Neuromuscular mouth guard draws performance debate

USA Today November 17, 2009

By J. Michael Falgoust,

Fatigue can be as much psychological as it is physical, especially for an NFL lineman who weighs in
excess of 300 pounds late in a 16-game season.

After misplacing his neuromuscular mouth guard for a few games, Derrick Dockery, a 6-6 guard now in
his second stint with the Washington Redskins, immediately recognized the difference.

Or so he thinks.

"The hardest part is to distinguish if it's psychological," Dockery says. "Is it? … I got more winded the
games I didn't have it in compared to the games I did have it. My breathing felt different when I wore it. It
seems like you have more energy."

All mouth guards are designed to direct and distribute the impact of force to the jaw to minimize injuries
such as lacerations, damaged teeth and concussions. Neuromuscular mouth guards are different from the
traditional boil-and-bite ones that can be purchased at sporting goods stores, and even from the custom-
fitted ones dentists often make for individual players of pro sports teams.

Rather than focusing on the pre-existing relationship where the teeth come together and the jaw joints set
in the sockets to find the bite like traditional dentists, neuromuscular dentists relax the muscles for a
"verifiable position" that usually results in a joint socket position that's typically more down and forward.

"If you pull the jaw forward, your tongue is forward, you have more space in the back. It's that simple,"
says Alex Naini of AestheticDentalSpa.net, a neuromuscular dentist in Vienna, Va., outside Washington
D.C., who fitted Dockery. "Anything that pulls the jaw forward opens the airway and automatically
releases tension in your jaw joints. You have more space to let oxygen into your lungs."

Pro athletes from various disciplines, including the NBA, soccer, mixed martial arts, boxing, golf and
Major League Baseball, have worn neuromuscular mouth guards because they believe they can
maximize their natural abilities such as endurance, strength and flexibility.

By aligning the lower jaw over the C1 and C2 vertebrae, which sit atop the spinal column to connect the
skull to the spine, a clear path is created to increase air intake. The oxygen bump is supposed to help the
muscles perform stronger tasks and repeat those tasks longer.

Use of the appliance — originally developed to treat jaw joint disorders, which includes migraine
headaches and ear, neck and joint pain — still isn't widespread and has yet to gain acceptance among
athletic trainers.

"Everybody's looking for that edge over their opponent," says Dockery, who also cites better balance and
isn't paid to endorse the product. "If it works, why not try it?"

The power train

It began with a theory in 1950 by the late Bernard Jankelson, the father of neuromuscular dentistry. He
coined the name in 1967 after researching with H.H. Dixon, a muscle physiologist, at University of Oregon
School of Medicine.

Jankelson graduated from dental school at Oregon in 1924, but biophysics had the imaging technology he
needed to test his theory that stimulation could restore muscles to their normal function and resting length
to eliminate muscle pain. That technique could then be applied to the jaw and facial muscles to kick-start
a chain reaction to make the human body perform at a higher level.
"What we hypothesized is if you can get the muscle healthy before you set the jaw position, you will have
a much more desirable muscle to help you generate efficiency for either force or speed," says Robert
Jankelson, 70, who joined his father in 1963 and has practiced for 45 years in the Seattle area.
The teeth function as the "gears," he says, and it is imperative that they're in sync with the joints and
muscles to make recruitment of strength throughout the body easier.

The key lies in the temporomandibular joint (TMJ) — two three-dimensional ball sockets, one on each
side of the face, that connect the lower jaw to the skull. The goal is to restore the ideal position of the balls
in those sockets to align the muscles.

"That's where that mouthpiece comes in. It allows the best joint function and recruitment of the power
muscles of the jaw, that's when you increase your athletic efficiency," Jankelson says. "This power train
goes all the way down, from the teeth, to the neck, the vertebrae, the back. The more you can get those
articulations in a chain that will recruit the power muscles, that is your ultimate goal in repositioning the
jaw."

Since the advent of Gatorade in 1965, researchers of all stripes, athletes, athletic trainers and even
dentists have sought alternative methods, liquids and devices to boost performance. Most notably, the
U.S. Olympic bobsled and luge teams wore custom mouth guards produced by an orthodontist at the
1980 Winter Games. They claimed it was responsible for the bobsledders' best results in 16 years and
best-ever results for the lugers.

The mandibular orthopedic repositioning appliance, or MORA, was touted as a stress reliever for the TMJ
that made decathletes stronger and college pitchers throw harder.

The Journal of the American Dental Association, however, published a 1984 study after 14 Louisville
football players were tested using no mouth guard, a placebo and a MORA. It concluded there was no
difference.

While the MORA was a start, it amounted to educated guesswork.

"It was hard for it to be reproducible, so the studies on its effectiveness were mixed because there was no
predictability behind the technique," says Gary Lederman, a New York-area neuromuscular dentist who
has fit athletes such as Shaun Ellis (New York Jets) and Paulie Malignaggi (junior welterweight boxer).
"There was no way to evaluate the athlete and find the precise point that it worked."

David May, his West Coast partner at Fightdental.com, has fit a number of mixed martial artists, including
Anderson Silva (UFC middleweight champion) and Lyoto Machida (UFC light heavyweight champion).

The difference between the MORA and a neuromuscular mouth guard?

Science, Jankelson says. The MORA relied on an orthodontist's pinkie fingers being inserted into a
patient's ears to determine if the TMJ is misaligned. Then, in an attempt at realignment, the jaw was
pushed forward.

Neuromuscular dentistry relies on the J5 and K7, the latter of which received the Seal of Acceptance from
the American Dental Association in 1986 for its safety and effectiveness. The J5 machine uses low-
frequency pulses to relax the facial muscles so the optimal position of the jaw can be found by the K7
using computer-assisted tracking.

Struggle for acceptance

Although there are notable athletes who have worn the mouth guard, such as Terrell Owens (Buffalo
Bills), Shaquille O'Neal (Cleveland Cavaliers), Michael Redd (Milwaukee Bucks) and Suzann Pettersen
(LPGA), it has not become mainstream or picked up by a pro sports league the way Breathe Right strips
became commonplace in the NFL.
The New Orleans Saints this season began using neuromuscular mouth guards, which are not available
over the counter. Marketing of the product has been minimal, and depending on the fee charged by the
lab that makes it, it can cost as much as $2,000, though Naini says she can produce it for less.

The ADA, however, doesn't recommend neuromuscular mouth guards. Even though it gave the K7 its
Seal of Acceptance, the organization doesn't recognize neuromuscular dentistry as one of the nine
specialties. As of 2006, there were 179,594 active dentists in the USA, but neuromuscular dentists aren't
accounted for in those numbers (estimates are about 3%, or 5,388).

"Dentists push your jaw back. That's what's taught in dental school. Even though the science is
overwhelming, there's still resistance," Jankelson says. "Nobody wants to be proven wrong that pushing
the jaw back doesn't make sense."

John Norwig, the president of the Professional Football Athletic Trainers Society, wants to see the
science tested through independent study in the USA, which has yet to happen.

"In the athletic training literature, there hasn't been any landmark studies. This appliance may be a great
breakthrough, but there's not any hardcore research in any of my professional journals," says Norwig,
who has worked with the Pittsburgh Steelers for 19 years.

"What we try to do is use something that has some science behind it. Years ago, they didn't use sports
beverages, but now sports beverages are the standard of care. … If it's something that works, I'm sure it'll
make its way into the NFL."

Says Naini: "A lot of people just haven't been exposed to it. They don't understand it. And let's face it, a
lot of athletes who use it like keeping the edge to themselves."