Monday, April 18, 2016

Structural Therapists And Dentists As Integrative Medical Solutions Teams

Why Evaluate And Treat Patients As A Team?

We use as tools patient's reports of their symptoms, radiographs, palpation, auscultation, functional evaluative tests such as range of motion and we make observations all the time.  

If other team members know the testing procedures you use, they can use these tests to evaluate the immediate functional efficacy of their own treatment and raise their own expectations to match yours.

Your mutual abilities for effective communication will improve. It's just like knowing scientific terminology.  It becomes both a faster and more meaningful communication.

A good example was a discussion of radiographs with my Chiropractic team member.  A radiologist described what he saw as a "military neck" due to muscle hypertonicity.  Ok, so I had something for my report.  It ended there.  Or, did it?...

I sat down with the Chiropractor who then told me what he saw and his interpretation.  Rather than thinking only of muscle spasticity he also showed me the effect of acceleration-deceleration trauma on a defatted, dry cervical spine with rubber discs and a weighted "head."  The "military neck" was always the result of "whiplash."  Every single time.

He then described the observed effect as the result of the structure of the vertebrae and the persistent lack of recovery of motion due to the hypertonic muscles as a result of the injury, tendon reflexes, the nerve impingement, etc.  

I was also taught to note smaller spinal defects while I learned this major concept. Anteriorly displaced vertebrae, rotations, diminished intervertebral spaces, odontoid process displacement, etc. all suddenly "appeared" because I knew what to look for.  "What the mind knows, the eyes will see."

Functional evaluation was now a part of my thinking.  I also learned from experience that by mandibular repositioning I could significantly improve or even eliminate many of those displacements.

I learned to take pre and post-treatment radiographs for the cervical spine just as I always took TMJ transcranial radiographs.  If he referred the patient I could immediately confirm positive changes with only post-treatment radiographs.  It became routine for us to share radiographs.

My radiographic evaluation now also included A-P Open Mouth (APOM), lateral cervical spine and "wagging jaw" when indicated.

Consider the difference to the patient and to you

  • When I appear more professional and then refer to you
  • When I referred them more appropriately with an effective test position for an intraoral orthopedic appliance 
  • I re-evaluate each time I adjust their functional appliance 
  • When I write a report for an attorney in accident cases
  • When our reports coincide totally in findings, terminology and recommendations for therapy
  • When we file for insurance coverage

The benefits compound further:

  • Patients keep appointment schedules and follow recommendations better when a team makes them.  
  • You save time, need fewer visits just to "get things right."
  • Attorneys refer more often to teams who work coherently.
  • Patients quickly benefit from more effective therapy

Integrative Medical Approaches Enhance Evaluations

Other tests that may not have been used routinely may prove to be more helpful because they give more information. 

Most notable below is the Compaction Compression Leg Lift Test which should be performed teeth approximated, 2-3 swallows, test with and without Orthopedic device in mouth.

Tests provide immediate measurable functional feedback. The other team members can use them before and after applying their own contributions to therapy .

Few dentists were taught why and how to use orthopedic neurologic testing as a part of their evaluations.  
It never seemed important.  It was even derided when it was first taught.  After all, what can it offer, "it's just a circus trick!"

  • It offers information of how the mandubular position is affecting the entire craniomanibular-cervical complex.
  • It allows a way to determine the effective change of the center of gravity of the "head complex," (the mandible and the cranium and all of the interconnected tissues;) as well as of the nervous system's response to that change.
  • It allows a way to evaluate how this area affects the cranial, spinal and sacral systems both individually and cumulatively.
  • It checks for a possible localized stroke
  • It permits testing of any areas of the body with and without such repositioning as long as it is standardized

How?  By simply placing the appliance in, then removing the appliance from the mouth, as long as testing is done with the teeth kept approximated and the patient swallows a few times before each test.

What?!  A dentist testing for strokes?  Yes, and we are supposed to take blood pressures, take full medical histories, know and understand all the medications patients take.  

Dentists are trained to be specialists and Stomatognathic Physicians, not tooth technicians or just doctors who perform surgery in the mouth.  We should be recognized for the background we have and that we can apply, especially if it is enhanced by, and contributes, to yours.

Testing With Regard To Integrative Medical Solutions

Use standard procedures for observation, auscultation and palpation.  BUT, now consider doing them before and after changing the mandibular position and compare and record those results.  BUT ALWAYS standardize mouth position.

Changes in those procedures:
Mouth closed, 2-3 swallows, teeth kept together during the entire the test.  It was never considered that whether the patient had their mouth closed, much less keeping their teeth together was important. The truth is that it does affect the results significantly.  It standardizes the test!

Don't believe me?  Lean your head back all the way with your mouth closed.  Let your mouth open.  You go further back. Close your mouth.  Your head comes forward.  Sure tissues are slackened or released.  But what was the test standard? Yet we record that as ROM evidence in an accident case.

Why does it matter to us here?  Because opening the mouth changes the center of gravity of the craniomandibular-cervical complex.  Opening may even "re-capture" an anteriorly displaced disc within the TMJ and totally change the OAA (Occiptio-Atlanto-Axial Junction,) the patient's balance and the neurologic impact of the entire area.

Integrative Medical Testing - Yours And Mine

Most Notable: Compaction Compression Leg Lift Test

CCLLT:  Critical for discerning 
Primary Pelvic Dysfunction vs Primary TMJD


  1. Patient lies supine, hands at sides
  2. Bite down on back teeth, swallow twice.
  3. Operator compresses temporal bones bilaterally and compacts the cervical spine (press head inferiorly)
  4. Patient attempts to lift legs - Note maximum range of motion

Normal:  90 Degrees

Repeat with Mandibular Orthopedic Repositioning Appliance      in mouth or in proposed test position for a new device


  1. Primary Pelvic Dysfunction: Cannot raise legs properly
  2. Primary TMJ Dysfunction with Secondary Pelvic Dysfunction:  Raises Legs normally ONLY with MORA in mouth

This could be "missing link," the answer to why your pelvic adjustments won't stabilize for a significant duration of time, though it seems "just right" after you've completed the adjustments.  

1800 swallows every day (1200 in daytime, 600 at night) are destabilizing the pelvis.  This mutual realization became a major factor in my Chiropractic Physician's referrals to me, as a Dentist.  

This is why other structural therapists would ask us to help their patients as a team if they lived too far away for them to be able to do it with me. We worked together until the patients stabilized, usually for 3-4 months.  

Our offices were only 1 mile apart!  Patients could start with either of us on "adjustment day," then see the other and immediately be rechecked or readjusted.  Examples will follow.


(WARNING:  Some boring stuff follows)
(Wink:  With surprises!)


  • Normal / Head forward / Lateral Tilt
  • Feet - normal, turned in, turned out
  • Hands at sides- Rotated anteriorly, posteriorly?

Range of Motion Tests

  1. Chin toward chest (Often measured in "fingers")
  2. Head Rotation
  3. Forehead elevation (Teeth kept together)
  4. Mandibular - (Note maximum vertically and laterally)
    1. Normal - Smooth, 48-52 mm (2",) in midline
    2. Abnormal - Uneven velocity 
      1. Note how far open at shift, also maximum
      2. Palpate external TMJs for sudden internal motion
      3. Joint sound at same time?
    3. Abnormal - Sudden or gradual shift Laterally
      1. Note how far open at initiation, also maximum
      2. Palpate external TMJs for sudden internal motion
      3. Joint sound at same time?
      4. Move laterally then return to midline?

Fast "TMJD Test"
We should all be able to place the middle knuckles of the non-dominant hand, curled like a fist, into our mouth.

Palpation - Especially Useful in Integrative Therapy
(Consider testing with the teeth approximated)

  1. Note sensitivity
  2. Rate level 1-10
  3. Enter in record

  1. External TMJ joint capsules
    1. Sensitivity
    2. Motion L vs R sides coincide? Smooth?
  2. Muscles of mastication
    1. Sensitivity
    2. Hypertonus
    3. Refer pain (see Myofascial Trigger Points)
  3. Spinous processes
  4. PSIS (Poster Superior Iliac Crests)
    1. Sensitivity
    2. Apparent vertical height
  5. Postural muscles - Sensitivity, hyper/hypotonus
  6. Longus colli muscle, bilaterally
    1. Fifth Cervical level, 
    2. Head bent forward
    3. Press in toward the spine from an anterolateral direction.  
    4. Patient "jerk" is considered pathognomonic for "whiplash"
During diagnostic testing palpate the hyoid bone during swallows.  Normally it should describe a smooth circle.  It may "jerk," move laterally, or rise on one side vs the other. 

Auscultation of Temporomandilar Joints

(Auscultation? -- "What'd He Say?" - Nothing!)  

Good sign!  The TMJs should be totally silent during function.

Common sounds (and often patient complaints):  
Popping, clicking, crackling, whooshing, and the worst possible ... CRACK, or again silence with restricted opening!

Ideally placing a MORA in the mouth silences all of these, but that's because it is NOT a splint! (Common name often misappropriately used). A splint reduces joint mobility.

A MORA is an orthopedic device which brings the head of the mandibular condyle back into proper position (ideally) under the depressed middle of the TMJ disc.  This is not a meniscus.  It is more fibrous and not prone to heal.

The popping, clicking, and crack are signals of the disc displacement due to stretching of the superior longitudinal ligament that is supposed to retain it in proposition.

Crepitus, or crackling is often because the disc is being deformed as it is pushed forward, or worse, already torn.

A loud crack means it was already somewhat deformed and is "recaptured" usually late upon opening.

Silence with restricted opening may mean that the disc's restraining ligament is so stretched that the disc is not recaptured and may now be shaped like a ball.

Sounds can and should be recorded as to type and position; early, middle or late upon opening.  They are helpful in predicting prognosis and later therapeutic decisions.

They may also change abruptly as I saw after second or third auto accidents.  They occurred later upon opening due to further stretching of the ligament and this was an evidentiary finding.

Orthopedic Neurologic Testing

C5 Test (Classic) - Middle Deltoid muscles, Arm horizontal                                    and forward, elbow bent 90 degrees

Combined C5-C6 Test - Middle and posterior deltoid                                              muscles, Arm out straight to side

Leg Raise 

Any tests of muscle strength across joints are valid but must be standardized!  Use of a dynamometer for hand strength has been used and shown 7-15% increased strength with a MORA in the mouth. A University study found the same results with broader muscle testing.

I must again emphasize using the closed mouth and swallow technique!  

  1. Test without anything between the teeth.  
  2. Retest with a spacer between the teeth.

YES!  I purposely changed the words from a MORA!

Gum chewers rarely crush their teeth together.  Cigarettes are spacers.  Pencil erasers and pens are spacers.  A child's thumb is a spacer AND an osteopathic adjustment device.  
We reset our own nervous systems because it feels better!

You can make a simple test device by rolling up paper towel or napkin, try different thicknesses AND reposition the mandible anteriorly and to the midline (align the midline freni)

Do not use the midline of the teeth as this may have shifted. 

Use maxillary and mandibular midline freni but make a pencil mark on upper teeth to match where lower midline teeth aligns at this proper position.

In my experience that realigning the mandible to midline often adds significant strength to the orthodedic test results.  

Most often there should be 1-3 mm between the posterior teeth and the mandible needs to be brought forward to where the upper teeth overlap the lower by about 1-2 mm. Mark it with a pencil.  If a space exists, note its height.

BUT use orthopedic testing to help you refine this.  Now, make a hard wax MORA.  You can send this home in paper towels, and in a small box (Don't leave in a hot car!) to the patient's dentist who can then complete a TMJ evaluation.

Both of you can now retest any tests you do.  He can retake TMJ Tomograms to compare with, vs without, repositioning.  

You can both note proper, or at least improved, mandilular motion.  There should now ideally be silent and aligned function of the TMJs. (Making the MORA is described below)

Myofascial Trigger Points

  1. Active - Describe referral area, subjects level of sensitivity and type (tingle, ache, dull/sharp, stab, etc.)
  2. Latent - Ache rating1-10
  3. Changes with the MORA

Retest all areas 

Reminder: After placing MORA in mouth, 
bite down and swallow 2-3 times.  
Keep teeth together.

Note all changes!

Making A Hard Wax MORA

Get a small bowl.  Add hot water, approx 128-135 degrees.
Get some hard pink wax from your dentist, or buy from Henry Shein or other company.  I like the harder one.  (If patients feel better then make 2-3 because they often wear them.)

Soften wax in water, roll a cylinder.  Curve it and place it in the mouth covering the back teeth but tuck in behind lower front teeth.  

Realign to proper new mandibular position per pencil marks and tuck wax around outer teeth gently. Let harden a bit, remove from mouth, chill in cold running water.  Retest for proper orthopedic positioning.  Can reset by squeezing it a bit if not fully hardened yet.


  • I have a video of the CCLLT with an injured patient I will reproduce and upload.  It is still on a VHS tape.

My Chiropractor suffered a low back-pelvic injury.  I went to his office after hearing about it to heat and adjust a hockey mouth guard appropriately.  He had severe back pain but wanted to treat his patients.

His cranial and pelvic testing became normal in the corrected mandibular position.  He was surprised!  He treated patients all day with only minor pain while wearing the MORA.

The next day he told me went out running that evening.  He returned home and unusually, remained awake until 4 AM!  Exercise that night did not tire him as was usual.  He was energized.  We laughingly blamed it on his body finally working right!

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·       PLEASE NOTE:  This is not meant to replace your Physician or other therapists and their advice. Please consult them for their opinions and further consideration. 

·       What is expressed here is purely my opinion, based on my experiences and the research I did for the benefit of my patients. 

·       It is meant to help people and therapists at all levels of expertise in the search for explanations. 

·       INTEGRATIVE MEDICAL SOLUTIONS will, I hope, help to advance the understanding of medical knowledge by contributing my perspective.

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