---------- Forwarded message ----------
From: tshewman@insight.rr.com
TENS instructions
First and most important, any bite including a TENS bite should not be done WITHOUT a proper diagnosis!! Without the proper diagnosis, there is room for error.....allot of error.
There are other ways and types of bite registration techniques and each have their place!
Lastly, not EVERYTHING can be included in an email and every patient should be treated as an individual case.
In otherwords, we assume no responsibility if you mess up. :-)
From: tshewman@insight.rr.com
TENS instructions
First and most important, any bite including a TENS bite should not be done WITHOUT a proper diagnosis!! Without the proper diagnosis, there is room for error.....allot of error.
There are other ways and types of bite registration techniques and each have their place!
Lastly, not EVERYTHING can be included in an email and every patient should be treated as an individual case.
In otherwords, we assume no responsibility if you mess up. :-)
Basic Step by Step Instructions:
First, most patients will be unfamiliar with the muscle stimulating process. Explaining what they will experience is important.
Step 1: Occlusal Connections and Placement
Connect the electrodes to the electrode cable(s)
Option A: Occlusal Two Channel three electrodes for balance of left and right muscles of mastication: use one electrode over each coronoid notch one electrode at the back of the neck for a total of three electrodes.
Option B: Occlusal and Cervical Two Channel with balance between the Occlusion and Cervical areas: use one electrode for each wire for a total of four electrodes. One electrode over coronoid notch and trapezius bilaterally.
Step 3. Clean the skin and dry
Wipe electrode sites with rubbing alcohol and dry
Step 4. Occlusal Placement
A. Occlusal TWO channel (three electrodes with left and right balance) Place each electrode with black wire over coronoid notches and the electrode with both red wires on the middle of the back of the neck below the hair line (if using Dolotens-if J4/5 you can have one dedicated "lead" to the neck electrode).
Caution: Care should be used to place the electrodes accurately. If the patient feels a pounding in their head, the electrodes have not been properly placed. The electrode on the back of the neck should be accurately placed in the exact centre of the middle of the neck to achieve balanced muscle contraction.
Occlusal AND Cervical Placement
B. For two channels, place one channel over coronoid notches and the other channel two wires over trigger points on the trap muscles.
Note: In the case of sideburns and beards, consider shaving the area.
Step 5. Turn the unit on.
Note: The unit automatically starts at the lowest setting when turned on. At any time if a pause in pulse stimulation is desired (for example when recording EMGs), press (P) to pause (with some units) and to restart the stimulation at the same setting, press (P) again. The stimulation will automatically and slowly ramp to the previous intensity.
Step 6. Increase Intensity slowly by and always ensure the patient is comfortable. Increase intensity slowly until the lower front teeth have a very slight upward movement, 1 to 2 mm. (place a little finger between the anterior teeth and have the patient close and rest their teeth on the little finger and adjust intensity for the first slight perceptive squeeze of the teeth on the finger). Adjust for balance and patient comfort depending on configuration.
The cervical area should have a light, gentle comfortable contraction or squeeze. If the teeth are tapping with each pulse, turn the intensity down until the mandible has slight movement without the lower and upper teeth contacting.
Note: After a few minutes, the muscles may "loosen up" and the movement of the mandible increase without change in intensity. It is common to reduce the intensity after a few minutes to avoid the teeth from tapping.
Step 7. Maintain the patient in a comfortable, quiet, relaxed upright environment for about 20-60 minutes.
Note: To evaluate balance on each side of the face, place one finger on each side of the mandible just below the electrodes and feel the masseter muscles for balance. Patient perception of balance is sometimes helpful. Visual observation of the muscles of facial expression are less valid when determining balanced muscle contraction.
Step 8. Establishing a physiologic rest occlusion, a position of the mandible needs to be found where the muscles are at relaxed without fatigue. Neuromuscular stimulation and a muscle rested position of the mandible are valuable for these clinical procedures:
1. Mandibular Rest Position
2. Occlusal Adjustments
3. Taking a bite registration, Neuromuscualar maxillo-mandibular relationship
4. Impressions and moulding denture boarders
5. Mastication and Cervical muscle relaxation
Note: The optimal mandibular rest position is where the muscles are all simultaneously at their rested muscle length and tone. Muscles of mastication are highly differentiated and even a few muscle fibers can be hyperactive while the majority of the muscle fibbers may be relaxed creating an muscle hyperactive maxillo-mandibular relationship. To sustain muscle relaxation, the clinician should start from a position which has relaxed muscles.
Step 9: Mandibular Rest Position, clinical suggestions:
A. Ensure patient is relaxed in an upright position, sitting or standing.
B. Make a mark on the patient's nose and chin for reference.
C. Evaluate aesthetics (vertical, lateral and anterior/posterior profile position of the mandible, habitual and desired).
D Evaluate disc position and joint sounds for possible joint position/disc improvement. (Seriously deranged TMJ disorder patients may take additional considerations.)
E. Measure the distance between the marks of the nose and chin (B) when the patient is biting in their habitual occlusion and compare with the aesthetic (C) and disc (D) considerations. Measure the distance between the nose and chin marks when the patient is relaxing and teeth are apart and compare with the habitual mandibular position (B).
If the patient is aesthetically over-closed, have the patient let their lips part, tell the patient to slightly open and relax. (The jaw will slowly close to its rested position. Re-evaluate and repeat if necessary.)
If the jaw is too open, tell the patient to slightly close with lips together and relax. For the discs, have the patient open and protrude, slowly closing and relax without popping off their discs. Repeat these movements as necessary.
F. Ensure the patient has a stable resting position and the jaw repeatedly returns to the position of rest (is stable without drifting up and down). If rest is not stable, consider additional TENS time and moist heat on the muscles.
.
Step 10: Taking an occlusal registration
A Have the patient open and place a slow set firm bite registration material between the teeth, leaving the TENS on (preferably subthreshold) during the entire set of the material. (The gentle pulsing provides about 1 to 2 mm of freeway space.
Tell the patient to relax their muscles, relax their tongue and slowly let the mandible float up. Have the patient close until the distance between the two marks on the nose and chin are at the selected rested position chosen above in 8 F.
Note: Although some prefer to PULSE into the BR material, it may be better to have the TENS be "SUBTHRESHOLD" during the actual BR procedure as the stimulation is neutrally mediated there is stimulation of OPENING AND CLOSING muscles. Therefore, by being subthreshold, the muscles remain relaxed and the patient slowly drifts into the BR material under the doctor's verbal guidance.
Note: If stimulating trapezius and mandibular muscles, before taking the bite registration, reduce or eliminate the trapezius stimulation as per Jankelson.
C. After the bite registration has set, confirm in the mouth the recorded bite registration position and expected aesthetic and disc positions are in fact as desired and the patient is comfortable without strain or stress closing into the bite registration.
Caution: The marks on the skin (soft tissues) do not always accurately represent the changes between the maxilla and mandible. The occlusal registration may need to be repeated to achieve the optimal position of physiologic rest, aesthetics, and joint arrangement.
Caution: The Doctor should avoid touching the patient during the occlusal registration. Any manipulation of the mandible by the doctor may negatively influence the result. Taking more than one bite registration, permits the patient to subjectively compare the differences.
Step 11: Turn the unit off. Remove the electrodes, discard the electrodes and clean the wires and device with rubbing alcohol or appropriate surface disinfectant.
Step 12: Evaluating the occlusal registration: Before any definitive restorative treatment permanently altering the dentition, the doctor should complete a thorough diagnosis which often includes a reversible temporary evaluation of the altered maxillo-mandibular relationship. Clinicians frequently use the bite registration to mount models on an articulator and construct a lower acrylic laboratory device (sometimes referred to as an orthosis, splint or guard) with minimal or no occlusal anatomy.
First, most patients will be unfamiliar with the muscle stimulating process. Explaining what they will experience is important.
Step 1: Occlusal Connections and Placement
Connect the electrodes to the electrode cable(s)
Option A: Occlusal Two Channel three electrodes for balance of left and right muscles of mastication: use one electrode over each coronoid notch one electrode at the back of the neck for a total of three electrodes.
Option B: Occlusal and Cervical Two Channel with balance between the Occlusion and Cervical areas: use one electrode for each wire for a total of four electrodes. One electrode over coronoid notch and trapezius bilaterally.
Step 3. Clean the skin and dry
Wipe electrode sites with rubbing alcohol and dry
Step 4. Occlusal Placement
A. Occlusal TWO channel (three electrodes with left and right balance) Place each electrode with black wire over coronoid notches and the electrode with both red wires on the middle of the back of the neck below the hair line (if using Dolotens-if J4/5 you can have one dedicated "lead" to the neck electrode).
Caution: Care should be used to place the electrodes accurately. If the patient feels a pounding in their head, the electrodes have not been properly placed. The electrode on the back of the neck should be accurately placed in the exact centre of the middle of the neck to achieve balanced muscle contraction.
Occlusal AND Cervical Placement
B. For two channels, place one channel over coronoid notches and the other channel two wires over trigger points on the trap muscles.
Note: In the case of sideburns and beards, consider shaving the area.
Step 5. Turn the unit on.
Note: The unit automatically starts at the lowest setting when turned on. At any time if a pause in pulse stimulation is desired (for example when recording EMGs), press (P) to pause (with some units) and to restart the stimulation at the same setting, press (P) again. The stimulation will automatically and slowly ramp to the previous intensity.
Step 6. Increase Intensity slowly by and always ensure the patient is comfortable. Increase intensity slowly until the lower front teeth have a very slight upward movement, 1 to 2 mm. (place a little finger between the anterior teeth and have the patient close and rest their teeth on the little finger and adjust intensity for the first slight perceptive squeeze of the teeth on the finger). Adjust for balance and patient comfort depending on configuration.
The cervical area should have a light, gentle comfortable contraction or squeeze. If the teeth are tapping with each pulse, turn the intensity down until the mandible has slight movement without the lower and upper teeth contacting.
Note: After a few minutes, the muscles may "loosen up" and the movement of the mandible increase without change in intensity. It is common to reduce the intensity after a few minutes to avoid the teeth from tapping.
Step 7. Maintain the patient in a comfortable, quiet, relaxed upright environment for about 20-60 minutes.
Note: To evaluate balance on each side of the face, place one finger on each side of the mandible just below the electrodes and feel the masseter muscles for balance. Patient perception of balance is sometimes helpful. Visual observation of the muscles of facial expression are less valid when determining balanced muscle contraction.
Step 8. Establishing a physiologic rest occlusion, a position of the mandible needs to be found where the muscles are at relaxed without fatigue. Neuromuscular stimulation and a muscle rested position of the mandible are valuable for these clinical procedures:
1. Mandibular Rest Position
2. Occlusal Adjustments
3. Taking a bite registration, Neuromuscualar maxillo-mandibular relationship
4. Impressions and moulding denture boarders
5. Mastication and Cervical muscle relaxation
Note: The optimal mandibular rest position is where the muscles are all simultaneously at their rested muscle length and tone. Muscles of mastication are highly differentiated and even a few muscle fibers can be hyperactive while the majority of the muscle fibbers may be relaxed creating an muscle hyperactive maxillo-mandibular relationship. To sustain muscle relaxation, the clinician should start from a position which has relaxed muscles.
Step 9: Mandibular Rest Position, clinical suggestions:
A. Ensure patient is relaxed in an upright position, sitting or standing.
B. Make a mark on the patient's nose and chin for reference.
C. Evaluate aesthetics (vertical, lateral and anterior/posterior profile position of the mandible, habitual and desired).
D Evaluate disc position and joint sounds for possible joint position/disc improvement. (Seriously deranged TMJ disorder patients may take additional considerations.)
E. Measure the distance between the marks of the nose and chin (B) when the patient is biting in their habitual occlusion and compare with the aesthetic (C) and disc (D) considerations. Measure the distance between the nose and chin marks when the patient is relaxing and teeth are apart and compare with the habitual mandibular position (B).
If the patient is aesthetically over-closed, have the patient let their lips part, tell the patient to slightly open and relax. (The jaw will slowly close to its rested position. Re-evaluate and repeat if necessary.)
If the jaw is too open, tell the patient to slightly close with lips together and relax. For the discs, have the patient open and protrude, slowly closing and relax without popping off their discs. Repeat these movements as necessary.
F. Ensure the patient has a stable resting position and the jaw repeatedly returns to the position of rest (is stable without drifting up and down). If rest is not stable, consider additional TENS time and moist heat on the muscles.
.
Step 10: Taking an occlusal registration
A Have the patient open and place a slow set firm bite registration material between the teeth, leaving the TENS on (preferably subthreshold) during the entire set of the material. (The gentle pulsing provides about 1 to 2 mm of freeway space.
Tell the patient to relax their muscles, relax their tongue and slowly let the mandible float up. Have the patient close until the distance between the two marks on the nose and chin are at the selected rested position chosen above in 8 F.
Note: Although some prefer to PULSE into the BR material, it may be better to have the TENS be "SUBTHRESHOLD" during the actual BR procedure as the stimulation is neutrally mediated there is stimulation of OPENING AND CLOSING muscles. Therefore, by being subthreshold, the muscles remain relaxed and the patient slowly drifts into the BR material under the doctor's verbal guidance.
Note: If stimulating trapezius and mandibular muscles, before taking the bite registration, reduce or eliminate the trapezius stimulation as per Jankelson.
C. After the bite registration has set, confirm in the mouth the recorded bite registration position and expected aesthetic and disc positions are in fact as desired and the patient is comfortable without strain or stress closing into the bite registration.
Caution: The marks on the skin (soft tissues) do not always accurately represent the changes between the maxilla and mandible. The occlusal registration may need to be repeated to achieve the optimal position of physiologic rest, aesthetics, and joint arrangement.
Caution: The Doctor should avoid touching the patient during the occlusal registration. Any manipulation of the mandible by the doctor may negatively influence the result. Taking more than one bite registration, permits the patient to subjectively compare the differences.
Step 11: Turn the unit off. Remove the electrodes, discard the electrodes and clean the wires and device with rubbing alcohol or appropriate surface disinfectant.
Step 12: Evaluating the occlusal registration: Before any definitive restorative treatment permanently altering the dentition, the doctor should complete a thorough diagnosis which often includes a reversible temporary evaluation of the altered maxillo-mandibular relationship. Clinicians frequently use the bite registration to mount models on an articulator and construct a lower acrylic laboratory device (sometimes referred to as an orthosis, splint or guard) with minimal or no occlusal anatomy.
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