Background Noise: The Role of Trauma in Sleep Physiology

The Trigeminal Cardiac Reflex (TCR) is a poorly misunderstood, highly complex condition that affects many patients who often fail to have successful results of traditional therapies for craniofacial pain and/or sleep disordered breathing.  The TCR is a neurological event where the impact of trauma has derailed the body’s ability to appropriately respond and accommodate to the changes in blood pressure and glucose levels in the brain during sleep.

Research indicates that there is a simultaneous activation of both the sympathetic (fight, flight, freeze) and parasympathetic (rest and digest) nervous systems when any aspect of the trigeminal (fifth cranial) nerve is stimulated.  This stimulation can result in periods where the body “pushes on the gas” then “slams on the brake” to regulate blood flow to the brain.  These rapid and sudden changes can result in events where the brain does not send the signal to the body to breathe as it overcompensates for its efforts to lower the blood pressure.

The body then attempts to regulate the blood pressure that is now too low by  clenching the teeth.  This activates the muscles of the face and neck while also utilizing a protective neurologic pathway in the trigeminal system (mesencephalic nucleus of the trigeminal nerve) to activate the body to shift gears from “too low” to what often presents as “too high”.  The excessive forces created as a result of this reflex often damage and inflammation to the teeth and delicate neurologic tissue as well as the joints and nerves of the head and neck.  Patients with this condition are capable of clenching with more intensity while they are asleep and "resting" as they can when they are awake and clenching at their maximal force in their conscious state.  The neurologic damage that occurs can precipitate neurodegenerative conditions and poor sleep quality as well as inadequate healing and poor growth in children.

Throughout the years of attempting to address the needs of the complex patient, it was thought that by increasing GABA that it would also increase the inhibition pathways.  However, this action resulted in requiring extra trigeminal input (clenching, lip pursing, tongue pressing, intense winking) to get enough dopaminergic signaling to facilitate automonic nervous system (ANS) state change. 

Many misinformed drug-oriented dental pain 'specialists' were prescribing gabaminergic medications for and getting more intense clenching, gastric reflux and other related events.  This increased awareness of the upregulated trigminal signalling efforts as a consequence of the unsuccessful treatment outcomes from utilizing inappropriate medications for the TCR patient indirectly yet clinically confirms the finding that "pain has primarily been studied at peripheral sites and not in the brain, with a goal of reducing or eliminating the sensory component of pain. Meanwhile, the emotional component of pain and associated comorbidities such as depression, anxiety, and lack of ability to feel pleasure that accompany pain has been largely ignored."

https://www.technologynetworks.com/neuroscience/news/circuitry-that-links-pain-to-negative-emotion-identified-in-rat-study-354881?fbclid=IwAR1ubCWWzJ5HNlLKhgUbgi5Lc73NLmYSIvpVY8gllnK5461jDvdzIIml7Gs

Medications that affect the reuptake of serotonin (SSRI's) have a similar effect for some patients in that they indirectly depress dopamine pathways resulting in the body's attempt to increase dopamine signalling through clenching and similar trigeminal stimulation efforts.

It is important to remember that the rhythm-generating centers that maintain breathing and circulation are dopaminergic.

It is unfortunate that patients were subjected to 'experimentation' as well as those also indirectly hurt in the process as medicine chased down those rabbit holes yet failed to address the underlying issues of : 

• physical trauma (concussions, beatings, accidents)
• emotional trauma (especially those associated with being trapped or abandonment)

There are at least three burdens that practitioners need to be aware of their challenge to identify and overcome with complex patients suffering from TCR and trauma-related conditions: 

1. gaps that neuroplasticity strives to close while expending valuable metabolic resources (eg. glucose to the brain during sleep)
2. inflammation (especially of the dura and gut)
3. the depression of critical pathways including dopamine production

Patients that were poor responders to the mandibular advancement appliances that he invented over 30 years ago caused Dr. Nordstrom to search for answers that were more complex than addressed by structural airway management. He asked radiologists to search for evidence through MRI documentation of scattered areas of intensities secondary to blood extravasation in the brain. Vascular fragility is associated with mast cell activation syndrome which causes a weakening the endothelial lining. When vascular fragility resulting in cerebral microbleeds is combined with an event that rapidly alters cerebral blood flow, it appears as a silent form of vascular seizure. Blood extravasation in the context of sudden episodes of bradycardia followed by tachycardia associated with the trigeminal cardiac reflex creates the potential for neurodegenerative diseases such as MS, ALZ and Parkinson’s Disease. If there is low blood sugar secondary to insulin resistance that causes the body to invoke the TCR to induce a rapid blood flow to support glucose metabolism, the patient is at greater risk for neurodegeneration and intracranial inflammation. 

Understanding the TCR begs the bigger question of whether there can be a correction, or whether that tendency is set for life and what are the safest supports. By utilizing H1/H2 blocking medications along with immune globulins will reduce activation of the mast cells and severity of the presentation of the TCR. Regretfully, even though maternal iron deficiencies appear to contribute to the problem of lack of myelinization for the developing baby, iron supplementation has not provided a safe solution for TCR resolution. Additional factors include, infections during pregnancy, unresolved trauma, and the inability for the developing child to learn to be able to have adequate oral function and to autoregulate to maintain healthy levels of neurotransmitters and glucose in the brain, 

Problem solving with case finishing should include evaluation and consideration of factors regarding hypomyelination and functional iron deficiency.

Addressing retained primitive reflexes and lack of autoregulation are tremendous opportunities for ALF Therapy providers. In addition, the sophistication of the appliance designs are ideal for providing gentle, bilateral, rhythmic and consistent neurologic feedback acts to help the patient to achieve the neurological sensation of the anterior coupling response and the mature, efficient swallow that supports peristalsis and creates resilience. By creating the sensations that the brain associates with comfort and calm, the body can better regulate its efforts in balancing the sympathetic and parasympathetic nervous systems which in turn reduces the severity of the TCR symptoms. 

As ALF Therapy is properly designed for the needs of the individual patient, properly trained providers can support the patient through the process of using oral appliance therapy to support the neurologic requirement of the anterior coupling response as well as the physical requirement of the mature swallow pattern. When ALF is utilized, it reduces the noise in the brain by creating comfortable familiar sensations and stimulating the cranial nerves that sense the patient's need for balance and regulation. Even though a lack of myelin cannot be changed, ALF can be implemented to help the patient hear the voice of reason over the background noise of the TCR.

Our hope is that as more practitioners become trained in ALF Therapy and OraLase that we will continue to find that a substantial percentage of patients with sleep disordered breathing will find significant relief with superficially simple, but sophisticated therapy targeted at addressing the underlying reasons that patients are vulnerable to an activation of the TCR. 

Supporting our patient’s ability to autoregulate and maintain resilience are the highest priorities of ALF Therapy providers. Addressing the unique needs of the patient with the TCR is one of the greatest opportunities to improve the quality of healthcare for patients of all ages.

By utilizing carefully designed and adjusted dental appliances in conjunction with the patients interdisciplinary care team, ALF providers may be able to support patient quality of life in ways previously not possible by the dental or medical professions.