Interesting question.

There is little argument w the concept that a decrease in disclusion time (immediate posterior disclusion and transition from cuspid/group to incisors quickly and smoothly) matters.

The question is when does it matter? Is it helpful treating pain patients or used as an adjunct to restorative care in a healthy, pain free patient? Disclusion time is not a functional activity, it is parafunctional activity, a concept that is not understood by far too many. The T-scan can measure the occlusal design as a parafunctional control system and theoretically, by improving the occlusal design, affect two things: Alter parafunctional force vectors that tend to be destructive; alter nociceptive afferent input to the trigeminal nucleus/system which certainly could help pain patients.

However, chronic pain patients need a whole lot more than decreased disclusion time. The suggestion is made that use of the T-scan is the KEY to reduced muscle activity and ‘TMD pain”, that occlusal treatment is all that is needed for chronic pain management. When dealing w chronic pain patients a Dx is needed and invasive care as a first line of treatment is not supported by the evidence based literature.

If you are analyzing muscle activity w EMG then you need to define the pathophysiology of muscle pain and it is very unlikely to be simply tired or stressed muscles. It has more to do with how that trigeminal signal is processed centrally. If parafunction by itself were causative, then there would be a dose response gradient to satisfy the Bradford Hill criteria of causation. There is no dose/response gradient. The relationship is non-linear. The folks who parafunction the most are not the ones who have the most pain. It is a problem of central sensitization.

Regards,

Thank you John for the elaboration.

What I've noticed about these patients responded to DTR  is that they have something in common: Most of them didn't respond well for non-invasive tx such as ( Splints, physical therapy, home care and TrP injections) But again, TMD is an umbrella term and has a multifactorial etiology and we can't just say a one type of tx will work.  

I use ICAGD to accomplish DTR on a daily basis, for both symptomatic muscular TMD patients, as well as conceptually in treatment planning and designing occlusal schemes on "normal" patients.  I've known Robert Kerstein for many years, and am a co-author in his recent 1st edition textbook on digital occlusal analysis.  Robert's research is amazingly practical, but not a panacea re TMD.  Sadly, nothing is, but DTR comes close, in a patient with objectively confirmed stable and adapted TMJ's, IF the problem is resultant of occlusal imbalances causing stomatognathic dystonia.  The hardest part is determining if the patient's stable and adapted, and if it's purely muscle causing their pain.  If it is, and ICAGD is properly commenced to perform the principles of DTR, it works predictably.  Hardest part is the "stable and adapted" determination.  CBCT, MRI, JVA, doppler, EMG-I use these adjuncts in combination constantly, always looking for dystonia resultant of excessive posterior frictional engagements "ramping up" an excessive efferent muscular response.  I would be happy to answer any questions you all may have in regards to the practical application of DTR.

Hi,

I have been associated with Robert from 2008 and have been working with this concept of ICAGD and DTR since then. Have produced some research articles on this. Agree with NICK, if the TMD issue is because of Hyperactive masticatory muscles, this is an wonderful objective treatment protocol.

Very interesting to know I would love to  learn more about this method I will make sure to read more. Thanks 

3 years ago, I began uploading case studies using DTR on tmd patients. The YouTube channel:  Drnickdds. There are presently over 90 case studies presented in video format.  Some of these videos are designed specifically for professionals.  The others are designed primarily for patients seeking answers. Hardly scientific, this effort is, however, amazingly practical.  Feel free to log into the channel to understand when it is appropriate and how we perform Icagd based upon Tscan/emg/MRI/cbct/jva/hx and exam. 

I have been doing DTR for over a year and have done 51 cases to date.  I graduated UMDNJ in 2005 and have been chasing TMD for about 8 yrs now.  I have to say many of these patients are misdiagnosed with other maladies.  Oddly enough when I do my work up there is either a bite force or timing issue.  That is what I treat and patients start doing better.  I use all of the same diagnostics Nick does plus Jaw Tracking.  Not using MRI as of yet though.  After DTR, patients have a greater ROM.  Friday I did DTR on a woman whose vertical opening was 26 mm and 45 min later it was 37!  Yes that is same visit.  One other thing that I see 100% of the time is there is a correlation between ROM on lateral excursion is restricted on the same side the pain is on.  She could slide 6mm to the right and only 3mm to the left, pain was on the left side.  TMJs were stable and adaptive.  The Hyper activity of the muscle is related to the working side group interferences (not non working side as so many believe).  Remove the working side interferences and muscle activity goes down.  There are different types of TMD this is true, but muscle is almost always a component on some level.  It is interesting to me and I keep hearing the phrase "evidence based dentistry."  Tekscan and DTR have 30 years of published results that DTR is a viable treatment option for TMD, yet only a handful of doctors actually measure anything when it comes to occlusion.  Shimstock, bite reg material, waxes and accufilm tell the operator nothing about bite force and timing.  I have not seen one evidence based paper that accufilm alone outperforms TScan.  DTR requires a very high level of accuracy, on the order that it can be measured on the TScan but the patients cannot perceive a change in many cases. Yagoub Alyami, it would be great to return to my alma mater with TScan and EMGs and work up a few cases.  I do have a NJ License maybe we can treat a patient or two.  Gary Heir still in Oral Medicine?

Quote, Ben Sutter: “It is interesting to me and I keep hearing the phrase "evidence based dentistry."  Tekscan and DTR have 30 years of published results that DTR is a viable treatment option for TMD, yet only a handful of doctors actually measure anything when it comes to occlusion.”

Perhaps you have misinterpreted the definition of "evidenced based.”

Evidence based practice modalities are simply defined as, " the practice of medicine or dentistry by making decisions through the judicious identification, evaluation, and application of the most relevant information."

Any study can have bias, but when these studies are looked at critically, the biases will be noted and the study can be evaluated accordingly. A systematic review does just that, it covers a particular topic by doing an exhaustive key word search in all available scientific databases and then grades the relative papers according to set standards (SORT, AMSTAR, Met-analysis, QUOROM). Opinions are then stated based on the preponderance of well qualified studies. Usually case reports, retrospective chart reviews and expert opinions are eliminated.

So, evidenced based is not one persons opinion or one study's results.

There needs to be some substance to support your invasive treatment modalities. There is no support for “DTR” in the evidence based literature, or any occlusal based treatment for TMD. There needs to be some validity, can you provide any?

The T-Scan technology has been measuring and reporting on posterior Disclusion Time durations since 1991.1 Since that time  the T-Scan system has been shown in many studies to be able to reliably distinguish differences in long and short Disclusion Time present during excursive movements.,2,3,4,5,6,7,8  

Disclusion Time was first isolated and described solely because of the T-Scan system’s capability to record real-time dynamic occlusal events in 0.01- 0.003 second increments.1,2,3  Prior to the development of the T-Scan system, no occlusal indicator could quantify and time -sequence occlusal contact order and durations.  The clinical significance of the Posterior Disclusion Time is it elevates muscle activity levels and increases the duration that the same muscles fire during excursive movements .1,5,6,8

A follow-on Disclusion Time measurement study to the original 1991study published in 1994 recalled at 1 year, the subjects of the 1991 study to reassess their Disclusion Times for any changes. This study showed that the subject group’s Disclusion Times all remained stable 1 year from their last Disclusion Time measurement.2

Then in 1995, a published 9-year long follow-up, Disclusion Time Reduction treatment results study reported on 102 muscular TMD patient symptoms that were treated previously with DTR therapy.3  Statistically significant reductions in the frequency and intensity of experienced muscular TMD symptoms, the amounts of medication used to control symptoms, and markedly lessened numbers of treated subjects who needed splints after undergoing DTR, were reported by the vast majority of subjects.3  

Later In 1997, a Disclusion Time occlusal adjustment treatment study involving 30 subjects (17 were treated with the ICAGD coronoplasty; 13 controls underwent “mock ICAGD tooth polishing), that were recalled 4-5 times during a 1-year long period of treatment or/control treatment,  showed that across the 1-year recall period the treated subjects reported many chronic muscular TMD symptoms were markedly lessened, but were maintained and caused painful levels of discomfort in the control group.4  The individual subject Disclusion Time means and standard deviations showed statistically significant similarities on each day of measurement, indicating that very consistent Disclusion Time data was gathered per subject, regardless of the recall date, while being recorded with many differing T Scan sensors.4  With so many subjects being recalled at multiple Disclusion Time recording measurement dates to report on their symptom changes, the pre ICAGD to post ICAGD symptomatic change data clearly indicated that once the Disclusion Time was shortened to physiologic levels, many muscular TMD symptoms abated, and declined in frequency and intensity across the 1-year period of observation.

Another study published in 2006 involving 62 subjects, where simultaneous recording of the Disclusion Times and muscle activity levels was employed when each subject made 4 right and 4 left excursive movements, demonstrated that reducing prolonged Disclusion Time to Short Disclusion time, created an improved  therapeutic muscular effect.  Within one month's time following the Disclusion Time Reduction, there was a statistically significant increase in the maximal clenching capacity of the masseter and temporalis muscles.5

Recently, two different studies have shown that shortening the Disclusion Time dramatically lessened hyperactivity in the masseter and temporalis muscles=,  and rapidly improved many chronic muscular TMD symptoms.6   In 2012, 45 symptomatic Occluso-muscle Disorder patients had 2 right and 2 left excursive movement Disclusion Times recorded with the simultaneous recording of 180 muscles’ electromyographic levels, once before undergoing the ICAGD coronoplasty, and again post ICAGD treatment. The Student’s paired t-test showed that the statistically significant change in the Disclusion Time length from pre to post ICAGD resulted in statistically significant muscle activity contraction level reductions during lateral excursive movements, from pre to post DTR treatment.6

Alternatively, a separate group of authors performed a DTR study involving 51 myofascial pain patients with symptoms in the area of the head and neck region, whom were treated with ICAGD and Disclusion Time data from T-Scan records. The authors reported that after correcting the prolonged Disclusion Time, the subjects demonstrated significant symptom relief.7 The Wilcoxon Signed Ranks Test illustrated that the changes in Disclusion Time were statistically significant (P < 0·05) from Day 1 to all measurement dates after Day 1.7  This study, like the 1997 DTR study previously described4,  included multiple dates of re-measurement of the Disclusion Time, and the reported marked reductions in chronic muscular TMD symptoms of the subject pool during the period of observation, after undergoing Disclusion Time Reduction treatment at Day 1.7  

Lastly, in a study that is presently under review for publication, 29 Occluso-muscle Disorder symptomatic subjects underwent simultaneous Electromyographic (EMG) and Electrognathologic (EGN) recordings of their right and left gum chewing before and after undergoing the ICAGD coronoplasty, to assess changes in their Average Chewing Pattern (ACP) resultant from shortening their pretreatment prolonged Disclusion Times. The Results showed that many chewing motion timing and strength parameters improved within 7 days after ICAGD.  The Peak Amplitude, the Time to Peak Contraction, the Time to 50% Peak Contraction, and decreased numbers of Silent Periods (SP) per side during chewing, were all observed. Other post ICAGD ACP improvements were:  the Terminal Chewing Position (TCP) became closer to Centric Occlusion (MIP), the Maximum and Average Chewing Velocities increased, the Opening and Closing Times, the individual chewing Cycle Time, and the Occlusal Contact Time, all decreased, indicating the post ICAGD, subjects chewed gum faster, stronger, and more consistently.8 This is the first occlusal adjustment study present in the literature to show that  human chewing function can be statistically improved in symptomatic subjects, by undergoing computer-guided occlusal adjustments.  

Reference

1.      Kerstein, R.B., Wright, N., An electromyographic and computer analysis of patients suffering from chronic myofascial pain dysfunction syndrome; pre and post - treatment with immediate complete anterior guidance development. Journal of Prosthetic Dentistry 1991; 66(5):677 - 686.

2.      Kerstein, R.B., Disclusion Time Measurement Studies: Stability of disclusion time. a 1 year follow - up study. Journal of Prosthetic Dentistry. 1994;72(2):164 - 168

3.      Kerstein, R.B., Treatment of myofascial pain dysfunction syndrome with occlusal therapy to reduce lengthy disclusion time - a recall study, The Journal of Craniomandibular Practice, 1995; 13(2):105-115.

4.      Kerstein, R.B., Chapman R., and Klein, M., A comparison of ICAGD (Immediate complete Anterior Guidance Development) to "mock ICAGD" for symptom reductions in chronic myofascial      pain dysfunction patients. The Journal of Craniomandibular Practice, 1997: 15(1):21-37

5.      Kerstein, RB. Radke, J. The effect of Disclusion Time Reduction on maximal clench muscle activity level. Journal of Craniomandibular Practice, July 2006: 24 (3); 156-165.

6.      Kerstein RB, Radke, J. Masseter and temporalis excursive hyperactivity decreased by measured anterior guidance development.  The Journal of Craniomandibular Practice, 2012; 30(4):243-254.

7.      Thumati, P. Manwani, R. Mahantshetty, M. The effect of reduced disclusion time in the treatment of myofascial pain dysfunction syndrome using immediate complete anterior guidance development protocol monitored by digital analysis of occlusion. The Journal of Craniomandibular Practice, 2014:32(4);289-299.

8.      Kerstein, RB. Radke, J. Average chewing pattern improvements following disclusion time reduction. In review at Clin Oral Inv, August 2015.

John hope this helps.

Re-

''Yagoub Alyami, it would be great to return to my alma mater with TScan and EMGs and work up a few cases.  I do have a NJ License maybe we can treat a patient or two.  Gary Heir still in Oral Medicine?''

Hello Ben, sorry for such a delayed response. That is so nice of you, thanks and I was talking to Dr Heir recently about DTR and neuromuscular dentistry in general. He is totally against the concept due to lack of strong evidence behind it. But, I will keep reading and searching about it. 

Thanks for your response. 

Good Morning.

As mentioned the cost of the procedure is not at all costly. I charge about $500 for the treatment using this technology. It depends which country we work in.

You can google out for my articles on ICAGD in google scholar

Regards

Prafulla Thumati. 

Dr. Robert Kerstein`s DTR is a very harmful procedure because it grinds down patients' teeth . By doing this dr. Kerstein triggered TMJ of my wife's other side, causing her much more pain than ever before, causing tingling in her entire body, headaches, numbness in her forearms and hands, insomnia, etc. Bonding would have been much appropriate. Now she needs all her molars restored. The DTR procedure should have never been done in case of dislocated and unstable jaw discs! Dr. Kerstein misdiagnosed her before the procedure as he did not look at her MRI. His office informed us of planned bonding procedure, but he did grinding instead. This was a grave error. As a result my wife needed another splint which she tried to get rid of by undergoing the DTR procedure. DTR is a huge marketing fraud!!! Selective grinding can also result in sleep apnea. DTR is a very stupid procedure!

We have to excuse Martin's total lack of knowledge of dentistry and specifically the Disclusion Time Reduction procedure because he is a physicist, maybe even a very good one. I don't know. I do know that there have been tens of thousands of TMD patients successfully treated with this procedure by thousands of dentists that have bothered to learn it. DTR is more conservative than any other occlusal equilibration procedure because it accurately targets only the high force points in the occlusion, usually only 2 or 3 contacts. Those who haven't learned this procedure usually are very skeptical, but that is only human nature. If DTR was truly a bad procedure and not efficacious, it would only take one study to prove that, but that study does not exist. According to the scientific method you can prove that something doesn't work with one example, but you can never prove it always works no matter how many samples.

John Radke is a salesman selling the overpriced Tekscan gadgets used in DTR. He is an MBA.The gadgets certainly produce electric signals that give an appearance of rigorous measurements. There has been a rigorous study made. But don't take my word for it since I am only a physics professor. Please, read Neuromuscular Occlusion for Diagnosis and Treatment of Temporomanibular Joint Disorders: A Review of the Clinical Evidence published by Canadian Agency for Drugs and Technologies on January 11, 2013. Also, look at the work by prof. emeritus Charles Greene. See his article: Adjunctive Diagnostic Tests.

There is a reason that 99% of dentists have no idea what DTR means. It is Kerstein's experiment that was never accepted by broad dental community. Both Kerstein as co-inventor and Radke have significant financial interests in dentists buying their gadgets. The problem is that dentists are not electrical engineers/physicists to make a critical evaluation of these measurements and are susceptible to believe what Radke/Kerstein tells them. Kerstein's DTR grinding destroyed my wife's bite and caused many long term problems for her. It is too bad Radke is so desperately trying to discredit me as his business is dependent on dentists paying significant amounts of money to get wonderful electrical signal that is highly questionable in value.

Yes, I do it day in and out from last 15 years. It costs my patients from 0-$500. It’s in my place. Depending on country it could be different. But, its absolutely objective quantum physics science , which helps the clinician to treat patient Obgectively👍💐

My 46 years of dental research publications speak for themselves. You can find them mostly all here on ResearchGate for public consumption and individual evaluation, so you don't have to depend on anyone else's opinion of them, least of all Charles Greene's. Greene has spent the past 52 years fruitlessly attempting to convince the world that TMD is a psychosomatic illness, but without producing any objective evidence to support his theory. No one else has, as of yet, produced a cognitive behavioral therapy that successfully cures TMD. I do not sell T-Scan, have no vested interest in Tekscan, Inc. but I have witnessed and published studies of the dramatic improvements commonly seen after DTR treatments for many, but not all of the 40 + conditions under the category of TMD.

The CADT in 2013 reviewed 15 of the 596 publications they found and concluded the following:

"The available evidence [from 15 out of 596 studies] does not support the use of electromyography as a diagnostic test for temporomandibular disorder. The use of electrical stimulation for the treatment of TMD is not supported by the current evidence. No conclusions can be made on the efficacy of occlusal splint based on the neuromuscular occlusion concept." No mention of T-Scan or DTR was included in their conclusions.

Martin is apparently still sore that his wife was not one of the tens of thousands of DTR treatment successes. No treatment for TMD is 100 % successful. Since TMD consists of 40 + distinct conditions and many TMD patients have more than one diagnosis. Perhaps his wife's condition was not one of the ones that responds in a positive manner or she had multiple conditions. However, the foremost reason Dr. Kerstein has so earnestly dedicated his career to the teaching of DTR is because of the tremendous successes that it has produced.

Best regards,

John