Kaprex® — 2 tablets twice daily. Non-responders by day 5 move to 3 tablets 2 -3 times daily. Time to benefit: Immediate to 10 days. Kaprex is a clinically tested herbal dietary supplement that provides natural joint relief that is easy on the gastrointestinal (GI) tract. It works by interfering with signals in the body that initiate the production of damaging compounds that cause minor pain and negatively impact cartilage and other joint tissues • • EPA-DHA 6: 1™ Enteric Coated — 2 softgels three times daily. EPA-DHA 6: 1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions. Iso D 3™ — 1 tablet three times daily. Vitamin D 3 with Isoflavones. Iso D 3 is designed to support optimal metabolism of vitamin D to its active form. If there is a soy sensitivity use: D 3 1000™ — 2 microtablets three times daily. High potency vitamin D 3 — the most bioactive form of supplemental vitamin D. www. Dr. Jeffrey. Tucker. Metaehealth. com 33

Anti-Inflammatory Diet www. Dr. Jeffrey. Tucker. Metaehealth. com 34

Major Categories of TMDS • Disorders of mandibular mobility (hyper- or hypo-mobility) Hypermobility Adhesion Ankylosis Coronoid process elongation Fibrosis of muscle (contracture) These disorders are treated by a Rehabilitation Chiropractor or physical therapist. Warm laser, as used by Dr. Tucker is an excellent pain-less nonsurgical treatment for the above symptoms. www. Dr. Jeffrey. Tucker. Metaehealth. com 35

Major Categories of TMDS • Growth disorders Hypoplasias Hyperplasias Neoplasias These conditions require co-management of multiple doctors. www. Dr. Jeffrey. Tucker. Metaehealth. com 36

OROFACIAL DISORDERS FUNCTIONAL ANATOMY Primary Functions of the Masticatory System: Ø Mastication Ø Swallowing Ø Speech Secondary Functions: Ø Respiration Ø Emotional expression www. Dr. Jeffrey. Tucker. Metaehealth. com 37

MANDIBULAR POSTURAL REST POSITION (MPRP) The normal MPRP is in equilibrium between the downward pull of gravity and the myotatic reflex contraction of the mandibular elevators. MPRP depends on muscle tonus of the anterior and posterior cervical muscles, head posture, and the inherent elasticity of muscles. www. Dr. Jeffrey. Tucker. Metaehealth. com 38

MANDIBULAR POSTURAL REST POSITION (MPRP) • Normally there is no occlusal (tooth-to-tooth) contact during MPRP. This interoccclusal space is termed freeway space and is usually 3 -5 mm when measured from MPRP to full occlusal contact. This dimension is increased in mouth breathers and is decreased in people who brux or clench. • Significance of MPRP is that, under normal conditions, it is a time for rest and repair of the TMJ system. • Head posture is probably the single most important factor governing MPRP. A Chiropractor is the most skilled practitioner to evaluate your head posture. www. Dr. Jeffrey. Tucker. Metaehealth. com 39

MANDIBULAR POSTURAL REST POSITION (MPRP) • Significance of MPRP is that, under normal conditions, it is a time for rest and repair of the TMJ system. www. Dr. Jeffrey. Tucker. Metaehealth. com 40

MUSCLES OF MASTICATION • Elevators (jaw closing) of the mandible: (these are commonly overactive) 1. Masseter 2. Medial pterygoid 3. Temporalis muscles www. Dr. Jeffrey. Tucker. Metaehealth. com 41

MUSCLES OF MASTICATION • The posterior fibers of the temporalis can retract the mandible and maintain the condyles posteriorly. The superficial fibers of the masseter protrude the jaw. The deep fibers act as a retruder. The medial pterygoid can protrude and lateral deviate it to the opposite side. www. Dr. Jeffrey. Tucker. Metaehealth. com 42

MUSCLES OF MASTICATION • Depressors (jaw opening) of the mandible: Digastrics • Protrusion (jaw jutting forward) of the mandible: Inferior lateral pterygoid www. Dr. Jeffrey. Tucker. Metaehealth. com 43

MASSETER MUSCLE • Actions: Elevate the mandible and close the jaw. Deep fibers also retrude the mandible. • Synergist: Temporalis, medial pterygoid • Antagonist: Digastric, inferior lateral pterygoid • It is frequently overactive and can become tight. www. Dr. Jeffrey. Tucker. Metaehealth. com 44

Masseter muscle nutrition • Fibroplex® Plus provides targeted nutritional support for soft tissues in those with muscle tenderness and discomfort. Featuring a blend of specific vitamins, minerals, and amino acids in an easy-to-use delivery form, this specialized formula works by supporting cellular energy production and muscular and nervous system function. • Provides targeted nutrition for soft tissue in those with muscle tenderness and discomfort. • Provides targeted support for energy metabolism and neuromuscular function. • Supports cellular energy production and mitochondrial function. www. Dr. Jeffrey. Tucker. Meta 45 • Provides magnesium in the form of an amino acid ehealth. com chelate designed to be easily absorbed

Tinnitis caused by the Masseter Muscle • Unilateral tinnitus may be associated with trigger points in the upper posterior portion of the deep layer of the masseter muscle. Unilateral tinnitus also may arise from TMJ intracapsular disease. If the tinnitus is bilateral, one should suspect a systemic, rather than a myofascial cause (Travell). • Vitamin-deficiency of niacinamide and thiamine may be related to tinnitus. (see next slide for nutrition) www. Dr. Jeffrey. Tucker. Metaehealth. com 46

• • • Tinnitis: Nutrition Appropriate Wellness Essentials™ formula — 1 -2 packets daily. Key Vitamins & Minerals, Essential Fatty Acids, PLUS gender specific nutrition. Co. Q 10 ST 100 — 1 softgel three times daily. Stabilized, Highly Absorbable Coenzyme Q 10 with Natural Vitamin E. According to a German study published in Otolaryngol Head Neck Surg. 2007 Jan; 136(1): 72 -7, “For a Subgroup of people Co. Q 10 may provide relief from the symptoms of tinnitus. ” The test group was administered 100 mg. of Co. Q 10 three times daily for 12 weeks. If a history of antibiotic use: Ultra Flora IB — 1 capsule daily with food. (minimum of 2 bottles). Ultra Flora IB is an enhanced potency probiotic formula designed to help relieve bowel irritation and related functional discomforts by promoting a healthy balance of intestinal microflora. If on prescription diuretics: MG/K Aspartate — 2 tablets daily with food. Magnesium and Potassium combination designed to optimally replace lost potassium levels. www. Dr. Jeffrey. Tucker. Metaehealth. com 47

MASSETER MUSCLE Exercise 1) Passive Mandibular Self-stretch 2) Three-step resistive exercise: 1. resistance held for 10 sec as the patient actively, gently tries to close the mouth while it is held wide open. 1 a. Relax. 2. patient tries to open the mouth as wide as possible with gentle assistance from the hand, slightly increasing the range of motion. 3. active opening effort of the patient is resisted by the hand. Repeat 3 X. The patient then opens and closes the mouth through the maximal active range of motion several times without resistance. www. Dr. Jeffrey. Tucker. Metaehealth. com 48

TEMPORALIS MUSCLE • Actions: Elevation (closure) of the mandible. The posterior fibers, in addition, are important for retrusion and lateral deviation of the mandible to the same side. • Synergists: ipsilateral: masseter, superior lateral pterygoid, medial pterygoid. contralaterally: same plus temporalis. • Antagonist: inferior lateral pterygoid, anterior digastric, omohyoid, mylohyoid. www. Dr. Jeffrey. Tucker. Metaehealth. com 49

TEMPORALIS MUSCLE • Trigger points may be activated: by bruxism & clenching; direct trauma i. e. fall on the head, impact from a ball, auto accident; prolonged jaw immobilization; cervical traction; excessive gum chewing. • Self Treatment: Massage the muscle and rub out the tender points found. www. Dr. Jeffrey. Tucker. Metaehealth. com 50

TEMPORALIS MUSCLE • Usually, about 2 ½ knuckles of jaw opening is reached if the temporalis, but not the masseter, muscle is involved. Masseter tension restricts opening more severely. • Giant Cell Arteritis (Temporal arteritis): headache, fever, consequent blindness, respond to corticosteroid therapy. • Exercise: Mandibular Self-stretch The patient is encouraged to induce a widewww. Dr. Jeffrey. Tucker. Meta 51 ehealth. com open yawn as a regular exercise.

MEDIAL (INTERNAL) PTERYGOID • Actions: Bilaterally, elevates the mandible: Unilaterally, deviates the mandible to the opposite side; it also can assist protrusion. • Symptoms caused by active trigger points are difficulty in swallowing & painful, moderately restricted, jaw opening. Stuffiness of the ear may be a symptom of trigger points. www. Dr. Jeffrey. Tucker. Metaehealth. com 52

MEDIAL (INTERNAL) PTERYGOID • Patient examination usually reveals contralateral deviation of the incisal path as the jaws are opened and closed, with restriction of opening. • Activation: sucking of thumb, excessive gum chewing, occlusal interference, bruxism (lateral grinding of the teeth), clenching, anxiety and emotional tension. www. Dr. Jeffrey. Tucker. Metaehealth. com 53

INFERIOR LATERAL PTERYGOID • Attaches, in front, to the lateral pterygoid plate and, behind, to the neck of the mandible. • Action: Bilateral=its primary role is protrusion (jaw jutting forward) Unilateral=lateral movement to opposite side With depressors=pulls the condylar head forward and down so that the condyle can translate over the posterior surface of the www. Dr. Jeffrey. Tucker. Meta 54 ehealth. com eminence, (essential for full opening)

INFERIOR LATERAL PTERYGOID • Examination: Slight decrease in jaw opening; lateral excursion of the mandible is reduced toward the opposite side, away from the involved muscle; midline incisal path deviates, usually away from the affected side. www. Dr. Jeffrey. Tucker. Metaehealth. com 55

INFERIOR LATERAL PTERYGOID • Lateral pterygoid function is practically eliminated by having the patient slide the tip of the tongue backward along the roof of the mouth to the posterior border of the hard palate, which stops translation of the condyles across the eminentia. If the incisal path straightens out when the mouth is opened in this way, it is chiefly lateral pterygoid dysfunction that is causing the muscular imbalance; if the incisal path still zigzags, other muscles and/or a TMJ derangement are responsible (Travell p. 264) www. Dr. Jeffrey. Tucker. Metaehealth. com 56

INFERIOR LATERAL PTERYGOID Exercise #1 • Both divisions are passively stretched by maximal retrusion of the mandible. Patient supine. Practitioner places his thumbs on the mandible from above; the patient is told to press chin gently forward against his thumbs, while breathing in; the patient then exhales, the Dr. pushes the mandible backwards with the teeth separated by only a few millimeters. Follow this up with full active ROM by maximally protruding & retruding the mandible, without manual resistance. www. Dr. Jeffrey. Tucker. Metaehealth. com 57

INFERIOR LATERAL PTERYGOID Exercise #2 • Rhythmic stabilization self stretch: patient grasping the mandible by the fingers & thumb, inside & outside the mouth, then slowly & smoothly, but firmly, pulling it forward until the muscles feel tight. Alternate, rhythmic protrusion and retrusion efforts by the hand. www. Dr. Jeffrey. Tucker. Metaehealth. com 58

INFERIOR LATERAL PTERYGOID Exercise #3 • Active resistive exercise (strength): patient protrudes the mandible against resistance, and then moves the mandible to each side also against resistance. www. Dr. Jeffrey. Tucker. Metaehealth. com 59

SUPERIOR LATERAL PTERYGOID • Originates from the infratemporal surface of the greater wing of the sphenoid bone and, attaches to the disc and capsule (40 percent) and condyle (60 percent). • Action: Pulls the articular disc forward & checkreins its backward movement, thus assisting mandibular elevation. Overactivity or Tr. P shortening, displaces the articular disc forward & impedes its return to its normal position on closure of www. Dr. Jeffrey. Tucker. Meta 60 the jaws. ehealth. com

SUPERIOIR LATERAL PTERYGOID • Patient examination: slight restriction of jaw opening, a distorted incisal path, and often occlusal abnormality. • Travell “Trigger point’s in this muscle are the chief myofascial source of referred pain felt in the TMJ area. ” P. 260 • Activation of trigger points: Satellites from the SCM (short leg), malocclusion, bruxism, gum chewing, playing an 61 instrument. www. Dr. Jeffrey. Tucker. Metaehealth. com

DIGASTRIC causes difficulty swallowing • Referred pain and tenderness from trigger points in the posterior belly are projected to the upper part of the sternocleidomastoid muscle. • Symptoms include difficulty swallowing. www. Dr. Jeffrey. Tucker. Metaehealth. com 62

DIGASTRIC • Action: Assist depression & retrusion (pulls the mandible back & down). • When the hyoid is fixed by the suprahyoid & infrahyoid muscles, the digastics (left & right) can depress the mandible & bring the teeth apart. • When the mandible is stabilized, the digastric muscles, with the suprahyoid & infrahyoid muscles, elevate the hyoid bone, which is a necessary function for 63 swallowing. www. Dr. Jeffrey. Tucker. Metaehealth. com

DIGASTRIC • Omohyoid & sternothyroid are both muscles involved in proximal stabilization for speaking and swallowing function of the mandible. Zang, B. A. The effect of the occlusal splint on the biomechanics of the cranium, cervical spine, mandible and the hyoid region. Orthodontic Review, Jan/Feb. , 1988. • Synergist: Inferior lateral pterygoid • Exercise: patient should do a self-stretch, jaw protruding passive exercise, lying supine. www. Dr. Jeffrey. Tucker. Metaehealth. com 64

DIGASTRIC SKILL TECHNIQUE • Hyoid restriction is most often associated with unilateral increased tension of the digastrics. This is evaluated by softly shifting the hyoid from side to side. Deviation of the cartilage can usually be seen on the side of increased tension. www. Dr. Jeffrey. Tucker. Metaehealth. com 65

DIGASTRIC SKILL TECHNIQUE • Post-isometric Release (PIR) is performed with the patient supine; one hand of the practitioner resists the opening of the mouth while thumb or finger of the other hand exerts minimal force on the hyoid on the side of increased tension or deviation. The patient is instructed to open their mouth gently, and breath in; to hold their breath, and then to breath out and relax. During relaxation, resistance in the digastrics will give under the practitioner’s thumb. www. Dr. Jeffrey. Tucker. Metaehealth. com 66

A PROPER TM CLINICAL EXAMINATION INCLUDES 1. 2. 3. 4. 5. 6. History ROM Mandibular tracking Auscultation Palpation Provocations (joint/muscle challenges) www. Dr. Jeffrey. Tucker. Metaehealth. com 67

Motor Vehicle Accidents & TMD History Questions 1. Have you noticed any clicking, popping or other noise in the temporomandibular (jaw) joints occurring with mouth movement which have arisen (or have increased) following the accident? Yes___ No___ 2. Since the accident have you noticed any inability to fully open or fully close the mouth without strain/pain? Yes___ No___. 3. Since the accident have you noticed any sense of an altered bite or altered jaw posture or altered jaw function during chewing, speech or other mouth movements? Yes___ No___ 4. Have you noticed any symptoms associated with your ears since the accident, specifically: A sense of diminished hearing Ringing in the ears A sense of pressure in the ears Pain in the ears 5. Since the accident have you experienced headaches, neck or shoulder pain? Yes___ No___ 6. Have you noticed any tendency to clench your teeth since the accident? Yes___ No___ 7. Have you experienced any of these symptoms before the accident? Yes___ No___ If yes, which ones? If yes, when was the last time you had this/these symptom(s) before the accident? If yes, describe the difference, if any, between the symptom before and after the accident? www. Dr. Jeffrey. Tucker. Metaehealth. com 68

TM Diagnostic Aides • Typical arthrogenous (joint) pain improves as the day progresses, especially if the jaw is active. • Masticatory myofascial pain is typically worse upon awakening if bruxism (grinding) is present. However, inflamed joints can be aggravated by bruxism as well and hurt upon awakening as well. www. Dr. Jeffrey. Tucker. Metaehealth. com 69

Whiplash/TMD Unique Factors 1. The onset of local signs and symptoms of TMD may be delayed by weeks to months. 2. Peripheral symptoms of TMJ inflammation such as headaches and neck pain will surface within hours to days. These symptoms may continue to be the dominant complaint indefinitely. www. Dr. Jeffrey. Tucker. Metaehealth. com 70

• • Causes of pain in the Region of the Temporomandibular Joint Differential Diagnosis Inflammation of the preauricular lymph nodes Otitis media or extrena Referred pain from a trigger point Tenosynovitis of the temporalis tendon as it passes behind the zygomatic arch Trigeminal neuralgia Dental caries Bony tumors, both benign & malignant (primary & metastatic) Inflammatory arthritides (i. e. , ankylosing spondylitis, rheumatoid arthritis, juvenile arthrits, psoriatic arthritis, etc. ) www. Dr. Jeffrey. Tucker. Metaehealth. com 71

DR. TUCKER’S INITIAL MANAGEMENT & TREATMENT • I want to reassure you that you can get better and have many treatment options. • Continue to become educated: a) Anti-inflammatory diet is very valuable. b) Self care includes the use of heat or ice. c) Avoid mechanically stressful activities, soft diet, avoid exhaustive chewing (chewing gum, eating caramels, biting a pen or pencil, chewing tough meat, bagels, pizza, cracking nuts or ice with teeth), avoid sleeping on stomach. www. Dr. Jeffrey. Tucker. Metaehealth. com 72

INITIAL MANAGEMENT & TREATMENT • Rest the jaw. That means minimal talking & chewing. • Maintain good posture. Get evaluated by a Chiropractor and learn how to enhance your posture. • Avoid clenching. • Practice the “lips apart & jaws relaxed” procedure. www. Dr. Jeffrey. Tucker. Metaehealth. com 73

INITIAL MANAGEMENT & TREATMENT • Approximately 10 to 30 days are usually required for chiropractic & home therapy to exert some effect. • Pain Control: Meditation, vitamins/herbs, NSAID’s, muscle relaxant, antidepressants. • Physiotherapy: Laser, Stretch-and-spray, ice packs, heat packs, diathermy, EMS, US, anesthetic injections, soft tissue mobilization & manipulation. www. Dr. Jeffrey. Tucker. Metaehealth. com 74

THANK YOU! • I appreciate that we could spend time together. • My email is Dr. JTucker@AOL. com • To order vitamins/minerals please go to my website www. Dr. Jeffrey. Tucker. com and click on the Metagenics link. www. Dr. Jeffrey. Tucker. Metaehealth. com 75