The future of dentistry involves evaluation of the patient providing collaborative optimal care alongside other healthcare practitioners. The increased interest and involvement with sleep, pain and airway requires the dentist to view their patient with new and expanded vision and thinking. The successful treatment of patients with sleep, TMD, and chronic pain will be based on recognizing the dentist’s role in understanding patient physiology.
In this new era, the dental focus will expand beyond function to become more centered on physiology. Today instrumentation is available to support the move towards a physiological focused practice.
For many years, dentists have designed and inserted oral appliances to treat bruxism, pain in the head and neck related to jaw pain, correct dysfunctions due to jaw position, vertical dimension, hyper contraction of muscles, and treat snoring and sleep apnea. When these oral appliances are designed, fitted and adjusted properly, patients often have not only demonstrated improvement of oro-facial symptoms but often reported improvement in a wide range of systemic symptoms and disorders. The basis of these adjustments has been driven by diagnostic films, clinical exam and patient subjective responses to pain questionnaires.
In attempting to provide this therapy, dentists have encountered several obstacles. The treatment results are individual and not necessarily predictable or consistent from practitioner to practitioner. The number of visits required to adjust and balance the orthotics varies and often dentists spend many more hours than anticipated modifying and adjusting the orthotics.
Practitioners have had difficulty in correlating objective data with subjective responses. Often the only evidence used to support results has been anecdotal as to what is occurring both locally and systemically.
A majority of dentists use bite registrations and determine jaw position based on averages of general population rather the patient’s individual physiology. Is it a protrusive of 40 percent, 50 percent, 60 percent and what should the vertical be? A growing number of dentists are embracing new technology and using physiological monitoring as a centerpiece of their changing practice needs.
Monitoring and assessment of heart rate variability (HRV) and autonomic nervous system (ANS) function are becoming a key tool to understanding the physiological basis for the inextricable relationship among dentistry, medicine, and other healthcare practices. HRV instrumentation with the addition of emgs, respiration rate and heart rate are providing real time assessment of optimal jaw position, muscle tension, ANS balance and more.
The autonomic nervous system (ANS), composed of the sympathetic (SNS) and parasympathetic nervous systems (PNS), controls the cardiovascular system in part by releasing neurotransmitters that increase or decrease heart rate (HR) respectively. The activity of the SNS increases heart rate and respiration rate.
HR and HRV are not the same. HR is an average over an epoch of time. The periodic fluctuations in HR and respiration rate intervals of consecutive heartbeats, modulated by the activation of the ANS on the heart is known as heart rate variability. 1-5
A high HRV is a sign of health, depicting the body’s resiliency in shifting between sympathetic and parasympathetic pathways. Lowered HRV is associated with disease states, increased sympathetic activity and poor adaptation to stress and physiologic dysfunction. 4
The use of HRV data is not new. It has been measured in medicine for many years, and there are 20,000 articles of its use in PubMed. It is accepted that decreased HRV is associated with age and poor health, predicts mortality after a heart attack and increased risk of disease and apnea in the future. It is an early warning system that can provide valuable information for more optimal diagnosis and treatment.
In dentistry, malocclusion, TMD, and surgical dental procedures have been shown to lower HRV. 6 Maixner et al. (2011), investigated the association between autonomic variables and TMD disorder, testing the hypothesis that dysregulation of the ANS contributed to the onset and persistence of TMD. The authors found that patients with TMD at rest showed reduced HRV compared with the control group.
William Hang, DDS, a pioneer who treats patients and teaching practitioners cutting edge airway orthodontic techniques has recently introduced the use of the HindexRV® Monitoring system into his practice. He believes, “The system scientifically documents and validates the efficacy of treatment by measuring HRV and will become a benchmark measurement of successful treatment in this new era.”
Several articles have shown that HRV changes with jaw position.
Relating to sleep, patients with OSA have lowered daytime HRV, even in the absence of hypertension, heart failure and other disease states. 7
Over the last fifteen years, Dr. Jeffrey Hindin has developed and refined instrumentation to monitor HRV and ANS balance and add a new level of understanding and care for patients with airway disorders. The result is the HindexRV® system which provides objective data (respiration rate, EKG and EMG) on the physiological effects of altered jaw position, tooth positioning and other dental procedures and is FDA cleared for monitoring.
With HindexRV® monitoring, the clinician can objectively view patient physiology, in real time, to evaluate the efficacy of treatment of treatment modalities, e.g. appliance position, and obtain the “physiological bite”.
John Tucker, DMD, a leader in sleep education states that this monitoring system is a “new technology that may be the “Holy Grail” for finding the best mandibular position for an oral appliance based on the patient’s individualized physiology”. “It had proven to be my most valuable asset in treating the CPAP intolerant patient with oral appliance therapy”.
Routine dental procedures can influence the airway and the physiology of the patient, whether the practitioner knows it or not. An extracted tooth, an over-contoured crown, loss of vertical dimension, an unbalanced occlusion, a retracted mandible, and findings that dentists observe, treat and modify can change a patient’s physiology, alter resiliency and ultimately impact health and function.
It is accepted that HRV is an early warning system that can provide valuable information for the clinician to use with clinical data to achieve optimal diagnosis and treatment. Soon, dentists will routinely monitor their patient’s physiological functions and assesses the risks and benefits of their treatment. In addition, treatment specifically aimed to promote and enhance physiological function where appropriate will be provided.
For more information about HindexRV® Monitoring and Physiological/HRV courses, email email@example.com or visit www.physiologicaldentistry.com. OH
Oral Health welcomes this original article.
1. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology: Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation 1996, 93:1043–1065.
2. Valenti VE, Guida HL, Vanderlei LC, Roque AL, Ferreira LL, Ferreira C, Silva TD, Manhabusque KV, Fujimori M, Abreu LC: Relationship between cardiac autonomic regulation and auditory mechanisms: importance for growth and development. J Hum Growth Dev 2013, 2013:23.
3. Vanderlei FC, Rossi RC, de Souza NM, de Sá DA, Gonçalves TM, Pastre CM, Abreu LC, Valenti VE, Vanderlei LCM: Heart rate variability in healthy adolescents at rest. J Hum Growth Dev 2012, 2012(22):173–178.
4. Abreu LC: Heart rate variability as a functional marker of development. J Hum Growth Dev 2012, 22:279–281.
5. Vitor ALR, Souza NM, Lorenconi RMR, Pastre CM, Abreu LC, Valenti VE, et al: Nonlinear methods of heart rate variability analysis in diabetes. Health Med 2012, 6:2647–2653.
6. Ekuni D, Takeuchi N, Furuta M, Tomofuji T, Morita M: Relationship between malocclusion and heart rate variability indices in young adults: a pilot study. Methods Inf Med 2011, 50:358-363.
7. Narkiewicz, K. et al. Altered cardiovascular variability in obstructive sleep apnea. Circulation. 1998 Sep15;98(11):1071-7
About the Author
Dr. Howard Hindin is celebrating 50 years of practice in all aspects of general dentistry, with an emphasis on cosmetic dentistry, temporomandibular joint disorders, craniofacial pain and sleep dental medicine. An acknowledged pioneer in the relationship between dental issues and whole body health, he was one first dentists to eliminate the use of mercury from his practice.
Dr. Hindin was President (2000-2010) of the Foundation for the Advancement of Innovative Medicine (FAIM). In addition, Dr. Hindin advanced the use of acupuncture in dentistry and general medicine as the Director of the Acupuncture Program for Substance Abuse in Rockland County.
Dr. Hindin is the co-founder and president of the Academy of Physiologic Medicine and Dentistry (AAPMD).