I. Background on masticatory musculature

II. Patient presentation
    a) Morning/Chronic headache, and/or stiff/sore/painful jaw, and/or TMJ symptoms/pain,
        and/or sensitive teeth, and/or chronic dental trauma, and/or stiff/sore neck…"TMD"

III. Identifying the Source of Symptoms
    a) Bruxism
        1. Current "casual" definition = "The clenching and grinding of the teeth"
                a) Bruxism is not a condition of teeth, but a condition that effects teeth.
                b) Appropriate definition:  Bruxism =  Intense jaw clenching, with or without forcible
                    excursive movement.
                1) The intensity of Temporalis clenching dictates the severity of  Lateral Pterygoid grinding.
                2) Bruxism is a dynamic muscular activity, pitting the forces of the Temporalis vs. the
                    Lateral Pterygoid against each other.
                a) "Primary Clenching":  Static temporalis clenching, without the influence of
                    the Lateral Pterygoids, resulting in stable and  protected TMJs (no signs
                    and/or symptoms of TMD), but presenting as chronic tension-type headache.
         1. Chronic tension-type headache patients without TMD, on average clench
             their jaws during sleep 14 times more intensely than asymptomatic controls.
                b) "Primary Clenching" patients typically present with:  Headache upon awakening
                    (rarely do they wake up feeling good),  unresponsive or minimal effect of typical
                    headache preventive medications, unremarkable TMD, toothaches and  sensitivity,
                    require/desire daily analgesics, history of dental trauma, typically unaware of any
                    clenching activity.

IV. Typical treatment following diagnostic work-up
    a) Splint therapy
    b) Occlusal intervention
    c) Pharmacology
    d) Alternative/Multidisciplinary/Heroic Physical Therapy, Surgery, Nerve block,
        Chiropractic, Acupuncture,  Psychiatric, Massage, etc.

V. Splint therapy for Bruxism with a traditional splint
         a) Lateral forces:  Relieving the resistance (a flat plane) to side-to-side movement
             (Lateral Pterygoid activity) allows for less muscular intensity, therefore, strain on the
             condyle and disc (the attachments) and the pterygoid plates of the sphenoid bone
             (the origin) is decreased, thereby reducing joint and facial symptoms.
         b) Vertical forces:  By creating full arch occlusal stability, the most efficient surface for
             clenching is provided, therefore, clenching intensity can increase.  Although joint symptoms
             may decrease, headache symptoms may persist, causing the dentist to diagnose "tension-type
             headache" separate from TMD.

VI. Identifying Mechanisms of Joint Strain
        a) Bilateral equal posterior contact = no joint strain and maximal Temporalis contraction intensity.
        b) Unilateral posterior contact =  no ipsilateral joint strain, maximal ipsilateral Temporalis
            contraction, maximal contralateral joint strain.
        c) Unilateral canine contact = minimal ipsilateral joint strain, near maximal ipsilateral Temporalis
            contraction,  moderate contralateral joint strain.
        d) Anterior midline contact = minimal bilateral joint strain, minimal Temporalis

VII. Nociceptive Trigeminal Inhibition reflex
        a) The "Jaw Opening Reflex" (JOR).   Direct force parallel to the long axis of  an anterior
            incisor (excluding the canines) stimulates the JOR, thereby suppressing the elevators and
           exciting the depressors.
        1) An anterior deprogrammer and an anterior-point-stop both exploit the JOR in a
            static, centric position.
            a) Dynamic excursive and protrusive movements of the mandible cause deprogrammer
                and anterior-point-stop failure.
             i) Protrusion allows the mandibular incisors to "get in front of" a point-stop, allowing
                for posterior clenching.
            ii) Excursive movements allow canine occlusion on the deprogrammer, allowing
                for significant joint strain
           b) Both the deprogrammer and anterior-point-stop are contra-indicated for therapeutic
               use due to above.

VIII. Long term mis-use and failure of anterior (bite-plane) splints
       a) An anterior bite plane provides occlusion for mandibular canines and incisors. Canines'
           ability to withstand chewing forces allows the patient to use the splint during function,
           that is, while eating.
             1) Masseter activity is decreased with absence of posterior occlusion
                 a) Jaw related symptoms are decreased with the use of an anterior  bite plane
             2) Temporalis activity remains at near maximal.
                 a) Headaches may persist,  although jaw symptoms may have decreased.
                 b) Due to reduction of jaw symptoms, a patient may continue to mis-use an anterior bite
                     indefinitely during function, thereby allowing for functional adaptation, that is, supra-
                     eruption of posterior teeth.

IX. Description of the NTI-tss  device (www.nti-tss.com or HeadacheHope.com)
               (Nociceptive Trigeminal Inhibition Tension Suppression System)
     a) An anterior-midline-point-stop, which extends anteriorly and posteriorly to maintain
         point-stop occlusion perpendicular to the long axis of a mandibular incisor in full protrusive
         and retrusive movement.
                  1) By keeping the occluding surface to a minimum (a point-stop instead of a
                      platform), the potential of joint-straining canine occlusion on the device is minimized.
     b) Lack of potential for functional adaptation
                  1) Chewing with the NTI-tss in place is impossible, due to the JOR and the discomfort
                      of intense masticatory impact forces on the incisors.
     a) Since the NTI-tss cannot be used during function, there is no potential for
         functional adaptation, that is, supra-eruption.

X. Results of NTI-tss use
      A)  Symptom reduction / resolution
           1.  Resolution of morning headache due to suppression of nocturnal clenching
            a) Relief of chronic tension-type headache due to suppression of causative element,
                that is nocturnal clenching.
            b) Irritating elements (triggers) still exist, but have less of a pre-existing condition to irritate.
           2.  Relief/resolution of joint/jaw pain
            a) Decrease strain on condyle/disc due to lack of resistance to Lateral Pterygoid contraction.
           3. Relief/resolution of chronic stiff/sore neck.
            a) Jaw clenching obligates the neck musculature (trapezius) which supports the skull to
                maintain stability.  Suppression of clenching intensity allows less intense contraction
                of neck musculature.
        4. Relief/resolution of face/sinus pain
            a) Lateral Pterygoid originate on the pterygoid plates of the sphenoid bone, which house
                the sinus.  In an excursive clench, static Lateral  Pterygoid contraction places constant
                strain on the pterygoid plate,   resulting in chronic swelling of the sinus passages (in the
                absence of disease/infection/allergen).
        5. Relief of tooth sensitivity
            a) Chronic compaction of the PDL causes chronic sensitivity.
                1. For several days following initial delivery of an NTI-tss, patients my report a
                    "itchiness" or "fatness" of their teeth as the PDL recuperates.
        6. Reduce frequency of migraine attacks by inhibiting effect of dysfunctional spindles.
    B) Objective changes
        1. Jaw mobility improves
        2. Occlusal scheme may change
            a) Resolution of Lateral Pterygoid dysfunction, which may have been contorting the neck
                of the condyle demonstrates a change of occlusion.
            b) Change of condylar position
                1) If, for example, the condyle had habitually been in a functional, but slightly anterior
                    and inferior position to ideal, the condyle may re-position to its musculo-skeletally
                    stable position, that is, CR.  In this example, the condyle would seat in a more
                    superior and posterior position, thereby rotating the mandible at the distal most dental
                    contact.  Depending on the original degree of incisal overlap, an anterior open bite
                    may result.
            c)  Although significant jaw relationship changes occur only in the presence of relief of
                 symptoms, all patients should provide an informed consent to this rare possibility.