Carl Gugino, D.D.S., M.S.

Robert Grove, Ph.D.

Advances in the Management of Oral Habits and Mouth Breathing: Part I

Bringing Oral Habits Under Control in Your Office Today:

A Realistic Model for the Average Practitioner Using Existing Staff

RESPIRATION AND

ORAL HABITS AWARENESS TRAINING

Version 1.0 01-27-08

DISCLOSURES AND PROPERTY RIGHTS

Drs. Gugino and Grove want you to know that they are co-owners in the products on which this presentation is based. They also own the intellectual property.

•The material presented here is based on the intellectual property of the presenters. The final product is based on 27 years of development.

ACKNOWLEDGEMENTS

•We could never do this by ourselves. We wish to thank hundreds of colleagues for their help over the years. Special thanks to Dr. Ivan Duc of Italy, Dr. Carl.F.Gugino’s Florida Study Group, The Bioprogressive Society of Japan, including Dr.Hiroshi Nezu, Dr. Kenji Nagata, Dr.Katsura Imai, Dr.Osamu Watanabe, Dr.Makoto Nakao, and Dr. Dr. Joseph Caruso, and Dr. James Farrage of Loma Linda Dental School, California, for their leadership.

Loma Linda Mafia

The Three Musketeers

Carl Gugino

Worked with Ricketts. Developed multi-modality office management.

Brought Breathing, Exercise, and Psychophysiology to Case Management.

Master Teacher of ‘ZeroBase’ – case management by level of difficulty.

Started sEMG in 1970s with the Cram Scan.

International Mentor – Europe, South America, Japan.

Brought together Grove and Duc in Italy to form SEMG team.

CoOwner, InnerSmilePro.

Ivan Dus

Works with Gugino in Europe. Extensive knowledge of physiology. MD.

Set up ‘ZeroBase’ computer team – case management by level of difficulty.

Brought together Grove to Italy to develop sEMG team.

Got degree in neurophysiology and behavior.

Bob Grove

Medical Psychologist @ neuropsychophysiology, biofeedback.

Primate surgery lab. Full physiology research laboratories.

Founded Neuronal Regulation Society.

Three times President, Biofeedback Society of California.

Rheumatology research. Soft-tissue evaluations.

Hundreds of sEMG CMD evaluations.

The missing link – psychophysiology in severe dental-ortho cases.

Pedodontic swallowing breathing researcher.

Loma Linda Dental School.

Co-Owner, InnerSmilePro.

SWALLOWINGFUNCTION

andSTRUCURE.

Concept of degree of difficulty.Neutral Zone – Neutral Matrix.

Ortotropic.Phagias.

It is commonly acknowledged that structural lesions produce

disturbances of function. Muscular imbalance, ineffective motor patterns and postural strain cause symptoms

by themselves and often precede structural changes.

from Brownstein, B. and Bronner, S. Functional Movement in Orthopaedic and Sports Physical Therapy:

Evaluation, Treatment and Outcomes (1997, p. 159)

DEVELOPMENTAL PHYSIOLOGY,ORAL HEALTH and INNER SMILES

“General exercises may neglect individual muscle contributions to specific movements. If an inhibited

muscle is not firing, continued practice of that exercise may never trigger it, thus perpetuating and possibly

amplifying impaired muscle function and imbalances.”

from Brownstein, B. and Bronner, S. Functional Movement in Orthopaedic and Sports Physical Therapy:

Evaluation, Treatment and Outcomes (1997, p. 159)

PHYSICAL THERAPY?

ORAL EXERCISES?

EXERCISES for INNER SMILING?

1. Biofeedback Billing Codes90901908759087690911

AMERICAN PRACTICES ONLY.

Who pays?

2. EvaluationSix Sessions

Re-Evaluation

The Problem:

Oral Habits Can lengthen and reverse any Bite Normalization Procedure.

1. Blocked airways are emerging as a MAJOR cause of Bite Regression.

2. Tongue-Thrusting mouth devices do not open airways nor reverse habits.

3. Oral Habits – grinding*, bruxing*, poor posture- also add to Bite Regression.

* Bruxing and grinding will not be covered in the presentation. We have other software to specifically address the behavioral aspects of these issues.

The Good News:

Oral Habits can be reversed in an average of 6 sessions for Class II Open Bites. The need for follow-up visits are re-evaluated at that time, especially if severe Class III.

1. This finding has been replicated in 3 counties over 27 years.

2. The effect is not due to placebo effect and is in most cases, permanent.

3. Habit Retraining can be done in about 20 minutes.

Background:

Historically Awareness Training began before the computer, as

‘Manual Awareness Training.’ developed by Dr. Gugino in the 1970s:

•Clinics in France report habit reversal using ‘manual’ – non-computer- techniques- over many sessions.

Computerized versions have been in use since 1990, first in Italy, then Japan, and the USA, called ‘Computer-aided Awareness Training.’:

•Computerized Clinics in Japan and Loma Linda report reversals in about 6 sessions.

•More difficult cases can benefit from Habit Retraining/Awareness coupled with bite normalization.

Breathing difficulties with mouth breathing can also be reversed with Habit Retraining in many cases (Rule out with NuTom nasal cavity images).

Nasal reflexes can be trained that open up most airways very quickly. These are part of our training program,

The Bad News:

1. Offices are reluctant because no one in their office can do it.

2. Patients are unlikely to ever go to an out-of-office referral for habit retraining.

3. Offices are unsure of how to market habit retraining.

4. Few have ever incorporated behavioral training, and need assistance for marketing, training and payment strategies.

SUMMARY: CURRENT BELIEFS ABOUT HABIT TRAINING FOR OFFICES:

•There is a common belief that it is too complex for the average office.

THE PROCEDURES

So how difficult is it?

EVERY STEP IS GUIDED BY A VIRTUAL INSTRUCTOR

Take the fear out of what to say.. ‘Neutralize staff fears first!

How we break Oral Habits, using InnerSmilePro. (Next Slide)….

Respiration and Oral Habits go together.

POLYGRAPH ASSESSMENT

ASSESSMENT-BASED EXERCISES

SIMPLE HOMEWORK EXERCISES

INTERNET-SUPERVISED EXERCISES

POLYGRAPH RE-ASSESSMENTS

TAKES 15 Minutes

TAKES 20 Minutes

Monitor Success at next visit

Schedule Home Sessions

Re-Assess every 6 sessions

PART I: HOW TO FIND WHERE TO BEGIN TREATMENT:

KEY: Take a computerized ‘snapshot’ of the mouth and breathing during mouth movements, breathing exercises, different postures and different swallows..

POLYGRAPH ASSESSMENT

Sensor Placement takes about 3 minutes:

Heart Rate- ECG ElectrodesHeart Rate- ECG Electrodes

Respiration BeltRespiration Belt

Digastric (Tongue)Digastric (Tongue)

Right MasseterRight MasseterLeft MasseterLeft Masseter

Remember.Yellow is Tongue..

The final result is a polygraph report of reactivity to standardized mouth, posture and breathing exercises.

It looks like this (next slide)…..

Typical ‘Swallowing’ Profile

THE RESP-ORAL HABITS ASSESSMENT PROFILE Quantifying the Functional Matrix .

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

RespirationRespiration Heart RateHeart Rate

This Polygraph profile provides a wealth of information.

Let’s begin with a look at one component, the DRY SWALLOW.

Dry Swallows can be categorized into 6 different patterns,

Like this (Next Slide)…..

SWALLOW TYPES

So what does the profile show? Here are a few examples:

Swallow Patterns:

•The Perfect Swallow

•Masseter-Dominant

•Tongue-Dominant

•Incomplete / Double Swallows

•Asymmetric Masseter Swallow

•Swallow with poor timing.

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

So what does the profile show? Here are a few examples:

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

Swallow Patterns:

•The Perfect Swallow – which one?

So what does the profile show? Here are a few examples:

Swallow Patterns:

•Masseter-Dominant

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

So what does the profile show? Here are a few examples:

Swallow Patterns:

•Tongue-Dominant

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

So what does the profile show? Here are a few examples:

Swallow Patterns:

•Incomplete / Double Swallows

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

So what does the profile show? Here are a few examples:

Swallow Patterns:

•Asymmetric Masseter Swallow

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

So what does the profile show? Here are a few examples:

Swallow Patterns:

•Swallow with poor timing.

BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

MICRO-ANALYSISOF

SWALLOWDYNAMICS

The Swallow Pattern needs to be broken down into its components.

Here is the swallow – slow and weak:

But this is a DRY Swallow..

Timing is good:

Masseters contract and release with tongue.

The Swallow Pattern needs to be broken down into its components.

DRY Swallow..

Compare it to A Wet Swallow.

Drink 4 oz of water…:

Conclusion: WET or DRY – the muscle activity is still weak.

Conclusion: WET or DRY – the muscle activity is still weak.

Compare it to Touching Teeth::

Take out the swallow and Masseters contract strongly With Asymmetry.

LEFT touches more strongly than right when the Tongue is

silent.

Compare it to Tongue Contraction Alone:

Conclusion:

Tongue Movement alone is also WEAK.

REVERSAL: Tongue alone

reverses the effect: Right touches more strongly than Left

TONGUE * TOUCH TEETH * SWALLOW * DRINKWEAK WEAK WEAKSTRONG

Right>Left Left>Right Right>LeftRight=Left

Conclusion:

The weak swallow is due to poor tongue control. Swallow timing is good.

Masseter asymmetry is reversed by a swallow or tongue movement.

Bite stabilization is indicated – then retest.

PUT IT ALL TOGETHER AND WHAT DO YOU GET?

RESPIRATIONand SWALLOWING

What do you call the swallowing of air?

When does swallowing stop?

BREATHING COMPONENT ANALYSIS

BREATHING MUST STOP DURING SWALLOWING.

But where in the breath cycle does a patient stop?

• STOP DURING INHALE?

• This is bad. It can trigger AEROPHAGIA.

•STOP DURING EXHALE? This is normal.

Take a look at the following slide (Next Slide)..

Breathing is in BLUE.TONGUE CONTRACTIONS are in YELLOW.

So when does the breath stop to swallow?

Here the breath stops during exhale or at the end of exhale.

Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

EXHALEEXHALE

TongueContractionOn Exhale

TongueContractionOn Exhale

Muscle Fatigue and Swallowing

Muscle Fatigue and Swallowing

Muscle Fatigue and Swallowing

Muscle Fatigue and Swallowing

LINKING SWALLOW to

BREATHING

LINKING SWALLOW to

BREATHING

LINKING SWALLOW to

BREATHING

LINKING SWALLOW to

Autonomic Balance

Advanced Topic- for a full 4 hours.

Hint: ECG patterns derive a signal which gauges sympathetic dominance.

Sympathetic dominance is linked to the muscle spindle.

LINKING SWALLOW PROFILE to TREATMENTS

LINKING POLYGRAPH ASSESSMENT TO TREATMENT PROGRAM

The Awareness Training Flow Chart Decision Matrix – Simplified.

The following charts show a simplified version of the major categories linking assessment problems to treatment exercises.

The details of these 40 exercises will not be presented here.

See Next Slide…

ASSESSMENT-BASED EXERCISES

RESP-ORAL Decision Matrix

Balance Bite(Stabilize Masseters)

Tongue Awareness

MalocclusionsWeak tongue touch

In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……

RESP-ORAL Decision Matrix

Productive Swallow(Exhale,Touch,Swallow)

Posture Stretch AwarenessHead-forward problem

In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……

Productive Swallow(Head Backwards,Touch,Swallow)

RESP-ORAL Decision Matrix

Pause on Exhale(Nose Breath, Easy Breathing)

Swallow Recovery(Inhale, Release)

Restricted AirwayNose/Mouth

•Posture-link

In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……

RESP-ORAL Decision Matrix

Restricted AirwayNose/Mouth

•Mechanical-link

Nose-Dilation Reflex Exercises

In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……

Vowels Speech Tongue Awareness

RESP-ORAL Decision Matrix

Balance Bite(Stabilize Masseters)

Productive Swallow(Exhale,Touch,Swallow)

Pause on Exhale(Nose Breath, Easy Breathing)

Tongue Awareness

Swallow Recovery(Inhale, Release)

Posture Stretch Awareness

Restricted AirwayNose/Mouth

•Mechanical-link

Restricted AirwayNose/Mouth

•Posture-link

MalocclusionsWeak tongue touch

Head-forward problem

Nose-Dilation Reflex Exercises

In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……

Productive Swallow(Head Backwards,Touch,Swallow)

Vowels Speech Tongue Awareness

We select from over 40 Exercises, individualized for each patient. Here is a partial list of our exercises.

MASSETEREXERCISES

SWALLOWEXERCISES

BREATHINGEXERCISES

TONGUEEXERCISES

POSTUREEXERCISES

RESP-ORAL Treatment Exercises

TWO EXAMPLES –in progress

CASE 1 - BEFORE

CASE 1 – Post 4 MONTHS

HOW DID CASE I’s RESPIRATION & ORAL HABITS PROFILE LOOK?

Next Slide…

CASE I WAS VERY CO-OPERATIVE AND ATTENDED EVERY SESSION

CASE 1 – PART I: POOR WET SWALLOW.

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

WET SWALLOW

TONGUE

TOOTH

POOR TONGUE CONTROL

BALANCED MASSETERS

GOOD TONGUE RELEASE

POOR DRY

SWALLOW.

MASSETERS

DORMANT

BETTER WET

SWALLOW.

MASSETERS

BALANCED.

INCOMPLETE SWALLOW.

DRY vs. WET SWALLOWTONGUE vs. MASSETER ISOLATION TEST

CASE 1 – BREATHING NOT DIFFERENT. CHIN POSTURE DIFFERENT.

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

CHIN BACK SWALLOW

INHALE

SWALLOW EXHALE

SWALLOW

POOR swallow VERY POOR SWALLOW

BEST SWALLOW.

POOR RELEASE

UNABLE TO SUSTAIN..

MASSETERS

DORMANT.

INCOMPLETE SWALLOWS.

CHIN FORWARD SWALLOW

INHALE vs. EXHALE SWALLOW CHIN FORWARD vs. REARWARD SWALLOW

CASE 1 – BREATHING DETAIL..

Breathing is in BLUE.TONGUE CONTRACTIONS are in YELLOW.

So when does the breath stop to swallow?

Here the breath stops during exhale or at the end of exhale.

Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

EXHALEEXHALE

TongueContractionOn Exhale

TongueContractionOn Exhale

END of CASE 1

This case is in progress.. A Reassessment Polygraph will be done soon.

CASE 2 – START

CASE 2 - Post 7 MONTHS

HOW DID CASE 2’s RESPIRATION & ORAL HABITS PROFILE LOOK?

Next Slide…

CASE 2 HAD FAMILY EMERGENCIES AND CANCELLED SEVERAL SESSIONS, EXTENDING TREATMENT TIME..

CASE 2 – PART I: THE COMPLETE PROFILE.

Digastric (Tongue)Digastric (Tongue)Right MasseterRight MasseterLeft MasseterLeft Masseter

POOR TONGUE

CONTROL

BALANCED MASSETERS

GOOD SWALLOW

TIMING

POOR DRY

SWALLOW.

MASSETERS

DORMANT

BETTER WET

SWALLOW.

MASSETERS

BALANCED.

INCOMPLETE SWALLOW.

DRY vs. WET SWALLOW

INHALE vs. EXHALE

SWALLOW

CHEW vs. TALK

CHIN FORWARD vs. REARWARD

SWALLOW

TONGUE vs. MASSETER ISOLATION

TEST

CASE 1 – BREATHING DETAIL..

Breathing is in BLUE.TONGUE CONTRACTIONS are in YELLOW.

So when does the breath stop to swallow?

Here the breath stops during exhale or at the end of exhale.

Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

EXHALEEXHALE

TongueContractionOn Exhale

TongueContractionOn Exhale

End of CASE 2

FREQUENLY ASKED QUESTIONS - …

Why include respiration? Aren’t my bite-muscle machines enough ?

MUSCLE ANAYSIS ALONE WILL BIAS YOUR ANALYSIS:

Bite muscle analysis is great – for bite-balance adjustments. But for thrusting swallowing problems, bite balance alone may be a waste of time. Muscles are active during a swallow. Breathing STOPS during a swallow. We need to see where breathing stops to understand compensations leading to mouth breathing habits.

NO. BREATHING DEPTH, BREATHING FREQUENCY AND BREATHING INTERRUPTIONS DEFINE THE DEGREE OF DIFFICULTY OF MUSCLE PROBLEMS.

Questions about RESP-ORAL Habit Retraining

WHAT IS IT?: A 15 MINUTE PHYSIOLOGICAL ASSESSMENT OF RESPIRATION, ORAL HABITS AND POSTURE.

WHEN DO YOU START?: DONE AT FIRST VISIT.

WHO WILL DO IT? : BY AN OFFICE ASSISTANT.

WHY DO IT?: 1. TO PRESENT TO PATIENT THE NEED FOR HABIT RETRAINING.

2. TO DOCUMENT A BASELINE FOR BITE-CLOSING PROCEDURES.

.

Questions about RESP-ORAL Habit Retraining

HOW:DO YOU DO IT?

1. Explain procedure – use brochure or video.

2. Attach sensors -

1. Right and Left Masseter, and Digastric Muscles.

2. Respiration Belt.

3. ECG sensors across wrists – autonomic balance and HR.

3. Run Procedure – Generate a printed report – 10 minutes.

4. DECISION: Start treatment? Discuss with patient or parents.

.

MAIN POINTS and CONCLUSIONS

KEY ADVANTAGES FOR AN OFFICE PRACTICE…

1. WE NEED A WAY TO ELIMINATE THE NEED FOR AN EXTERNAL ‘TRAINER.’

RESP-ORAL Dx: TRAIN AN EXISTING STAFF MEMBER TO DO A 15 MINUTE RESPIRATION -ORAL HABITS PHYSIOLOGICAL ASSESSMENT AT FIRST VISIT.

2. WE NEED A STANDARDIZED WAY TO RANK THE SEVERITY OF NASAL BLOCKAGE AND ORAL HABITS FOR TREATMENT PLAN

RESP-ORAL Tx SCHEDULE WITH REGULAR VISITS – ABOUT 20 MINUTES.

ASSIGN HOMEWORK. EVALUATE/DEMONSTRATE LAST HOMEWORK.

DO SECOND RESP-ORAL Dx AFTER 6 SESSIONS.

REINFORCE WITH FOLLOW-UPS IF NEEDED.

Present Computer print outs of sessions at staff meetings to consolidate total treatment package.

The number of causes for Nasal Blockage and Oral Habits is also quite small:

•Overactive Tongue

•Poor Bite – Imbalanced Bite – Malocclusion

•Head-forward posture.

•Blocked nose – mechanical and/or vasoconstrictive.

•Oral tics and habits – biting nails, sucking, improper chewing.

THE POOL OF EXERCISES IS OVER 40, BUT THE NUMBER OF TREATMENT EXERCISES IS SMALL. 70 % OF CASES RESPOND TO 5 EXERCISES.

3. WE NEED A SIMPLE, RELIABLE WAY OF GUARRENTEEING THAT A PATIENT IS ASSURED OF PERSONALIZED EXERCISES.

STANDARIZATION IS BUILT INTO THE GUIDED EXERCISE VIDEOS.

“Tongue Thrusting” or Reverse Swallow” are descriptive, not diagnostic.

The real question is what is the cause of the problem, and how severe is it.

BAD ORAL HABITS

POOR POSTURE

MOUTH BREATHING

MALOCCLUSIONS

TONGUE-THRUSTING

REVERSE SWALLOW

NERVOUS ORAL TICS

THANK YOU

WHAT: ALL OF THESE PROBLEMS HAVE BEEN SUCCESSFULLY TREATED.

WHO: BY OFFICE ASSISANTS, PRIVATE AND GROUP PRACTICES.

WHEN: AT FIRST VISIT.

HOW: USING A LOGICAL ASSESSMENT AND BIOFEEDBACK-AIDED HABIT RETRAINING.

WHY: LONG-TERM TREATMENTS REQUIRE HABIT CHANGE.

GOOD TEETH REQUIRE GOOD HABITS.

CONCLUSION:

END