Introduction/pt

Introdução

Video: Introdução à Masticationpedia

Gostaríamos que nosso leitor tivesse uma percepção imediata dos temas que serão debatidos em Masticationpedia; revisaremos algumas das questões mais atuais relativas à evolução epistemológica da ciência em geral, e da medicina médica e odontológica em particular. You are not logged in, you cannot watch the video here on the left, but you can read this page.

Nesta fase consideraremos dois aspectos fundamentais do Progresso da Ciência, segundo os Paradigmas de Kuhn, e Epistemologia que questiona os conceitos de "Inferência Estatística" e "Interdisciplinaridade".

Esses dois temas, que aparentemente parecem estar em conflito um com o outro, já que o primeiro precisa de disciplinaridade para destacar as "Anomalias no Paradigma" e o segundo precisa de "Interdisciplinaridade", eles se integrarão através um elemento de resolução que consiste em "andaimes metacognitivos", isto é, pontes cognitivas entre disciplinas especializadas. Neste contexto, portanto, o leitor poderá apreciar melhor a abordagem estocástica em relação a um dos tópicos mais polêmicos em reabilitações mastigatórias, como, "Maloclusão", de onde vem a maior parte os procedimentos de reabilitação mastigatória como ortodontia, prótese e cirurgia ortognática.

Assim, além de nos anteciparmos ao aspecto científico e filosófico da Masticationpedia, enfocaremos finalmente em tópicos como "Sistemas Complexos", o "Comportamento Emergente" de Sistemas Complexos e "Coerência de Sistemas": passos necessários para introduzir tópicos clínicos científicos que trazem com eles dúvidas, questionamentos e ao mesmo tempo inovações paradigmáticas que tendem a mudar o status quo da rotina do pensamento clínico determinista e reducionista, perante uma lógica de linguagem estocástica e interdisciplinar.

Article by  Gianni Frisardi

Ab ovo

Antes de chegar ao cerne do tratamento da Masticationpedia, cabe uma premissa, que diz respeito principalmente a dois aspectos da realidade social, científica e clínica da era atual e da época imediatamente anterior.

No século passado, testemunhamos um crescimento exponencial em "inovações" tecnológicas e metodológicas, especificamente em odontologia.; essas inovações têm de alguma forma influenciado estratégias de tomada de decisão, opiniões, escolas de pensamento e axiomas a fim de melhorar a qualidade de vida, conforme afirmado na "Exposure Science in the 21st Century". No entanto, esse crescimento exponencial traz consigo, implicitamente, áreas cinzentas conceituais (em termos práticos "efeitos colaterais") que às vezes são subestimadas, mas que podem questionar algumas certezas científicas ou torná-las menos absolutas e mais probabilísticas.

A mudança de fases do paradigma segundo Thomas Kuhn

Os dois aspectos sensíveis da atual realidade social, científica e clínica (que parecem conflitar entre si, mas como veremos no final desta leitura serão complementares) são o "Progresso da Ciência" segundo Kuhn e o "Epistemologia".

Progresso da Ciência de acordo com Thomas Kuhn

Thomas Kuhn em sua obra mais famosa afirma que "a ciência passa ciclicamente por algumas fases indicativas de seu funcionamento". De acordo com Kuhn, a ciência é paradigmática, e a demarcação entre ciência e pseudociência pode ser traçada até a existência de um paradigma. A evolução do progresso científico é assimilada a uma curva contínua que sofre descontinuidade nas mudanças de paradigma. Por exemplo, na fase 2 dos Paradigmas de Kuhn, chamada de Ciência Normal, os cientistas são vistos como solucionadores de problemas, que trabalham para melhorar a concordância entre o paradigma e a natureza.

Esta fase, de facto, assenta num conjunto de princípios básicos ditados pelo paradigma, que não são questionados mas aos quais, sim, se incumbem a tarefa de indicar as coordenadas das obras que se seguem. Nesta fase, são desenvolvidos os instrumentos de medição com os quais os experimentos são feitos, a maioria dos artigos científicos é produzida e seus resultados constituem um crescimento significativo do conhecimento científico. Na fase normal da ciência, tanto os sucessos quanto os fracassos serão alcançados; as falhas são chamadas por Kuhn de anomalias ou eventos que vão contra o paradigma.

Como um bom solucionador de problemas, o cientista tenta resolver essas anomalias.

Kuhn, no entanto, divide a evolução de um paradigma em cinco fases; este é um processo fundamental para a Masticationpedia, mas para nos mantermos atentos ao projeto, limitar-nos-emos a descrever as duas fases mais significativas:

Fase 4, ou a Crise do Paradigma Como consequência da crise, diferentes paradigmas serão criados durante este período. Esses novos paradigmas, portanto, não surgirão dos resultados alcançados pela teoria anterior, mas sim do abandono dos esquemas pré-estabelecidos do paradigma dominante. Seguindo esse caminho, na Masticationpedia, a crise do paradigma de reabilitação mastigatória será discutida revisando teorias, teoremas, axiomas, escolas de pensamento e os Critérios de Diagnóstico de Pesquisa e então o foco mudará para a fase 5.

Fase 5, ou a Revolução Científica A fase 5 trata da revolução (científica). No período de atividades científicas extraordinárias, será aberta uma discussão na comunidade científica sobre qual novo paradigma aceitar. Mas não será necessariamente o paradigma mais "verdadeiro" ou mais eficiente a vir à tona, mas aquele que será capaz de captar o interesse de um número suficiente de cientistas e ganhar a confiança da comunidade científica. Os paradigmas que participam desse embate, segundo Kuhn, não compartilham nada, nem mesmo as bases e, portanto, não são comparáveis (são "incomensuráveis"). O paradigma é escolhido, como dito, em bases sócio-psicológicas ou biológicas (os jovens cientistas substituem os mais velhos). A batalha entre paradigmas resolverá a crise, o novo paradigma será nomeado e a ciência será trazida de volta à Fase 1. Pelo mesmo princípio da Fase 4, a Masticationpedia irá propor, no capítulo intitulado Ciência extraordinária, um novo modelo paradigmático no campo da reabilitação do Sistema Mastigatório discutindo seus princípios, motivações, clínica científica experiências e, sobretudo, uma mudança radical no campo do diagnóstico médico. Esta mudança é essencialmente baseada na Inferência do Sistema, ao invés da Inferência de Sintomas, dando principalmente valor absoluto à objetividade dos dados.

É quase óbvio que a filosofia científica kuhniana prefere a disciplinaridade, já que uma anomalia no paradigma genômico será melhor percebida por um geneticista do que por um neurofisiologista. Agora, esse conceito parece estar em contraste com a evolução epistemológica da Ciência, então é melhor parar um minuto sobre ele em detalhes.

Epistemologia

O cisne negro simboliza um dos problemas históricos da epistemologia: se todos os cisnes que vimos até agora são brancos, podemos decidir que todos os cisnes são brancos? Jura?
	Kuhn usou a ilusão de ótica para demonstrar como uma mudança de paradigma pode fazer com que uma pessoa veja a mesma informação de uma maneira completamente diferente: qual animal é o que está aqui de lado? Certo?

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Epistemologia (do grego ἐπιστήμη, epistème, "certo conhecimento" ou "ciência", e λόγος, logos, "discurso") é aquele ramo da filosofia que lida com o as condições sob as quais o conhecimento científico pode ser obtido e os métodos para alcançá-lo. The term specifically indicates that part of gnoseology which studies the foundations, validity and limits of scientific knowledge. In English-speaking countries, the concept of epistemology is instead mainly used as a synonym for gnoseology or knowledge theory — the discipline that deals with the study of knowledge.

Incidentally, the basic problem of epistemology today, as in Hume’s time, remains that of verifiability.

The Hempel paradox tells us that each sighted white swan confirms that crows are black; that is, each example not in contrast with the theory confirms a part of it:

$A\Rightarrow B=\lnot A\lor B$

According to the objection of falsifiability, instead, no theory is ever true because, while there are only a finite number of experiments in favour, there is also theoretically an infinite number that could falsify it.

But it’s not all so obvious...

...because the very concept of epistemology meets continuous implementations, like in medicine:

$P-value$: In medicine, for example, to confirm an experiment, a series of data coming from laboratory instruments or from surveys, the "Statistical Inference" is used, and in particular a famous value called "significance test" ($P-value$). Well, even this concept, now part of the researcher's genesis, is wavering. In a recent study, attention was focused on a "Campaign" conducted on "Nature" against the concept of "significance tests". With over 800 signatories supporting important scientists, this "campaign" can be considered an important milestone and a "Silent Revolution" in statistics on logical and epistemological aspects. The campaign criticizes the too simplified statistical analyses that can still be found in many publications to date. This eventually led to a discussion, sponsored by the American Statistical Association, which spawned a special issue of "The American Statistician Association" titled "Statistical Inference in the 21st Century: A World Beyond p <0,05", containing 43 articles by forward-looking statisticians. The special question proposes both new ways to signal the importance of research results beyond the arbitrary threshold of a P-value, and some guides to conduct of research: the researcher should accept uncertainty, be reflective, open and modest in his/ her statements. Future will show whether or not those attempts to statistically better support science beyond the significance tests will be reflected in future publications. In this field too, we are on the same wavelength as the Progress of Science according to Kuhn, in that we are talking about the re-modulation of some descriptive statistical contents within the scope of disciplinarity.

Interdisciplinarity: In science policy, it is generally recognized that science-based problem solving requires interdisciplinary research (IDR), as proposed by the EU project called Horizon 2020. In a recent study, the authors focus on the question why researchers have cognitive and epistemic difficulties in conducting IDR. It is believed that the loss of philosophical interest in the epistemology of interdisciplinary research is due to a philosophical paradigm of science called "Physics Paradigm of Science", which prevents recognition of important IDR changes in both the philosophy of science and research. The proposed alternative philosophical paradigm, called "Engineering Paradigm of Science", makes alternative philosophical assumptions about aspects such as the purpose of science, the character of knowledge, the epistemic and pragmatic criteria for the acceptance of knowledge and the role of technological tools. Consequently, scientific researchers need so-called metacognitive scaffolds to assist them in the analysis and reconstruction of how "knowledge" is constructed in different disciplines. In interdisciplinary research, metacognitive scaffolds help interdisciplinary communication analyse and articulate how the discipline builds knowledge

Anomaly vs. Interdisciplinarity

Given the above, on a superficial view of the epistemic evolution of the Science, the two aspects of disciplinarity ("Physics Paradigm of Science", highlighting the anomaly) and Interdisciplinary ("Engineering Paradigm of Science", metacognitive scaffold), might seem to be in conflict with each other; in reality, however, as we are just going to see right in this chapter, they are two sides of the same coin because both tend to generate "Paradigmatic Innovation" without any conflict at all.

Now we could conclude that the "Innovations" are already "Progress of Science" in themselves, as stated in the article "Scientific basis of dentistry" by Yegane Guven, in which the effect of biological and digital revolutions is considered on dental education and daily clinical practice, such as personalized regenerative dentistry, nanotechnologies, virtual reality simulations, genomic information and stem cell studies. The innovations mentioned by Guven are obviously to be considered as technological and methodological in nature; however, the Progress of Science does not move forward with this kind of Innovations, which are called "Incremental Innovations" and "Radical Innovations", but it occurs substantially through "Paradigmatic Innovations".

In the strictest sense of the phrase, "Paradigmatic Innovations" are essentially a change of thought and awareness that pervades the whole of humanity, starting from different social strata, from the Copernican scientific revolution to the current trend of Stochastic approach to the biological phenomenon.

In this epistemological context (in addition to other initiatives such as the Research Diagnostic Criteria in the field of the Temporomandibular Disorders — RDC/TMDs), of the Evidence Based Medicine (and other), the Masticationpedia project inserts itself in order to highlight the dialectics dynamism about the progress of the masticatory rehabilitation science. Masticationpedia tends, moreover, to highlight the anomalies that inevitably stimulate a change of thought and therefore a "Paradigmatic Innovation".

Before proceeeding, it could be appropriate to observe a very concrete and significant case.

Malocclusion

Malocclusion: it literally means a bad (malum, in Latin) closure of the dentition. The closure is easy to understand, we believe, but the epithet "bad" must be understood with care as well, because it is not as simple as it seems.

To briefly grasp the concept, in this first introductory reading we will try to present a simple but highly debatable question that involves a series of other questions in the field of masticatory rehabilitation and especially in orthodontic disciplines: what is "Malocclusion"? Bear in mind that in 2019, a Pubmed query about this term returned a result of "only" 33,309 articles, which says it all about the hypothetical terminological agreement on the subject; and, therefore, very meaningful conclusions could be drawn every now and then from these articles, such as the ones we reproduce in full from an article by Smaglyuk and collaborators, a somewhat "sensational" article that deals with the interdisciplinary approach in the diagnosis of malocclusions:

«The diagnostics, treatment tactics and prevention of dento-facial anomalies and deformations should be considered in the context of the integrity of the child's unformed organism, the interdependence of the form and functions of its organs and systems»

Another noteworthy fact is that if in the same 2019 Pubmed was questioned on interdisciplinarity in the diagnosis of malocclusions, the result dropped drastically to just four articles.

These premises to the "Malocclusion” question indicate, on one hand, an alert about anomalies that tend to activate Kuhn phase 4 and, on the other, a bifurcation in the epistemic choice on the subject: one that generates Incremental Innovations (others 33,309 articles, perhaps) and another that prefers a new gnoseological path of "Paradigmatic Innovation”.

Let’s try to approach part of the concept that considers the "Paradigmatic Innovation” as essential, asking ourselves for example:

Figure 1a:
Patient with malocclusion, open bite and right posterior crossbite who in rehabilitation terms should be treated with orthodontic therapy and / or orthognathic surgery.

What does "Malocclusion" mean?

We will answer this question by reporting a clinical case of evident “Malocclusion”.

Patient is with an occlusion that orthodontists call “Malocclusion” because it has a posterior unilateral crossbite and anterior openbite; it is a malocclusion that can be treated with a fixed orthodontic therapy and possibly in combination with an orthognathic intervention. Crossbite is another element of disturbance in normal occlusion because of which it is obligatorily treated together with the openbite.

It is self-evident that an observer with a deterministic mindset facing a phenomenon of such evident occlusal incongruity considers crossbite and openbite the cause of malocclusion (cause/effect) or vice versa; and it is obvious, as well, that the observer recommends an orthodontic treatment to restore a “Normocclusion”. This way of reasoning means that the model (masticatory system) is “normalized to occlusion”; and if read backwards, it means that the occlusal discrepancy is the cause of malocclusion and, therefore, of disease of the Masticatory System. (Figure 1a).

But let's hear what the two players say, the dentist and the patient, in the informative dialogue.

Figure 1b: Motor evoked potential from electrical transcranial stimulation of the trigeminal roots. Note the structural symmetry calculated by the peak-to-peak amplitude on the right and left masseters.

The dentist tells the patient that he is suffering from severe malocclusion and that it should be treated to improve its aesthetics and chewing function. The patient, however, replies firmly: «No way, I haven't the slightest idea to do it at all, doctor, because I might even have an unrepresentative smile, but I eat very well.» The dentist’s reply is ready, so the practitioner insists by saying: «but you have a serious malocclusion with an openbite and a unilateral posterior crossbite, you should already have problems with bruxism and swallowing, as well as posture.» The patient closes the confrontation in a decisive way: «absolutely false: I chew very well, I swallow very well and at night I snore alot so I don’t grind; besides, I’m a sportsman and I don’t have any postural disturbance».

Now the conclusion remains very critical because we might be finding ourselves in front of a verbal language of the patient which is misleading because it is not specific and does not respond to a detailed physiopathogenetic knowledge of the occlusal state; or, paradoxically, we are otherwise facing a machine language converted into verbal language which guarantees the integrity of the system. At this point the situation is truly embarrassing because neither the patient nor the observer (dentist) will be able to say with certainty that the System is in a “Malocclusion” state.

Figure 1c: Mandibular reflex evoked by percussion of the chin through a triggered neurological hammer.
Note the functional symmetry calculated by the peak-to-peak amplitude on the right and left masseters.

It is precisely at this moment that one remembers the criticism of the American Statistician Association titled “Statistical inference in the 21st century: A World Beyond p <0.05”, which urges the researcher to accept uncertainty, be sensible reflective, open and modest in his statements: which basically translates into a search for interdisciplinarity.

Figure 1d: Mechanical silent period evoked by percussion of the chin through a triggered neurological hammer. Note the functional symmetry calculated on the integral area of the right and left masseters.

Interdisciplinarity, in fact, could answer such a complex question; but it is nonetheless necessary to interpret the biological phenomenon of "“Malocclusion”" with a stochastic forma mentis of which we will discuss in detail later.

A stochastic observer may observe that there is a low probability that the patient, at the moment $T_{n}$, is in a state of occlusal disease, as the patient's natural language indicates ideal psychophysical health; he/she then concludes that the occlusal discrepancy could not be a cause of neuromuscular and psychophysical functional disorder. In this case, therefore, the Masticatory System can not only be normalized to the occlusion only, but a more complex model is needed too, so it has to be normalized to the Trigeminal Nervous System. The patient was then served a series of trigeminal electrophysiological tests to assess the integrity of his/her Trigeminal Nervous System in these “"Malocclusion”" clinical conditions.

We can see the following output responses, which we report directly in figures 1b, 1c and 1d (with explanation in the caption, to simplify the discussion). These tests and their description by now should only be considered as “Conceptual Rationale” for the “Malocclusion” question; later they will be widely described and their analysis detailed in the specific chapters. It can already be noted in this first descriptive approach to the masticatory phenomenon that there is an evident discrepancy between the occlusal state (which at first would support the orthodoxy of classical orthodontics in considering it as “Malocclusive State”) and the neurophysiological data indicating incredible synchronization and perfect symmetry of the trigeminal reflexes.

These results can be attributed to anything less than a "malocclusion": we are obviously in front of an error of the logic Language in medicine, in this case it is in fact more appropriate to talk about...

Occlusal dysmorphism and not Malocclusion (which, as we shall see a little further on, is quite another thing)

Conclusion

Even before drawing conclusions, conceptual clarity must be made on some fundamental points which of course will be treated in detail in the specific chapters of Masticationpedia.

The Masticatory System should be considered as a “Complex System”, not as a Biomechanical System focused exclusively on dental occlusion, because in this sense the “Occlusion” is nothing more than a subset of the Complex System interacting with the other subsets, such as periodontal receptors, neuromuscular spindles, recruitment of motor units, central nervous system, temporomandibular joint, etc., to give shape to an “Emerging Behaviour”, the masticatory one.

The peculiarity of this concept is that it is not possible to interpret or predict the “Emerging Behaviour” of a System by extracting objective data from a single subset. Instead, the integrity of the System must be quantified in its entirety, and only then can a segmentation of the whole be attempted to make an analytical description of the node itself. There are very important intellectual and scientific movements that are engaging with this issue; in this regard, the extraordinary work of Prof. Kazem Sadegh-Zadeh: Handbook of Analytic Philosophy of Medicine comes to mind.

In the presented case, the question is resolved in the following language logic:

The subsets of the Masticatory System (teeth, occlusion, Temporomandibular joints, muscles, etc.) are in a state of "Coherence” with the Central Trigeminal Nervous System (see figures 1b, 1c and 1d), so the term “Malocclusion” cannot be used, the phrase “Occlusal Dismorphism” should be considered instead.

«This does not mean abolishing prosthetic, orthodontic and orthognathic masticatory rehabilitation treatments: on the contrary, this forma mentis tends to restore medical knowledge to dental rehabilitation disciplines, as well as offering an alternative to the scientific reductionism that converges in a deterministic interpretation of the biological phenomenon.»

Going beyond the specialist perimeters of the disciplines, as previously reported on interdisciplinarity, helps expanding the diagnostic and therapeutic models as it can be seen in the clinical Case in which a patient was treated with the OrthoNeuroGnathodontic method is reported.

In this way, an overall view of the entire Masticatory System is presented in order to gather the aesthetic and functional-neurophysiological components together to determine “Occlusal Stability” and to avoid “Relapses”, especially in orthodontic and orthognathic treatments.

These are just some of the topics that will be covered extensively both in this chapter and in what we call “Extraordinary Science”. Meanwhile, in a fitting diversion our colourful friend Linus Sapiens, the little yellow man on the left, asks us:

«What do we mean by “Complex Systems” when we are talking about masticatory functions?»

 

Welcome   The logic of medical language

Bibliography & references

  Book Index

Next contents:

Source Chapter

Introduction

• Logic of medical language
  • Classical logic
  • Probabilistic logic
  • Fuzzy logic
  • System logic
• 1^st Clinical Case: Emimasticatory spasm
• Complex Systems
  • Coherence and decoherence
• Conclusive considerations

Bruxism

• Status quo and Criticity
• 2^rd Clinical Case: Pineal Cavernoma
• Conclusions

Occlusion and Posture

• Status quo and Criticity
• 3^th Clinical Case: Meningioma
• Conclusions

Orofacial Pain

• Status quo and Criticity
• 4^th Clinical Case: Eaton Lambert myasthenia
• 5^th Clinical Case: Postpoly syndrome
• 6^th Clinical Case: Temporomandibular disorders
• Conclusions

Are we really sure to know everything?

• Status quo and Criticity
• 7^th Clinical Case: glioblastoma of the cranial base
• Conclusions

Connectivity and Complex Systems

• Definition of the Fundamental Unit
• Structural and functional connectivity Separation
• Understanding of "Emergent Behavior"
• Connectivity measurement

System Inference vs Symptom Inference

• System Stochasticity
• Markov chains
• Inference of nonlinear Markov processes
• Understanding of Network nodes

Neurophysiology and network nodes

• Center of the Masticatory Pattern
• Mesencephalic mechanisms
• Trigeminal Motor nucleus

Sensory network nodes

• Proprioceptive mechanisms
  • Neuromuscular spindles
  • Sensory mechanisms from the depressor muscles
  • Golgi Tendon Organs
• Role of impulses from the neck muscles
• Periodontal and Oral Sensory Factors
• Pharyngeal sensory factors
• Reflex of mandibular closure
• Sensory factors of the TMJ

Conclusions to the Source Chapter

• information transferred over time
• System Coherence Recovery

• 8^th Clinical Case: Coherence Recovery in ort Orthognathic

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Crisis of the Paradigm

Research Diagnostic Criteria (RDC)

• Sensitivity, Specificity and Predictive Values
• Advantages and limitations of the RDC

Masticatory cycles

• Jaw opening width
• Speed of mandibular movement
• Complexity of chewing kinematics

Temporomandibular Joint

• Computerized Tomography of the TMJ
• Magnetic resonance imaging of the TMJM

Mandibular kinematic replicator

• Advantages and limits of pantography
  • Pantographic Reproducibility Index
• Advantages and limits of axiography
• Advantages and limits of the electrognatography

Transcutaneous Electric Nerve Stimulation

• Free way space before stimulation
• Free way space after stimulation
• Closing trajectory from TENS

Electromyography(EMG)

• Interferential EMG
• EMG at rest position
• Quantitative analysis of the EMG
  • Fourier transform
  • Wavelett

---

Extraordinary Science

Overall view of the Masticatory System

• Trigemnal electrophysiology
• Trigeminal electrophysiological segmentation
  • Electric Motors Evoked Potentials
  • Magnetic Motors Evoked Potentials
  • Jaw jerk reflex
  • M-wave
  • Masseteric Mechanical Silent Period
  • Masseteric Electric Silent Period
  • Masseteric Laser Silent Period
  • Recovery Cycle of Masseteric Inhibitory reflex

Trigeminal System Connectivity

• Definition of the Fundamental Unit
  • Maximal Neuronal Energy Evoked
  • Organic motor symmetry
  • Functional motor symmetry
  • Renormalization
• Separation of structural and functional connectivity
  • Organic vs Functional Symmetry
    • Functional Neuro Gnathological Index "NGF"
• New paradigm in masticatory rehabilitations
  • Prosthetics
  • Implantoprosthetics
  • Orthodontics
  • Orthognatics

Masticationpedia is a charity, a not-for-profit organization operating in dentistry medical research,
particularly focusing on the field of the neurophysiology of the masticatory system
 

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