Mandibular Tracking and the use of Ultra Low Frequency TENS (ULF-TENS) in the Diagnosis and Treatment of TMJ/ CFP

•Over 40 controlled studies that support the rationale for mandibular jaw tracking.
•Over 45 international supporting studies supporting the use of the TENS for TMD/CFP diagnosis and treatment.
•Research clear that low frequency TENS has a high degree of specificity when utilized for craniofacial pain and is both safe and efficacious for muscle relaxation and pain control.
•Numerous other supportive studies



ULF-TENS stands for Ultra Low Frequency Transcutaneous Electrical Nerve Stimulation.  This stimulation is used in neuromuscular dentistry as a therapy specific for the treatment and resolution of TMD and cranio-cervico-facial conditions. The TENS delivers an electronic impulse through the nerves that control the masticatory, neck and facial muscles. The rhythmic pulsing of the nerves relaxes the muscles and  allows us to determine the correct relation of the mandible to the base of the cranium. It also relieves pain and shortening of the muscles of the face and neck caused by spasms and tension. In addition, the mandible settles to a position which is conducive to relaxed musculature. Use of the TENS involves the placement of electrodes bilaterally in the pre-auricular area, just lateral to the coronoid notch as well as on the posterior triangle of the neck. The current emanating form the electrodes stimulates both  the sensory and motor divisions of the fifth, seventh and eleventh cranial nerves. The effectiveness of the TENS therapy is documented by EMG recordings.

The TENS is applied most effectively when monitored in conjunction with CMS and EMG recordings simultaneously in objectively documenting and diagnostically gathering information before, during and after treatment.

There is evidence to support the effectiveness of such diagnostic instrumentation as verified and confirmed by the American Dental Association (ADA) and the Food and Drug Administration (FDA).

ADA “Seal of Acceptance” and FDA approval

•The American Dental Association’s Council on Scientific Affairs has awarded surface electromyography (SEMG), Computer Mandibular Scanning (CMS), and Sonography its “Seal of Acceptance”, as diagnostic aids in the management of temporomandibular disorders.
(Report on Acceptance of TMD Devices, ADA Council on Scientific Affairs, JADA, Vol. 127, November 1996)

•The U.S. Food and Drug Administration has granted 510k status to each of these mentioned devices for use in the diagnosis and management of TMD in my practice. This reflects that the U.S. Government and the dental profession acknowledges the safety and efficacy of the devices as recording and measuring devices used in the diagnosis and management of TMD and orofacial pain.

This is the Third Edition of this collection of references from the scientific literature that document the validity of the use of electronic diagnostic aids in dentistry. The First Edition was produced some twenty years ago, but many of the references and rationales cited are classic and are as valid today as they were when the collection was originally assembled. Primary and secondary references are given for each topic. For the benefit of the reader who does not have ready access to scientific library facilities, excerpts and abstracts of certain key scientific articles are provided.
In 1995 the Second Edition was produced, adding an Addendum consisting of an expanded list of references specifically supporting the use of surface electromyography in dentistry. Because this list was originally compiled for a different purpose, one may find therein some articles that were previously included in the First Edition. In this Third Edition a second Addendum has been added, containing a more current listing (1987-2009) of articles and abstracts describing clinical application of instrumentation in the field that has come to be known popularly as Neuromuscular Dentistry. As a service to the Dental Profession, this substantial work is provided to interested parties at a cost substantially less than the actual cost of researching, assembling and printing the material.

Supportive Scientific References:

1. Wilke, Dr. Muscle, Studies in Biology, 2nd Ed., London, A Edward Ltd, 1979.

2. MacGregor RJ. Neural and Brain Modeling, San Diego, Academic Press Inc., 1987.

3. Guyton AC. Human Physiology and Mechanisms of Disease. 3rd Ed. Philadelphia: WB Saunders Co; 1982.

4. Griffin CJ. Temporomandibular joint dysfunction and the brain stem reticular formation. Aust dent J. 9(6);524. 1964.

5. King EE, Minz B, and Bigelow. The effect of the brain stem reticular fomation on the linguomandibular reflex. J. Comp Neurology 102(3):565, 1955.

6. Jankelson B, et al. Kinesiometric Instrumentation: A New Technology. J. Am Dent Assoc, 90:834-840, April 1975.

7. Hunnam AG et al, The Kinesiographic measurement of jaw displacement, J of Prosth. Dent. Vol 44:88-93, July 1980.

8. Moller, E Clinical electromyography I dentistry. Int Dental J. 19:250-266, 1969.

9. Mannheimer JS and Lamp GN. Clinical Transcutaneous Electrical Nerve Stimulation. 5th Ed. Philadelphia FA Davis Co. 1985.

10. Kasman GS, Cram JR and Wolf SL. Clinical Application sin Surface Electormyography. Gaithersburg, Maryland, Aspen Publishers Inc. 1998.

11. Soderberg GL. Ed. Selected Topics in Surface Electromyography for Use in Occupational Setting: Expert Perspectives, U.S. Dept of health and Human Services. DHHS Pub No 91-100, March 1992.

12. Travell JG and Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Baltimore MD. Williams and Wilkins, 1993.

13. Phillips C. The modification of tension headache pain using EMG biofeedback. Behav Res Ther, 15:119, 1977.

14. Konchak P., et al. Freeway space measurement using mandibular Kinesiograph and EMG before and after TENS. The Angle Orthodontist, pp. 343-350 Oct 1988.

15. Wessberg GA, et al. Transcutaneous electrical stimulation as a adjunct in the management of myofascial pain dysfunction syndrome. J. Of Prosth Dent. Vol 45, No 3, March 1981.

16. Dixon HH and Dickel HA. Tension headache. J. Northwest Medicine. Vol 66 pp 817-920, Sept 1967.

17. Dixon HH and O’Hara M. Fatigue contracture of skeletal muscles. J. Northwest Medicine. Vol 66 pp 813-815. Sept 1967.

18. Lasanga M and Orlandi C. Modificazioine die flussi ematici musculocantei indott dollo stimulazione neurale transcutanea isichemia e dolore nella patologia occlusale. J Odontostromatogiea e Lymplantopratessi, 1986.

19. Rodbard S and Pragay EB. Contraction frequency, blood supply and muscle paoin. J. Of Applied Physioloyg. Vol 24, No. 2 Feb, 1968.

20. Jankelson B et a. The Mmyo-moniotr: Its use and abuse, Quintessence Internation 9(2), Quintessence Pub, 1978.

21. Wilkie DR, Ibid.

22. Lasagna M and Orlandi C. Ibid.

23. Thomas, NR Utilization of electromyographic spectral analysis in the diagnosis and treatment of craniomandibular dysfunction. Neuromuscular Dentistry Anthology Vol. V, Hickmanm DM Ed. Pp. 159-170, 1999.

24. Mohl ND et al, Devices for the dianosis and treatment of temporomandibular disorder: Part III: Thermography, ultrasound, electrical stimulation and electromyographic feedback. J. Prosthet Dent 63(4) 472-477, 1990.

25. Lund JP et al. Use of electronic devices in the diagnosis and treatment of temporomandibular disorders, J. Canadian Dent Assoc. 55(9):749-750. 1989.

26. Dinham R. Treatment of tic douloureux with Jankelson Myo-monitor. J Hawaii Dent Assoc, Vol III, 1970.

27. Vesanen E and Vesanen. The Jankelson Myo-moniotr and its clinical luse. J Finn Dent Soc. 69:244-247, 1973.

28. Wessberg GA et al. Transcutaneous electrical stimulation as an adjunct in the management of myofascial pain dysfuncti0n syndrome. J of Prosth Dent. Vol 45, No 3, March 1981.

29. Panteleo T and Prayer-Galletti F et al. An electromyographic study in patients with myofacial pain dysfunction syndrome. Bull. Gr int. Rech., sc Stomat. Et Odont. Vol 26 pp 167-179, 1983

30. Konchak P and Thomas N et al. Ibid. 1988.

31. Choi B. On the mandibular position regulated by Myo-monitor stimulation. J Japenses Prosthetic dent. Vol 17 pp 73-96, 1973.

32. Jenkelson B et al. Neural condiction of the Myo-monitor stimulus: a quantitative analysis. J Prosth Dent Vol 34 No. 3 pp 245-253, Sept 1975.

33. Baker LL. Clinical uses of neuromuscular electrical stimulation. In; Nelson RP and Currier DP, eds Clinical Electrotherapy, 2nd ed. Norwalk, CT, Appleton and Lange pp 143-170, 1991.

34. DeVahl J. Neuromuscular electrical stimulation (NMES) in rehabilitation. In: Gersh MR ed. Electrotherapy in Rehabilitation, Philadelphia: FA Davis pp 218-268, 1992.

35. Currier DP. Neuromuscular stimulation for improving muscular strength and blood flow and influencing changes. In Nelson RP and Currier DP eds. Clinical Electrotherapy. 2nd ed. Norwalk, CT. Appleton and Lange pp 171-200, 1991.

36. Morrissey MC. Neuromuscular electrical stimulation in the rehabilitation of orthopedic injury. Phy Ther Pract. 1:20-29, 1992.

37. Kasman GS, Cram JR and Wolf Sl. SEMG triggered neuromuscular electrical stimulation. In: Clinical Applications in Surface Electromyography, Aspen Pub. Pp 193-211, 1998.

38. Lamb R and Hobar D. Anatomic and physiologic basis for surface electromyography. In Selected Topics in Surface Electromyography for use in the occupational setting: Expert Perspectives, U.S. Dept of Health and Human Services, DHHS No 91-100, pp 6-22, 1992.

39. Moller E. Clinical electromyography in dentistry. Int. Dent. Journal. 19:250-266, 1969.

40. Cooper B, Cooper D and Lucente F. Electromyopgraphy of masticatory muscles in craniomandibular disorders. Laryngoscope 101:150-157, 1991.

41. Jankelson RR. Clinical electromyography. In Neuromuscular Dental Diagnosis and Treatment. St. Louis, MO. Ishiyaku EuroaAmerican, Inc pp 97-174, 1990.

42. Jankelson RR. Temporomandibular joint musculoskeletal dysfunction. In:Neuromuscular Dental Diagnosis and Treatment, St Louis Mo. Ishiyaku EuroAmerican Inc pp 249-24

43. Nordin M and Frankel VH. Basic Biomechnics of the musculoskeletal System. 2nd ed. Philadelphia: Lea and Febiger, 1989.

44. Gossman MR, Sahrman SA and Rose SJ. Review of the length associated changes in muscle: experimental evidence and clinical implications. Phys Ther. 62:1791-1808, 1982.

45. Hagberg M. Occupational musculoskeletal stress disorders of the neck and shoulder a review of possible patholphysiology. In Arch Occup Envir Health, 53:269-278, 1984.

46. Mortimer JT, et al. Muscle blood flow in the human biceps as a function of developed muscle force. Arch Surg, 103:376-377.

47. Veiersted KP, Westgaard RH and Andersen P. Electromyographic evaluation of muscular work pattern as predictor of trapezius myalgia. Scan J Work Envir Health. 19:284-290, 1993.

48. Cooper, BC. Craniomandibular disorder. In: Cooper BC and Lucente FE, eds. Management of Facial, Head and Heck Pain. Philadelphia: WB Sauders; pp153-254, 1989.

49. Tilley L and Hickman DM. TMD-an upper quarter condition. In: Neuromuscular Dentistry: The Next Millenium Vol V. Intern College Craniomand Orthop, 1999.

50. Garry JF Upper airway obstruction and TMD/MPD. Anthology of Craniomandibular Orthopedics Vol II ed. Coy RE, 1992.

51. Jankelson RR, Clinical Electromyography, In: Neuromuscular Dental Diagnosis and Treatment St. Louis Mo, Ishiyaku EuroAmerica, Inc. pp97-174, 1990.

52. Jankelson RR. Effect of vertical and horizontal variants on the resting activity of masticatory muscle. In: Anthology of Craniomandibular Orthopedics Vol IV, Ed. Coy RE, International Col Craniomand Orthopedics, Seattle 1997.

53. Jankelson RR. Op cit pp97-174, 1990.

54. Lippold OC. The relation between itegrated action potentials in human muscle and its isometric tension. J Physiology, 117:492-499, 1952.

55. Molin, C. Vertical isometric muscle forces of the mandible: A comparative study of subjects with and without manifest mandibular pain dysfunction syndrome. Act Odont. Scand. 30:485-499, 1992.

56. Jankelson RR. Analysis of maximal electromyographic activity of the masseter and anterior temporalias muscles in myocentric and habitual centric in temporomandibular joint and musculoskeletal dysfunction. In: Pathophysiology of Head and Neck Musculoskeletal Disorders. Bergamine ed Front Oral Physiol. Basel, Karger, 7:83-98, 1990.

57. Sheikholeslam A and Risse C. Influence of experiemental interfering occlusal contacts on the activity of the anterior temporalis and masseter muscles during submaximal and maximal bite in the intercuspal position. J Oral Rehab. Vol 10 pp207-214, 1983.

58. Risse C and Sheikholeslam A. Influence of experimental interfering occlusal contacts on the activity of the anterior temoral and masseter muscles during mastication. J oral Rehab. Vol. 11 pp325-333, 1984.

59. Bixby G. Clinical Technique for determining appropriate orthopedic-orthodontic mechnaics as verified by the Quin-sectograh, K6-I mandibular kinesiograph and advance Sassouni analysis, In: Neuromuscular Dentistry: The Next Millenium, Hickman ed. P149-153, 1999.

60. Melkonian RW. Relationship of condylar position and vertical freeeway space as measured on the Quint-sectograph and K6-I Mandiubular Kinesiograph. I: Anthol of Craniomandibular Orthop. Vol II Coy RE, ed pp239-246, 1992.

61. Chan, CA: Treating Craniomandibular Dysfunctional Patients Implementing Gnathological or Neuromuscular Concepts. The Application of the Principles of Neuromuscular Dentistry to Clinical Practice, Anthology Volume VI, International College of Craniomandibular Orthopedics (ICCMO), pp. 15-33, 2003.

62. Chan, CA and Thomas NR: Clinical and Scientific Validation for Optimizing the Neuromuscular Trajectory Using the Chan Protocol, Advanced scan interpretation course manual, Las Vegas Institute for Advanced Dental Studies, July, 2004.

63. Occlusal effects on longitudinal bone alterations of the temporomandibular joint.

Zhang J, Jiao K, Zhang M, Zhou T, Liu XD, Yu SB, Lu L, Jing L, Yang T, Zhang Y, Chen D, Wang MQ.
J Dent Res. 2013 Mar;92(3):253-9. doi: 10.1177/0022034512473482. Epub 2013 Jan 22.

Department of Oral Anatomy and Physiology and TMD, School of Stomatology, Fourth Military Medical University, 145 Changlexi Road, Xi’an 710032, China.

The pathological changes of subchondral bone during osteoarthritis (OA) development in the temporomandibular joint (TMJ) are poorly understood. In the present study, we investigated the longitudinal alterations of subchondral bone using a rat TMJ-OA model developed in our laboratory. Changes in bone mass were examined by micro-CT, and changes in osteoblast and osteoclast activities were analyzed by real-time PCR, immunohistochemistry, and TRAP staining. Subchondral bone loss was detected from 8 weeks after dental occlusion alteration and reached the maximum at 12 weeks, followed by a repair phase until 32 weeks. Although bone mass increased at late stages, poor mechanical structure and lower bone mineral density (BMD) were found in these rats. The numbers of TRAP-positive cells were increased at 12 weeks, while the numbers of osteocalcin-expressing cells were increased at both 12 and 32 weeks. Levels of mRNA expression of TRAP and cathepsin K were increased at 12 weeks, while levels of ALP and osteocalcin were increased at both 12 and 32 weeks. These findings demonstrated that there is an active bone remodeling in subchondral bone in TMJs in response to alteration in occlusion, although new bone was formed with lower BMD and poor mechanical properties.

64. Jaw-motor effects of experimental jaw-muscle pain and stress in patients with deep bite and matched control subjects.

AuthorsSonnesen L, et al. Show all Journal
Arch Oral Biol. 2013 Oct;58(10):1491-7. doi: 10.1016/j.archoralbio.2013.07.003. Epub 2013 Jul 23.

Orthodontic Section, Department of Odontology, Faculty of Health Sciences, University of Copenhagen, 20 Nørre Allé, DK-2200 Copenhagen, Denmark; Orthodontic Section, Department of Dentistry, Faculty of Health Sciences, Aarhus University, 9 Vennelyst Boulevard, DK-8000 Aarhus C, Denmark. Electronic address:

OBJECTIVE: The effect of experimental jaw-muscle pain and stress on masticatory muscle activity in TMD-patients has been discussed. Furthermore, associations between TMD and deep bite patients have been studied. Accordingly in the present study, comparison of EMG responses at rest, maximal clenching, during evoked pain and stress between deep bite patients and controls was investigated.

DESIGN: In 30 deep bite patients and in 30 sex-/age-matched controls with neutral occlusion EMG activity was recorded bilaterally from masseter and anterior temporalis muscles before and during evoked pain and before and during a stress task. Evoked pain was induced by injections of glutamate into the masseter (local pain) and brachioradialis (remote pain) muscles and resting EMG activity was recorded before and after 1, 2, 3, 4, 5 and 10min. A precision task was used to simulate a stressful condition and EMG activity was recorded twice during the task. Maximal EMG activity was recorded during maximal clenching.

RESULTS: Resting and maximal EMG activity were significantly different between groups and age with no gender differences. EMG activity during local pain and during the precision task were significantly different between groups, gender, age and time, whereas no time effect was found for the EMG activity during remote pain.

CONCLUSIONS: Patients with deep bite have significantly different jaw motor responses to painful stimulation of the trigeminal region and manual precision tasks suggesting a differential integration of both somatosensory and behavioural stimuli.

Copyright © 2013 Elsevier Ltd. All rights reserved.
PMID 23890660 [PubMed – in process]

65. Three-dimensional computed tomographic analysis of changes to the external features of the nose after surgically assisted rapid maxillary expansion and orthodontic treatment: A prospective longitudinal study

American Journal of Orthodontics & Dentofacial Orthopedics
Volume 144, Issue 3 , Pages 404-413, September 2013

The aim of this prospective, longitudinal study was to evaluate changes to the external shape and form of the nose after surgically assisted rapid maxillary expansion and orthodontic treatment. The changes were registered using a 3-dimensional computer tomography technique, based on superimposition on the anterior base of the skull.

The subjects comprised 35 patients (mean age, 19.7 years; range, 16.1-43.9 years). Low-dose, helical computerized tomography images were taken at treatment start and after orthodontic treatment, about 18 months postsurgery. The 3-dimensional models were registered and superimposed on the anterior cranial base.


There were in general significant widening and overall anterior and inferior displacement of the nasal soft tissues. The changes varied in size and direction. No correlation was found between the initial and final widths of the nose, or between the initial and final widths of the nostrils.


After surgically assisted rapid maxillary expansion, the most obvious changes to the external features of the nose were at the most lateral alar bases. The difference in lateral displacement profoundly influenced the perception of a more rounded nose. Patients with narrow and constrained nostrils can benefit from these changes. The 3-dimensional superimposition applied in this study is a reliable method, circumventing projection and measurement errors.

66. Oral myofunctional and electromyographic evaluation of the anterior suprahyoid muscles and tongue thrust in patients with Class II/1 malocclusion submitted to first premolar extraction.
J Appl Oral Sci. 2007 Feb;15(1):24-8.
de Souza DR, Semechini TA, Kröll LB, Berzin F.
Source: São Paulo Federal University, UNIFESP, São Paulo, Brazil.



The aim of this study was to assess the existence of myofunctional alterations before and after first premolar extraction in Class II/1 malocclusion patients that could endanger the long-term dental arch stability.


The study was performed by means of morphological, functional and electromyographic analyses in 17 Class II/1 malocclusion patients (group T) and 17 Class I malocclusion patients (group C), both groups with 12-30-year age range (mean age: 20.93 +/- 4.94 years).


Data analyzed statistically by Student’s t-test showed a significant decrease in the maxillary and mandibular dental arch perimeters after orthodontic treatment (p<0.05). The Kruskal-Wallis test analyzed data from tongue posture at rest and during swallowing, not showing significant differences after treatment (groups Tb and Ta) (p>0.05). However, group T differed significantly from group C (p<0.05). The electromyographic data showed that the anterior right and left suprahyoid muscles acted synergistically in both groups, while having a lower myoelectric activity in group T during swallowing.


Myofunctional alterations observed after the orthodontic treatment in Class II/1 malocclusion seemed to jeopardize the long-term orthodontic stability, making recurrence possible. Further research should be conducted to compare electromyographic data before and after orthodontic treatment in order to corroborate the results of the present investigation.
J Appl Oral Sci. 2008 May-Jun;16(3):226-31.


Information courtesy of:

Occlusion Connections, Dr. Clayton Chan

Dr. Sahag Mahseredjian, Las Vegas Institute for Advanced Dental Studies