I graduated from my orthodontic residency in 1965, 47 years ago, and immediately went into practice in June of that year. By 1967, I had begun to treat temporomandibuar joint (TMJ) patients. A young man approximately 12 or 13 years old, suffering with chronic headaches, repeated absences from school, clicking and locking of his jaw joints, and a myriad of typical TM joint symptoms, came to my office. This was my first TMJ case, and its successful treatment whetted my appetite for these types of patients, which continues to the present day.
Approximately 25 to 30 years ago, I was asked to give a presentation on TMJ problems in children for a dental organization. This was at a time in the development of TMJ thinking where it was thought that TMJ was a middle-aged person’s disease and that there was no such thing as TMJ dysfunction in children. Terms like pediatric headaches had not yet been used. In evenings subsequent to the request to give this presentation, I was viewing the slides of many, many patients whom I had treated, looking for children with TMJ problems. While perusing approximately 400 cases, I noticed in the records and photography that a high percentage of the patients had movement disorders, either too much movement or too little movement. I was not sophisticated enough to know the specific labels that would later be attached to various movement disorders. All I knew then was the generic term, movement disorders, and that by the end of my treatment most of these were totally gone. To this day, one young woman in particular stands out; she was a newly-married 27-year-old who had just bought her first house. She had stated that she and her new husband made the mistake of buying a townhouse because she had to crawl up and down the stairs on her hands and knees and wished that she had bought a one-level ranch style house. I came across this in the notes during my review, and while I did not pay attention to it initially, I noticed in the review of the records that at the end of treatment she could go up and down the stairs normally. This was in addition to having eliminated her facial pain and her limited and deviated mouth opening.
As the years went by, I continued to treat craniofacial pain and TMJ disorders with little thought to movement disorders. My underlying treatment philosophy evolved into the fact that many, but not all, of the movement disorder patients had an underlying internal derangement of the temporomandibular joints or a malrelationship of the mandible to its cranial base, which had not yet resulted in an internal derangement of the TMJs, but had resulted in an abnormal maxillomandibular relationship. It was this internal derangement or malrelationship that caused the movement disorders. I continued to treat patients with this philosophy with great success.
I have difficulty remembering my first Tourette’s patient, but the successful treatment of that patient resulted in word spreading throughout the Tourette's underground, and more Tourette’s patients began to knock on my door. I have enjoyed success, as well as personal satisfaction, in treating these children without having to use medications, behavior modification, etc.
For a century and a half, Tourette’s syndrome has been a mystery to the medical profession, with physicians first believing that it was a psychological disorder, then a neurological brain disorder, and then an infect-ious disease caused by streptococcus.
What was never considered was that this disorder was due to a structural abnormality, which would manifest itself as a neurological problem. What has since been discovered is that Tourette’s syndrome is neither psychological, infectious, genetic, nor environmental in origin, but is what we have termed a structural-reflex disorder. It has been shown in a pilot study1 of multiple cases how and why Tourette’s, and its multiple comorbid disorders, can be discontinued with an intraoral orthotic device that requires no medicine or surgery.
Tourette’s syndrome is defined as an inherited neurological disorder that is a chronic idiopathic syndrome, characterized by the presence of multiple motor tics and vocal tics that have their beginning before adulthood (usually with an onset in childhood between ages 5-8).2-4 Tics are repetitive, stereotypical movements or phonetic events, which are non-rhythmic and involuntary (motor tics), such as blinking, coughing, sniffing, shoulder shrugging, neck stretching, throat clearing, etc.
Diagnosis criteria for Tourette Syndrome (TS) (DSM-IV-TR 307.23)
1. The onset is before 18 years old.
2. The tic is not due to the direct effect of substances (e.g. stimulants) or medical conditions (e.g., Huntington’s disease or Postural Encephalitis).
3. Tics occur multiple times a day for more than one year, and there was not a tic-free period for more than three consecutive months.
4. Both multiple motor and vocal tics are present and are not concurrent.
Tourette’s syndrome was originally thought to be a rare and severely bizarre disorder, most often associated with coprolalia, which occurs in approximately 10% of those with Tourette’s.5 Now T.S. is understood to be less rare and is often classified as a condition having a wide range of severity. It is currently treated with medications that seem to incapacitate the patient or by frequent psychological counseling that teaches behavior modification when a promontory urge is felt immediately prior to the tic(s).
Tourette’s patients seem to have normal intelligence and a normal life expectancy. The most common disability is within a social setting, and those with T.S. find it embarrassing when severe movements or vocalizations occur.6 People with Tourette’s can achieve success in all walks of life, from athletics to professional careers. Prejudice or ostracizing is very common at school or at work.7-9
In February of this year, Dr. Anthony Sims and I made a presentation explaining my technique to the Board of Directors of the National Tourette’s Associ-ation in New York City. We were well-received. They were interested because of the many phone calls received from parents of patients asking why they were still being treated with medications and/or psychological counseling when they had personally experienced the results of my treatment techniques. These calls originated not only from the United States, but also from Europe as a result of my having lectured there. The Tourette’s Association of America is currently in the process of formulating grant proposals to test my methodology, which will probably be funded in the near future.
As word of my treatment successes spread, other people approached me with different types of movement disorders. These were older patients, many of whom had been diagnosed with Parkinson’s or pre-Parkinson’s type tremors or had not yet received an official diagnosis by a neurologist, or who were trying to avoid being labeled as Parkinsonian. Their thinking was that if I could treat someone’s head from shaking back and forth, then I should be able to treat their arms from flailing up and down. I then began to think about the treatment of Parkinson’s movement disorder patients. Applying these same principles, I successfully treated a number of Parkinson’s patients. In January 2010, I was invited to be the keynote speaker at the National Meeting of the Parkinson’s Research Association in Palm Springs, California. This presentation was also well received. As a result of their referrals, I successfully treated a Parkinson’s patient who was previously unsuccessfully treated with an implanted brain stimulator.
All the foregoing led to the treatment of cervical torticollis and other types of movement disorders. My premise has always been the same: that the internal derangement and/or the resulting abnormal maxillomandibular relationship is the underlying cause of the motor component of movement disorders. I do not think the treatment I stumbled upon treats anything other than the motor component of movement disorders. I leave the evaluation of various changes to the central nervous system (CNS) to others who are smarter than I.
I am fortunate to practice adjacent to an MRI center. In fact, it’s the Chief of Radiology of the NIH who specifically reads all of my MRI films. I do not treat a TMJ or any kind of movement disorder patient without first securing MR images of the left and right temporomandibular joints to see with what I am dealing. These patients also get tomographic imaging of their left and right temporomandibular joints prior to the institution of any treatment, as well as frontal and lateral head x-rays.
What I accomplish with my appliances is the repositioning of the mandible into a new and different maxillomandibular relationship, decompressing the auriculotemporal nerve, and eliminating noxious input through the 5th cranial nerve into the central nervous system. To accelerate the patient’s response, I frequently combine the use of these appliances with a very deep penetrating soft-tissue Lumix 2 (USA Laser Biotech, Inc., Richmond, VA) laser that penetrates deeply into the TM joints, the retrodiscal area, the middle-ear area, and any other part of the craniofacial anatomy on which I choose to use it.
As the title of this editorial indicates, I have been on a journey. I had no idea where I would arrive when I started practicing in 1967. I also had no idea that along with treating TMJ and craniofacial pain patients, I would also treat patients with movement disorders. It’s been a long journey, but one filled with learning and the personal satisfaction of having made a difference in the lives of my patients.
Brendan C. Stack, D.D.S., M.S.
Vienna, Virginia
References
1. Sim AB, Stack BC: Tourette's syndrome: a pilot study for the discontinuance of a movement disorder. J Craniomandib Pract 2009; 27(1):11-18.
2. Jankovic J: Tourette’s syndrome. N Engl J Med 2001; 345(16):1184-1192.
3. Keen-Kim D, Freimer NB: Genetics and epidemiology of Tourette syndrome. J Child Neurol 2006; 21(8):665-671.
4. Marcus D, Kurlan R: Tics and its disorders. Neurol Clin 2001; 19(3):735-758, viii.
5. Pauls DL, Leckman JF: The inheritance of Gilles de la Tourette’s syndrome and associated behaviors: evidence for autosomal dominant transmission. N Engl J Med 1986; 315(16):993-997.
6. Coffey BJ, Miguel EC, Savage CR, Rauch SL: Tourette’s disorder and related problems: a review and update. Harv Rev Psychiatry 1994; 2(3):121-132.
7. Kurlan R, et al.: Prevalence of tics in schoolchildren and association with placement in special education. Neurol 2001; 57(8):1383-1388.
8. Burd L, Freeman RD, Klug MG, Kerbeshian J: Tourette Syndrome and learning disabilities. BMC Pediatr 2005; 1(5):34.
9. Singer HS, Schuerholz LJ, Denckla MB: Learning difficulties in children with Tourette syndrome. J Child Neurol 1995; 10(Suppl)1:S58-61.
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