A technical article about Dr. Parker and his work with TMD and TMJ
This article was published in the September, 2002, issue of Doctor of Dentistry Oregon/SW Washington
High Technology, High Touch Practice
in the Treatment of Temporomandibular Disorders
Just as Dr. Arthur L. Parker's business card depicts a triangle with TMJ printed in the center and Teeth, Muscles, Joints spelled out around the three sides, so he sees the importance of their relationship to each other in oral health: All equally important, each vitally connected and every part dependent on the Trigeminal nerve. Head, neck and facial pain, which if caused by a temporomandibular disorder (TMD), can result if these three important elements are not working in harmony.
As a neuromuscular practitioner for over 20 years and dentist since 1972, Dr. Parker's Portland practice specifically treats TMD. He has treated over 2,000 patients suffering from some form of TMD in the past 20 years. Since 1998, he has limited the practice to TMD in order to "focus on helping more TMD sufferers more efficiently."
"The study and treatment of TMD is an interest and love of mine," said Dr. Parker.
An early interest in how other health care professionals viewed and treated the temperomandibular structures greatly influenced his approach to treatment. "I soon realized that physical therapists, chiropractors and osteopaths understood the bio mechanics of the temperomandibular joints better than we dentists in many cases," explained Dr. Parker. "In fact, they were often quite adept at restoring improved function. Through my study of their methods, I was better able to sort out what we now call 'Ascending and Descending Influences' of the temperomandibular structures."
Dr. Parker's physiologic approach to treatment was and is widely accepted among health care practitioners in the medical community, but this has not always been the case among dental colleagues. In fact, in the early years, he met resistance to the use of computerized electro diagnostic equipment in the treatment of TMD among many dentists. "There were and still are a lot of misconceptions and even prejudices about this process because it isn't widely known and is taught only at a couple of dental schools," explained Dr. Parker. "The acceptance of this technology is changing for the better. One of the country's most renowned post-graduate institutes—the Las Vegas Institute (LVI)—has adopted this concept and actively teaches and promotes it. It's still a controversial topic, although increasingly more dentists are avidly studying these concepts and returning to their communities to treat patients with these methods."
This technology is designed to record and provide meaningful interpretation of internal temperomandibular joint sounds. This 20-year-old technology is now well-researched and has been found to be over 90 percent accurate when compared to MRI and open surgeries of the temperomandibular joints. The K61 records the power or loudness of any joint sounds and where it occurs during opening and closing of the jaw. Then the software provides a spectral frequency analysis of each occurring sound. The interpretation of this data representing the loudness and frequency of these sounds provides valuable insights into the state and health of the articular disks. These sounds are recorded and maintained as computer files from the patient's first visit and then periodically throughout their process as a means of assessing progress and effectiveness of treatment.
The EMG recordings are another modality that measures and analyzes electrical activity in the muscle movements within the jaw. The different muscles - anterior temporalis, masseters, posterior temporalis, and digastrics - bilaterally guide and support the jaw. Healthy muscles create low levels of activity, measured in micro-voltages. These readings are used for determining the status of the jaw's muscles both at rest and in function.
Part of the increased interest and acceptance comes from the changing attitudes toward technology. More dentists have accepted computers into their lives, and therefore into their practices. Likewise, more dentists trust that the results from computerized testing can record data and provide reliable guidance for treatment and recognize technology as a valuable tools for helping patients. Bernard Jankelson, the father of neuromuscular dentistry, liked to say, "It's a fact if you can measure it; if not, it's an opinion." Dr. Parker feels that reliable quantifiable data is essential to helping sort out patient symptoms, which can often be vague and confusing. Almost as critical to Dr. Parker is the ability to accurately measure the effectiveness of his treatment.
Dr. Parker evaluates, treats and charts the progress of a patient's recovery from the multitude of problems associated with TMD by evaluating a patient's condition with several diagnostic practices. Those practices include clinical exams, functional testing, X-rays, CT Scans and general patient history of lifestyle and habits.
Functional Testing—the K61
The functional testing is performed with electro diagnostic equipment, which includes a conventional PC and a software package called "K6I." The K6I software performs jaw tracking scans and provides two important measurements; electromyographic (EMG) monitoring of the jaw muscles and sonograhic recordings of the temporomandibular joint sounds. The K6I system is capable of presenting up to 20 different "scans" of mandibular related function, with the flexibility of customizing the protocol to a particular symptom and/or view. In addition to the sonographic and EMG capability, K6I visually measures and records the movements of opening, closing, right and left, swallowing action, rest position, freeway space and movement to the habitual bite. These movements are then viewed as computerized linear graphs.
In Dr. Parker's opinion, one of the most important K6I capabilities is the ability to accurately record and measure the movement of the mandible from the patient's physiologic rest position up through three-dimensional space to the habitual centric occlusion. "We can actually visualize and measure a person's 'envelope of function,'" clarifies Dr. Parker with the term he uses to describe how the jaw muscles, joints and teeth interact and how the computer graphically records the path in precise measurements.
His Com-Cat CT-scan is a constant motion tomography machine. He is not aware of a similar CT scan machine in any other Portland area dentist's office. It is considered to be the highest available imagery for the TMJ; it sees the joints, but it moves beyond the standard up, down, side-to-side or linear type of imaging. The scan from the Com-Cat is hypocycloidal. "An analogy is if you take a piece of string, stretch it out and then pinch the middle," explains Dr. Parker as he holds his arms apart with an imaginary line between his hands. "The two ends can move around the center point and provide images from various angles, giving a less distorted and more accurate reproduction of the joint's bony structures."
The graphic readouts from the K6I added to the CT scans, clinical exams, X-rays, and general patient history of lifestyle and habits enable Dr. Parker and staff to determine the most accurate prescription for treatment. The learning curve for the different software to operate this technology is high, as is the cost of equipment. Therefore, many dentists using the neuromuscular concepts in their practice refer patients to Dr. Parker just for the diagnostic data recordings and preparation. "I provide the dentist with a blueprint of how they can rebuild the person's bite with the various modalities of testing and recordings of physiologic data," he explains. "I don't carry out the treatment plan; I just provide the information that describes the start point and the end point in order to safely restore an esthetic and functional occlusion."
Another unique aspect to Parker's office is the assistance of Cher Donnell, LMT, who was raised in a dental family and has worked in the dental field since she was a teenager. Cher began working with Dr. Parker 16 years ago and is trained on the electro diagnostic equipment. "She can prepare the patient for testing, run the computers, collect the data and is often consulted on the clinical evaluation," says Parker. Cher is a Licensed Massage Therapist and therefore often has valuable, holistic insights into their life as a whole and how that is most likely affecting jaw function. In addition, she provides cranialx and soft tissue manipulation and massage, teaches patients how to perform self-care exercises, and assesses their lifestyle and dietary habits in relation to their TMD.
"Once you have an injury or are dealing with chronic pain, it usually takes a number of things to change in order to get better," explains Cher. "It's not just getting an orthotic, or medication, or just physical manipulation. It's a combination of treatment processes that works. It's necessary to spend the time to know the individual because we're considering body structure and posture, diet, habits of motion, and their potential effects on mandibular function."
"Cher is quite a resource for local dentists who have the equipment but not the training or staff because of the extensive technical skills required," enthuses Dr. Parker. "She works with a number of Oregon dentists providing her expertise and training in neuromuscular data collection."
"Within the treatment of TMD there currently isn't a comprehensive, standardized approach," said Dr. Parker. "There are a lot of ways to treat it, so traditionally TMD has been considered a multi factorial problem. What sets this practice apart is the ability to diagnose the hierarchy of the severity of TMD problems."
The technology and the ability to access the appropriate allied healthcare professionals enables the staff to comprehensively assess and treat the patient's problem. "We provide an effective, conservative, non-invasive approach to treatment because the precision of the orthotic's prescription and refinement of the treatment plan for the individual incorporates science and technology with hands-on care," says Dr. Parker. "My approach is high-tech andhigh-touch, simply because I have found that to be an effective way to help people feel better. With our prescribed treatments and precise evaluation processes, we experience and observe dramatic improvement in people's health from teenagers to octogenarians, and I derive great satisfaction from that."