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Advances in the Management of Oral Habits and Mouth Breathing: Part I. InnerSmilePro. RESPIRATION AND ORAL HABITS AWARENESS TRAINING. Carl Gugino, D.D.S., M.S. Robert Grove, Ph.D. Bringing Oral Habits Under Control in Your Office Today:

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slide1

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

InnerSmilePro

RESPIRATION

AND

ORAL HABITS

AWARENESS TRAINING

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

Robert Grove, Ph.D.

Bringing Oral Habits Under Control in Your Office Today:

A Realistic Model for the Average Practitioner Using Existing Staff

Version 1.0 01-27-08

slide2

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.
carl gugino
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
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
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.

slide8
SWALLOWINGFUNCTION andSTRUCURE.Concept of degree of difficulty.Neutral Zone – Neutral Matrix.Ortotropic.Phagias.
slide9

DEVELOPMENTAL PHYSIOLOGY,ORAL HEALTH and INNER SMILES

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)

slide10

PHYSICAL THERAPY?

ORAL EXERCISES?

EXERCISES for INNER SMILING?

“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)

slide11

AMERICAN PRACTICES ONLY.

Who pays?

1. Biofeedback Billing Codes

90901

90875

90876

90911

2. Evaluation

Six Sessions

Re-Evaluation

slide12

The Problem:

  • Oral Habits Can lengthen and reverse any Bite Normalization Procedure.
  • Blocked airways are emerging as a MAJOR cause of Bite Regression.
  • Tongue-Thrusting mouth devices do not open airways nor reverse habits.
  • 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.

slide13

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.
  • This finding has been replicated in 3 counties over 27 years.
  • The effect is not due to placebo effect and is in most cases, permanent.
  • Habit Retraining can be done in about 20 minutes.
slide14

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,
slide15

The Bad News:

  • Offices are reluctant because no one in their office can do it.
  • Patients are unlikely to ever go to an out-of-office referral for habit retraining.
  • Offices are unsure of how to market habit retraining.
  • Few have ever incorporated behavioral training, and need assistance for marketing, training and payment strategies.
slide16

SUMMARY: CURRENT BELIEFS ABOUT HABIT TRAINING FOR OFFICES:

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

So how difficult is it?

slide18

Take the fear out of what to say..

‘Neutralize staff fears first!

EVERY STEP IS GUIDED BY A VIRTUAL INSTRUCTOR

slide19

Respiration and Oral Habits go together.

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

slide20

POLYGRAPH ASSESSMENT

TAKES 15 Minutes

ASSESSMENT-BASED EXERCISES

TAKES 20 Minutes

SIMPLE HOMEWORK EXERCISES

Monitor Success at next visit

INTERNET-SUPERVISED EXERCISES

Schedule Home Sessions

POLYGRAPH RE-ASSESSMENTS

Re-Assess every 6 sessions

slide21

PART I: HOW TO FIND WHERE TO BEGIN TREATMENT:

POLYGRAPH ASSESSMENT

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

slide22

Sensor Placement takes about 3 minutes:

Left Masseter

Right Masseter

Digastric (Tongue)

Remember.

Yellow is Tongue..

Respiration Belt

Heart Rate- ECG Electrodes

slide23

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

It looks like this (next slide)…..

slide24

THE RESP-ORAL HABITS ASSESSMENT PROFILE

Quantifying the Functional Matrix .

Left Masseter

Right Masseter

Digastric (Tongue)

ORAL

Respiration

Heart Rate

RESP

Typical ‘Swallowing’ Profile

slide25

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)…..

slide27

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

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.

THE ORAL COMPONENT

slide28

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

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

  • Swallow Patterns:
  • The Perfect Swallow – which one?

Left Masseter

Right Masseter

Digastric (Tongue)

slide29

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

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

  • Swallow Patterns:
  • Masseter-Dominant

Left Masseter

Right Masseter

Digastric (Tongue)

slide30

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

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

  • Swallow Patterns:
  • Tongue-Dominant

Left Masseter

Right Masseter

Digastric (Tongue)

slide31

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

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

  • Swallow Patterns:
  • Incomplete / Double Swallows

Left Masseter

Right Masseter

Digastric (Tongue)

slide32

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

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

  • Swallow Patterns:
  • Asymmetric Masseter Swallow

Left Masseter

Right Masseter

Digastric (Tongue)

slide33

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

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

  • Swallow Patterns:
  • Swallow with poor timing.

Left Masseter

Right Masseter

Digastric (Tongue)

slide35

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.

slide36

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.

slide37

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

Compare it to Touching Teeth::

LEFT touches more strongly than right when the Tongue is silent.

Take out the swallow and Masseters contract strongly With Asymmetry.

slide38

Compare it to Tongue Contraction Alone:

REVERSAL: Tongue alone reverses the effect: Right touches more strongly than Left

Conclusion:

Tongue Movement alone is also WEAK.

slide39

PUT IT ALL TOGETHER AND WHAT DO YOU GET?

TONGUE * TOUCH TEETH * SWALLOW * DRINK

WEAK

STRONG

WEAK

WEAK

Right>Left

Left>Right

Right=Left

Right>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.

respiration and swallowing
RESPIRATIONand SWALLOWING

What do you call the swallowing of air?

When does swallowing stop?

slide41

THE RESPIRATION COMPONENT

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)..
slide42

Breathing is in BLUE.

TONGUE CONTRACTIONS are in YELLOW.

Tongue

Contraction

On Exhale

EXHALE

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).

linking swallow to autonomic balance
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.

slide52

ASSESSMENT-BASED EXERCISES

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…

slide53

RESP-ORAL Decision Matrix

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……

Balance Bite

(Stabilize Masseters)

Malocclusions

Weak tongue touch

Tongue Awareness

slide54

RESP-ORAL Decision Matrix

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)

Head-forward problem

Posture Stretch Awareness

Productive Swallow

(Exhale,Touch,Swallow)

slide55

RESP-ORAL Decision Matrix

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……

Pause on Exhale

(Nose Breath, Easy Breathing)

  • Restricted Airway
  • Nose/Mouth
  • Posture-link

Swallow Recovery

(Inhale, Release)

slide56

RESP-ORAL Decision Matrix

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……

  • Restricted Airway
  • Nose/Mouth
    • Mechanical-link

Nose-Dilation Reflex Exercises

Vowels Speech Tongue Awareness

slide57

RESP-ORAL Decision Matrix

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……

Balance Bite

(Stabilize Masseters)

Malocclusions

Weak tongue touch

Tongue Awareness

Productive Swallow

(Head Backwards,Touch,Swallow)

Head-forward problem

Posture Stretch Awareness

Productive Swallow

(Exhale,Touch,Swallow)

Pause on Exhale

(Nose Breath, Easy Breathing)

  • Restricted Airway
  • Nose/Mouth
  • Posture-link

Swallow Recovery

(Inhale, Release)

  • Restricted Airway
  • Nose/Mouth
    • Mechanical-link

Nose-Dilation Reflex Exercises

Vowels Speech Tongue Awareness

slide58

MASSETER

EXERCISES

RESP-ORAL Treatment Exercises

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

BREATHING

EXERCISES

SWALLOW

EXERCISES

POSTURE

EXERCISES

TONGUE

EXERCISES

slide62

CASE I WAS VERY CO-OPERATIVE AND ATTENDED EVERY SESSION

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

Next Slide…

slide63

CASE 1 – PART I: POOR WET SWALLOW.

Left Masseter

Right Masseter

Digastric (Tongue)

TONGUE vs. MASSETER ISOLATION TEST

DRY vs. WET SWALLOW

TONGUE

TOOTH

WET SWALLOW

POOR DRY

SWALLOW.

MASSETERS

DORMANT

BETTER WET

SWALLOW.

MASSETERS

BALANCED.

INCOMPLETE SWALLOW.

POOR TONGUE CONTROL

BALANCED MASSETERS

GOOD TONGUE RELEASE

slide64

CASE 1 – BREATHING NOT DIFFERENT. CHIN POSTURE DIFFERENT.

Left Masseter

Right Masseter

Digastric (Tongue)

INHALE vs. EXHALE SWALLOW

CHIN FORWARD vs. REARWARD SWALLOW

CHIN FORWARD SWALLOW

INHALE

SWALLOW

CHIN BACK SWALLOW

EXHALE

SWALLOW

BEST SWALLOW.

POOR RELEASE

UNABLE TO SUSTAIN..

MASSETERS

DORMANT.

INCOMPLETE SWALLOWS.

POOR swallow

VERY POOR SWALLOW

slide65

CASE 1 – BREATHING DETAIL..

Breathing is in BLUE.

TONGUE CONTRACTIONS are in YELLOW.

Tongue

Contraction

On Exhale

EXHALE

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).

slide66

END of CASE 1

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

slide69

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

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

Next Slide…

slide70

CASE 2 – PART I: THE COMPLETE PROFILE.

Left Masseter

Right Masseter

Digastric (Tongue)

CHIN FORWARD vs. REARWARD SWALLOW

TONGUE vs. MASSETER ISOLATION TEST

DRY vs. WET SWALLOW

INHALE vs. EXHALE SWALLOW

CHEW vs. TALK

POOR DRY

SWALLOW.

MASSETERS

DORMANT

BALANCED MASSETERS

GOOD SWALLOW TIMING

POOR TONGUE CONTROL

BETTER WET

SWALLOW.

MASSETERS

BALANCED.

INCOMPLETE SWALLOW.

slide71

CASE 1 – BREATHING DETAIL..

Breathing is in BLUE.

TONGUE CONTRACTIONS are in YELLOW.

Tongue

Contraction

On Exhale

EXHALE

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).

slide74

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

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

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.

slide75

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.

.

slide76

Questions about RESP-ORAL Habit Retraining

    • HOW:DO YOU DO IT?
      • Explain procedure – use brochure or video.
      • Attach sensors -
        • Right and Left Masseter, and Digastric Muscles.
        • Respiration Belt.
        • ECG sensors across wrists – autonomic balance and HR.
      • Run Procedure – Generate a printed report – 10 minutes.
      • DECISION: Start treatment? Discuss with patient or parents.

.

slide78

KEY ADVANTAGES FOR AN OFFICE PRACTICE…

  • 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.
  • WE NEED A STANDARDIZED WAY TO RANK THE SEVERITY OF NASAL BLOCKAGE AND ORAL HABITSFOR 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.
slide79

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

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

STANDARIZATION IS BUILT INTO THE GUIDED EXERCISE VIDEOS.

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.
slide80

CONCLUSION:

“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

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.

THANK YOU