Carl Gugino, D.D.S., M.S. Robert Grove, Ph.D. Advances in the Management of Oral Habits and Mouth...
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Transcript of Carl Gugino, D.D.S., M.S. Robert Grove, Ph.D. Advances in the Management of Oral Habits and Mouth...
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