FAQ

What is Neural Occlusion?

Neural Occlusion is an objective screening protocol using numerous computerized measurement tools to help your doctor decide if the timing in your dynamic bite movements (which can cause chewing muscles to become hyperactive and painful) are at least partly responsible for your TMD problems, which may include headaches, jaw fatigue, trouble chewing, broken and worn teeth, hypersensitive teeth, and other issues within the head and neck region due to potentially overactive chewing muscles.

Why should dentists, physicians, chiropractors, neurologists, naturopaths, physical therapists, nurse practitioners, physicians assistants, nurses, dental hygienists, dental students, dental laboratory technicians and other related health care practitioners know about the CNO, Neural Occlusion screening, and DTR therapy?

The timing within the human dynamic bite and/or the cartilage position and condition within the TMJ's themselves, if misaligned, can alter the bite, readily causing neurological changes that may result in chronically overactive muscles of chewing/mastication due to biomechanical over-compressions of posterior teeth periodontal ligaments in their bony sockets.  This can readily lead to headaches and other head and neck issues that medical professionals simply are not aware of, resultant of the painful ischemia (lack of sufficient blood flow) which may develop within the muscles of mastication. Stated a different way, the TIMING within the bite, as well as how, and which teeth collide against one another, in the functional movements, coupled with the objectively confirmed status of the TMJ “hinges” and the influence that these joints have upon the bite, can readily cause the chewing and related muscles in the head and neck to overwork and hurt chronically.  Additionally, unmeasured dental restorative care and/or unmeasured orthodontic movements may readily cause these issues by altering the timing and alignment of the dynamic bite, with similar sequelae.  Improperly fitting dental work may not be as benign a problem as most health care professionals think!  Most dentists and other medical practitioners are simply not aware of these facts and the supporting research, yet!  Bottom line for all involved, a very significant percentage of the chronic tension type headaches and other typical TMD related pains that doctors and patients face all over the world are potentially related to the timing within the human dynamic bite. The CNO seeks to empower all health care practitioners with the knowledge that the timing of the dynamic human bite (which can be measured digitally and objectively in 3/1000 second increments) should be placed within the differential diagnoses of chronic headaches and other seemingly mysterious chronic “TMJ”, orofacial, head, and neck pains.

http://www.createdentalharmony.com/content/library/2/T-scan-article.pdf 

Haines, Duane E. Neuroanatomy: An atlas of structures, sections, and systems. Vol. 153, no. 2004. Lippincott Williams & Wilkins, 2004, p.185. 

http://www.tmdheadacheoregon.com/assets/docs/4.pdf

What does Neural Occlusion screening consist of?

Neural Occlusion utilizes computerized tools to objectively measure the timing within the dynamic bite, the muscular activity of many of the muscles moving the jaws around, and the status of the patients TMJ's.  Couple this sort of objective data with the knowledge required to interpret and act upon this digital information, and you then have a working definition of the Neural Occlusion screening protocols.  Minimally, the practitioner should use the T-Scan® to measure timing, along with the Bio-EMG III, which connects to the T-Scan technology, simultaneously, measuring muscular output to show how the timing in the bite affects the chewing muscles, in 3/1000-second increments. Talk about amazingly accurate measurements! Lastly, a digital screening tool for TMJ cartilage known as Joint Vibration Analysis (JVA) is useful to help determine if the cartilage, which resides within the TMJ’s, is functioning properly during the patients jaw movements. Advanced CNO level 3 doctors are also ordering and interpreting 3D imaging of the TMJ's, using 3D X-rays (CBCT-for bone) and MRI (for soft tissue cartilage, fat and fluid), to provide supplemental objective data which often makes a huge difference towards arriving at a proper diagnosis (or diagnoses) of TMD and orofacial pains, thereby increasing the predictability of DTR therapy implementation.

What is DTR therapy and how is it done?

Disclusion Time Reduction (DTR) therapy is performed via the Immediate Complete Anterior Guidance Development (ICAGD) bite adjustment protocol, on patients with objectively confirmed stable and adapted TMJ's (proved via objective tools such as JVA, CBCT and MRI).  Minuscule amounts of tooth structure (typically artificial parts of tooth structure such as crowns and fillings on restored teeth that don't "fit" properly in the patients dynamic bite) are removed off of back teeth, and/or tiny amounts of precisely placed additions of bonded white material are added to the front teeth, to get the patient off of their back teeth very rapidly as they move their lower jaw around (during the dynamic movements of the bite), in time.  The exact timing of how fast the back teeth disengage frictionally in the sideways movements/excursions is known as Disclusion Time.  The threshold amount of time statistically (per the scientific research) for a proper Disclusion Time is <0.5 seconds.  Neurologically, DTR decreases the muscular output required for the jaws to move around, increasing their efficiency.  Reduce the muscular output, and you should reduce the sore muscle pain.  This is a relatively permanent bite change that has been shown repeatedly in published scientific papers to remain lasting in patients with stable and adapted joints.  Realize that much of the time DTR therapy is simply correcting poor dental work from the past that CAUSED the muscles to overwork and hurt, using objective, reproducible, and digital tools to precisely guide this change (T-Scan and BioEMG III). http://www.igi-global.com/chapter/employing-t-scan-synchronized-with-electromyography-to-treat-chronic-occluso-muscle-disorder/122075 https://youtu.be/Q0xkJNF0l_E https://youtu.be/QmWDnSJFR94?list=PLrsyoxXDGZ4YxS3ThCRSd-kVJAJ4kCCXS

Why do most patients with muscular TMD issues have cold sensitivity with their teeth?

In 2015, a chapter in a 1st edition dental textbook relating to digital occlusal/bite analysis was published describing for the first time the measured correlation between sensitive teeth and patients with muscular TMD issues. The pilot study found that statistically all 34 muscular TMD patients were less sensitive after their bite alignment and timing issues were addressed via DTR therapy, one of the core procedures taught by the CNO.  Another paper, which will be published by 2017, statistically proves that 99 different patients were found to have a decreased sensitivity response to a 5 second ice water swish after DTR therapy improved their timing and the alignment of their bite.  Excessive muscular force against opposing teeth in patients with muscular TMD issues, in time, seems to be causative for many tooth sensitivity issues.  CNO trained doctors are taught FDH theory and application as it applies to occlusal (bite) and TMD issues.

http://www.igi-global.com/chapter/occlusal-considerations-in-the-hypersensitive-dentition/122077

What is Frictional Dental Hypersensitivity (FDH)?

Theoretically, too much muscle force applied to opposing teeth, in time, decreases the threshold whereby a patient perceives cold sensitivity in their teeth.  Applying DTR therapy to such a patient, with confirmed stable and adapted TM joints, seems to increase the threshold whereby they perceive sensitivity, essentially decreasing their painful sensitivity experience during the consumption of cold foods and drinks.  There are neurological reasons for this change, which typically occurs during the DTR treatment visit on the typical muscular TMD patient.  A combination of trigeminal and sympathetic nerve inputs are likely responsible for this change. It is blatantly obvious that FDH is a common problem for dental patients, and that a bite timing discrepancy is usually the reason why teeth remain hypersensitive after dental work or orthodontic tooth movements.  There are even times when DTR therapy may eliminate the need for root canal therapy in chronically hypersensitive teeth after restorative dental work!

Does every doctor do the same thing before performing DTR?

No.  Every doctor is independent and on their own.  The mission of the CNO is to help calibrate doctors so that they are more likely to do everything that they can to first objectively measure and screen a TMD patient to help ensure that the patient is a good candidate for DTR therapy.  DTR is not for every TMD patient.

Does every doctor do DTR the same way?

No.  There are different ways and sequences of adding and subtracting on the teeth, in precise and minuscule amounts, to better align the dynamic bite in its functional movements. There are also times when orthodontic therapy is initiated to affect this alignment change, followed by a precise alignment and timing adjustment at the end of the orthodontic treatment (as theoretically and ideally all orthodontic treatments should be finished objectively using digital measurement technologies, not via subjective feel using analog bite papers, waxes and foils).  A muscular TMD issue is akin to dealing with the timing of a machine being out of kilter...  The less efficient the timing, the more energy is expended.  Conversely, the more efficient the timing, the less energy is expended.  The less energy expended by the muscles once the timing in the bite is corrected, the less likely the muscles will be sore and painful, particularly if the way the teeth are shaped and arranged within the dynamic movements of the bite are responsible for the patient’s muscular TMD pain issues in the first place, which it often is.

Who is the ideal patient for DTR therapy?

Who DTR works very well for is the muscular TMD patient who possesses relatively stable and adapted cartilage within their TMJ's. These patient’s typically present with chronic pain due to dental or orthodontic work that does not fit well within the "chewing machine" in regards to timing and alignment, confirmed via computerized objective measurement technologies such as T-Scan and EMG. Please note that most dental and orthodontic work is not objectively measured and finished relative to force, timing, and concurrent muscular activity. Typically, the traditional ink bite paper is all that is used to “dial in” the final result. The problem is, this subjective, analog, and inaccurate ink paper is not accurate and cannot show the doctor what is happening between the teeth, in time. Timing matters for the Central Nervous System, and when not within proper parameters, bad timing within the dynamic bite can readily lead to muscular problems that may lead to painful “TMJ” pains. In other words, just because it may look and feel good, does not mean that it fits properly within the chewing system. “Tap-tap-tap” and “How does that feel to you…?” are not accurate and objective means of checking your bite…

How do I find someone who can do DTR therapy properly for me?

Look to the CNO database for doctors who have studied Neural Occlusion screening protocols and DTR therapy.  Only doctors who have passed the requirements of the various CNO levels may choose to list themselves within the CNO directory found on this website. The higher the ranking, the more likely you can expect them to properly diagnose you and properly implement DTR therapy effectively for you, IF it is indicated.  Level 0 practitioners have a very basic understanding of what DTR is.  Level 1 doctors have a firm understanding of DTR theory and Neural Occlusion screening, and have passed a didactic examination to prove competency.  Level 2 doctors have been clinically tested and calibrated by a CNO mentor who physically watched them perform DTR therapy on several patients in person. Those doctors that performed satisfactorily during this clinical experience are thereafter labeled Fellows as CNO Level 2.  Level 3 doctors are not only very well versed and experienced in DTR therapy, but they are also capable of competently incorporating 3D imaging into the Neural Occlusion screening protocols prior to implementing DTR therapy. They have earned Mastership in the CNO. 3D imaging of the TMJ’s via CBCT and MRI are the ultimate measurement steps to either confirm or deny that the patients TMJ’s are indeed stable and adapted. DTR therapy, technically, should only be performed on patients with stable and adapted TMJ’s. Level 3 doctors are also more able to recognize times when DTR therapy is not likely to help a given patient, since they are privy to the vast information gleaned from the 3D imaging (CBCT and MRI) protocols.

Does DTR fix the joints if they are damaged?

No, it does not.  However, DTR therapy does theoretically help catch the bite up to damaged TMJ "hinges", so that the muscles affected by the TMJ’s should not overwork and brace as much once DTR is performed, provided that the damaged joints have already orthopedically adapted and stabilized to their damaged state.  The less damaged the right and left TMJ's are in a particular patient, the more likely they will respond to the DTR therapy occlusal/bite adjustment therapy.  This is partly why the CNO is so adamant about screening the TMJ's at all levels, because the joints can readily affect the bite, and the timing within the bite can readily cause overactive chewing/masticatory muscles, with subsequent muscular ischemia and pain.

Should my dentist and orthodontist be using DTR principles for my everyday dental work?

Absolutely!  If more dental practitioners actually MEASURED their dental work objectively and understood the:
1) principles of deciding if the TMJ's are stable and adapted or not
2) principles of Disclusion Time and Immediate Complete Anterior Guidance Development
…there would be very few patients walking around the planet with muscular TMD issues due to bite timing and alignment issues!

Is DTR a bite adjustment procedure?

Yes, precisely accomplished using computerized bite and muscle analysis tools, which study the dynamic bite movements in 3/1000 second increments.  Very precise, very objective, very minuscule, and accomplished only when a patient has objectively confirmed stable and adapted TMJ's.  Normally in dental medicine, ink ribbon paper is used to "check" the bite.  Ink bite ribbon paper is very inaccurate and very subjective (less than 30% accurate in measuring force per unit time in the literature (Qadeer et.al., 2007)).  It is virtually impossible to perform DTR therapy without the T-Scan and the EMG technologies.  Numerous scientific papers have been written over the years to statistically prove this statement.  The almost universal usage of the inaccurate analog bite ink paper is partly why so many patients have muscular TMD problems due to a bad bite in the first place!!

Will DTR cure my TMD?

If your TMD issue is from a bite alignment problem due to old dental or orthodontic work not fitting properly, in time, and your pain is from muscles overworking and not due to damaged TMJ cartilage or other orthopedic reasons; likely, yes.  If your TMD issue is due to reasons other than a bite and timing issue; not necessarily.  Remember, TMD (Temporomandibular Dysfunction) is a general term describing well over 40+ possible pathologies.  Though overworked and hyperactive muscles from a poorly aligned and poorly timed bite are a big percentage of why people have TMD issues, it is not the only reason.  This is why the CNO pushes the Neural Occlusion screening protocols, to objectively eliminate other reasons that TMD patients might be experiencing problems.

What is a T-Scan®?

The T-Scan® (Tekscan Inc., Boston, MA, USA) is a painless computerized tool with a bite sensor that the patient bites into.  It measures how forceful the top and bottom teeth collide together in 3/1000 second increments, both in normal closure, and as the teeth move around in sideways motions.  Just to be clear, for DTR therapy, T-Scan usage is most helpful in regards to measurements of the sideways movements, not the normal straight down clench/bite. T-Scan sensors measure force and timing between the teeth very accurately (95% per the scientific literature (Koos, et.al., 2010)), and the software provides a permanent record within the patients chart so that their treatments can be tracked and archived over the years.  No other computerized bite technology presently exists that can measure, record, and guide a knowledgeable operator in regards to force per unit time in the occlusion/bite; most certainly not the analog ink ribbon bite paper!  The T-Scan is a required tool for DTR therapy.

What does the timing of the bite have to do with TMD?

The longer the amount of time that our back teeth engage with one another as we chew, clench, or grind, the more likely our nervous system will push the muscles that move things around harder than normal.  The harder those muscles work, the more likely these muscles become fatigued and ischemic.  Ischemic muscles hurt.  Getting on our front teeth quickly as we chew around is a good and healthy thing.  Conversely, if we cannot get on our front teeth quickly because we are hung up on our back teeth for some reason, that is a bad thing.  Shorten the time that opposing back teeth engage with one another, in time, and our nervous system will statistically push the muscles less to accomplish the same tasks.  This new muscular efficiency gives previously overworked muscles a chance to rest, recover, lose their ischemia, and subsequently the patient should lose their pain, if the ischemia was the only layer responsible for their pain (which it typically is).  Most patients with TMD have a problem due to overworked muscles of mastication/chewing. The key lies in understanding why these muscles are overworked in the first place…  This is why the CNO understands the importance of the following phrase:  Measured Matters.  Using precise and objective tools to measure and potentially alter the timing of the bite is a new and unknown concept in both mainstream medicine and dental medicine.  DTR therapy can readily create a newfound and instantaneous muscular efficiency, confirmed via the simultaneous usage of muscle electromyography (EMG) to prove that this newfound muscular efficiency now exists, during treatment. DTR therapy is profoundly and amazingly effective, for the right patients!

What is EMG?

Electromyography (BioEMG-Bioresearch Associates, Deer Borne, WI, USA) is a painless diagnostic tool used to measure the tiny electrical outputs that muscles put out both when they rest, and when they function.  Think of an EMG like a tachometer reading several of the chewing muscles.  It is possible for Bioresearch Associates' EMG technology to connect with T-Scan technology, so that a DTR practitioner may actually objectively prove that the muscles are now working more efficiently/less hard after adjusting/aligning the bite with the data acquired from T-Scan.  EMG is a required tool for DTR therapy in that it confirms whether or not muscular shutdown of the involved muscles has occurred or not, objectively.

What is JVA?

Joint Vibration Analysis (JVA-Bioresearch Associates, Deer Borne, WI, USA) is a painless screening tool that looks like a music headset.  It rests over both of the temporomandibular joints and gives an adept doctor a good idea of what is going on with the cartilage within their patients TMJ’s as they open and close throughout their entire range of motion.  Basically, perfectly normal and healthy cartilage interposed between where the jawbone connects to the skull creates little to no vibration (since structurally normal cartilage acts like a “pillow” between these two bones).  The JVA headset and software will sense and display little to no vibration as normal.  When the cartilage is torn in one or both of the TMJ’s, the software will show spikes and warn the clinician that things are not quite normal.  The software also quantifies the vibrations that it measures, which can be cross-referenced with a database to correlate with particular degrees and types of cartilage damage.  Though by no means diagnostic, JVA is a quite useful screening tool.  Nothing beats the MRI for truly knowing what is going on with the TMJ’s and the cartilage within the TMJ’s.  Remember though, that the cartilage condition, position, and possible tears of the cartilage “pillow” can readily affect the bite, and even increase the amount of time that the back teeth touch, leading to an increase in muscular activity with potentially painful muscular TMD consequences.  Think of the JVA as the “poor man’s MRI”.  The JVA is quick and quite useful as a screening tool, but not always completely accurate.  Compared to normal clinical palpation and other unmeasured and subjective examinations of the TMJ’s used by most doctors though, it is light years ahead!  It is a good idea to make sure that your particular DTR doctor at least uses JVA to screen your TMJ cartilage, and ideally, CBCT and MRI as well (level 3 CNO doctors).

What is CBCT imaging?

Cone Beam Computerized Tomography (CBCT-various manufacturers) is basically 3D imaging of the bone and the spacing between bones. CBCT measures calcium (which healthy bone has plenty of). A 3D x-ray that can be manipulated, rotated, and measured very precisely.  CBCT is very useful at objectively inspecting the teeth, sinuses, the jawbones, spacing, and growth and development of the TMJ's.  Ideally a CBCT of the temporomandibular joints should be taken and competently interpreted before initiating DTR therapy.  Level 3 doctors are acutely aware of this and have been tested on the usage of CBCT in regards to TMD diagnosis and treatment.

What is MRI imaging?

Magnetic Resonance Imaging (MRI-various manufacturers) looks at hydrogen content in human tissues.  Soft tissues, water and fat within the human body contain hydrogen.  Fluids that do not belong in the TMJ's show up on a properly exposed MRI series, and are generally a sign of acute inflammation.  Cartilage also has hydrogen, which shows the radiologist and the clinician where the cartilage lies in each of the right and left TMJ’s.  Fat within the marrow of bone shows up as well on the MRI, a sign that the bone is alive if there is fat present, or conversely, lack of fat in the bone marrow of the mandibular condylar head is a sign that there is the distinct possibility of a serious TMJ orthopedic problem, such as dying bone. MRI basically lets us see things that cannot be seen in other ways, showing us if there are hidden problems within the TMJ jaw "hinges" themselves.  Level 3 CNO doctors are acutely aware of these nuances and have been tested on the usage of MRI in regards to TMD diagnosis and treatment.  MRI imaging does not expose the patient to radiation. Only manipulations of magnetic fields occur in this type of imaging. MRI imaging of the TMD patient is an idealistic step that can lead to more predictable outcomes!

What's the point of imaging the TMJ's?

To see things that cannot be seen otherwise, helping us rule out other problems that might be contributing to your bite or TMD issues.

Why is cartilage important for my bite?

Cartilage sits quietly between your skull and the condylar head of your lower jaw (the mandible) which is held stably in place by ligaments, in perfect health. The cartilage serves to protect your lower mandible from rubbing bone on bone with your bony skull, a cushion of sorts. It has a thickness that deflects your mandible slightly downwards in perfect health. When the cartilage is knocked out of place, that thickness between skull and mandible will typically decrease. Since your lower teeth are connected to the mandible, they hit your upper teeth sooner in this scenario (on that side with the decreased thickness). Hence, the back teeth of the side where damaged cartilage is present hit sooner than before (and engage longer as you chew sideways, in time, inciting muscular hyperactivity), and this will often separate your front teeth slightly on the opposite side. If both TMJ’s have the cartilage knocked out of place, that can lead to decreased separation of the mandibular condylar bony head from the skull socket on both sides, leading to the back teeth hitting too hard on both sides, and the anterior/front teeth separating on both sides. Cartilage tears can happen from a bite being too “high” for too long, and can also happen from physical traumas such as a blow to the chin, which may transfer enough force through the mandible and up to the TMJ’s and “pop” the cartilage down and forwards. Cartilage is almost always torn forwards due to the anatomy of the TMJ. Bottom line, the cartilage condition, position, and degree of displacement can readily lead to a change in your bite/occlusion.

Why is bone within the TMJ’s important for my bite?

If bony components wear down, that too will decrease the height of the mandible on the affected side, increasing posterior/back tooth contact on that side and increasing the space between front teeth on the opposite side. A change in bone dimension will almost always alter the bite/occlusion. Bone typically degenerates/breaks down in the TMJ’s if the cartilage is torn out, and does not if the cartilage is normal.

Is the bite the only thing that can throw the muscles into spasm with resulting pain?

No.  Torn cartilage, bony degeneration, cervical issues, neurologic issues, Lymes disease and many other inputs can also cause muscular spasms and pain in the TMD patient.  The more a practitioner looks into this with objective tools such as T-Scan, EMG, JVA, CBCT and MRI, the more likely they will find why and if their patents pain(s) is (are) due to an occlusally (bite) based muscular TMD issue.

Why should I see a CNO doctor rather than someone that says they know how to do DTR and is not CNO certified?

DTR is a very precisely orchestrated adjustment procedure, which requires experience and guidance in regards to interpreting technical data and the application of this data to implement treatment.  One-on-one training with experienced CNO DTR practitioners is invaluable for a doctor to properly implement DTR.  The creator of DTR therapy, Dr. Robert Kerstein, is one of the doctors who personally travels to various offices to carry out the level 2 clinical training for the CNO.  As a matter of fact, one of the reasons that the CNO was formed was to help ensure that DTR practitioners would be calibrated and on the same page with the concepts and treatment protocols in line with Dr. Kerstein’s 30 years of experience implementing DTR therapy.

I heard that DTR does not involve bite splints.  Why not?

Splints basically separate back teeth and/or reposition the mandible.  Ideally, splint construction should depend upon first ascertaining cartilage condition and position, since the splint can actually increase damage to the joints themselves by physically straining already compromised and damaged cartilage within the TMJ’s.  Without objective ways of imaging and measuring the cartilage within the TMJ’s (via MRI) as well as how the joints effect the connected teeth, it is hard to predict which splint design is most appropriate for a particular patient, especially since one joint may be in a different condition than the other joint (example right to left side) in the same patient.  Additionally, splints also remove the patients adaptive capacity to “move” their teeth around in the jaw bones via chronic muscular forces to fit to the status of their TMJ "hinges" since the teeth are all locked together by the splint, and muscular force is unable to move the teeth and align them properly (via clenching and grinding), in space and time, to "catch their bite up to the condition of their TMJ's".  DTR “catches the bite up to the condition of the TMJ’s”, and can be expected to last for the patient as long as the joints themselves do not change their position, condition and general stability over time.  Once the timing is proper due to a good alignment, muscular activity should reduce, with less pain and ischemia.

Is the T-Scan all that my dentist needs to do proper DTR?

Though the T-Scan is a required tool to accomplish DTR therapy, standalone it is not as effective as when used with the EMG. Avoid full-blown DTR therapy on the entire bite if the doctor is only using the T-Scan itself; the outcome is more predictable when the T-Scan is linked simultaneously to the EMG. Using the T-Scan alone to help dial in dental work for the patient not experiencing TMD issues, say for a few crowns and fillings? This scenario is very acceptable and recommended in the opinion of the CNO.

What’s the purpose of the CNO?

To disseminate objective and reproducible knowledge and treatment protocols pertaining to occlusion (the bite), TMD, and the neurology involved between them.  Removing as much subjectivity as possible, the CNO strives to arrive at a proper working diagnosis before implementing treatment, unlike many other traditional occlusal and TMD protocols that are used to treat occlusal and TMD conditions, which are typically lacking adequate diagnostics and quantifiable and reproducible endpoints regarding treatment.  The CNO is the best resource for patients seeking nearby DTR doctors via the CNO database, as the CNO is the only organization actively teaching and testing doctors on DTR therapy protocols.

Will I have to go back many times for DTR therapy?

Though every case is different, most patients with stable and adapted TMJ's should respond to treatment within one or two treatment visits.

Does DTR hurt?

DTR therapy does not hurt.  No anesthetic is needed.

Does the Neural Occlusion screening hurt?

No.  It is painless.

How does DTR stop some headaches?

There are muscles in the head and neck that may overwork and become ischemic (lack of sufficient blood flow) and painful due to bite misalignment and a resultant timing discrepancy.  This timing discrepancy in the dynamic bite is all but unknown in the medical and dental fields.  This bite misalignment can readily continue to perpetuate the overworked muscular condition, with perpetual ischemia and pain in the temple muscles (for example).  Screening this patient for long Disclusion Times (excessive engagements of back teeth over time) is an effective way to confirm or eliminate this as being contributory for a patient’s headache condition. To be clear, DTR is not a cure for all headaches, but it is quite effective when the genesis of the headache is from overworked chewing muscles due to a “bad bite”, which it often is!

Does DTR stop my clenching and grinding?

In many cases, DTR therapy will reduce the propensity for clenching and grinding.  Realize that clenching and grinding is, to an extent, a normal physiologic process whereby the Central Nervous System (CNS) attempts to adapt the position of the teeth via muscular forces to “fit the teeth properly” to where the TMJ “hinges” want the teeth to be, in time. Teeth adapt to joint condition through muscular force, over time.  When teeth are not within the normal anatomic and timed neurologic parameters deemed appropriate by the CNS, the CNS recruits muscles to change the timing and “alignment” accordingly, via muscular output which crudely initiates the movement of teeth by tipping, breaking, or intruding them into bone; whatever it takes.  So, if the teeth are close to where the ideal position would be in space and time based upon what the CNS dictates, the clenching and grinding would typically decrease.  DTR therapy helps get the patient closer to that desirable aligned position by tapping in to these neurological pathways, all the while confirming that the alignment and the timing involved are appropriate via objective instrumentation.

Can you tell from my symptoms & pains if I’m a candidate?

No.  You must be measured with the Neural Occlusion screening tools.  Minimally T-Scan, EMG and JVA.  Ideally, you should be screened with CBCT and MRI as well.

Who started the CNO?

The CNO is the brainchild of two doctors, Dr. Nick Yiannios and Dr. Robert Kerstein.  Dr. Kerstein is the clinician and researcher who since the early 1990's has been researching the effect that long Disclusion Times have upon the muscles of the head and neck using the T-Scan and EMG technologies.  Dr. Yiannios is the first dentist who took Dr. Kerstein's research seriously many years ago and applied the DTR principles in his everyday practice of dental medicine, with astounding results!  Dr. Kerstein's concepts involving the bite are very important, but other principles involving the actual TMJ joints themselves are also addressed within the CNO core curriculum, mostly in line with the foundational occlusion teachings of Dr. Mark Piper, the world-renowned TMJ oral and maxillofacial surgeon and creator of the Piper classification system for the temporomandibular joints (TMJ’s).



Why should I have an MRI done and can we do the MRI in the dental office?

The MRI is optimally acquired before initiating TMD therapies such as DTR, to help ascertain whether or not the patient possesses a pair of stable and adapted joints.  As MRI machines are very large machines that require special technicians and radiologists to use and interpret, the patient is sent off to a dedicated medical imaging center for their TMJ MRI's.  The process is quite painless and easy, and typically takes under an hour to complete.  There is no radiation with an MRI scan, as it only involves magnetic field manipulations, not radiation. Please understand that a proper TMJ MRI protocol is not easily found in every imaging center and hospital setting though, as it is a controversial and rarely imaged part of the human body. CNO doctors are given tips to help ensure that they acquire the most useful protocols within their geographic area to aid with interpretation and proper diagnosis, based upon the 30 years of experience and resultant protocols of Dr. Mark Piper, creator of the Piper classification system of the TMJ’s.


Why should I have a CBCT 3D x-ray and can we do the CBCT in the dental office?

The CBCT helps elucidate the hard tissues of the TMJ's and lets an adept practitioner decide what hard tissue factors might be contributing to their TMJ problems.  Though there is a small amount of radiation that a patient is exposed to with a CBCT, it is a fraction of what a medical grade CT generates.  Some modern dental practices have a CBCT machine on site, as these machines are much smaller than MRI machines and easier to operate within the confines of a dental practice.

How many visits are needed for DTR therapy?

Typically 1-2 treatment visits are needed.  Remember that every case is completely unique, and this can vary.

Should I do any dental work I need now before getting DTR done?

It totally depends on each patient and their condition.  Remember though, many times dental work that goes in without respect for the timing and alignment within the patients dynamic bite is the very reason why they have a TMD problem in the first place.  Make sure that a doctor knowledgeable in DTR theory does your dental work if you have some done after DTR therapy, so that the new work will not likely rekindle an alignment and timing issue.

Does insurance cover anything for DTR therapy?

No.  It does not exist in their eyes.  Only a handful of practitioners even do this therapy worldwide.

What does DTR cost?

The cost varies from practice to practice. Contact the dental provider of your choosing and ask them for their fees.

Why don't more doctors know about DTR and Neural Occlusion?

DTR is very different from traditional philosophies, plus it invalidates traditional thinking regarding occlusion and TMD as is typically taught and practiced in dental medicine.  As with all new concepts, it is resisted initially by most for political, academic, financial, and even egotistical reasons.

Is DTR therapy (via the ICAGD protocols) the same thing as equilibration?

No.  Not even close.  DTR therapy (via the Immediate Complete Anterior Guidance Development (ICAGD) occlusal adjustment protocols) objectively and precisely decreases back tooth contacts in the sideways movements of the mandible (lower jaw bone; the mandible is all that ever moves), in time.  Equilibration increases back teeth contacts in the sideways movements of the mandible, and is typically done with bite ribbons and foils, without the usage of precise, digital measurement technologies such as the T-Scan.  Equilibration does not address the timing in the sideways movements at all, the core reason why DTR therapy is so effective for muscular TMD patients. DTR therapy is performed where the patient’s muscles naturally bring the teeth together, the Maximum Intercuspation position (MIP). Equilibration is performed in the most superior and anterior position of the mandibular condyles within the glenoid fossa of the temporal bone, the Centric Relation (CR) bite position, usually slightly back from the MIP bite position. These bite adjustment procedures are very different from one another for the previously stated reasons and many, many more.

What bite position is DTR therapy accomplished in?

Maximum intercuspation (MIP), where the patient’s teeth come together as their chewing muscles naturally close their lower jaw/mandible. In most patients, this is an acceptable position in which to work. In a very small percentage of patients, the MIP position may not be ideal. This is one of the reasons why the CNO recommends 3D imaging to help ascertain if orthopedic factors in a given patients joints are amenable to treating the patient’s bite in the MIP position, based upon cartilage condition, position, degree of displacement, and possibly even bony or inflammatory issues within the TMJ’s themselves.