The early years, from 1965- 1987, provide insights and appreciation for the intellect and courage of one man, Bernard Jankelson (Dr. J), as he single handedly challenged the dental gnathology establishment and their cherished dogmas. The fight to bring new technology and a new paradigm of treatment of dental occlusion and TMD pain/dysfunction was met with epic professional resistance from a small group of politically entrenched academics associated with identified organizations that attempted to stain the professional and personal character of Dr. JANKELSON. and those associated with the new science of Neuromuscular dentistry.
The textbook, The Body Electric, Electromagnetism and the Foundation of Life, Becker and Selden is a requisite primer to understand the motives, psychology and modus operendi of the anti- neuromuscular and anti- instrumentation operatives. Becker aptly refers to them as Pigeons of Zeus, an appropriate symbol for the entrenched academic and political dental hierarchy.
“At this point the gloves come off. Already a lightning rod for the wrath of the Olympian peers, the would be Prometheus writhes under the attacks on his or her honesty, scientific competence and personal habits. The pigeons of Zeus cover the new ideas with their droppings and conduct rigged experiments to disprove them. In extreme cases, government agencies staffed and advised by the establishment begin legal harassment.” 1
Using Becker’s vernacular, Dr. Jankelson and colleagues who continued his work discovered that the dental pigeon of Zeus is not the gentle bird content to search for tasty morsels in the town square. This pigeon of Zeus is a fierce, persistent bird of prey willing to destroy dental colleagues and patient welfare that gets in the way of the Zeus agenda. These pigeons can be found roosting in places built on entrenched dogma but lacking scientific foundations.
These pigeons appear to have limited vocabulary with favorite words repeated time after time, year after year. They can be heard repeating pigeon mantras such as “sensitivity”, “specificity”, “over treatment”, “dangerous”, “experimental”. These words frequently fall on the pages of respected dental journals where compliant editors have allowed pigeon scat to leave a distinctive 30 year trail.
The story of neuromuscular dentistry is not unique in the history of science and medicine. The iconoclast is labeled a pariah. His ideas, hypothesis and technologies are cast to the outer fringes of scientific credibility. Only the preponderance of evidence and the iconoclast’s conviction support him as his family, character and state of mind are impugned by the establishment priesthood. This is the story of Dr. Jankelson’s neuromuscular concepts and neuromuscular technology under assault from the pigeons of Zeus.
The second political era explores the politics following Dr. Jankelson’s death in 1987 and encompasses epic battles in the American Dental Association and U.S. Food and Drug Administration. By 1986 the scientific foundation for neuromuscular concepts and techniques was firmly rooted in the scientific literature. The technology was recognized as safe and effective for the purposes intended by the American Dental Association Council on Scientific Affairs. The clinical techniques were precise, predictable and clinically successful. Yet, the neuromuscular clinicians, their philosophy and their instrumentation continued to be attacked by gnathologic gurus whose status and livelihood depended upon the defense of the scientifically indefensible, by third party carriers intent upon denial of payment, by IME’s who supported the insurance company’s ability to deny patient claims, and by psychosocial academicians whose research funding depended upon adherence to a particular TMD paradigm.
The third chronologic era begins with the new millennium until the Present. The millennium dawned with enormous renewal of interest in neuromuscular dentistry and utilization of neuromuscular instrumentation. The Pigeons of Zeus were nursing ruffled feathers, broken wings and indigestion after the resounding rebukes following determination that they had “rigged” the 1994 FDA Advisory Panel. Despite the pigeons efforts to discredit neuromuscular instrumentation the American Dental Association Council on Scientific Affairs extended the ADA Seal of Acceptance to all neuromuscular instrumentation in 2004.
Sidebars of argument over the biomechanical vs psychosocial model of TMD continued into the new millennium. Millions of grant dollars flowed to the academic psychosocial coffers. Choosing not to execute the meticulous techniques necessary to diagnose and treat the occlusal component of TMD, the psychosocial paradigm provides a welcome refuge from technical tedium and the burden of having to learn new skills. When gross attempts at occlusal therapy fail the validity of their occlusal treatment is not questioned. The patient is then identified as a psychosocial TMD patient. It’s so much easier to write a drug script than to spend your energy, eye/hand motor skills and intellect addressing the underlying biomechanical problems.
Therein lays the appeal of the psychosocial paradigm. The dentist doesn’t have to discipline himself to find a precise orthopedic position of the mandible to the cranium, doesn’t have to mechanically address micro occlusal prematurities or to differentiate a myriad of biomechanical problems originating at other levels of the postural chain. When a crudely placed appliance fails to improve the patient’s symptoms, Tricyclics, Prozac and other psychotropic mood altering pharmacology become an all too ready therapeutic recourse. The prescription pad is easier than mastering an understanding of the biomechanical issues and executing precise therapeutic protocols.
The last year of the first decade of the new millennium, 2010, witnessed the tentative return of our 1994 Pigeons of Zeus to some of their original haunts, namely the pages of the Journal of the American Dental Association (JADA) and other dental periodicals such as Journal Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics (OOOOE). The Jeffersonian admonition that “The price of Freedom is eternal vigilance” is appreciated when we realize pigeons apparently have no shame, but great persistence.
Kuhn, in The Structure of Scientific Revolutions stated: “Led by a new paradigm, scientists adopt new instruments and look in new places. Even more important, during revolutions scientists see new and different things when looking with familiar instruments in places they have looked before.”
How persistent the attachment to dogma when we do not have the ability to see the truth hidden in space or sub-molecular spaces. Almost every scientific breakthrough has been preceded by a technologic breakthrough that allows us to see the previously unseen. Galileo’s telescope opened the universe to new observation and cosmic theories. The light microscope, followed by the electron microscope, revealed previously hidden secrets of the cell, leading to previously unimaginable medical breakthroughs. Angle recognized the importance of muscle forces on occlusal form and function as early as 1906. 3
However, an occlusal paradigm that integrated the neuromusculature into a diagnostic and therapeutic protocol awaited the technologic breakthrough that could predictably restore masticatory muscle to a more physiologic state prior to occlusal therapy.
The genesis of neuromuscular dentistry began with the collaboration of Bernard Jankelson and Dr. H.H. Dixon, a renowned muscle physiologist, working together at the University of Oregon School of Medicine in the early 1960s. In 1967 Dixon wrote:
“Experimental work with the myograph and chemical analysis indicates that fatigued muscle restores its energy with light, free motion at a rate below 60 contractions per minute. Fatigue spasm can be reduced by electrical stimulation. The device used should deliver a fraction of a millampere, at around 100 volts, in a biphasic wave, at a rate of 40 to 60 impulses per minute.” 4
The technology to change muscle metabolism and resting states was the breakthrough that broke the clinical dependency upon an elusive and unproven CO/CR occlusal reference. The electrical parameters established by Dixon, the serendipity of anatomic proximity of the V and VII cranial nerves to the coronoid notch and a clinical paradigm of muscle relaxation as a precursor to occlusal diagnosis and treatment culminated in Dr. J’s development of the first prototype Myo-monitor in 1967.
“Transcutaneous electrical stimulation has the essential ability not only to relax the musculature, but also to initiate controlled isotonic muscle contraction to propel the mandible from rest position on an isotonic trajectory through the interocclusal space to a neuromuscularly oriented occlusal position in space.” 5
The Myo-monitor provided a clinical tool to facilitate masticatory muscle relaxation and to generate an isotonic path of closure that was central to the neuromuscular paradigm. As so often occurs in science, the technology, i.e. the Myo-monitor, was necessary to define the new neuromuscular paradigm and execute the necessary clinical procedures.
The resistance to Dr. Jankelson’s neuromuscular theory and the Myo-monitor was swift and predictable. Many a genius has been destroyed by people of lesser talent defending the status quo. It was inevitable that the genius and elegance of Dr. J’s model for neuromuscular occlusion would be challenged. Becker again reminds us that pigeons of Zeus inhabit other halls of science and medicine:
“In the past, character flaws couldn’t wholly prevent the recognition of scientific truths. Both sides of a controversy would fight with equal vehemence, and the one with better evidence would usually win sooner or later. In the past four decades, however, changes in the structure of scientific institutions have produced a situation so heavily weighted in favor of the establishment that it impedes progress in health care and prevents truly new ideas from getting a fair hearing in almost all circumstances. The present system in effect is a dogmatic religion with a self perpetuating priesthood dedicated only to preserving the current orthodoxies.”
Since 1986 TMD has been the arena for those opposing neuromuscular concepts and instrumentation. However, the early “Myo-monitor wars” were fought on the occlusal battlefield. Resistance to Dr. J’s neuromuscular theory came from the entrenched gnathologic school of occlusion. A little known foot note of dental history is that Gnathology had its origins in Bonwill’s revealed “divine dream” published in Journal Northwest Medicine in 1850.6 This theory postulated that during function, teeth slid against each other in a characteristic mechanical pattern. Centric relation was originally defined as “the mandibular position when the heads of the condyles are in their most retruded positions from which the jaw can make free lateral movement.” 7 Lacking more physiologic parameters, gnathology also mandated that it is necessary to use a border reference position of the jaw as described by Posselt. 8
Reproducibility became the operative mantra for seeking a “terminal hinge” position, however un-physiologic that position may be. Even reproducibility was an illusion. 9,10 Lacking objective physiologic data the gnathologic literature degenerated into semantic obfuscation as each new definition of centric relation failed to meet scientific and clinical scrutiny. In 1959, Shore listed twenty six different definitions of centric relation. 11 After 130 years of gnathologic tradition, Dawson was describing occlusal bite registration in terms that seem more appropriate to a Victorian romance novel than to legitimate scientific discourse: “Now with gentle manipulation, the open jaw is lightly ‘romanced’ into the terminal hinge position.” 12 Forty years later the romancing continues, but hard objective evidence that CR, however elusive the definition, results in the desired therapeutic effect is notably lacking. With seven definitions of centric relation in the Prosthetic Glossary, 13 only the definitions change to accommodate the anachronisms of a nineteenth century mechanical theory of how the mandible functions.
The apparent inadequacy of the operator was said to explain every clinical failure. The gnathologic gurus admonished and promised more predictable results if only the clinician could be more precise:
“If the operator (or researcher) does not capture the true terminal hinge relationship, the value of a correct relationship cannot be fully appreciated. Furthermore, most experienced operators have confidence that their centric relation recordings are correct, but the study showed that experience cannot compensate for inadequate methods of manipulation or recording. Most of the methods used to manipulate the mandible into its terminal hinge axis do not work.” Dawson then continues, “It is also clear that recording it correctly is a demanding skill that must be carefully learned and precisely executed.” 14
Even the most unapologetic of gnathologists concede the elusiveness of Centric Relation, yet rationalize clinical failure and the continuing semantic obfuscation by ascribing an almost mystical level of skill and competence to achieve desired results. McNeil re-enforces such thinking:
“Unfortunately, the definition of centric relation keeps changing in the literature. However the changes simply relate to improvements in jaw manipulation techniques and new knowledge regarding the anatomic and physiologic position of the mandible.”15
Clearly, in the world of gnathology, the definition must change if it does not fit or fulfill the latest advancement in manipulation. Not exactly the “scientific method”.
While electro-stimulation was a familiar modality in the everyday practice of physical medicine, neurology and cardiology, such modalities were deemed inappropriate by a dental establishment searching for the perfect mechanical articulator. Many of the iterations for the perfect articulator may also have had their origins in divine dreams similar to Bonwills’ dream in 1850. Early practitioners utilizing the Myo-monitor were frequently derided as “jaw jerkers” or “jaw shockers”. Those pioneering the early use of the Myo-monitor were amazed at the dramatic patient response to the myocentric occlusal treatment position. A common patient response to the myocentric occlusion was “that’s where I told all the other dentists my bite should be.” While initially anecdotal the clinical evidence that the Myo-monitor was a clinical breakthrough in treatment of occlusal and TMD problems quickly mounted. 16,17,18,19,20,-21
The Myo-monitor war of 1970- 1975 found the gnathologic occlusal establishment, with all the resources of their refereed journals, aligned against a singular foe, Dr. Bernard Jankelson and ‘his’ Myo-monitor. Becker was aware that the pigeons gather in comforting flocks to take flight against the infidel when cherished dogma are threatened by new ideas, evidence and technology.
“The pigeons of Zeus cover the new ideas with their droppings and conduct rigged experiments to disprove them. Manuscripts submitted to scientific journals are reviewed for validity in the same way as grant requests. And who better qualified to judge an article than those same eminent experts with their laurels to guard. Publication is accepted as evidence that an experiment has some basic value.”
Dr. Jankelson, a meticulous researcher and writer, had paper after paper rejected by the reviewers for peer reviewed journals, only to find an anti-Myomonitor article of little or no scientific merit in these same journals. Their conclusions were always the same: the Myo-monitor centric position is always anterior to centric relation 22,23,24 and the Myo-monitor only stimulates muscle directly, not via neural mediation as suggest by Dr. Jankelson. Any assault on the sanctity of centric relation upon which reputations were built was to be stopped at the castle wall. The refereed journal was the platform to repulse the invasion of original thinking. The pigeons of Zeus were circling the challenger to centric relation.
Methodology in these studies often included the use of antiquated clutches, gothic arch devices and wax bite registration materials and protocols assured to produce the researchers desired outcome. The finding that the Myo-monitor position was always anterior to centric relation was enough to condemn the Myo-monitor to the outer perimeters of scientific credibility. Practitioners using this device were assigned ‘fringe’ status by the establishment. Accepting centric relation (take your choice of 26 definitions) as the occlusal gold standard was, and still is, an intellectual arrogance unsupported by scientific evidence. Yet the CR icon stood unquestioned and off base to critical scrutiny by ‘men of science’.
The establishment literature quickly ‘proved’ that the observed muscle contraction was only direct muscle stimulation, not neurally mediated via the V and VII motor nerves. 25-26 If this were proven it would invalidate Dr. Jankelson’s theory of a Myo-monitor neurally mediated isotonic closure to a myocentric position.
Meanwhile several studies, most conducted at Japanese Universities, supporting the premise of neural mediation were published. 27,28,29 Dr Jankelson’s intensity duration curve research, after several years of delay at the referee level, was finally published in 1975.30 Ten years later Williamson’s study confirmed the Japanese University findings. Williamson administered succinylcholine as a muscle paralyzer at time of intubation for orthognathic surgery. Succinylcholine antagonizes acetylcholine at the myo-neural end plate preventing neutrally mediated muscle contraction. The only way a muscle can contract under such conditions is by direct depolarization of the muscle itself. There was no muscle contraction with the Myo-monitor stimulus under the effect of succylcholine. This was definitive evidence that Myo-monitor induced muscle stimulation is neutrally transmitted.31
By 1986 the weight of scientific evidence began to quiet all but the most strident Myo-monitor foes. The period from 1977 to 1987 was marked by rapid improvements in neuromuscular instrumentation which was now being routinely used in clinical and research settings around the world while vigorously resisted by the same small academic groups in the United States.
Dr. Jankelson endured personal and professional vilification during the early years of the Myo-monitor and introduction of the neuromuscular theories and clinical techniques. Strength of character and scientific validity were his only defense. After development and introduction of the clinical TENS, J-2 Myo-monitor, in 1969 he now tackled the challenge of developing objective measurement instrumentation to document masticatory function.
In 1973 Lerman addressed the ‘missing link’ in diagnosis and treatment of occlusion and TMD: “It cannot be overemphasized that since symptoms are muscle based, occlusal therapy of MSD (TMD) should be muscle oriented. Unfortunately, present clinical techniques which establish either terminal hinge or centric placement do not consistently accomplish this. With current techniques, an entire physiologic dimension is largely missing from the analysis of the occlusion, namely the occlusion’s compatibility with the muscles.” 32
Fortunately, Lerman’s lament regarding the missing component of occlusal and TMD diagnosis and treatment was soon to be addressed. Funding the project himself, Dr. Jankelson assembled a R & D group of former Boeing engineers and biomedical engineers in 1970 to develop biomedical instrumentation to track jaw movement in three dimensions. Four years later, in 1974, the first clinical K5 Mandibular Kinesiograph was introduced. The system sensed the spatial location of a small magnet attached to the labial of the lower incisor teeth helping the clinician diagnose and treat occlusal mandibular dysfunction with objective physiologic data.
Technology to monitor masticatory muscle activity at rest and in function in a clinical environment was necessary to elevate diagnosis and treatment of occlusion from art to science. Surface electromyography (sEMG) is the technique by which the action potentials from muscle fibers are recorded and displayed. Surface EMG had been used in research institutions for many years to study masticatory muscle function. The first EMG was designed in 1979 to specifically monitor masticatory muscles in a clinical setting. Real time EMG was integrated into the three dimensional computerized jaw tracking system in 1987, allowing clinicians to objectively correlate muscle activity and jaw position.
At the time of Dr. Jankelson’s death in 1987 most of his dreams had been fulfilled. A new occlusal paradigm was gaining wider acceptance. The Myo-monitor was being used successfully by thousands of dentists around the world. He had pioneered and developed the first three dimensional jaw tracking system. He collaborated with colleagues in Japan to develop the first clinical EMG to specifically monitor masticatory muscle activity. His contribution to the science of dentistry was a product of his professional passion and conviction. Shortly after Dr. Jankelson’s death his disciples would need the same courage and conviction.
In 1986 the American Dental Association Council on Scientific Affairs granted the coveted Seal of Recognition to Myotronic’s neuromuscular instrumentation. Later, after the FDA investigations of the rigged 1994 Dental Advisory Panel, the ADA Council on Scientific Affairs granted the even more prestigious ADA Seal of Acceptance on Myotronics instrumentation in 2003-2004. The ADA council on Scientific Affairs describes the Seal of Acceptance in their letter of acknowledgment of Myotronics achievement:
“The Council extends its congratulations on receiving the ADA Seal of Acceptance as a symbol of safety and efficacy... The ADA’s Seal of Acceptance gives assurance to the dental profession and the public that a product has met the ADA’s stringent criteria for safety and efficacy.”33
At this time a new industry referred to as “Independent Medical Examiners” was establishing credentials in the new insurance world of third party medicine and dentistry. While most IME’s diligently called them as they saw them a certain group of IME’s were often favored for their willingness to summarily reject legitimate claims for TMD services. Hardly independent, the examiner denying claims was a much sought after and rewarded resource to save the insurance company money. One of the major providers of IME services was American Dental Examiners with Charles Greene serving as their TMD consultant. Ignoring the fact these patients were successfully treated, neuromuscular practitioner’s claims for TMD services using neuromuscular instrumentation were summarily and uniformly rejected. Pompous pigeons proclaimed their only motivation was to protect the patient. Insurance correspondence to a successful neuromuscular practitioner quickly quells the noble notion. The response to a neuromuscular claim had nothing to do with the validity of therapeutic response or welfare of the patient.
“You indicated that your patient had improved as a result of your therapy. It should be understood that most TMDs are episodic in nature…..Patient improvement, in and of itself, is inadequate justification of medical necessity.34
After the 1986 ADA Seal of Recognition was bestowed on neuromuscular instrumentation it became more difficult to summarily dismiss all claims on the premise that the instrumentation was considered experimental. Specious and shameful dismissal of claims by American Dental Examiner (ADE) consultants for neuromuscular services based upon Greene’s arguments is evident in this 1985 letter to a neuromuscular practitioner from an ADE consultant.
“Our ‘TMJ consultant, Dr. Charles Greene, who has over 20 years of association with the TMJ and Facial Pain Research Center at the University of Illinois, where he was involved in a multidisciplinary research program funded by NIDR. Dr. Greene was one of the 5 participating consultants involved in the 1982 TMJ position paper of the ADFA Council on Dental Care Programs….It is Dr. Greene’s position that the scientific community regards these devices (i.e.EMG,MKG) as valuable for various research assessment of mandibular function and dysfunction, but not for individual diagnosis, treatment selection, or monitoring of treatment progress.”35
The speciousness of Greene’s position is evident when we consider his statement that the devices are “valuable for various research assessment of mandibular function and dysfunction” , yet he summarily dismisses clinical use of the devices for the very same assessment of patient function/dysfunction. Clinical diagnosis and treatment of the TMD patient involves assessment of the same function versus dysfunction involving anatomic and physiologic events being studied in the research laboratory. If the devices are valuable in a research environment to monitor physiologic parameters of function and dysfunction they must be equally valuable in the clinical assessment of individual patients when monitoring the same events. Only in the dysfunctional world of a self serving IME consultant is this not evident.
The political battlefield shifted from occlusion to TMD. A small flock of like minded pigeons emerged from the roost to deposit pigeon droppings on the pages of compliant dental journals.
In 1988 a small group identified with the gnathologic occlusal paradigm joined a small group from the American Academy of Orofacial Pain (AAOP) and the International Association Dental Research (IADR) to exert political pressure upon the ADA to rescind the Scientific Council Seal of Recognition for neuromuscular devices. Norman Mohl was retained by the ADA to review the scientific safety and efficacy of these devices as aids in diagnosis and treatment of TMD. Mohl’s DRAFT REPORT CONCLUDED:
“Except for devices that have been developed for electromyographic biofeedback, none of the other devices intended for treatment of TMD have the scientific evidence required for their recommendation.” 36,37,38
The 1989 ADA Mohl Draft Status Report rejecting the safety and efficacy of transcutaneous electrical neural stimulation (TENS), jaw tracking, electromyography and electrosonography became the manifesto of the anti- instrumentation Luddites. It appeared that the anti-instrumentation pigeons were strategically roosting within the American Dental Association and waiting to slay neuromuscular dentistry after the death of Dr. Jankelson.
Taking flight in 1988 in the apparent pursuit of their anti-instrumentation agenda , four individuals, Charles Greene, Norman Mohl, James Lund and John Rugh, authored or coauthored forty eight anti-instrumentation articles using both the JADA and Journal of Prosthetic Dentistry as depositories prior to the “rigged” FDA Advisory Panel.35 These articles were not based upon original research, but were “literature reviews” or personal opinions and position papers of their respective organizations. All four individuals, Greene, Lund, Mohl and Rugh were later implicated in the rigged FDA Panel activities.44,45 Despite being marked Draft Only, Not to be Referenced and despite its rejection by the Council on Scientific Affairs, the Mohl Draft Status Report appeared in over twenty referred journals in the next six years. Many years after its rejection by the ADA Council, the pigeon droppings from the original Mohl Draft Report trace a scatologic trail through the mainstream dental literature. 40-43 (Note: Complete list of these articles available on request).
“Manuscripts submitted to scientific journals are reviewed for validity in the same way as grant requests. And who better qualified to judge an article than those same eminent experts with their laurels to guard.”
Despite the egregious use of the dental journals and compliant or cooperative editors the scientific evidence supporting neuromuscular instrumentation was overwhelming. Again after intense scrutiny within the ADA Council of Scientific Affairs the Council again granted the ultimate approval of the Seal of Acceptance to Myo-tronics instrumentation in 1994. The pigeons were predictably outraged that fact and science could derail their personal agendas. It was now time to use other strategies, legal or illegal. Ultimately their efforts resulted in the pigeons finding themselves as major ingredients of pigeon stew.
“In extreme cases, government agencies staffed and advised by the establishment begin legal harassment…"
Failing to achieve their political and personal agendas through the American Dental Association, the anti-instrumentation pigeons resorted to improper and illegal distortion of the regulatory process, culminating in their “rigging” the October 1994 FDA Dental Advisory Panel convened to classify muscle monitoring devices. An Orwellian nightmare for the manufacturers of neuromuscular instrumentation began in 1991 when an anti instrumentation cabal subverted an FDA regulatory process to bring the full wrath of the FDA regulatory process down upon them. The 1994 FDA Dental Advisory Panel was designed to be the death knell of neuromuscular instrumentation and ideas.
Documents obtained during investigation of the “rigged” FDA Dental Advisory Panel process traced the origin of the illegal activity to the following August 10, 1994 letter from Charles Greene to Drs. Tylenda and Singleton.
You may recall that we met at the recent NIDR Conference on TM Disorders in Huntsville, MD, when we had lunch with several FDA people and about four members of our group (including Dr. Norman Mohl), As we discussed at the time, we have been preparing some formal statements about the validity and so-called TMD diagnostic devices for the Neuroscience Group of the IADr. The ultimate purpose of these documents is to enable the AADR to make a public policy statement about the potential dangers of such devices…….”
“I appreciate receiving a phone call last week from Dr. Tylenda, in which she informed me that the hearing on these devices is scheduled for October 13 & 14, 1994. I am working on getting some of our members to represent our position in person at that hearing.”
“Thank you for your attention to this most important public health issue.”44
Ground zero for initiation of the rigged FDA Dental Advisory Panel was clearly under Greene’s pigeon roost. The FDA Office of Internal Affairs interview of Greene further implicates and clarifies the roles of Greene, Lund, Mohl and Rugh:
“Dr. Greene indicated that he, along with Dr. James Lund, provided testimony in person before the October, 1994 Dental Advisory Panel that was considering the classification of “Muscle Monitor Devices”. In addition, Dr. Green stated he personally read into the record of the panel meeting, a letter authored by Dr. John Rugh which was also offered as testimony before the panel. Dr. Greene characterized the testimony he and Drs. Lund and Rugh provided as strongly advocating a recommendation that the FDA place muscle monitor devices into Class III…..Dr. Greene stated that he, Dr. Lund, Dr. Rugh and Dr. Norman Mohl, who served as the panel’s special consultant, share the same views regarding musclemonitor devices, and the need for clinical studies to scientifically show safety and efficacy.”45
It should be noted that the neuromuscular instrumentation had already been rigidly scrutinized by the ADA Council on Scientific Affairs for safety and efficacy before granting the ADA Seal of Recognition in 1986. Again, in 1994 only four months previous to Greene’s letter to the FDA, the safety and efficacy of the instrumentation was again confirmed when the ADA Council on Scientific Affairs granted the Seal of Acceptance to all neuromuscular devices.
From the same investigative memorandum:
”Dr. Greene was queried about a luncheon meeting that he attended with FDA officials including Drs. Tylenda and Singleton, in April 1994, during a conference on Temporomandibular Joint Disorders (TMJ). Dr. Green recalled that Dr. Mohl set up the luncheon meeting with the FDA officials to introduce him (Greene) and others who shared their views on the devices to the FDA personnel…Dr. Greene stated that the non-FDA dentists were all members of the IADR, as well as members of the American Academy of Orofacial Pain (AAOP and re-iterated that they all held views that he characterized as anti-muscle monitor devices.” 45
The pigeon stew was starting to simmer. Dickinson’s FDA Review in an article entitled Perverted FDA: Officials Under Criminal Probe chronicles the Machiavellian script written by the pigeons of Zeus:
“Without revealing that Myotronics’ products, and similar ones made by another firm, Bioresearch, were the only ones to be dealt with by the panel on a very loosely defined agenda (muscle monitor devices’ a term that could cover over 30 other types of products as well), the FDA than appointed a notorious opponent of Myotronics’ products and AADR member, State University of New York at Buffalo professor Norman Mohl as the panel’s expert advisor.
Not only did the FDA conceal until the morning of the hearing its choice of old foe Bertolami to chair the hearing, but the FDA (or one of its special government employees’ on the panel) allegedly leaked Myotronics’ presentation in advance to a witness who testified against the company’s products.
Myotronics and Bioresearch got another shock when they saw the witnesses: three well known political opponents of their technology, who had earlier fought unsuccessfully to get the American Dental Association to rescind its approval seals for the firms’ products.”46
For two years the investigative trail involved the FDA’s Office of Internal Affairs, Special Investigator, Sub-Committee on Oversight and Investigations of the Committee on Commerce House of Representatives, and after testimony before the U.S. Congress House Commerce Oversight Committee, referral to the U.S. Department of Health and Human Services Inspector General for investigation of criminal misbehavior.
The “rigged” Panel recommended a Class III category for low frequency TENS, jaw tracking, surface electromyography and electrosonography. The class III category is reserved for implantable life threatening devices such as cardiac pacemakers etc. The Panel recommendation would effectively put the manufacturers of neuromuscular dental devices out of business. The individuals orchestrating misuse of the FDA Dental Advisory Panel had apparent victory within their grasp. Within months the manufacturers of these devices would be forced out of business. The pigeons of Zeus had killed the messenger. The neuromuscular clinician would no longer have technology to objectively measure masticatory muscle function or relax masticatory muscle. Dr. Jankelson’s neuromuscular paradigm, dependent upon its objective measurement devices, would die on the altar of FDA regulatory prohibition.
Drs. Barry Cooper and Robert Jankelson represented the neuromuscular instrumentation position at the October 14, 1994 FDA Dental Advisory Panel Meeting. The pigeons of Zeus were circling vultures picking the final meat from the bones of Dr. Jankelson’s neuromuscular dentistry carcass. However, the pigeons would soon be in a stew of their own making.
The next three years was a David versus Goliath battle to re-instate the legitimacy of neuromuscular instrumentation and to expose the egregious misuse of the governmental regulatory process by a small group of anti-instrumentation foes. With only conviction and facts on their side, a few neuromuscular disciples took on the AAOP, AADR, IADR and the governmental FDA Goliath. Few could have predicted the outcome. Few will ever appreciate the price paid by the neuromuscular advocates committed to exposing the efforts of the anti-instrumentation adversaries to corrupt the FDA regulatory process.
The irregularity and illegal activity surrounding the Oct 1994 FDA Dental Advisory Panel initiated an invitation from the U.S. House of Representatives for Roland Jankelson to testify before the House Subcommittee on Oversight and Investigation. Following is excerpts from his testimony before the House Oversight and Investigation Committee:
“To understand how it has come to pass that persons inside the FDA have conspired with outside private interests, it is necessary to understand the long and contentious history of efforts by a small group of dental academics to discredit electronic measurement instrumentation, and eliminate it from the marketplace, and how this group, first working through the American Dental Association and then the , FDA, has worked tirelessly to remove electronic measurement instrumentation from use in clinical dentistry. The history of the activities of this group is documented in detail in a compendium prepared by the American Alliance of TMD Practitioners, dated June 10, 1995.”47
The House Oversight Committee found Roland Jankelson’s testimony so compelling, the credibility of FDA Commissioner David Kessler’s testimony to the Committee regarding the Myotronics’ issues so lacking and the evidence of FDA cover-up so powerful that the criminal investigation was transferred to the Inspector General, Department of Health and Human Services. The battle and its outcome have been chronicled in the Medical Devices and Diagnostic Industry (MDDI) Reports:
“ An investigation was begun by the FDA Office of the Chief Mediator in conjunction with the FDA Ombudsman’s Office in response to a 33 page letter of complaint filed in January 1995 by the Washington D.C. law firm of Hyman, Phelps & McNamara on behalf of Myotronics and BioResearch. In July 1995 Myotronics President Roland Jankelson testified at a hearing before Rep. Barton’s House Commerce Oversight Subcommittee on allegations of FDA retaliation that the FDA’s Office of Internal Affairs planned to conduct its own inquiry.”48
The two year investigation concluded:
”In 1994 the Dental Products Advisory Panel of the Center for Devices and Radiologic Health (CDRH) assessing a Myotronics Inc. dental measuring device was indeed rigged.” The probe resulted in discipline and dismissal of certain FDA employees, including the author of the 1988 ADA Draft Status Report.”48
Dr. James Garry, Past President of ICCMO, Dr. Barry Cooper, Past President of ICCMO, Dr. Larry Tilley, Past Chairman of the American Alliance of Temporomandibular Disorders, Dr. Robert Jankelson, Roland Jankelson and countless others gave their time and energies to overcome seemingly insurmountable adversaries. Yet, time after time, the disciples of Dr. Jankelson prevailed and the pigeons of Zeus retreat, only to reappear. Their venues change but their agendas remain the same. After reconvening the FDA Dental Advisory Panel the neuromuscular instrumentation was classified in safest device category, Class II.
The Sept 1997 Dickinson FDA Review reports:
“In 1994 the Dental Products Advisory Panel of the Center for Devices and Radiologic Health (CDRH) assessing a Myo-tronics Inc. dental measuring device was indeed rigged, and this past July FDA deputy commissioner for external affairs Sharon Smith Holston told House Commerce oversight and investigations chairman Joe Barton (R-Tx)---who is investigating at least two other CDRH panels for similar concerns---about actions taken to remedy the situation. Omitting individuals’ names, she said FDA has:
Verbally admonished General and Restorative Devices reviewer D. Gregory Singleton, who left the agency 8/1;
Disciplined panel executive secretary Carolyn A. Tylenda by inserting a confession of “inappropriate conduct” into her record for four years (she left the agency two years ago);
Accepted the “voluntary resignation of panel chairman Charles Bertolami, a former marketplace competitor of Myo-tronics who had brought an unsuccessful lawsuit against the company over the products being reviewed;
Elected not to renew the appointment of non-voting panel consultant and discussion leader Norman Mohl, whom Myo-tronics identified as a well-known opponent of its technology.”49
In addition, the Oct 20, 1997 M-D-D-I Gray Sheet, an industry trade journal, in an article entitled Dental Products Advisory Panel Chair Resigns reported that: “Singleton was dismissed from the Agency in a quick and discreet manner, FDA says…”48
After three years of investigations leading to a finding that the 1994 Dental Advisory Panel was indeed “rigged” the FDA awarded monetary compensation for legal costs to Myotronics. It was a just conclusion of the David versus Goliath anti-instrumentation wars.
The pigeons of Zeus could not abide the messengers of objective data particularly after the instrumentation received the coveted ADA Council on Scientific Affairs Seal of Acceptance and the impending criminal investigations of the 1994 FDA Dental Advisory Panel threatened to unravel their best laid plans. It threatened old dogma and most importantly made it more difficult for hired independent medical examiners, IMEs, to deny neuromuscular clinician’s claims for treatment of TMD patients. It threatened the income of those willing to become IME servants of the insurance industry. The pigeon of Zeus can be a fearsome bird of prey—self described “killers”. Shortly after the rigging of the FDA Advisory Panel began to unravel, Donald Seligmen, President of AAOP at the 20th Annual Meeting on Orofacial Pain and TMJ Disorders at the Disney World Convention Center, February 15, 1995 describes the new battle plan before his minions:
“The new policy or plan of the AAOP is not again to try to influence the policies of federal agencies with regard to TMJ instrumentation. We will not try to influence and interfere with the FDA classification of the instruments. The FDA will eventually have to classify the instruments, and the classification must be Class III because the ‘instruments are dangerous. Therefore, all insurance companies will realize that they cannot acknowledge claims (reimburse) that are based on TMJ diagnostic and therapeutic instruments. Logically, we will ‘kill off’ all TMJ instrument users through non-reimbursement. If a dentist sees that the patient is not reimbursed, then he will not use the instruments. In our new edition of the ‘Guidelines’ (which McNeill is working on right now) we will point out that all TMJ instruments used for diagnosis and treatment are of no use, that they are ‘dangerous’ and the ‘Guidelines will then be ‘given to all insurance companies so they can deny reimbursement by reference to the ‘Guidelines. That is the way it works in the U.S.---you simply ‘starve the dentist’ who uses TMJ instruments.”50
Seligman goes on to make sure the IME pigeon agenda is given the American Patriot Seal.
”In fact we already have three companies (intercontinental, etc.) that use the present ‘Guidelines to deny claims. The New ‘Guidelines’ will be used by all companies---nationwide--- and nationwide the New ‘Guidelines will be used to justify denial of claims. The users of TMJ instruments will have killed themselves. That is the way it works in America.” 50
The ultimate victims are patients seeking relief from quality of life destroying TMD pain and dysfunction. That is not the American way! That is why dedicated practitioners of neuromuscular dentistry continue to fight for our patients and Dr. Jankelson’s legacy.
The start of the new millennium witnessed an explosive growth of neuromuscular dentistry throughout the world. Neuromuscular instrumentation is now used in almost 100 medical and dental schools in 35 countries. Thousand of clinicians and countless patients benefit from the insights and inventions of Dr. Jankelson. With ruffled feathers and the taste of ignominy stuck in their craws the pigeons of Zeus retreated to their dark caves of ignorance and malice emerging occasionally to recycle the anti-instrumentation mantras of the 80s and 90s. There they brooded until they apparently deemed enough time had passed so they could take flight again.
In 2010 Charles Greene, one of the original principals involved in the rigging of the 1994 FDA Dental Advisory Panel, once again used the compliant American Dental Association Journal to again recycle his long discredited ideas. 52,53 Greene’s involvement in events surrounding the “flawed” and “rigged” 1994 FDA Panel resulting in Congressional Hearings and referral to the U.S. Inspector General is well documented. The tentative venture from the cave is reminiscent of many previous flights. Recruit a few naïve, compliant or sympathetic dental editors, call in the faithful flock of peer review cronies and recycle the discredited 1990’s anti-instrumentation articles. Ignore the usual protocols of scientific publication and miraculously watch the coordinated flight pattern of the pigeons littering multiple dental publications with the same anti-instrumentations articles regurgitated from the 1990s campaign.
How could pigeon droppings of 20 year vintage emerge from the cave of darkness and disgrace to simultaneously deposit residue of long discredited opinions among the pages of two prestigious dental journals? The persistent and pernicious flock solidarity of the anti-instrumentation pigeons bodes the question: What is in it for them? David Miller describes the not so hidden agenda in the January 2011 Journal of Craniomandibular Practice:
“ Greene and his fellow travelers, unable to win on the basis of merit would like to win on the basis of bureaucratic dictate. A small cadre of research and educational elite want to force their will on the great mass of clinicians and patients who only see clinical success and scientific validity in the use of neuromuscular concepts and instrumentation.” 53
Greene continues to ignore the vast and overwhelming body of scientific literature supportive of neuromuscular dentistry and instrumentation. Over 600 refereed articles were presented in support of instrumentation in the ADA and FDA wars. They were compelling then, they are compelling now. The literature review is readily available but ignored by Greene since the science makes his position untenable. Greene’s neuromuscular expertise is best understood in his own words from the transcript of his legal testimony where he testified that he has never attended a neuromuscular course nor read an instrumentation instruction manual:
“Attorney Question: Have you taken any courses in the use of these four machines?
Greene Answer: No, I haven’t
It is possible he should become familiar with the instrumentation and science, if for no other reason, than to ‘know thy enemy’ which in this case is TRUTH and the body of SCIENTIFIC literature standing in the way of his anti-instrumentation agenda. This same body of literature led to the granting of the American Dental Association Seal of Recognition in 1986. Despite unrelenting efforts by the pigeons of Zeus to get the Seal rescinded, the ADA granted a new ADA Seal of Acceptance for neuromuscular devices in 1994-1995. This ADA Seal of Acceptance was again renewed in 2004. This ADA program was eventually phased out for all devices and products in 2007. While the scientific scrutiny of these devices was unprecedented over a 20 year period the neuromuscular science always prevailed within the ADA Council of Scientific Affairs. However, in 2010 Greene again uses the same roosting sites he used twenty years ago by seeking credibility under the aegis of the International Association for Dental Research (AIDR) and the American Association of Dental Research (AADR). Greene explains how he became a self appointed standard bearer for a 2010 Standard of Care recycled from the thoroughly discredited Mohl Draft Status report of ADA and FDA infamy 20 years ago.
“Several years ago, the Neuroscience Group appointed a new committee, headed by myself…Our mission was to develop a new TMD Statement that would reflect the considerable advances in knowledge about TMD disorder…52
Pigeons, it seems, just don’t stray too far from the roost. One month later in the JADA Greene assures the profession that:
“Therefore, the publication of this new TMD statement could be regarded as the closest thing to date to a true standard of care in this contentious field.”51.
What would be the new AADR/Greene standard of care for TMD patients?
“..the consensus of recent scientific literature about currently available technologic diagnostic devices for TMDs is that, except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups.”51
Greene’s use of the AADR and the JADA to discredit neuromuscular instrumentation and establish a standard of care, in his vision, is a return to his ADA and FDA efforts of yore. Greene’s JADA and JOOE 2010 Editorials recycle the discredited articles and position papers of Greene, Mohl, Lund, and Rugh leading to rigging of the 1994 FDA Dental Advisory Panel. The conscientious neuromuscular practitioner daily treating and helping TMD patient’s best abide by Jefferson’s admonition that “the price of freedom is eternal vigilance.”
The pigeons of Zeus first littered the occlusal landscape with 100 year old dogma and personal agendas. When the weight of scientific evidence made flight impossible over the occlusal fields the surrogate ‘TMD’ landscape became littered with IME and Standard of Care control agendas. In 2010, emerging from the AADR refuge Greene again uses the JADA to deposit his recycled Orwelian pigeon doublespeak in the Sept 2010 JADA:
“However, the consensus of recent scientific literature about current available technologic diagnostic devices for TMDs is that, except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups.”51
As previously mentioned, pigeons have limited vocabularies and favorite mantras. This is almost verbatim the wording of the Greene and Mohl reports appearing in over 50 dental journals prior to the rigging of the 1994 FDA Panel. However let’s explore in depth the straw man of sensitivity and specificity in the field of TMD. TMD is a musculoskeletal pain and dysfunction syndrome with over 60 signs and symptoms that can present in any number of combinations, severity, periodicity and chronicity. There is not uniform agreement among academicians, researchers and clinicians regarding classification of normal versus TMD subject groups.
Few patients, if any, will ever appear with the same combination of signs, symptoms, severity, periodicity or chronicity of symptoms. It can accurately be said that the less the clinician knows about the signs, symptoms and pathogenesis of TMD the more normal the patient will appear. Sensitivity and specificity algorithms can be applied to study any one of the 60 signs and symptoms but cannot distinguish the TMD patient from the non patient. To date it is not realistic for any instrumentation or psychometric test to delineate the TMD patient from non-TMD patients.
Losing the ADA and FDA battle of the 1980s and 1990s the pigeons have now migrated to the land of psychosocial nirvana. This is a land where the clinician never has to worry about occlusal function or the tedium of precisely adjusting an occlusal appliance. For them and their patients this is a land of tricyclics, Prozac and other pharmacologic wonders where biomechanics and proprioception become non-operative.
The field of TMD psychosocial research has absorbed millions of taxpayer’s dollars bestowed upon a small group of academicians often associated with AAOP. Some of these individuals were involved in the failed ADA and FDA anti-instrumentation crusades. Greene continues to diminish the role of biomechanics and promote the psychosocial model in his recent editorial in the JOOOOE, Aug2010:
“The importance of biopsychosocial variables, which tend to be ignored or minimized by mechanistic approaches, has been emphasized throughout the medical pain management world.”52
In his latest visit to the pages of the JADA Greene reiterates the psychosocial model:
“..it has become accepted widely among pain experts in the medical and dental profession that these types of pain condition must be managed within a biopsychosocial framework in which behavioral approaches supplement conservative medical care.” 51
What does the recent literature say about the sensitivity and specificity of psychometric matrix analysis for distinguishing TMD patients from non patients? After millions dollars of taxpayer’s grants for development of psychosocial metrics for TMD even the developers of these models concede:
“Results: Target sensitivity and specificity were not observed for any of the eight RDC/TMD diagnoses.” The authors further conclude: “Conclusion: The RDC/TMD Axis I diagnoses did not reach the targets set at sensitivity >0.70 and specificity of >0.95. Target validity was obtained only for myofascial pain without differentiation between normal and limited opening. Revision of the current Axis I TMD diagnostic algorithms is warranted to improve their validity.”55
Further clouds over the sensitivity and specificity of psychosocial studies which Greene so expounds in his latest flight to the pages of the JADA is provided by Aggarwal et al from the University of Manchester School of Dentistry:
“Selection Criteria: Randomized controlled trials which include non-pharmacologic psychosocial interventions for adults with chronic orofacial pain compared with any other form of treatment (e.g. usual care like intraoral splints, pharmacologic and/or physiotherapy….Authors’ Conclusion: There is weak evidence to support the use of psychosocial interventions for chronic orofacial pain.”56
The attempt to deny or diminish the importance of occlusal causality and biomechanical factors has been chronicled earlier in this article. For the past 60 years, dating from the work of pioneer anatomist Harry Sicher and physiologist Hans Selye, academics and clinicians such as Shore and Bell have approached the problem as a primary physical (biomechanical) etiologic condition, albeit with concomitant secondary psychosocial overlays. The clinical and scientific evidence for such a model is consistent with anatomic and physiologic models of function/dysfunction.
The masticatory system with its unique mechanism of bilateral diarthrodial joints, precise tooth intercuspation and highly developed proprioception of the trigeminal system suggests a biomechanical pathogenic model that is generic to other musculoskeletal structures. Treatment to physiologically reposition the mandible to the cranium has been the foundation of TMD treatment for sixty years. The dental literature is replete with refereed studies supporting the scientific and clinical basis for such treatment.
When biomechanical and psychosocial stressors impose demands that exceed the accommodative (adaptive) capacity of the organism, dysfunction and symptoms of TMD occur. The pathogenic model for TMD should embrace both the biomechanical and the psychosocial models. Both the medical and dental literature suggests a primary biomechanical model of musculoskeletal dysfunction with a secondary psychosocial overlay. Trained neuromuscular dentists routinely treating chronic TMD will acknowledge the psychological component of TMD. Understanding the psychosocial component of TMD does not mitigate the need to address the biomechanical needs of the patient.
There is one universal agreement among knowledgeable neuromuscular clinicians and the anti-neuromuscular anti- instrumentation pigeons. Treatment of TMD patients should be based upon reversible and evidenced based therapeutic modalities. The abiding paradigm of neuromuscular diagnosis and treatment is that occlusal therapy must be reversible until all physiologic data and resolution of patient symptoms indicates the stomatognathic system is optimal prior to any phase II irreversible treatment.
The past history and evidence is clear: the present continuing effort by a small academic group to impose a primary psychosocial model for TMD is more related to political agendas, allocation of grants for TMD research, IME consulting fees and pretense for denial of insurance re-imbursement, rather than sound scientific methodology. In 1970 Dr. Bernard Jankelson was armed only with conviction and facts. Forty years later that is still the compelling defense of the neuromuscular disciples. The ADA and FDA victories attest to the strength of this conviction and fact. The victories also suggest that another Chicago eminence, the famous baseball coach Leo Durocher, was wrong when he said “Nice guys finish last”.
Neuromuscular dentistry is much more than occlusion. It transcends mechanical dental constructs and embraces generic biologic and physiologic principles that apply to all articular, muscular, neural and central nervous system organs. The most strident pigeons appear to flutter from the citadels of old and threatened occlusal dogma while other pigeons feasting on IME fees or with other self serving agendas reject occlusal or biomedical causality and impose their Standard of Care. The iconoclast and his neuromuscular paradigms quickly became the lightning rod for wrath of the establishment. Innovators and free thinkers are seldom received with joy by established authorities. These ‘authorities’ immediately launch into condemnation of newer truths. At every crossroads to the future there are a thousand self-appointed guardians of the past. True to the history of scientific inquiry, as the new ideas become more accepted, the diminishing guardians of the past become more strident, more than ever intent on destroying the iconoclast regardless of the scientific and clinical record.
“A great theory has never been accepted without opposition. Such must always be the course of things so long as men are endowed with different degrees of insight; where the genius discerns the distant truth which it pursued, the mind not so gifted often sees nothing but the extravagance which it avoids.”
When the pigeon of Zeus flutters from the bell tower of arrogance and ignorance into you professional radar screen proclaiming “neuromuscular dentistry doesn’t work” the pigeon has no idea of the encompassing principles and clinical techniques of neuromuscular dentistry. You will see them in dark corners at dental meetings or on their favored website searching for crumbs of neuromuscular cases that do not meet their exalted standard. The many thousands of patients rescued from the pain and dysfunction of chronic intractable TMD by clinicians using neuromuscular principles and instrumentation are never mentioned. Thousands of patients treated successfully to a neuromuscular position are summarily dismissed as anecdotal by the ever righteous pigeons of Zeus.
Every dental clinician, regardless of occlusal philosophy, has felt the sting of clinical defeat. The patient that does not respond according to accepted dental criteria, the patient that continues the pathologic destruction of our ideal restorations, the patient with unresolved pain and dysfunction of TMD and the patients who’s hidden agendas were not recognized are not unique to a particular occlusal or treatment philosophy. However, the pigeons of Zeus feel compelled to selectively drop their detritus on neuromuscular failures, while conveniently dismissing their own abundant failures.
The words of 15th century physician Paracelsus is most appropriate for the conscientious ‘wet fingered’ (gloved) clinician entrusted with the dental and TMD health of our patients.
“I please nobody except the people I cured.”
The masticatory system is one of the most complex and fascinating organ systems in the human body. It consists not only of teeth, but joints, nerves, muscles and the central nervous system. Neuromuscular dentistry is much more than an occlusal philosophy or occlusal instrumentation. Neuromuscular dentistry is a global concept of physiologic and biologic principles that help guide diagnosis and treatment of the masticatory apparatus.
The dentist as diagnostician and therapist of the Vth and VIIth Cranial Nerves and all associated structures inherits a daunting responsibility. It involves understanding the exquisite relationships between teeth, muscle, joints and the nervous system. It requires incredible attention to micro details in occlusal management. As general knowledge in other disciplines change, neuromuscular dentistry also changes. Neuromuscular dentistry is now more an evolution than a revolution. It is a way of thinking, of diagnosing and implementing therapeutic procedure that address the underlying understanding of pathophysiology. The basic principles of neuromuscular dentistry which Dr. Jankelson defined almost 50 years ago have withstood scientific scrutiny and remain the foundation of our diagnostic and treatment protocols. However, we must realize that neuromuscular dentistry is a continuing quest for answers and solutions. It is an ongoing search for scientific truth and clinical excellence. Neuromuscular dentistry, contrary to pigeon speak, does not proclaim to have an exclusive on these truths.
“Admire the person seeking truth, beware the person proclaiming to have found the truth.”