Tooth Related Infection and Inflammation Current Science
The mantra of modern dentistry has been “Save teeth at all costs”. This has now been challenged by a recent study* published in conjunction with the Department of Oral Facial Pain at the School of Dentistry at the University of Southern California. They found that both infection and inflammation can change the neurophysiology of tissue surrounding a tooth within a period of as little as two weeks. These changes affect the molecular pathophysiology of pain with abnormal expression of sodium channel genes and its contributions to hyperexcitablility of primary sensory neurons. This is reported in the publication “Pain.1999 Aug;Suppl 6:5133-40”. These changes are permanent at the level of genetic expression in nerve tissue and are pathologic regarding pain associated to the oral cavity. The areas this pain can and does have affect is consistent with pain related to the condition of TMJ. These areas are readily seen in the application of local anesthetic to the affected teeth and the lack of adequate anesthesia that is obtained to complete dental procedures. Before this study it was widely accepted that there were accessory nerves or acidic infection present to counter the efficacy of the local anesthetic. The study clearly demonstrates there are permanent changes in neuronal histology affecting sodium channel physiology of nerves supplying the tooth
and adjacent tissue which in the mouth is the 5th cranial or Trigeminal Nerve. This nerve has the ability to experience the phenomena of referring pain to other areas of its innervation including pain commonly associated with TMJ.
3-D Cone Beam Xray Technology
There is an old truism that a picture is more valuable than a thousand words to describe something not clearly understood. The problem with this is that until recently the pictures(2-D X-Ray of the teeth and surrounding bone) were insufficient to reveal hidden areas of pathology found around these teeth. The current technology not only reveals previously hidden views of pathology related to unresolved inflammation and infection, it also magnifies and varies picture resolution to clearly demonstrate areas of pathology. Another significant advance in regards to cone beam cat scan technology is its capability to illustrate what are known as idiopathic bone cavities or cavitations. These areas have been an area of considerable disagreement regarding their existence and if they are etiologically active in causing disease or pain. In the study presented by Dr. Clark a small sample of these cavities were present, did not respond to therapy offered in the study, and continued to be a source of oral facial pain in follow up examination. Many of the areas diagnosed as bone cavities clinically have a history of failed root canal treatments or chronic inflammation in the periodontal(gum) tissue that becomes inflamed around 3rd Molars. This becomes a major reason they are extracted. According to the results of the study referenced in this paper the changes made in the tissue around the end of teeth does not respond well to pharmological therapy including difficulty in obtaining anesthesia. In removing teeth either by forceps or surgically it is not the customary standard of care to remove the tissue and bone aggressively beyond the immediate anatomy of the tooth and its supporting bone. There is a considerable amount of clinical data that demonstrates these bone cavities behave similar to the nerve tissue that is changed by chronic inflammation and infection. I am not aware of any study documenting that bone cavities form from this tissue however there is clinical data that supports they do exist where prior inflammation and infection were treated by root canals and extraction of teeth. Three dimensional cone beam technology has initiated a new data source to document this process and in time will verify the etiology of bone cavities.
Medical Acupuncture Perspective on Dental Treatment of Infection and Inflamation
For years a minority group of dentists have found many procedures in the oral cavity adversely affect patient’s health including chronic pain associated with TMJ. These areas act very similar to large scars found in other parts of patient’s anatomy in the manner they disrupt the acupuncture meridians. The root canal procedure has been particularly been a target of this group of dentists. If one critically evaluates the root canal procedure, it is the process of mummifying a piece of living tissue and leaving it Intact in the bone of a patient. I am not aware of any other medical or dental procedure that meets this standard. First of all it is literally impossible to sterilize living tissue(the ultimate goal of any root canal), especially while in the oral cavity. From an energetic perspective one is leaving a “Maximum Yin” ( mummification or death of tooth) in areas of considerable energy exchange of several principle meridians. “Energetic Equilibration Therapy “ and the “ Principal of Contrary and Inverses” does not accommodate this extreme yin condition in treating both acute and chronic pain. The effect of these procedures cause huge energetic blockages in the interchange of the twelve Principle Meridians and their application to treating many health conditions including TMJ related pain. In addition, there always remains some level of infection with direct effects on the immune system. The study by Clark and his associates recognizes that there are changes in the adaptation to tetrodotoxin in nerve cells becoming more and less resistant with changes occurring in Sodium Channel gene expression. Additionally, a recent study at the University of Pacific Department of Endodontics by Ove A. Peters, DMD, MS, PhD promotes a tapered funnel design in root canal preparation and obturation to minimize residual Biofilm and unfilled accessory lateral canals regularly present after root canal preparation. Both of these areas found in root canal protocol are teaming with bacterial, viral, and fungal growth. On a microbial level this is is clinically problematic. According to a recent position statement at the Endodontics Extraordianire 2 presented by The University of Pacific School of Dentistry “a good level of disinfection” is the realistic goal of the highest level of root canal therapy today.
Clinically, a large percentage of root canals are not completed to the level of expertise that was presented by the endodontists at the University of Pacific. This increases the odds that your patient with TMJ related pain has etiology in existing completed dental work. The patient may not be aware of pain directly in the tooth that is contributing to their pain associated with TMJ. This recent research demonstrates these areas are causing trigeminal neuropathies and a host of other acute and chronic pain issues including sympathetic mediated pain. Infection and inflammation express as yang energy and will reflect as rising and bounding in the pulse of a patient. Symptoms of fire and eventually depletion of moisture is the best that can be expected if left untreated on an acute basis. Chronically depletion on a yin level will end up in any of the Principle Meridians depending on the location of the affected tooth. The most common acute manifestation, outside of pain, I observe systemically is a disruption in Stomach Qi. This is consistent with the points found on the face. Acupuncture treatment including Li4 is also very helpful with the TMJ related pain.
Dental Interference Fields
This phenomenon was first observed and documented by a dentist in Germany, Dr. Reinhold Voll in the 1940’s. The technique has met with much criticism from organized dentistry over the years because it condemns the use of mercury based fillings and the premises of its validity are not tested or documented by the scientific method. The resistance of organized dentistry to acknowledge dental procedures have direct effects on total body health is well documented over a long period of time. This position has been successfully challenged by recent revelations of the connection between infection in gum tissue and cardiovascular disease. The tongue is a primary source for diagnosing for a majority of acupuncturist. Both medical and traditionally trained acupuncturist successfully use this relationship involving the tongue and the oral cavity as part of successful total body acupuncture. Oral facial pain conditions associated with TMJ dental care can be diagnosed and successfully treated using the tenants of medical acupuncture. Examples of common dental situations you may encounter and what you should be considering are as follows:
When a tooth is removed with forceps, sustained force pathology is introduced into the cranium. Without treatment this area will become a facilitated segment or interference field manifesting through the cervical vertebrae as an energy cyst described in the diagnostic realm of osteopathic physicians. Procedures such as scalp acupuncture or cranial osteopathy will correct this trauma before it can become pathological.
Bone loss in the gum tissue is very prevalent in patients as they grow older. Bone is controlled by the energy associated with the Kidney Energy in acupuncture. As we grow older our Kidney Energy decreases and bone loss results. We literally do not have the energy to rebuild new bone. This is seen as horizontal bone loss which is dentally considered either a hygiene or occlusal issue in its cause. Overall rebuilding of Essence and deep Yin energy will serve the patient with better results and an increased level of wellness.
A denture, partial denture, or bridge is placed and crosses the midline of the upper jaw. This restricts the mid palatal suture and locks up the movement of the maxilla in the cranial sacral respiration. Headaches and clenching begin within days of placement of the dental work. The patient develops migraine type head pain along with neck and lower back pain. The patient who was already showing signs of Kidney Energy deficiency now develops fibromyalgia and chronic fatigue. Any therapy will be limited in its success until the original issue from the dental appliance is released and the results of the blockage is treated and successfully resolved. Acupuncture in the points associated with the oral cavity will have to be incorporated into a homeostasis protocol. Areas of chronic infection or inflammation will have to be evaluated and treated to reduce or eliminate their interference in pain management. This can be completed with surgery, injections, needling, or a combination of all three. The patient will improve steadily with each step taken to gain overall balance in their system. They will feel better and have an improved level of wellness and the TMJ related symptoms will dissipate.
An infected tooth is scheduled for extraction by a dentist. The patient has both local pain in the area of the tooth and up the side of their head around the TMJ. The dentist wants to place them on antibiotics for a while to calm down the infection. You now know this will cause permanent changes in the nerve tissue at the end of the tooth and urge your patient to get the tooth out quickly, but they will not. You find the pulse reflecting the area of the tooth very obstructed and decide to treat the patient for this acute Yang issue. Any treatment you provide to keep the Qi moving through this obstruction before and after the tooth is removed will be a great service to your patient and make the job of the dentist much easier regarding preoperative and postoperative pain. This will help prevent this area from becoming a focus for oral facial TMJ type pain or locallzed chronic bone infection or inflammation (a dry socket). The medical acupuncture procedure of Tendinomuscular Therapy is a great choice in this situation because it directly applies Wei Qi to the acute injured area.
Conclusion
The application of acupuncture principles in dentistry will change the way the public thinks about their dentist and his or her role in their total health.
From the moment a patient experiences some injury or infection in their dentition the treatment will always be a compromise with additional consequences. Root canals certainly are not perfect but ultimately the patient’s unique circumstances will determine how the procedure needs to be addressed. Evaluating patients with existing root canals, silver fillings, orthodontics, extractions, or teeth with ongoing pain will be paramount to getting long term stability and success in your treatment of those patient’s pain. Unknowingly, dentistry has been affecting the acupuncture system and patients level of wellness with dental procedures that are common to everyday dentistry. Technology and science have now begun to illustrate the importance of this connection to overall health. These findings are proving to be consistent with what acupuncture has been revealing regarding their affect on total body health for literally thousands of years.
*Ram, Teruel, Kumar, & Clark, Clinical Characteristics and Diagnosis of Atypical Odontalgia: Implications for Dentists
Dr Edward Shapiro, DDS
TMJ Solution Center
Using Eastern thought & Western technology to treat TMJ pain, symptoms, and the root cause.
www.tmjsolutioncenterca.com
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