Nociceptive trigeminal inhibition tension suppression system

Last updated

The Nociceptive trigeminal inhibition tension suppression system (abbreviated to NTI-TSS, or NTI-tension suppression system), [1] is a type of occlusal splint that is claimed to prevent headache and migraine by reducing sleep bruxism (night-time tooth clenching and grinding). Sleep bruxism is purported to lead to a hyperactivity of the trigeminal nerve, often triggering typical migraine events. The hyperactivity of trigeminal neurons during trigemino-nociceptive stimulation is a proposed cause of migraine and is correlated with imaging of migraine sufferers. [2] The objective of the NTI-TSS is to relax the muscles involved in clenching and bruxing, thus supposedly diminishing the chances for migraines and tension headaches to develop through the reduction in nociceptive stimulation normally caused by parafunctional activity. It is sometimes used for temporomandibular joint dysfunction (TMD).

The NTI-TSS is a small transparent plastic device which is, in its most widely used form, worn over the front four teeth, of either arch, at night, and intended to prevent contact of the canines and molars. It is normally fitted by a dentist trained in the technique, and is constructed by a dental laboratory. [3]

However, in FDA trials the Nociceptive Trigeminal Inhibition Tension Suppression System (NTI-tss) had been proven to provide a 77% reduction of migraine events in 82% of subjects tested. [4] [5] Practical Neurology Oct. 2005 [6] The origin of the pain must be determined in each individual, and each contributory factor must be addressed. Most migraine sufferers have a combination of two or more of the following: a) vascular pain (pain originating in the arteries of the scalp), [7] b) muscular pain (pain originating from the jaw and neck muscles), [8] [9] [10] [11] c) pain or abnormal sensitivity of the skin of the scalp (known as cutaneous allodynia), [12] and hypersensitivity of the brain to incoming pain messages [13]

Evidence and safety

As the NTI-TSS does not cover all of the teeth, it is classed as a partial coverage occlusal splint. Partial coverage splints are recommended by some experts, but they have the potential to cause unwanted tooth movements if worn 24 hours a day 7 days a week with no tooth contact (which is never recommended), [14] which rarely can be severe. Since the patient cannot wear the NTI-tss device while chewing food, the posterior alveolar structures receive regular stimulation every day, therefore, there is no opportunity for a functional adaptation of the occlusal scheme, that is supra-eruption of the teeth.[ citation needed ] Research shows[ citation needed ] that alveolar bone requires at least 8 days of lack of stimulation before bone growth at the apex (supra-eruption) can initiate. Periodontal ligament that surrounds the root and holds the tooth in place - if this ligament is stimulated (exercised) it will continue holding the teeth in correct position.[ citation needed ]

As for anterior intrusion, the lack of continuous apical force does not provide adequate opportunity to intrude an incisor. A 2010 review of scientific studies carried out to investigate the use of occlusal splints in TMD concluded the following with regards anterior bite appliances (another term for partial coverage occlusal splints that cover only the front teeth):

"Other types of appliances, including [...] anterior bite appliances, have some RCT (randomized control trial) evidence of efficacy in reducing TMD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use." [15]

Related Research Articles

<span class="mw-page-title-main">Migraine</span> Disorder resulting in recurrent moderate-severe headaches

Migraine is a genetically influenced complex neurological disorder characterized by episodes of moderate-to-severe headache, most often unilateral and generally associated with nausea and light and sound sensitivity. Other characterizing symptoms may include vomiting, cognitive dysfunction, allodynia, and dizziness. Exacerbation of headache symptoms during physical activity is another distinguishing feature. Up to one-third of migraine sufferers experience aura, a premonitory period of sensory disturbance widely accepted to be caused by cortical spreading depression at the onset of a migraine attack. Although primarily considered to be a headache disorder, migraine is highly heterogenous in its clinical presentation and is better thought of as a spectrum disease rather than a distinct clinical entity. Disease burden can range from episodic discrete attacks to chronic disease.

<span class="mw-page-title-main">Temporomandibular joint dysfunction</span> Medical condition

Temporomandibular joint dysfunction is an umbrella term covering pain and dysfunction of the muscles of mastication and the temporomandibular joints. The most important feature is pain, followed by restricted mandibular movement, and noises from the temporomandibular joints (TMJ) during jaw movement. Although TMD is not life-threatening, it can be detrimental to quality of life; this is because the symptoms can become chronic and difficult to manage.

<span class="mw-page-title-main">Headache</span> Pain in the head, neck, or face

Headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches.

<span class="mw-page-title-main">Bruxism</span> Disorder that involves involuntarily grinding or clenching of the teeth

Bruxism is excessive teeth grinding or jaw clenching. It is an oral parafunctional activity; i.e., it is unrelated to normal function such as eating or talking. Bruxism is a common behavior; reports of prevalence range from 8% to 31% in the general population. Several symptoms are commonly associated with bruxism, including aching jaw muscles, headaches, hypersensitive teeth, tooth wear, and damage to dental restorations. Symptoms may be minimal, without patient awareness of the condition. If nothing is done, after a while many teeth start wearing down until the whole tooth is gone.

<span class="mw-page-title-main">Cluster headache</span> Neurological disorder

Cluster headache is a neurological disorder characterized by recurrent severe headaches on one side of the head, typically around the eye(s). There is often accompanying eye watering, nasal congestion, or swelling around the eye on the affected side. These symptoms typically last 15 minutes to 3 hours. Attacks often occur in clusters which typically last for weeks or months and occasionally more than a year.

<span class="mw-page-title-main">Triptan</span> Class of pharmaceutical drugs

Triptans are a family of tryptamine-based drugs used as abortive medication in the treatment of migraines and cluster headaches. This drug class was first commercially introduced in the 1990s. While effective at treating individual headaches, they do not provide preventive treatment and are not considered a cure. They are not effective for the treatment of tension–type headache, except in persons who also experience migraines. Triptans do not relieve other kinds of pain.

<span class="mw-page-title-main">Mouthguard</span> Protective device for the teeth and gums to avoid injury to them

A mouthguard is a protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips and gums. An effective mouthguard is like a crash helmet for teeth and jaws. It also prevents the jaws coming together fully, thereby reducing the risk of jaw joint injuries and concussion. A mouthguard is most often used to prevent injury in contact sports, as a treatment for bruxism or TMD, or as part of certain dental procedures, such as tooth bleaching or sleep apnea treatment. Depending on the application, it may also be called a mouth protector, mouth piece, gumshield, gumguard, nightguard, occlusal splint, bite splint, or bite plane. The dentists who specialise in sports dentistry fabricate mouthguards.

Neuralgia is pain in the distribution of a nerve or nerves, as in intercostal neuralgia, trigeminal neuralgia, and glossopharyngeal neuralgia.

<span class="mw-page-title-main">Allodynia</span> Feeling of pain from stimuli which do not normally elicit pain

Allodynia is a condition in which pain is caused by a stimulus that does not normally elicit pain. For example, sunburn can cause temporary allodynia, so that usually painless stimuli, such as wearing clothing or running cold or warm water over it, can be very painful. It is different from hyperalgesia, an exaggerated response from a normally painful stimulus. The term comes from Ancient Greek άλλος (állos) 'other', and οδύνη (odúnē) 'pain'.

<span class="mw-page-title-main">Calcitonin gene-related peptide</span> Peptide hormone in animals

Calcitonin gene-related peptide (CGRP) is a member of the calcitonin family of peptides consisting of calcitonin, amylin, adrenomedullin, adrenomedullin 2 (intermedin) and calcitonin‑receptor‑stimulating peptide. Calcitonin is mainly produced by thyroid C cells whilst CGRP is secreted and stored in the nervous system. This peptide, in humans, exists in two forms: CGRP alpha, and CGRP beta. α-CGRP is a 37-amino acid neuropeptide and is formed by alternative splicing of the calcitonin/CGRP gene located on chromosome 11. β-CGRP is less studied. In humans, β-CGRP differs from α-CGRP by three amino acids and is encoded in a separate, nearby gene. The CGRP family includes calcitonin (CT), adrenomedullin (AM), and amylin (AMY).

<span class="mw-page-title-main">Dental attrition</span>

Dental attrition is a type of tooth wear caused by tooth-to-tooth contact, resulting in loss of tooth tissue, usually starting at the incisal or occlusal surfaces. Tooth wear is a physiological process and is commonly seen as a normal part of aging. Advanced and excessive wear and tooth surface loss can be defined as pathological in nature, requiring intervention by a dental practitioner. The pathological wear of the tooth surface can be caused by bruxism, which is clenching and grinding of the teeth. If the attrition is severe, the enamel can be completely worn away leaving underlying dentin exposed, resulting in an increased risk of dental caries and dentin hypersensitivity. It is best to identify pathological attrition at an early stage to prevent unnecessary loss of tooth structure as enamel does not regenerate.

Occlusion, in a dental context, means simply the contact between teeth. More technically, it is the relationship between the maxillary (upper) and mandibular (lower) teeth when they approach each other, as occurs during chewing or at rest.

<span class="mw-page-title-main">Crossbite</span> Medical condition

Crossbite is a form of malocclusion where a tooth has a more buccal or lingual position than its corresponding antagonist tooth in the upper or lower dental arch. In other words, crossbite is a lateral misalignment of the dental arches.

Migraine surgery is a surgical operation undertaken with the goal of reducing or preventing migraines. Migraine surgery most often refers to surgical nerve decompression of one or several nerves in the head and neck which have been shown to trigger migraine symptoms in many migraine sufferers. Following the development of nerve decompression techniques for the relief of migraine pain in the year 2000, these procedures have been extensively studied and shown to be effective in appropriate candidates. The nerves that are most often addressed in migraine surgery are found outside of the skull, in the face and neck, and include the supra-orbital and supra-trochlear nerves in the forehead, the zygomaticotemporal nerve and auriculotemporal nerves in the temple region, and the greater occipital, lesser occipital, and third occipital nerves in the back of the neck. Nerve impingement in the nasal cavity has additionally been shown to be a trigger of migraine symptoms.

Preventive treatment of migraine can be an important component of migraine management. The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraine attacks, and to increase the effectiveness of abortive therapy. Another reason to pursue prevention is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which can arise from overuse of pain medications, and can result in chronic daily headache. Preventive treatments of migraine include medications, nutritional supplements, lifestyle alterations, and surgery. Prevention is recommended in those who have headaches more than two days a week, cannot tolerate the medications used to treat acute attacks, or those with severe attacks that are not easily controlled.

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing is a rare headache disorder that belongs to the group of headaches called trigeminal autonomic cephalalgia (TACs). Symptoms include excruciating burning, stabbing, or electrical headaches mainly near the eye and typically these sensations are only on one side of the body. The headache attacks are typically accompanied by cranial autonomic signs that are unique to SUNCT. Each attack can last from five seconds to six minutes and may occur up to 200 times daily.

Atypical facial pain (AFP) is a type of chronic facial pain which does not fulfill any other diagnosis. There is no consensus as to a globally accepted definition, and there is even controversy as to whether the term should be continued to be used. Both the International Headache Society (IHS) and the International Association for the Study of Pain (IASP) have adopted the term persistent idiopathic facial pain (PIFP) to replace AFP. In the 2nd Edition of the International Classification of Headache Disorders (ICHD-2), PIFP is defined as "persistent facial pain that does not have the characteristics of the cranial neuralgias ... and is not attributed to another disorder." However, the term AFP continues to be used by the World Health Organization's 10th revision of the International Statistical Classification of Diseases and Related Health Problems and remains in general use by clinicians to refer to chronic facial pain that does not meet any diagnostic criteria and does not respond to most treatments.

Dentomandibular sensorimotor dysfunction (DMSD) is a medical condition involving the mandible, upper three cervical (neck) vertebrae, and the surrounding muscle and nerve areas.

<span class="mw-page-title-main">Orofacial pain</span> Medical condition

Orofacial pain is a general term covering any pain which is felt in the mouth, jaws and the face. Orofacial pain is a common symptom, and there are many causes.

<span class="mw-page-title-main">Tooth mobility</span> Medical condition

Tooth mobility is the horizontal or vertical displacement of a tooth beyond its normal physiological boundaries around the gingival area, i.e. the medical term for a loose tooth.

References

  1. Stapelmann, Henrike; Türp, Jens C. (2008). "The NTI-TSS device for the therapy of bruxism, temporomandibular disorders, and headache – Where do we stand? A qualitative systematic review of the literature". BMC Oral Health. 8: 22. doi: 10.1186/1472-6831-8-22 . PMC   2583977 . PMID   18662411.
  2. Burstein, R., Noseda, R., & Borsook, D. (April 29, 2015). Migraine: Multiple Processes, Complex Pathophysiology. Journal of Neuroscience, 35(17), 6619-6629.
  3. "NTI-tss™ Plus for Migraine Therapy & Headaches from a Dental Lab". nationaldentex.com.
  4. Practical Neurology Oct. 2005
  5. Blumenfeld, Andrew M.; Boyd, James P. (April 3, 2004). "Adjunctive treatment of chronic migraine using an oral dental device: overview and results of a randomized placebo-controlled crossover study". NLM. 22 (1): 72. doi: 10.1186/s12883-022-02591-8 . ISSN   1471-2377. PMC   8895632 . PMID   35246048.
  6. p
  7. Shevel E (2011). "The Extracranial Vascular Theory of Migraine – A Great Story Confirmed by the Facts". Headache. 51 (3): 409–417. doi:10.1111/j.1526-4610.2011.01844.x. PMID   21352215. S2CID   6939786.
  8. Tfelt-Hansen P; Lous I; Olesen J. (1981). "Prevalence and significance of muscle tenderness during common migraine attacks". Headache. 21 (2): 49–54. doi:10.1111/j.1526-4610.1981.hed2102049.x. PMID   7239900. S2CID   42206728.
  9. Jensen K, Bulow P, Hansen H (1985). "Experimental toothclenching in common migraine". Cephalalgia. 5 (4): 245–251. doi:10.1046/j.1468-2982.1985.0504245.x. PMID   4084979. S2CID   23648142.
  10. Fernández-de-Las-Peñas C; Cuadrado ML; Arendt-Nielsen L; Pareja JA. (2008). "Side-to-side differences in pressure pain thresholds and pericranial muscle tenderness in strictly unilateral migraine". Eur J Neurol. 15 (2): 162–8. doi:10.1111/j.1468-1331.2007.02020.x. PMID   18093151. S2CID   8537431.
  11. Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA (2006). "Myofascial trigger points, neck mobility and forward head posture in unilateral migraine". Cephalalgia. 26 (9): 1061–70. doi:10.1111/j.1468-2982.2006.01162.x. PMID   16919056. S2CID   12915013.
  12. Burstein R, Cutrer MF, Yarnitsky D (2000). "The development of cutaneous allodynia during a migraine attack". Brain. 123: 1703–9. doi: 10.1093/brain/123.8.1703 . PMID   10908199.
  13. Strassman AM, Raymond SA, Burstein R (1996). "Sensitization of meningeal sensory neurons and the origin of headaches". Nature. 384 (6609): 560–4. Bibcode:1996Natur.384..560S. doi:10.1038/384560a0. PMID   8955268. S2CID   4323574.
  14. Wassell R, Naru A, Steele J, Nohl F (2008). Applied occlusion. London: Quintessence. pp. 73–84. ISBN   9781850970989.
  15. Fricton J, Look JO, Wright E, Alencar FG Jr, Chen H, Lang M, Ouyang W, Velly AM (2010). "Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders". Journal of Orofacial Pain. 24 (3): 237–54. PMID   20664825.