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Measured Matters!

Our Purpose: DIAGNOSIS!

To train health care professionals in TMD diagnosis, 3D Imaging, and Measured Anterior Guidance/DTR Therapy concepts so that they can in turn provide hope and direction for many patients with bite issues, tension and temporal headaches, and TMD.

We believe in measuring “TMJ” problems whenever possible. Many times the TIMING of your bite is out of alignment and that IS the root cause of your “TMJ” problems. Sometimes though, things are more complex than just your bite being off… Neural Occlusion Screening (NOS) greatly aids a practitioner in identifying the root cause(s) of your confounding “TMJ” and orofacial pain troubles, as they relate to your bite, muscles, ligaments, cartilage, bone, and the neurology within your chewing complex.

CNO protocols assist in objectively finding a proper diagnosis (or diagnoses), followed by predictable treatment protocols, to address the root of your orofacial issues. TMJ issues are rarely psychological, though they ARE “in your head”; ligaments, muscles, cartilage, the timing and force between your teeth, bone, inflammation, and much, much more - all located within your head and neck!

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What is "TMJ?"

TMJ is just anatomy. TMD is an umbrella term that involves orthopedic, muscular, neurological, and/or dentally related issues.

CNO Founder’s Letter

Dr. Nick Yiannios

Orofacial and TMD pain has long demanded the attention of medical and dental professionals. When a physician or dentist becomes involved in this field, he or she begins to appreciate the fact that the purviews involved cross the manmade boundaries, since essentially, everything in the human body is connected in some way, shape or form…Continue Reading

Common Signs and Symptoms

 

Headaches

When muscles are overworked, they can become ischemic and painful. The neurology of the human stomatognathic (chewing) system is such that the more opposing back teeth engage one another as we move the lower jaw (mandible) around, in time, the more our nervous system reacts by pushing harder on the chewing muscles. Additionally, the status of the TMJ’s themselves can readily alter the human bite, once again causing excessive back tooth contact. So, “head” aches; the head contains muscle groups relating to chewing of course. What if you overworked those muscles, unknowingly, and what if almost no health practitioner knew that this timing relationship can be causative for your non-specific headaches?!

Grinding/Clenching

​Clenching and grinding ones teeth is essentially mother natures way of “catching our bite up” to the status and biomechanical position of our right and left TMJ’s. Neurologically, our nervous system “dials in our bite” to match up to the TMJ hinges, basing how much alteration should happen upon the neurology that is definitively linked to muscular hyperfunction; the DTR theory. Too much opposing back teeth contact, in time, stimulates nervous system to push, tip, intrude, grind or possibly intrude teeth into bone, until such time as the front teeth do their job of separating the back teeth apart during function.

Clicking/Popping

​Cartilage normally sits atop the mandibular condylar head, that part of the lower jaw bone that inserts into the skull base, just in front of our ears. The cartilage is attached to the condylar head with ligaments, and the cartilage has a muscle, called the lateral pterygoid muscle, inserted into it. When the cartilagenous ligaments get stretched or torn, the physical displacement of the cartilage coupled with the tension that may be imparted to cartilage from the lateral pterygoid muscle, may readily cause a click or pop to be heard or felt as the cartilage is snapped between the condylar head and the skull base. This clicking and popping is a sign that the cartilagenous ligaments are loose, and that the cartilage is displaced. Sadly, clicking and popping is common and typical since many people have torn or stretched ligaments. Silencing of clicking and popping is not necessarily a good sign, since it implies that the cartilage is even further displaced forwards over time, subjecting the bony condylar head to even less protection from mechanically rubbing against the lower skull base bone.

Tooth Sensitivity

Recent research has elucidated the relationship between cold sensitivity and muscular TMD issues. A phenomenon known as Frictional Dental Hypersensitivity (FDH) is thought to be responsible, in that excessively flexed teeth due to hyperactive muscles of chewing, lowers the threshold whereby cold stimulation is perceived by the nervous system. Applying DTR therapy to a patient with hyperactive chewing muscles, almost universally reduces their cold sensitivity perception. Bottom line, sensitive teeth are typically due to either dental work or orthodontic movements that have the opposing top and bottom back teeth contacting​ too long in sideways movements, in time. This is typically curable by applying DTR therapy, regardless of the level of exposed dentin or cementum (in contrast to the 1964 Hydrodynamic theory of Branstrom and Anstrom). The CNO coursework introduces doctors to the FDH concepts.

Depression

​Deprive a chronic pain patient of hope in regards to what is wrong with them and naturally that patient will become depressed over time. Subjective and empirical diagnoses and treatments that fail TMD patients leads to depression, because nobody typically has an objective and definitive answer, unless they have been exposed to the CNO curriculum of course!

Anxiety

​Chronic pain, no hope, chronic anxiety. Simple.

Muscle Tension

​Muscle spasm and fibrosis can readily result from either displaced cartilage and/or opposing back teeth engaging one another for too long, in time. Chronic muscular tension of the chewing muscles may result which are often times painful, as well as accessory muscles of mastication (chewing) that are present in and around the neck.

Neck Tension

​Several muscles in the neck are accessory muscles of mastication. These muscle groups are often recruited to assist chewing muscles that are overworked and spent, resulting in a chronic neck tension. Additionally of course, cervical spine damage can directly cause neck tension as well, and it is relatively common for a patient with damaged TMJ cartilage to also have damaged cervical cartilage. The trick is delineating which source is primarily responsible for the neck tension, or is it both?

Shoulder Tension

Accessory masticatory muscles such as the trapezius and platysma muscles may also become overworked and spent due to overworked chewing muscles leading to shoulder tension at times.

Common Symptoms

Common Causes

 

Unmeasured Dental Work

Most Dentists are unaware of how their work on your teeth can affect your chewing muscles. For instance, a crown(s) or filling(s) can change the bite and cause problems resulting in common TMJ symptoms, simply by the bite being “high” or the tooth anatomy is the wrong shape. This inaccuracy is directly connected to the fact that research shows that dentists can only choose the proper contact 12% of the time when they only using traditional bite ribbon. This means that they are going to choose INCORRECT tooth contacts to address a patients bite issues 88% of the time! There are studies that have statistically demonstrated this! Unmeasured tooth alignment can readily cause headaches, tooth hot and cold sensitivity, grinding, stiff neck and shoulder muscles, and other “TMJ” issues. The key lies in diagnosis (or multiple diagnoses, or layers), proving objectively (whenever possible) that your temporomandibular joints and surrounding structures are both stable. IF SO, then these issues are likely happening because your bite is misaligned and muscular spasms are causing your tempormandibular dysfunction. IF NOT, then your issues may also have other layers that are causing your problems. Again, “TMJ`’ is typically NOT a psychological problem; it is literally in your head, NOT your mind! Teeth, muscles, bone, joints and cartilage; we methodically measure all of these co-factors to arrive at a working, and ultimately, a definitive diagnosis.

Damaged Cartilage

​In perfect TMJ health, cartilage sits on top of where the lower jawbone articulates into your skull base in front of your ears. That cartilage has a thickness. There are ligaments holding that cartilage there, just like there are ligaments holding the cartilage in place between the long bones of your leg. Tear or stretch the ligaments, and the cartilage will likely displace forwards in the TMJ. When the cartilage is forwards, many times this will change the bite, with back teeth typically hitting harder than they should. When back teeth hit too hard, your nervous system does not like this and responds by making the chewing muscles work harder and harder, not allowing those muscles to take a break. This can readily lead to chronic pain due to the muscles being overworked. Bottom line, damaged cartilage is another pathway by which your bite may change, potentially leading to chronic pain around your TMJ’s, teeth, and/or temples.

Dead Bone

If the blood supply to your mandibular condyle is cut off, then the jaw bone can die. This is known as Avascular Necrosis (AVN). AVN can happen for several reasons, but perhaps the most common is due to the cartilage ligaments being torn and the anteriorly displaced TMJ cartilage pinching off the blood supply to the condyle. This may happen in particular if the cartilagenous disk is displaced forwards and medially. AVN is fairly rare, but needs to be identified. The only non-invasive way to properly identify AVN is via proper MRI imaging of the TMJ’s.

Head Trauma (recent or old)

Physical trauma can tear ligaments, both in your TMJ’s and in your cervical spine. This can cause TMD issues from both the TMJ’s and the cervical regions.

Whiplash

A whiplash is a rapid, acute injury to the head that can once again tear or stretch the ligaments in one or both of your TMJ’s and in your cervical spine. These cervical and TMJ issues may manifest as “TMD”.​

Improper Bite

Think of top and bottom teeth as parts of a machine. When they don’t hit and interact properly, there can be muscular issues that may manifest as pain resultant of the muscles not being perfectly aligned biomechanically and neurologically, in time.

Jaw Dislocation or Injury

​Dislocations and injuries damage cartilage, which can lead to inflammatory and degenerative changes of the bone, both of which can readily alter the bite and lead to chronic pain conditions.

Arthritis

Displaced cartilage is fairly common, and when that protective layer is missing, jaw bone rubs on skull bone, with ensuing arthritic breakdown. As the jawbone breaks down, that too can change the bite and cause pain in and around the TMJ’s.

Erosion of the Joint

Excessive inflammatory fluid buildup in the TMJ mandibular condylar head is defined as an erosion. Erosions can only be seen on TMJ MRI’s and are a sign of active joint breakdown.

Structural Jaw Issues

When the jaw bone is of abnormal size or shape, this can alter the entire stomatognathic (chewing) system. The body will adapt and remodel to this change over time. How it adapts dictates whether or not things are stable and adapted.

Cervical Neck Damage

​Cervical issues readily contribute to TMD pain issues. The neck should always be considered as a potential player in the TMD patient.

Sympathetic Input

The sympathetic branch of the autonomic nervous system is basically the bodies “fight or flight” mechanism. Of significance, sympathetics cause vasoconstriction (shrinking) of blood vessels​. Chronic vasoconstriction starves muscle cells of oxygen, leading to ischemia and pain. Excessive sympathetic stimulation in the head and neck can readily create chronic pain for patients. Excessive contact between opposing teeth, over time in the functional movements, can overstimulate the sympathetic nerves in and around the teeth leading to chronic pain.

Facial Muscle Tension

When muscles overwork, they become ischemic and painful as they cannot get enough oxygen​. A term known as claudication occurs when the demand for oxygen outstrips the amount of supplied oxygen to a muscle group. Chronically overworked muscles of the head and neck due to bite and/or TMJ orthopedic imbalances can cause just these sort of events, and manifest as chronic facial muscle tension.

Acute Effusion

An effusion is a site of active inflammation in the TMJ spaces and can only be seen on a TMJ MRI. Effusion(s) are an objective sign(s) of a TMJ that is not stable nor adapted.

Common Causes

Current Treatments Only Targeting Symptoms

Here is a list of Treatments that targets only the Symptoms

SPLINT THERAPY

Splints may indeed protect the teeth, but technically may cause more problems within the joints themselves. Imaging the cartilage and bone within the joints should ideally occur prior to deciding on splint therapy or orthotic construction relative to bite position and splint design. Splints universally remove the patients’ ability to adapt their teeth to the status of their TMJ’s as teeth individually adapt to muscular changes, over time, to self-resolve TMD issues.

ORTHODONTICS / BRACES

Braces take years to move teeth, and many cases of TMD do not respond after orthodontic therapy since the actual cause of the TMD may have been joint based and never properly diagnosed. Additonally, if orthodontic movements (on a patient with initially perfectly normal set of TMJ’s) are left unmeasured in relation to timing and force between opposing teeth, orthodontics can actually cause painful muscular TMD issues relating to not only hyperactive muscles of mastication, but also to orthopedic issues involving the lateral pole of the cartilagenous disk.

BOTOX INJECTIONS

Injecting Botox into muscles biochemically “relaxes” them, but only for several months. If the patients finds that they had great relief with Botox but their symptoms returned, they are likely a great candidate for DTR therapy, after the other tools used by the CNO have objectively confirmed that other issues do not exist.

MUSCLE RELAXANTS

If a patient reacts positively (but temporarily) to muscle relaxers, that is a good sign that a CNO doctor can help, as this implies that the masticatory/chewing muscles are overworking. If it is the bite causing this (which it often is due to orthodontic or dental work that is placed unmeasured), DTR therapy would likely help the patient.

MASSAGE

Treating the muscles throughout the head and neck to break up trigger points only gives the TMD patient temporary relief.

DIET

Are you avoiding chewing gum, tougher foods, and cold foods and drinks? These are signs of a potential TMD issue…

TRIGGER POINT INJECTIONS

Injecting anesthetics into muscle does not address the core reasons for a muscular TMD issue.

CHIROPRACTOR / OSTEOPATHY

Chiropractic treatments typically give only temporary relief for TMD.

DRUGS or PAIN TABLETS

Ibuprofen, Naproven, Anti -Inflammatories, narcotics, anxiolytics: find the root cause of your problem and get off of the meds!

PSYCHOTHERAPY

Have you been told that your “TMJ” is all in your head? They are right, but they are wrong. The joints, muscles, nerves, teeth, cartilage, bones and ligaments that contribute to TMD issues are just that, in your head.

TENS THERAPY

Transcutaneous Electrical Nerve Stimulation: temporarily relaxes the muscles, period.

REDUCING STRESS

Your emotional well-being or problems at school or work have little to do with your TMD condition. Stress as it relates to TMD is physical, biomechanical, infectious, hormonal, or biochemical in nature.

MASSAGE

Treating the muscles throughout the head and neck to break up trigger points only gives the TMD patient temporary relief.

Anxiety

​Chronic pain, no hope, chronic anxiety. Simple.

Muscle Tension

​Muscle spasm and fibrosis can readily result from either displaced cartilage and/or opposing back teeth engaging one another for too long, in time. Chronic muscular tension of the chewing muscles may result which are often times painful, as well as accessory muscles of mastication (chewing) that are present in and around the neck.

Neck Tension

​Several muscles in the neck are accessory muscles of mastication. These muscle groups are often recruited to assist chewing muscles that are overworked and spent, resulting in a chronic neck tension. Additionally of course, cervical spine damage can directly cause neck tension as well, and it is relatively common for a patient with damaged TMJ cartilage to also have damaged cervical cartilage. The trick is delineating which source is primarily responsible for the neck tension, or is it both?

Shoulder Tension

Accessory masticatory muscles such as the trapezius and platysma muscles may also become overworked and spent due to overworked chewing muscles leading to shoulder tension at times.

Current Treatments Only Targeting Symptoms

How Neural Occlusion Screening Works

Neural Occlusion screening involves a combination of hi-tech objective technologies and knowledge to ascertain whether or not a patient possesses a proper bite and stable and adapted TMJ's, and/or if their problem(s) arise from other sources.

1

Measure

We believe in measuring “TMJ” problems whenever possible. Many times the TIMING or the alignment of your bite is incorrect and that IS the root cause of your “TMJ” problems.

What We Measure

Force & Time (T-Scan)

This device called a T-Scan reads the force and timing of your bite. Placing this into the patient’s mouth it is possible to objectively record and measure the bite.

EMG

Electromyography (EMG) is an electrodiagnostic medicine technique for evaluating and recording the electrical activity produced by skeletal muscles in microvoltages. CNO uses the EMG.

X-Rays

Allows us to look inside your teeth. Sometimes your past dental work is responsible for your TMD issues, or at least a contributing layer.

Ice Water Swish

Frictional Dental Hypersensitivity (FDH) can occur when the patients muscles are overworking due to a misaligned bite. The patient with a TMD issue solely due to overactive muscles from a bite issue will typically have hypersensitive teeth that shows up when they are challenged with the ice water swish. Once the bite alignment is corrected, the sensitivity will typically go away. There are neurological reasons for this that are not fully understood, which may relate to the overactivity of the sympathetic branch of the autonomic nervous system.

JVA

Joint Vibration Analysis is a screening tool of the TMJ cartilage. JVA is based on simple principles of motion and friction: When smooth surfaces rub together, little friction is created…and little vibration. If these surfaces become rough, as would be the case when the TMJ cartilage is damaged relative to the bone in one or both joints, then the friction and vibration that is created when these surfaces articulate would show up as an aberration in the JVA readings.

CBCT Scan

CBCT scan, also called X-ray cone beam computed tomography, is a low-radiation way of studying the bony jaw bone and the skull, objectively elucidating spacing between these bones as well as growth and development issues. It is also very effective at identifying degenerative and arthritic changes that might be taking place within the TMJ’s as well.

MRI

Magnetic Resonance imaging uses magnetic pulses rather than ionizing radiation to study cartilage, fluid, and fat content within both TMJ’s. An extremely useful tool, MRI often identifies problems that would go completely unnoticed otherwise.

2

Categorize Patient

After all scans and measurements are complete, patients are then categorized.

CNO Patient Types

CNO Type A
Stable Adapted Joints

Objectively Confirmed Healthy TMJ's

No Organic Issues

Other MD's, Neurologists, and Chiropractors Have Ruled Out Other Systemic Issues

The bite is off

Dental Work, Tipped Teeth or Braces Caused This TMD Problem

  • This case is very likely to respond to DTR bite alignment therapy
  • Very Treatable
  • High Percentage of Success
CNO Type B
Relatively Stable & Adapted Joints

Alignment of the Bite Can Help

Damaged Cartilage

People Are Unaware, But It Is Common

Minor Bone Wear

Usually Due to Damaged Cartilage in the TMJ

  • There Is Hope
  • Usually At Least Partially Treatable with DTR Bite Alignment Therapy
  • Good Percentage Of Success
CNO Type C
Unstable Maladapted Joints
Dead Bone
Acute Inflammation & Effusion
  • Help is at Hand
  • Bite Alignment Treatment Should Not Be Attempted
  • May Need to be Referred for Workup by a TMJ Surgeon

3

Digitally Directed “Alignment”, IF Indicated

Measured Anterior Guidance Development (MAGD) therapy is a bite/occlusal adjustment procedure used in patients that possess stable and adapted temporomandibular joints (TMJ’s). Objective confirmation of stable & adapted TMJ's leads to predictable outcomes regarding restorative dentistry &/or TMD therapy!

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When back teeth contact/touch too long in TIME during function, research has shown repeatedly for decades that this neurologically overstimulates muscular contraction within the chewing complex. Many of these muscles, when overworked, become very fatigued and painful, resulting in unexplained headaches and tension within the head and neck.  In a practical sense, muscles that overwork chronically can lead to not only broken teeth, but failing dental work as well!

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A precise and objective, digitally directed “alignment” of the way the teeth relate to one another over TIME, can reduce this overstimulation of the muscles (in patients with objectively confirmed TMJ's), leading to not only a reduction in painful symptoms, but in the likelihood that dental work will not fail over time as well!

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Based upon three decades of evidence-based research by Dr. Robert Kerstein and others, DTR therapy does not involve the usage of splints, medications, injections, lasers, chiropractic therapy or other temporary adjuncts. DTR addresses what is often the genesis of the problem that causes the chewing muscles to overwork; excessive contact of posterior teeth, over passing TIME.  MAGD is essentially DTR therapy on steroids, in that the TMJ's and the influence that the joints impart upon the occlusion have been objectively measured before the initiation of treatment.  In other words, the joints and their influence upon the occlusion are taken into consideration with MAGD, whereas they are not with DTR therapy.  Those doctors who have trained through CNO Level 3 have demonstrated that they possess intimate knowledge about the TMJ's and are capable of performing MAGD therapy after objectively imaging the TMJ's.

What others are saying

Neural Occlusion Screening (NOS) is revolutionizing TMD diagnosis and treatment, and improving the likliehood of successful dental treatment outcomes! Check out what patients and doctors are saying about it!

peter_dmd

“Because the measured linkage of force and muscle activity in DTR is a critical component of treating occluso-muscular disorders, I was happy to be able to take the Certification exam to ratify that the learning I had undertaken would enable me to serve my patients' best interests.”

– Peter Barnett, DMD, FCNOPlano, TX

Coker_facesmaller

"The motto says it all: "Measured Matters". Dentistry has wandered thru the wilderness of solving oro-facial pain for our patients, and the CNO concepts are a huge step forward in our ability to help the people we serve. It is an exciting time for dentistry!"

– Rick Coker DDS, FCNOTyler, TX

canada-flag-canada-flag-canada-flag-canada-flag-canada-flag-3ENJTu-clipart

"Hello from Calgary, Alberta! It's been a few weeks since my computer-guided bite treatment, and I have to tell you that you've changed my life! It took a few days for my jaw to settle out, but since then, I haven't had any jaw pain. I continue to sleep without my splint, and although I had a couple of pressure points early on, my teeth do not hurt at all. My muscles still seem tight when I wake up (I might still be clenching at night), but my joints do not cause me any pain. This is very different from before treatment, when a sore jaw was a daily and significant occurrence. Also, I have again tried the dreaded "ice water test," and while I was still an 8/10 in your office right after the treatment, I would now put my pain at a 0/10. It feels cold, certainly, but not at all painful. When I first tested it out last week I couldn't believe it, and had to keep swishing to see if it was true! So amazing. So needless to say, I am incredibly happy with the results of my DTR treatment. I can't believe the difference you have made in my life, and I can't possibly thank you enough." Her case study: https://youtu.be/8Vx58frPGqc

– Vikki-a DTR patientCalgary, Alberta

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“Nobody in my area, not one dentist, could get my bite right. Every time I had dental work done, the bite was shifting all over to the point that I had teeth banging from my front teeth to my back teeth. Jaw pain, headaches in the back of my head, neck and shoulder pain; all of that has improved since getting my bite balanced to the way it was supposed to be!” Her case study: https://youtu.be/rJEN8CoqGTA

– Darleen-a DTR patientMichigan, U.S.A.

Turkey_flag

"Before doing DTR my mouth was telling my brain that things weren’t right, but I didn’t know what to do about it. Several months after having done DTR, I have nothing bad to say about it! If things keep going the way they are, I’m going to be a very happy person! The things that I’ve done w/ this disability… imagine what I’m going to do without it! I’m going to take over!" His case study: https://youtu.be/AWv-1-_JhKQ

– Taner-a DTR patientIstanbul, Turkey

DOCTORS - Get CNO Certified.

Positively Change Lives.

As a CNO trained health professional, you will be well-suited to identify, diagnose, and address many confounding bite and TMD problems. The higher your level, the better suited you will be to consistently diagnose and treat many TMD conditions, resulting not only in a more rewarding experience for you and your patients, but also an ethical, practical, and ubiquitously needed skill set which will set your practice apart from the rest!

Practitioners who have passed the various certification levels and who possess an active CNO annual membership will be listed in the CNO "find a doctor" database, used by patients to find a CNO trained practitioner.

CNO Foundations
Included w/ $695 Annual Membership

All health care providers
  • Learn how unmeasured dental and orthodontic work can actually cause muscular TMD problems, headaches, and pain.
  • Learn how neurologic, orthopedic, and timing issues within the bite can profoundly influence a TMD patients condition.
  • Become more proficient at diagnosing occlusal (bite) and TMD conditions
  • Why analog bite ribbon is so prone to error, yet most every dentist uses it exclusively.
  • Learn why "Measured Matters" for bite & TMD.
  • Maintain an active CNO membership to be listed in our CNO Doctors database as a CNO Foundation level provider (upon CNO F didactic exam completion).
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CNO Level 1

Dental practitioners & all health care providers
  • Gain a thorough understanding of both Joint Based Occlusal and Measured Anterior Guidance concepts as they pertain to both occlusal and Temporomandibular Dysfunction.
  • Why ICAGD is completely different from occlusal equilibration.
  • The importance of midcourse corrections.
  • Instructed via live lecture by Dr. Yiannios, and/or other CNO Board members either on the road or at CNO headquarters in Rogers, Arkansas.
  • In-depth instruction on use of tools such as the T-Scan, BioEMG III, JVA, and other objective measurement tools as they relate to TMD diagnosis and treatment.
  • Maintain an active CNO membership to be listed in our CNO Doctors database (upon CNO 1 didactic exam completion).
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CNO Level 2

Dental practitioners
  • A CNO instructor will travel to your office and observe as you perform DTR therapy on 3+ appropriately selected TMD patients.
  • Prove to the instructor that the practitioner knows how to properly identify patient type and assess whether or their chosen patients are appropriate candidates for DTR therapy.
  • Prove to the instructor that the practitioner is capable of proficient use and proper operation of all tools relevant to DTR Therapy & Measured Anterior Guidance Development (MAGD) concepts.
  • Maintain an active CNO membership to be listed in our CNO Doctors database (upon CNO 2 clinical one on one training completion).
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CNO Level 3

Dental practitioners
  • 3D imaging introduction including CBCT hard tissue imaging and MRI soft tissue imaging of the TMJ.
  • Didactic and practical clinical instruction regarding both image-based Measured Anterior Guidance Development (MAGD) and DTR concepts conducted at the CNO headquarters in Rogers, Arkansas and/or at the Piper Education & Research Center (PERC) in St. Petersburg, Florida.
  • How to objectively determine if a patients has stable and adapted TMJ’s
  • Maintain an active CNO membership to be listed in our CNO Doctors database (upon didactic & oral exam completion).
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