The use of transcutaneous electrical nerve stimulation (TENS) in a major cancer center for the treatment of severe cancer-related pain and associated disability.

Loh J1, Gulati A2.: 

• Pain Med. 2015 Jun;16(6):1204-10. doi: 10.1111/pme.12038. Epub 2013 Feb 25.

Abstract

BACKGROUND:

Cancer pain is difficult to treat, often requiring a multimodal approach. While medication management remains the mainstay for the treatment of cancer pain, medications are often associated with undesired side effects. Transcutaneous electrical nerve stimulation (TENS) provides a potential adjunctive method for treating cancer pain with minimal side effects.

OBJECTIVE:

Few studies have been performed evaluating the efficacy of TENS on cancer pain. We sought to examine the usefulness of TENS on all cancer patients and to specifically look at the use of TENS as a goal-directed therapy to improve functionality.

DESIGN:

Retrospective cohort study.

METHODS:

Since 2008, patients with chronic cancer pain and on multimodal pain regimens were trialed with TENS. Those patients who showed an improvement in pain symptoms or severity were educated about and provided with a TENS unit for use at home. Pain symptoms and scores were monitored with the visual analog scale (VAS), the numerical rating pain (NRP) scale, and Short-Form McGill Questionnaire at the start of TENS treatment and at 2 months follow-up.

RESULTS:

TENS proved beneficial in 69.7% of patients over the course of 2 months. In TENS responsive patients, VAS scores decreased by 9.8 on a 0-100 mm scale (P < 0.001), and NRP scores decreased by 0.8 on a 1-10 scale (P < 0.001).

LIMITATIONS:

Lack of placebo and lack of blinding of physician and patient.

CONCLUSIONS:

TENS provides a beneficial adjunct for the treatment of cancer pain, especially when utilized as a goal-directed therapy.

Wiley Periodicals, Inc.

KEYWORDS:

Cancer Pain; Goal-Directed Therapy; Outcomes; Pain Management; Retrospective Review; Transcutaneous Electrical Nerve Stimulation

The Myo-monitor and the myo-facial pain dysfunction syndrome

Wessberg GA., Dinham, Richard: "The Myo-monitor and the myo-facial pain dysfunction syndrome".  Journal of the Hawaii Dental Association.  vol. 10, No. 2, Aug. 1977.

Summary:
Thirty patients presented symptoms with the Myo-facial Pain Dysfunction Syndrome.  All of these patients received Myo-monitor oriented therapy and nearly all of them professed some initial relief or total remission of their symptoms during the short time  span of this study,

The data presented is based largely on clinical observations and patient response to comparison of their symptoms before and after treatment.  Symptoms evaluated were generally related to muscle tenderness and mandibular mobility.
Conclusion:
Due to clinical observations and patient response in this investigation, it is concluded that:

1. The centric occlusion position is seldom coincident with the myo-centric position of occlusion in patients who exhibit symptoms associated with Myofacial Pain Dysfunction Syndrome.
2. A Myo-monitor generated occlusal position affords some relief if not complete remission of symptoms in 90% of cases treated.
3. Long-term follow-up studies are necessary to evalutate the success of treatment.

Electromyography Tension and FrequencySpectrum Analysis Before and After TENS

Bazzotti L:Electromyography tension and frequency spectrum analysis at rest of some masticatory muscles, before and after TENS. Electromyogr Clin Neurophysiol. 997 Sep;37(6):365-78.

University of Liège, D.U. of Stomatology (Nancy).

Abstract:

On a population of 52 subjects surface electromyographic recordings were performed of 13.5 sec. of duration before and after ULF (Ultra Low Frequency)-TENS relaxing procedure, while they were holding their mandible at rest. For each recording the average of tension (IEMG) and the median of frequency was calculated. To compute the median of frequencies a Fast Fourier Transformer (FFT) was applied. In order to compare modifications induced by the 45' ULF-TENS relaxing procedure, so that the influence of ULF-TENS could be well isolated from any influence due simply to the time passing between one recording and another, three recordings were performed at different times: the first at time 0', the second at time 0' + 20', and only the third after TENS, time 0' + 20' + 45'. The results of the study permit us to draw the following conclusions: 1. it is confirmed that ULF-TENS can decrease muscle IEMG; 2. the study of the IEMG and frequency of the electromyographic signal at rest can be carried out starting from a window whose size and position in the 13.5 sec. of recording is arbitrary; 3. there is no connection between IEMG and frequency: in other words, at rest, there is no necessary correspondence between high or low IEMG and a high or low frequency values; 4. on application of the neurodiagnostic test of ULF-TENS, the IEMG of the electromyographic signal decreases, while the frequency of the signal remains unchanged. These last two observations permit us to hypothesize that the IEMG and the frequency of the electromyographic signal reflect some different and independent characteristics of the electrical activity of the muscle at rest.

Short-term and Long-term Effects of TENS

Eble OS, Jonas Ie, Kappert HF: "Transcutaneous electrical nerve stimulation (TENS): its short-term and long-term effects on the masticatory muscles." J Orofac Orthop. 2000;61(2):100-11.

Department of Orthodontics, University of Freiburg/Br., Germany. eble@zmk2.ukl.uni-freiburg.de

Abstract

In an electromyographic study on subjects with no functional disturbances of the masticatory muscles, the duration of the post-therapeutic effects of transcutaneous electrical nerve stimulation (= TENS) on the superficial masseter and anterior temporal muscle was analyzed. The myoelectric signals were registered from 20 healthy volunteers in 3 different mandibular positions. The recordings were performed before a 20-minute TENS application with the J-4 Myomonitor and continued with a sequence of follow-up registrations with increasing interval to the initial stimulation. The EMG signals underwent computer-aided analysis and were evaluated by determining the integrated values as a parameter of muscle activity, and after Fourier transformation by 7 describing parameters of the power spectrum (e.g. mean power frequency = MPF). A detailed analysis of variance of all data was used to investigate significant changes of the parameters during the observation period. Muscular response to TENS includes a decrease in muscular activity (= reduction in integrated EMG signals) and a shift in the power spectrum to higher frequencies (increase in MPF). These changes were statistically highly significant for both analyzed muscles and for all different mandibular exercises. As these reactions to TENS are contrary to muscle fatigue, the results can be interpreted as indicating that this type of therapy stimulates a change in the biochemical and physiological muscular conditions, which leads to muscle relaxation. Electromyographically, the post-therapeutic effect lasted for 2 hours in case of normal masticatory muscle activity but for more than 7 hours in case of low muscular loading. The alterations of the integrated EMG values were more persistent than those of the parameters of the power spectrum.

Effects of TENS on EMG and Kinesiographic Activity

Monaco, A, Sgolastra, F, Ciarrocchi, I, Cattaneo, R.: "Effects of transcutaneous electrical nervous stimulation on electromyographic and kinesiographic activity of patients with temporomandibular disorders: a placebo-controlled study". J Electromyogr Kinesiol. 2012 Jun:22(3):463-8. doi: 10.1016/j.jelekin.2011.12.008. Epub 2012 Jan 14.

University of L'Aquila, Department of Health Sciences, L'Aquila, Italy. 

Abstract

The purpose of this study was to assess the effect of a single 60 min TENS application on sEMG and kinesiographic activity in TMD patients in remission, and to assess the sEMG and kinesiographic effect of TENS in placebo and untreated groups. Sixty female subjects, selected according to the inclusion/exclusion criteria, suffering from unilateral TMD in remission were assigned to one of the following group: Group TENS, that received a single session of 60 min of TENS; Group Placebo that received a single session of 60 min of sham TENS; Group Control, that received no treatment. Pre- and post-treatment differences in sEMG of TA, MM, SCM, and DA and interocclusal distance values within groups were tested using the Wilcoxon test. Differences in sEMG and kinesiographic data, among the three groups, were assessed by Kruskal-Wallis test. Significant differences were only observed in the TENS group, for masticatory muscles of both sides; one-way analysis of variance revealed that sEMG values of masticatory muscles of both sides in the TENS group were significantly reduced, in comparison with placebo and control groups. Kinesiographic results showed that the vertical component of the interocclusal distance was significantly increased after TENS only in the TENS group. TENS could be effective to reduce the sEMG activity of masticatory muscles and to improve the interocclusal distance of TMD patients in remission; the placebo effect seems not present in the TENS application.

Myomonitor Efficacy and Myofacial Pain

Wessberg Geroge A., Dinham, Richard, DMD.  "The Myo-monitor and the myo-facial pain dysfunction syndrome."  Journal of the Hawaii Dental Association.  vol. 10, No. 2, Aug. 1977.

The Myofacial Pain Dysfunction Syndrome (MPD, TMJ Syndrome, Craniocervical Syndrome) has plagued dentistry for many years. Therapy for this type of pain  has been highly imaginative.  A few of the more common modalities mentioned (Ramfjord  1971) are occlusal adjustment, occlusal bite splints, immobilization of the mandible, drug therapy, placebo, diathermy, physical therapy, sclerosing agents, psychotherapy, and surgery.  Recent studies of mandibular  movement (Jankelson 1976) stress the importance of a "muscularly oriented occlusal position" for the treatment of the MPD Syndrome.

....Jankelson (Jankelson 1976) assumes a compromise in these trends of thought actually exists.  He describes a relatively precise PRPM at any given stage of development that fluctuates within a minimal range of normal as determined by states of equilibrium within the mandibular musculature.

The postural rest position of the mandible (PRPM) is by definition (Academy of Denture Prosthetists, Glossary of Prosthetic Terms, 1956) the mandibular position assumed when the head is in an upright position and the involved muscles, particularly the elevator and depressor groups, are in equilibrium in tonic contraction, and the condyles are in a neutral, unstrained position.

Summary:
Thirty patients presented symptoms with the Myo-facial Pain Dysfunction Syndrome.  All of these patients received Myo-monitor oriented therapy and nearly all of them professed some initial relief or total remission of their symptoms during the short time  span of this study,

The data presented is based largely on clinical observations and patient response to comparison of their symptoms before and after treatment.  Symptoms evaluated were generally related to muscle tenderness and mandibular mobility.
Conclusion:
Due to clinical observations and patient response in this investigation, it is concluded that:

1. The centric occlusion position is seldom coincident with the myo-centric position of occlusion in patients who exhibit symptoms associated with Myofacial Pain Dysfunction Syndrome.
2. A Myo-monitor generated occlusal position affords some relief if not complete remission of symptoms in 90% of cases treated.
3. Long-term follow-up studies are necessary to evalutate the success of treatment.

Myomonitor Efficacy - An Electromyographic Study with Myofacial Pain Dysfunction

Pantaleo, T.,M.D., Prayer-Galletti, F. M.D., Ph.D., Pini-Prato, g., M.D., and Prayer-Galletti, S.,M.D. "An electromyographic study in patients with myofacial pain-Dysfunction syndrome." Bull. Group. int. Rech.sc Stomat. et Odont. Vol. 26, pp. 167-179, 1983.

Recently dental research has turned to neuro-muscular system: many dental procedures, in order to be entirely successful, require that the masticatory muscles are relaxed and perfectly balanced.  The use of the transcutaneous electrical nerve stimulation (TENS) has been introduced, obtrained with adquate stimulators, such as the Myo-moniotr (Myo-tronics) (Jankelson 1975, Jankelson 1978, Wessberg, 1981): TENS has been able to relieve pain and eliminate the sustained muscle tension of the masticatory muscles of patients with myofacial pain-dysfunction (MPD) syndrome (laskin 1969), combined with occlusal malrelation, which may be the primary cause of MPD syndrome (Lindblom 1953, Alling 1977).

Summary:
An electromypgraphic (EMG) study of ipsilateral masseter and temporalis muscles was undertaken in healthy volunteers and in patients with MPD syndrome, with the aim of getting further insight into the pathophysiology of this disease.  Unlike controls, patients had abnormal MKG features and displayed involuntary sustained EMG activity at rest, chiefly in the temporalis muscles.

Transcutaneous electrical nerve stimulation (TENS) performed with the Myo-monitor induced relaxatio and relief of pain: these effects were however revesred by voluntary mouth closures.

The correction of occlusal position by acrylic splints was able to induce  persistant reduction or a suppression of the abnormal EMG activity at rest and a good relief of pain: moreover, after the corretion, higher levels of EMG activity were found during maximal  biting in the intercuspal position.

Mechanisms underlying these effects were discussed and in particular it was suggested that abnormal afferenct activity from periodontium and jaw muscles may contribute to the establishment of sustained contraction leading to muscular pain, which in turn may cause reflex muscle activity i vicious circles.

Scientific Studies Validating the Low Frequency TENS

There are numerous studies in the scientific literature that support the efficacy of low frequency T.E.N.S. in the diagnosis and treatment of TMJ/TMD.

Three distinct categories for TENS modalities are recognized in this field: 1) Conventional High Frequency TENS - 50-100 Hz asymmetrical biphasic wave (40-75 usec) which is designed to selectively actuate the large myelinated afferent muscle fibers.  Muscle fasiculation is no apparent, there is a fast on set of relief, short therapeutic effect, generally not exceeding length of stimulation with little to no endogenous opiate liberation, no reversal by naloxone and is primarily a local CNS segmental effect, 2) Low Frequency TENS operates at a pulse rate of 0.5 Hz to 10.0 Hz using a asymmetrical biphasic wave form of 150-500 usec.  It produces muscles contract, with slow onset of 20 minutes or more, has a long therapeutic effect, allows a period of muscle recovery between pulse stimulation by surface electrodes in segmentally related myotromes being most efficacious and hasa  acupuncture-like effect and 3) Electrogalvanic Stimulator (EGS) which is characterized by having a monophasic, twin peak wave for each pulse of 10-20 msec utilizing direct current.  EGS is used for local tisseu effect, not pain control.

Both low and high fequency TENS have ample and specific documentation in the medical literature regarding local histochemical and endorphin effects.  The following articles addres the mode of action of conventional hight frequency TENS and low frequency TENS.

1. Ersek, R. (1977) "Transcutaneous neurostimulation: a new therapeutic modality for controlling pain."  Clinical  Orthopedics and RElated Research. Vol. 128:314-324.
2. Eriksson, M.D. and Sjolun, B.H. (1978) "Pain relief from conventional versus acupuncture-like T.E.N.S. in patients with chronic facial pain."  Pain Abstracts. 2nd World Congress on Pain, Montreal: IASP, p. 128.
3. Takokora, K., et al. (1979) "Pain control by transcutaneous electrical nerve stimulation using irregular pulse of 1Hz fluctuation." Applied Neurophysology. 42:314.
4. Muarray, W. and Miller, J. (1960) "Potency differences of mophine-type agents by radiant head and 'crampin'analgesic assays provide evidence for potentializing substance from the posterior pituitary gland." J. Pharmocologic Exp. Ther. pp. 128-380.
5. Goldstein, A., Lowney, L., and Pal. B. (1971) Steroespecific and no-specific interactions of the morphine narcotic congener leurophanol in subcellular functions of rat brain." Proc. Nat. Acad. Science USA. 68:1742.
6. Moyer, J.D., Price, D.D., and Rafii, A. (1977) "Antagonism of acupuncture analgesis in man by the narcotic antagonist naloxone," Brain Reserach. pp. 121-368.
7. Akil, H., et al. (1978) "Encephalin-like material elevated in ventricular cerebrospinal fluid of pain patients affter analgetic facial stimulation." Science. 201:463.
8. Simanto, r., et al. (1976) "The regional distribution of a morphine-like encephalin in monkey brian." Brain Research. 106:189.
9. Sjolund, B. and Eriksoon, M. (1979) "Endorphins and analgesia produced by peripheral conditioning stimulation." Advances in Pain research and Therapy, Vol. 3, Bonica, et al., eds, Raven Press, N. Y.
10. Wall, P.D. (1980) "The  role of substantia gelatinosa as a gate control." Pain. Reserach Ed. Bonica, 58:205.
11. Kerr, F. W. (1975) "Neuroanoatomical substrates of noceception in the spinal cord." Pain 1:325.
12. Loeser, J.D., et al. (1975) "Relief of pain by transcutanous stimulation." J. Neurosurg. 42:308.
13. Arcangeli, P. and Galletic, R. (1974) "Endogenous pain producing substances." Recnt Advances on Pain: Pathophysiology and  Clinical Aspects. Ed. Bonica, p. 36.
14. Thorsteinsson, G., et al. (1977) "Transcutaneous electrical stimulation: A double-blind trial of its efficacy for pain." Arch. Phys. Med. Rehab. 58:8.
15. Long, D. and Hagfors, N. (1975) "Electrical stimulation in the nervous system: The current status of electrical stimulation of the nervous system for relief of pain." Pain. 1:109.
16. Dooley, D.M. and Kasparak, M. (1976) "Modification of blood flow to the extremities by electrical stimulation of the nervous system." S. Med. Journal 69:1309.
17. Abruam, S.E. (1976) "Increased sympathetic tone associated with transcutaneous electrical stimulation." Anesthesiology. 45:575.
18. Abram, S. E., el al (198) "Increased skin temperature during transcutaneous electrical stimulation." Anesth. Analg. 59:22.
19. Rowlingson, J., et al. (1978) "The effect of transcutanous nerve stimulation on blood flow in normal extremeties." Pain Abstr. Vol. 1, 2nd World Congress on Pain, Int. Assoc. for Study of Pain, Seattle, p. 155.
20. Murphy, T. M. and Bonica, J.J. (1977) "Acupuncture analgesia and anestheesia." Arch. Surg. 112:896.
21. Andersson, S.A. and Holmgren, E. (1977) "Analgesic effects of peripheral conditioning stimulation parameters." Acupunc. Electro. Res. 2:237.
22. Sjolund, B. H. and Ericksson, M.E. (1976) "Electro-acupuncture and endogenous morphines." Lancet. 2:1085.
23. Voll, R. (1975) "Twenty years of electroacupuncture therapy using low-frequency current pulses."  American J. of Acupuncture. 3:291.
24. M
25. Terenius, L. (1978) "Significance of endorphins in endogenous antiociception."  Advances in Biochemical Psychoparm. Ed. Costa and Trabucchi. Raven Press, N. Y., p. 31.
26. Adams, J.E. (1976) "Naloxone reversal of analgesia produced by brain stimulation in the human." Pain 2:161.
27. Hosobuchi, Y., et al. (1977) "Pain releif by electrical stimulation of the central grey matter in humans and its reversal by naloxone." Science. 197:183.
28. Burton, C. and Marrer, d.D. (1974) "Pain suppression by transcutaneous electrical stimulation." IEEE Trans. Bimed. Eng 21:81.
29. Andersson, S.A., et al. (1976) "Evaluation of the pain suppression effect of different frequencies of peripheral electrical stimulation in chronic pain conditions." Act Orthop. Scandia. 47:149.
30. Wolf, C.J., et al. (1980) "Antinociceptive effect of peripheral segmental electrical stimulation in the rat." Pain. 8:237.
31. Malow, R. M. and Dougher, .J. (1979) "A Signal detection analysis of the effects of transcutaneous stimulation on pain." Psychosom. Med. 4: 101.
32. Ebersold, J.J., Laws, E.R. and Albers, J.W. (1977) "Meaasurements of autonomic function before, during and after transcutanous stimulation in patients with chronic pain and in control subjects." May Clin. Proc. 52:228.
33. Pert, A. and Yaksh, T. (1974) "Sites of morphine induced analgesia in the primate brain: Relation to pain pathways." Brain Research. 80:135.
34. Sjolund, B.H., Terenius, L. and Ericksson, M.B. (1977) "Increased cerebrospinal fluid levels of endorphin after elecro-acupuncture." Acta Physiolo. Scan. 100:382.
35. Mayer, D. J., Price, D.D. and Raffii,  A. (1977) "Antogonism of acupuncture analgesia in man by the marcotic antogonist naloxone." Brain Res. 121: 368.
36.  Schlen, H. and Bentlye, G. A. (1980) "The possibility that a component of morphine induced analgesia is contrubted indirectly via the release of endogenous opioids." Pain 9:73.
37. 
    

The medical literature is clear and unequivocal about the use of low frequency TENS (0.5-10 Hz) is both safe and efficacious for muscle relaxation and pain control.  It is also  clear that low frequency TENS has a hgih degree of specificity when utilized for craniofaical pain (Andersson, 1979: Eriksson eta l., 1984; Chapman et al., 1979; Andersson et al., 1977; Andersson and Homgren, 1975; Sjolund et al., 1975; Reichmanis and Becker, 1977; Hansoon and Ekbolom, 1983; Tereshalmy et al., 1982; Phero, 1987; Lasagna et al, 1986; Thomas, 1986; Pantaleo et al., 1983; Wessberg and Dnham, 1977; Kknchak et al., 1988).

Choi and Mitani at Osak Dental University in 1973 applied the Myomonitor 10 15 subjects and monitored the evodked respons using wire EMG electrodes.  The study concluded "The evoked EMG was recorded from the  anterior ortion  of the temporal, the masseter, the anterior ventrl of the digastrics, andobicularis oris and the buccinator muscles.  The Myo-monitor pulse stimulates the nerve trunks of the fifth and seventh cranial neves at the superior mandibular notch percutanously and it appeared to have afferent and efferent effects."
 Using accepted intensity-duraction methodology Jankelson, et al., 1975 demonstrated that the chronaxy values for Myo-monitor generated curves were well below those for direct muscle stimulation.  Further verification of neural mediation resulted from the study of Williamson and Marshall,  1986 using succinylcholine.  The study concluded "Succinylcholine acts by competing with acetylcholine at the myoneural end plate and, therefore, no neurally stimulated muscle contraction under such conditions is by direct depolarization of the muscle itself.  With the Myo-monitor evoking electrical impulses, there was no muscle contraction  either instance.  This information would suport the conclusion that the Myomonitor stimulus is transmitted neurally."

Fuji 1977 at the Univestity of Osak used multiple site monitoring to distinguish M wave and H wave response.  Using multiple anatomically separate recording sites and the study concluded "Two kinds of response were obtained with latencies of about 2.0 msec. and about 6.0 msec. respectively.  The former was assumed to be a direct potential (M Wave) and the latter a monsynaptic reflex potential (H wave)."  The use of recording sites anatomically distant from  the input stimuli is essential for valid conclusions using this methodology.  in a 1988 study of Myo-monitor stimulation, Dao, Feine and Lund for unexplaned reasons place the recording needle proximate to the electrode stimuli site.

McMillan et al., 1987 at the University of Hong Kong concluded that "Contraction of muscles of the upper and lower eyelids, the lateral aspects of the nose and the upper lip indictes stimulation of the facial nerve, in particular its zygomatic and buccal branches.  The results of our anatomic investigation indicate that this effect is produced by the stimulation of the branches of the upper division of the facial  nerve as they pass in a more or less direct anterior course over the preauricular region.  These branches will then be directedly beneath a surface electrode placed according to the standard protocol.  Propagation of the Myo-monitor stimulus along branches from  the buccal anastomotic loops of the nervew would ensure contraction of muscles  of the upper lip and angles of the mouth.  This observation supports electromyographic evidence and results of intensity duration tests that indicate muscle contraction resulting from Myo-monitor stimulation is neurally mediated."

Goodgold and Eberstein examined eight individual investigative studies and found that normal stial latency and conduction velocity of peripheral motor nerves ranged from 2.1 to 5.6 msec. and 44.8 to 67.9 msec., respectively.  They concluded that the latency to the obicularis oris which is innervated by the facial nerve in response to stimulation at the angle of the jaw, averages 2.5 to 3.0 msec.  Bamajian summarized the results of six studies conducted by separate authors on peripheral nerve conduction velocity and found an range of conduction velocity between 37 and 73 meters/sec.  Assuming the distance between the stimulation electrode and the wire recording electrode was approximately 2 cm, it should have taken 0.27 to 0.54 msec. for the pulse to travel this distance if the muscle were stimulated directly.  This time interval is much less than the 1.80 to 4.4 msec. measured in the Dao study.  This suggests the pulse must have traveled a much longer  distance.  A neurally mediated pulse would have: 1) 0.5 msec. charging the dermal capacitance, 2) neural conduction time of 0.7 msec. assuming a nerla conduction pathway of 4 cm and conduction velocity of 55 meters/sec. which is the average of Basmajian's review, 3) residual latency  (delay at the myoneural junction) of 0.6 msec., 4) intermuscular  delay of approaximaterly 0.4 msec. depending upon electrode placement.  Adding the sum of these phenomena we find the latency of 1.8 o to 4.04 msec. as measure by Dao, et al. is well within the range of neurally mediated respose, despite their electrode placement.

The Myo-monitor: Its use and abuse

Jankelson, Bernard, (1978) The Myo-monitor: Its use and abuse (I). Quintessence International No. 2: Report 1601, pp 47-51.

SUMMARY
The Myo-monitor transcutaneously stimulates the motor branches of the Vth and VIIth cranial nerves, relaxes the associated musculature, and then records an occlusal position that is compatible with a continued state of relaxation. Additional techniques have been developed for taking denture impressions (or relining old dentures) functional occlusal diagnosis, occlusal adjustment, and treatment of TMJ and MPD syndrome.

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