W. G. Sutherland Temporomandibulo-Cranial Dental Group, Inc.
Disruption and Re-establishment of the Cranial Rhythmic Impulse: Part IX
Method: 42 Patients with multiple symptoms of TMJ pain and dysfunction (according to Dr. Weldon Bell) were treated with hot packs, a soft diet, a muscle relaxant and a narcotic (or synthetic narcotic). Prior to treatment, dento-cranial palpation was performed. This palpatory examination was repeated two hours after treatment and 24 hours after treatment. The results are listed below:
Osteofacial Restrictions of the Dento-Cranial Complex
- Prior to Treatment - 42
- Two Hours after Treatment - 38
- 24 Hours after Treatment - 33
Relief of Pain
- Two Hours after Treatment - 35
- 24 Hours after Treatment - 41
Discussion: Although this study has a limited number of subjects which might not be representative of the entire population, the study did reveal to dentists and osteopaths that dento-cranial changes do not occur as frequently as might be expected even though pain is reduced or eliminated in the majority of patients. For a long time dentists trained in the Sutherland concept have assumed that muscle relaxants and relief of pain by medication eliminate or reduce disruption of the cranial mechanism. This was probably due to the fact that Sutherland's concepts were so effective when applied to TMJ pain and dysfunction patients without the need for medication. Due to the sudden attack by medicine-oriented TMJ specialists on other TMJ specialists, it seemed appropriate to set up a study of what is going on dento-cranially with standard TMJ pain and dysfunction treatment. The results were rather shocking to say the least. All but one of the patients experienced a relief of pain. However, the disruption of the dento-cranial biomechanics (probably the etiology of the pain) remained in the majority of patients. Further palpation also revealed that in the seven patients who had relief of osteofascial restrictions of the dento-cranial complex, six of these showed new lesions in the cervical or upper thoracic areas. The lower thoracic, lumbar and sacral areas were not palpated for new lesions due to the medico-legal circumstance. The narcotic and muscle relaxant simply masked symptoms.
Conclusion: The "standard of care" TMJ patient who has been medicated presents problems to dentists and osteopaths. Although these patients may be pain-free, they are still structurally compromised and could easily injure themselves further. (The additional problem of addiction has not been addressed here at all, but is another factor.) Most Sutherland-trained dentists think function and structure to such an extent that it would be wise for us to stop and try to realize what the "standard of care" people are really doing; to try to understand the effects of "standard care" treatment on the cranial mechanism; to question how effective treatment is!Back to Top.
Case History submitted for the Dento-Cranial Competency Exam.
The patient was a 53 year old female with a history of chronic pain involving the left shoulder, left TMJ and occipital triangle. There was a fullness felt in the left ear and pressure above the left eye. She experienced chest pains which were attributed to a 70% blockage of one coronary artery. This was diagnosed with a cardiac catherization. There was a transient numbness of the left inferior alveolar nerve. In 1951 she struck her head in an auto accident. After this trauma her left TMJ began to crack and pop. She wore an upper complete denture and was edentulous posterior to the first bicuspids on the lower jaw. In 1974 bilateral blade implants had been positioned in the mandible to support bridgework that replaced the missing teeth. The vertical dimension of the occlusion had collapsed causing these implants to be driven further into the bone in close proximity to the inferior alveolar nerve canal. The left implant was mobile. She had a jaw opening of 39mm (48-52mm is normal) which deviated to the left. This indicated that an anterior dislocation of the meniscus had occurred and she had a closed lock of the left TMJ. The midline of the mandible deviated 4mm to the left relative to the maxilla.
The following muscles were painful when palpated intra-orally and extra-orally:
- right and left lateral pterygoids
- left medial pterygoid
- left trapezius
- left masseter
- left pectoralis major clavicular and sternal
- occipital triangle
Dento-cranial palpation revealed a left lateral strain of the Spheno-basilar-symphysis and the left temporal bone was in external rotation. The cranial rythmic impulse was vital and normal in rate and amplitude.
Treatment involved the placement of a mandibular orthotic appliance (bite splint) with a flat biting surface. After compression of the fourth ventricle and venous sinus drainage procedures were performed the occlusion was balanced on the splint. Gradually, the left side of the appliance was increased in height to aid in correcting the dysfunctional left TMJ. Cranial procedures were performed at each office visit. Within six weeks the patient experienced a popping of the left TMJ and the jaw unlocked. At this time the appliance was altered to support the mandible in a position that prevented the meniscus from redislocating. This new relationship brought the maxillary and mandibular midlines into harmony.
For the next four months the patient was treated with cranial manipulation and muscle energy to improve the function of the head and neck. Fulford shoulder release and occipital triangle techniques were also utilized in treating the patient. At the end of this time her symptoms were alleviated. Physical therapy was instituted to strengthen the muscles of the left shoulder. Stabilization of the patient involved the construction of a new upper denture and a lower bite restorer (permanent splint). The bite restorer was used to establish proper cranially balanced occlusion to maintain the correct maxillary/mandibular relationship that resulted from treatment. Even though the left implant became stable, crown and bridge procedures were not utilized because of the possibility of future implant removal due to further impingement on the inferior alveolar nerve.Back to Top.
A very pleasant 56 year-old female, presented to the office on Monday after having a fall on the previous Saturday. She related that she was standing on a steep bank when her feet flew out from under her, and she landed on her back, hitting the back of her head. She was diagnosed as having a mild concussion by her physician. Chief complaints at her initial visit to me were:
- Teeth were sore
- Jaw was sore
- Maxillary and mandibular removable partial dentures did not fit any more.
She thought she bent her partial dentures during the fall. Two years prior to the fall, a temporomandibular joint examination on the patient revealed a mild intermediate pop in the right temporomandibuiar joint, a maximum opening of 55 mm (45 mm to 55 mm is considered normal) with no pain, a 13 mm left and a 13 mm right lateral jaw movement (12 mm is considered normal) and no jaw deviation on opening and closing. Temporo-mandibular joint palpation revealed mild pain on the lateral capsule of the right side, moderate pain of the lateral capsule on the left side, mild pain of the posterior capsule on the right side. Examination at present revealed an initial opening and double closing pop of the right and left temporomandibular joints, maximum opening of 26 mm without pain and 38 mm with pain, and deviation of the mandible of 15 mm to the right on opening. Joint palpation revealed moderate pain of the lateral capsule of the left temporo-mandibular joint. Cranial evaluation revealed lesions of the right basi-occiput, compression of the sphenobasilar symphysis, right torsion and compression of the maxilla, external rotation of the right temporal and an internal rotation of the right zygoma. The strain pattern went through C 1, C2 and C3 to the right sacroiliac.
Diagnosis was a sprain, strain of the right and left temporomandibular joints with an anterior disc displacement of the right temporomandibular joint, cranial lesions as described and spinal lesions as described. Prescribed treatment on her temporomandibular joints consisted of:
Hot and cold therapy on temporomandibular joints
- 10 minutes of heat
- 5 minutes of ice
- 10 minutes of heat
- 5 minutes of ice
- 10 minutes of heat
- Proteolytic enzymes
- Cranial manipulations
- Non steroidal anti-inflammatory as needed
After cranial treatment, the patient's jaw was opening back to normal, her headache decreased by 50%; however, the rest of her body was very sore. She was treated three times and then referred to her chiropractor for full body manipulations. Three weeks later, she was referred back to me for continued cranial manipulations because she was still having headaches. her teeth and gums felt "spongy" and her partial dentures did not fit.
Treatment included cranial manipulations of the sphenobasilar symphysis, maxilla, palatine, zygoma, temporal and mandible. These manipulations cleared her headaches, and she stated that her teeth and partial dentures fit correctly again.
Discussion: There are four issues to take into consideration in this case:
- Proper diagnosis of the cranial and body lesions. This case was not going to resolve with cranial treatment alone. Even though full body work is necessary and I might know how to do it, this can be risky on a dental license, especially on the accident case.
- When you live in a small town and the closest osteopathic physician is one and a half hours away, you have to use the resources you have. She had a chiropractor of record and was referred to her. Due to my schedule (being out of town for two weeks) and the chiropractor's treatment, it was three and a half weeks before I saw the patient again. Without the combined treatment, this case would not have resolved.
- It can be hard to determine if a partial denture was bent or if it was the cranial lesions behind the symptoms. If the cranial lesions are not treated first and a new partial is made, this can doom the patient to problems for life by stabilizing the cranial lesions in place.
- If a dentist saw her with no previous history of a temporomandibular joint examination and knowledge of cranial diagnostic skills, his treatment after physical therapy and medication would usually be splint therapy to decompress the joint. If temporomandibular joint treatment were begun with splint therapy, the issue would be that the splint must be made out of flexible material so the cranial manipulations could be done so the splint would not pull them back into a lesion.
Sensitive upper left first molar (#14). Several days in duration. Sharp pain, sensitive to cold. also, sensitive to biting.
The periapical x-ray was negative. The tooth was not sensitive to percussion. There were no periodontal involvements. There was no open margin, decay or food impaction between the teeth. There were no burnish marks on the gold occlusal surface of a crown that was placed approximately one year earlier (4/2/1991). A root canal was suggested because the pain was sharp, but there was no apparent abscess. Upon further questioning, he revealed that he had twisted his left ankle two days prior to the onset of pain. The left temporal bone was locked in internal rotation.
Full body structural diagnosis reveled that the patella-tibial relationship on the left leg was distorted with the tibia lateral. The rotation of the left leg from the ankle was also impeded, and the left ankle was locked.
A cranially trained doctor treated his left ankle/knee/hip with Dr. Fulford's knee release. The structures all released in the leg, hip and ankle. The patient immediately noticed a change in the way the tooth felt. The left temporal bone was moving now. The tooth was still sensitive to cold water. I still referred him to an endodontist for a root canal if the tooth did not improve.
At his next visit, he stated that there was no further problem with the tooth. The pain did not return after it was treated by a cranially trained doctor.
Brief Case Report: Rapid Improvement of Bell's Palsy
History: A 45-year old female presented with history of left sided facial droop and numbness with left ear pain, extending to the neck, starting on waking 8 days earlier. Other symptoms included inability to close the left eye, numbness of the left side of the face, and difficulty eating & moving the lips on teh left. Symptoms remain steady from onset to the time of the office visit.
Work up prior to the visit insluded Head CT, with no focal findings, and Lyme titer, results pending(for history of a ticvk bite several weeks earlier.) the newurologist's assessment was Bell's Palsy, with Valterex 1000mg T.I.D. and Prednisone prescribed. The primary physcian and neurologist conveyed that 4 to 6 months or more might be needed for improvement.
Findings and treatment: Findings in the cranio-cervical region included left lateral strain of the sphenobasilar symphysis (SBS), left external and right internal temporal bone rotation, posterior O-A, and rotation of C2 and C3. Diaphragm restriction was noted, and treated with a Fulford method release technique. OCF treatment ws applied to teh SBS, uppermost cervial, and temporal regions, followed by balancing above and below foramen magnum. The patient was advised to observe the progression of treatment results over 72 hours, and return later for office evaluation.
Clinical course: The patient reported immediate relief of some numbness and return of sensation to the left side of the face and tongue after the single treatment. Several hours later she was able to drink, eat without food pocketing on the left, move the left side of the lips and center her lips. Three days later, she noted continued imporvement in left facial movement and sensation. She could fully smile and close the left eye within two weeks. See the pictures below.
Discussion: It has been noted that Bell's palsy can recover in days to weeks for neurapraxic or purely demyelinative lesions. The physicians who made the initial diagnosis for this case estimated many weeks for recovery, in a range reported for a series of Bell's Palsy patients of similar age. The onset of recovery and rapid progress conincided with one application of OCF treatment. The patient was relieved to no longer look and talk "like a pirate" and was very appreciative of treatment!!
Fig. 1: Pre-Treatment
Fig. 2: Immediately Post-Treatment
Cell phone camera pictures of the patient are shown below:
Fig 3: One Day Post-Treatmant