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Earned Placement: NTI Myths Busted by Dr. Stacy Ochoa

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Earned Placement: NTI Myths Busted 

NTI OmniSplint: Clenching treatment reimagined

by Dr. Stacy Ochoa, D-ABDSM, FICOI

I began using the NTI-tss Plus (Fig. 1) for my patients who were chewing through night guards or complaining that the full-arch appliances were making their headaches worse. Overwhelmingly, my patients gave us glowingly positive reports about their NTIs when they came in for follow-up appointments.
Earned Placement: NTI Myths Busted
Fig. 1

During my entrée to the world of parafunctional control with the NTI therapeutic protocol, I did encounter some naysayers—especially a few vocal ones in certain social media groups. I wondered if I should stop using it. At the very least, I had to learn more.

As a doctor, I took an oath to do no harm. So, I dug deeper to learn more. I read reams of research, attended CE courses, befriended the gurus and assessed my own patients’ experiences.

I’m a dentist, not an epidemiologist or a neurologist, but during this process I did learn a lot about the etiology of migraines and headaches; about anatomy; and about how and why the NTI works for my patients.

The most common myths about the NTI seem to be traceable to some orthodontists who said the NTI could change bites by extruding molars or intruding anterior teeth. The well-intended but misinformed myths sound something like the following:


MYTH #1:  “Anterior open bites develop when patients wear the NTI because the posteriors are out of occlusion and supraerupt.”

Myth busted: The first thing I thought about was the fact that patients wear the appliance for only about eight hours, while they’re asleep. Is that enough time to cause supraeruption if the teeth are in normal function the other 16 hours of the day? During the rest of the day, patients are eating, swallowing, talking and, yes, even clenching. According to the research and my own empirical observations, this alveolar stimulation is sufficient to eliminate any supraeruption.

One peer-reviewed study of TMD patients wearing the NTI for eight weeks found that no tooth movement occurred with nightly appliance wear.1 Other studies have shown that unopposed teeth require from anywhere from 24 hours2 up to eight days3 for movement to occur.

Dr. Jim Boyd shared a thought-provoking anecdote on this topic. He said, “I talked to an orthodontist who was adamant the appliance causes supraeruption. I asked him, ‘If you had a patient in treatment and you needed to extrude #2 and #15, but you couldn’t place any brackets on them, couldn’t use an appliance, and the teeth were in normal function 16 hours every day, how long would it take to move those molars?’

“You know what he said? ‘I couldn’t do it, so maybe it’s actually intrusion.’ ” That takes us to the next myth…


MYTH #2: “All of the forces from the appliance are on the opposing anteriors. This intrudes them and causes an anterior open bite.”

Myth busted: I always want what’s best for my patients—always. So I dug deeper on this myth. At first glance, it seems to hold some water: All the bite forces are centered on the opposing anteriors while the NTI is worn. The myth is full of holes and easily debunked when we consider the device reduces bite forces by approximately 70%. In this case, less is more.


MYTH #3: “It’s so small, patients will swallow it.”

Myth busted: The standard coverage of the NTI-tss Plus is canine-to-canine. The small size makes it extremely comfortable for patients to wear at night. Several bruxing patients told me, “Uh-uh, no way, I’m not wearing a nightguard.” After showing them how small the NTI-tss Plus is, they changed their minds and wear it every night.

Relatively speaking, it is very small and because of this, some clinicians tout the myth that the device is frequently swallowed and aspirated. Consider that the device is much larger than any temp crown your patient is sleeping in. Also, consider that the device is custom-fabricated for an ideal fit. At delivery, we always instruct patients to use all the force they can muster to try to remove the device with their tongue or lips.

Lastly, consider what was found in the Patterns of Use for an Enhanced Nociceptive Trigeminal Inhibitory Splint published in 2011. It documented more than 78,000 NTI deliveries by more than 500 dentists and there were “no cases of aspiration verified by radiographic imaging.” 4


MYTH #4: “It changes people’s bites.”

Myth busted (kind of): Is this true? Maybe you’ve even seen a case yourself. They aren’t exactly Yetis, but they’re close.

This claim is tied to the first two debunked myths. My patients are aware of this potential side effect because treatment is explained thoroughly, and they sign an informed consent form.

In extremely rare occurrences, can the NTI therapeutic protocol potentially contribute to a bite change? In Patterns of Use, 512 dentists responsible for the delivery of 78,711 NTI devices reported the incidence of bite change to be only 1.6% (Fig. 2).2 This means that bite changes are uncommon—less than two out of 100 cases. In this same article, 96.8% of respondents said they would increase NTI use or continue at the same rate (Fig. 3). I extrapolate from this what I’ve seen in my own practice. The immense benefits far outweigh any uncommon risks.
Earned Placement: NTI Myths Busted

Now, consider this: Not every side effect is negative—some are actually desirable.

For example, the drug finasteride was introduced in 1992 to treat noncancerous enlargement of the prostate gland, but was later discovered to regrow hair. Today it’s marketed under the trade name Propecia and effectively used by millions to treat male pattern baldness.5

A common hypothesis among dentists that frequently prescribe NTI devices is that the rare bite changes are actually attributable to muscles relaxing, which leads to ideal condylar positioning. This is a positive occurrence. It exposes that the condyles and thus, the bite, were in a pathological position.

With this new information, we have options about how to proceed:

1. Do nothing.
2. Tell the patient to stop wearing it.
3. Refer to an orthodontist.
4. Restore the patient to this new bite.

In my experience over the past decade of using the NTI therapeutic protocol, patients usually select Option 1, do nothing. They are feeling better. Their headaches and migraines are significantly reduced or eliminated.

Patients are instructed to bring their appliances into each of their appointments— prophy, crown seating, whatever. After failing to bring in her NTI to the past couple appointments, I was really adamant that one patient bring it next time. She sheepishly admitted that she had noticed a slight difference in the way her teeth come together and hasn’t been bringing the device in because she was afraid I’d tell her to stop wearing it.

Patients do not want to give up their device. It’s given them back their lives.

NTI Omnisplint covers all the bases (and all the teeth)

To address some dentists’ concerns and to help them deliver pain-free lives to their headache, migraine and TMD patients, Glidewell Dental Lab offers the NTI OmniSplint (Fig. 4), which eliminates concerns about these myths while still effectively delivering all the benefits of the NTI therapeutic protocol.
Earned Placement: NTI Myths Busted
Fig. 4

The OmniSplint reduces clenching and bruxing intensity through a full-arch design. By covering both arches, the OmniSplint provides patients with a comfortable solution for their migraines or tension headaches while eliminating all concerns of aspiration, supraeruption of the posterior teeth or long-term use. It is FDA-cleared for the prevention of migraines and tension-type headaches.

Although patients’ bite forces are dramatically reduced with the device, it doesn’t seem to work for dogs. The NTI OmniSplint is digitally designed and 3D printed, so it fits accurately each time and because files are stored, any time Fido decides to maul a patient’s appliance, we can easily order a new one from Glidewell without another records appointment.

This is a simple rule of thumb I share with my patients: The NTI should never touch the canines and canines should never touch the NTI. Because of the journey I shared here, more than ever I am confident in my use of the NTI for my headache, migraine and orofacial pain patients.

References
1. Arau´jo, CSR , Ralin, TGP, Rodri´guez, JEC, Marques, L, Dias, CC, and Guimaraes, AS. “Skeletal Muscle Changes Caused by the Use of an Occlusal Device: A Study by Computerized Tomography.” J Young Pharm, 2021. 13(2): 161–6.
2. Zainal Ariffin, SH, et al. “Cellular and Molecular Changes in Orthodontic Tooth Movement.” The Scientific World Journal, 2011. 11: 1788–1803.
3. Kinoshita, Y, Tonooka, K, and Chiba, M. “The Effect of Hypofunction on the Mechanical Properties of the Periodontium in the Rat Mandibular First Molar.” Arch Oral Biol, 1982. 27(10): 881–5.
4. Blumenfeld, Andrew, et al. “Patterns of Use for an Enhanced Nociceptive Trigeminal Inhibitory Splint.” Inside Dentistry, Vol. 7, Issue 11. https://www.aegisdentalnetwork. com/id/2011/12/patterns-of-use-foran- enhanced-nociceptive-trigeminalinhibitory- splint
5. McClellan, KJ, Markham, A. “Finasteride: A Review of Its Use in Male Pattern Hair Loss.” Drugs, 1999 Jan. 57(1): 111–26.

Author Bio
Dr. Stacy Ochoa Dr. Stacy Ochoa, D-ABDSM, FICOI, is a general dentist, practice owner and entrepreneur. Before graduating from the University of Missouri–Kansas City School of Dentistry in 2002, Ochoa was a registered dental hygienist and attended the University of Missouri–St. Louis for premed studies.
Ochoa has attended and delivered hundreds of hours of continuing education on the topics of headache, migraine, TMD, and adult and pediatric sleep-disordered breathing. For the past decade, she has worked closely with the St. Louis medical community to develop new clinical pathways for patient management.
 

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