‘Barnstorming’ is the only way to describe Dr Barry Glassman’s lecture that launched the 2011 Bruxism Awareness Week at the Royal College of Physicians in London.
The event, organised by dental splint specialists and founders of Bruxism Awareness Week – S4S – was a rare opportunity to hear and learn from a true pioneer who had promised to ‘muddy the waters of truth with the stick of enquiry’ and is no stranger to challenging convention and assumptions in a profession plagued by fear of failure which he said, ‘should not prevent people from getting treatment’.
Dr Glassman is one of the world’s leading experts on chronic pain management whose pioneering clinical and academic work has challenged many of dentistry’s notions regarding occlusion. He argues that it is not occlusion that is the problem, it is occluding yet generations of dentists seeking the ‘Holy Grail’ connecting the oral cavity and pain, have been indoctrinated with beliefs and assumptions about ‘fixing’ the problem without first understanding what the problem is.
The audience of dentists from all over the UK, was urged to, ‘let go, think differently and accept that there are some things we don’t know so stop making assumptions and making stuff up. Learning is fun and easy, unlearning is difficult but you can’t win a competition against science’.
Dr Glassman admitted that for many years, he too had ‘bought and taught’ the established view that bruxism could be treated by altering surfaces through changing functional occlusion – or fixing the bite – rather than checking and changing the force of parafunctional behaviour.
By way of illustration in a frequently entertaining and constantly informative lecture, Dr Glassman said that dentists blaming the teeth for grinding and clenching was ‘….like looking at a tree with a car wrapped round it and, because you’re a tree bark specialist, blamed the accident on the shape of the bark… which therefore must be altered.’
Bruxism is an unknown cause of muscular contractions at night, usually in Stage II sleep and although an apparently purposeless movement, parafunction may play a functional role in the neonatal as observed by ankylosis of the condyle to the glenoid fossae when experimentally halted in animals during growth and development.
Dr Glassman explained that because dentists are trained to concentrate on looking at teeth, they often ignore ligaments and joints, muscles and the all important trigeminal nerve.
The fifth and largest of 12 cranial nerves that leave the brain via holes in the skull, the trigeminal’s main branches are ophthalmic, maxillary and mandibular and it controls muscles used in chewing and provides sensation to the face.
Consequently, when the build up of micro-trauma through bruxism impedes the body’s adaptive capacity to deal with pain, it is necessary to ‘find the biggest pipe that is most readily shut off – parafunction sending messages to the root nucleus of the sensory branch of the trigeminal – to shut down to halt the overflow.’
Understanding the tethering and contracting muscle activity immediately prior to bruxing is essential as is recognising that damage occurs according to the force and duration of teeth clenching which, during sleep can be for as long as 30 seconds as opposed to the split second that teeth touch while we are awake, during swallowing, chewing, and so forth.
Hence, says Dr Glassman the ‘absurdity’ of how dentists have traditionally tried to evaluate night time parafunction; ‘In the daytime, it’s a crash scene investigation, looking at the damage, not the cause. Why do we dentists think that by fixing the bite – the part we know about –everything else will adapt to it?’
If it is the dentist’s job to protect the teeth, he argued, then it follows that they must learn how to ‘turn destructive forces into adaptive forces’ which can be achieved with an NTI-tss (nociceptive trigeminal inhibition tension suppression system).
To demonstrate the huge reduction (around 70%) in force, Dr Glassman showed EMG measurements while an audience volunteer clenched and unclenched with and without an NTI but he admitted there was still ‘prejudice towards fixing chronic pain with a little piece of plastic’. That ‘little piece of plastic’ is the keystone of Dr Glassman’s practice at the Allentown Pain Centre, Pennyslvania where he always starts patients on an NTI, never medication because of its side effects.
The day-long lecture that ended with live demonstrations and lively discussion, was marked, not just by Barry Glassman’s expertise as a dentist and skill as a speaker but his passion and commitment to alleviating chronic pain.
He implored his audience to remember that patients are part of the treatment team – ‘honesty with patients makes dentists more honest with themselves. This is not about us, so keep your eye always on patient care and let science guide our art – otherwise it’s voodoo!’