Diagnosing Postural Issues – Dr. Curtis Westersund
There is an assumption among dentists that people are born and grow to adulthood with ‘normal’ cranial facial bones. In fact they are often not. There can be influence from birth defects, defective genetics, traumatic injuries, breathing disorders, diet issues, tongue posture and destructive habits. When we look past the head there can be defective foot, hip, back and neck movements, all that have the potential to alter the function and growth of cranial facial bones. After all, our bones do not ‘grow’, they are ‘grown’. The posture of the patient directly affects this growth.
Our patients rarely have a perfect posture. Posture fluctuates to accommodate body function in order to allow a human to survive and thrive. Over time these postural accommodations will add up within our body. This means that we can cope with postural accommodations in development and growth until we cannot accommodate. Therefore seeing these problems in posture may allow health care providers to inform their patients prior to pain or damage occurring.
The problem is that while dentists and other health care providers are trying to help, they often ignore changes in posture that are relevant to a patient’s health beyond their area of expertise.
If patients arrive at our dental offices with structural strain that they live with, throughout their bodies, we dentists simply fail to see or understand the effects that this structural strain has in regards to our expertise, occlusion. As well, we fail to see what the effect occlusion has upon postural structural strain within our patient . Our patients have problems that leave us scratching our heads as to the cause, not knowing the problem may be past the teeth entirely.
In the treatment of TMD, these postural strains are key to helping solve the troubles a patient may have with their malocclusion. Many treatments can have limited success, simply due to the fact there is an unstable posture present. While dentists may limit their scope of treatment to teeth and jaws, that does not mean that dentists can limit their understanding of how postural strain will affect their patients’ health. Regardless of our ability to recognize them, these challenges will exist, persist, and can deeply influence the outcomes of our interventions.
I cannot stress enough that while we are not taught to treat postural issues in Dental School, it is not enough to rest on that lack of education if we wish to help our TMD patients. Just because this is not taught in dental school doesn’t make it any less relevant. TMD causes people to suffer and dentists need to be better investigators…”
For that reason, I take photos of the patient’s posture to allow us to see these problems, and to inform our patients that we are looking at a whole person, not just a jaw joint or a set of teeth. Our simple photo protocol can summate the strains moving both directions in the body – from and to the teeth or what is often called ascending and descending forces in the body. If ignored, this strain pattern will cause many treatments to be partially successful or out right fail.
So we may agree that Posture is important. How can we assess it? Fortunately, while it is very simple to assess postural misalignment, it requires very precise treatments to improve. Since we dentists are not trained to provide chiropractic or massage therapy, we need to collaborate with others who can help us provide stability to our patients.
What is Posture?
First, let us consider posture. How and why do humans exist in an upright position and why is it important that this position be able to be neutral?
Posture is an expression of our body’s relationship to gravity. As gravity is the single greatest force that we exist within, how we manage it greatly influences our daily function. The challenge is that stress to posture can influence movement and therefore function of all joints including the
TMJ. If imbalances are allowed to remain there are limitations to movement and function that will inherently be present.
Many see our bodies merely as buildings that are standing upright. Unfortunately this comparison doesn’t explain the agility we humans have.
Let us consider two really crucial components to posture:
Most think in error that the body is a building. Bodies are agile and have motion. Buildings do not. Body parts are under compression and tension constantly. While our patients stand, with their feet being supported on the ground it is easy to understand that there is a compressive force down. Tension though, is how we support that compression. Think muscles supporting the body. The interplay of muscles allow us to have compression and yet be able to function or move.
To think of this another way I refer to a colleague NUCCA Chiropractor, Dr. Jeff Scholten. His explanation is “We have a muscular system to inflate ourselves against gravity. Without this neural stimulation to our muscles would not allow us to stand.”
This brings us to the term Tensegrity. Tensegrity is the constant tension with a variable compression. As you walk the foot that is lifted up is under tension while the other foot, while on the ground is under compression. Yet both feet are showing tensegrity within the body as both feet under a combined compression and tension.
Sensory Balance and Coupled Motion
Input from our sensory organs allows the tensegrity to balance our posture so we can function.
Head balance is affected by sensory balance input. Visual input is very important for sensory balance but vestibular input, input from tendons, ligaments and muscles, and cerebellar input are also involved in balance.
We must adjust our bodies to allow us to stand upright as we approach our environment. Why do you not fall over in standing. Beside body tensegrity, we need neurologic input from various sensory organs to help us balance and function.
This means we need to have “Coupled Motion” within the body to match our actions. You cannot affect one part of the body without influencing or altering its connected structures.
You cannot turn your skull sideways without torsion of your cervical vertebrae, This is a normal coupled motion. If the cervical vertebrae do not function properly, due to cervical misalignment or head, neck or back muscle tension, you have to twist at the hips and/or turn your shoulders to look sideways. That is an abnormal coupled motion.
“Normal coupled motion” is motion about multiple axes that reduce stress in each other.
“Abnormal coupled motion” creates a situation where structures in motion increase the stress in
Try this yourself: If you tilt your head right, the force or pressure on your left teeth reduces and the force or pressure on the right side increases. If you tip your head back you will have more force or pressure on your posterior teeth. If you tip your head forward you will have more force on
your anterior teeth. This is normal coupled motion of the mandible and the cervical vertebrae.
This also means that if you have a noxious tooth contact on your left dental arch, your head tilts right, and there is a left rotation of the head. This is a normal coupled motion.
If you have a noxious contact on your left dental arch and your head tilts left that is an “abnormal coupled motion”. The body is unable to respond in a normal manner to relieve a noxious tooth contact or interaction. Instead other factors in the cranial cervical alignment are in play.
The photos I take at each and every TMD or New Patient examination look for this coupled motion within the body. The photos allow me to document problems I see that even the patient may be unaware of. Remember that patients may have extensive postural distortions but yet they will feel perfectly normal. That is how we are able to accommodate all this strain. What is quite ‘normal’ to the patient, is actually creating structural strain and functional limitations in the body. This strain directly or indirectly affects the patient’s occlusion.
Let us take an example of a common presentation of our patients, the ‘Low Shoulder’. If a patient has a low shoulder on their photo the question becomes “why?”.
Understand that when body parts are not balanced they will elicit strain within their kinematic chain. We can think of this strain to our body as being either reflexive, active, or habitual or a combination.
The low shoulder can be due to reflexive, active or habitual strain along with neural sensory input.
If the patient has a high contact on a tooth the sensory input from the periodontal ligaments to the Trigeminal Nucleus will be immediate. These inputs create a reflexive action that causes activation of the head and neck muscle. Remove the noxious contact and the structural system
responds immediately. This is a ‘Reflexive’ strain. The entire system can relax without the noxious interference to the occlusion.
An example of ‘Active’ strain is how the painting of a patient’s house will cause their shoulder muscles to hurt, be weak and prevent them from lifting their arm fully. The patient cannot instantly correct the low shoulder. The patient will have to clear an active overuse situation
before restoring structural balance. If you build or balance a bite to this postural strain, it will be a long term stress to the patient.
Patients can also have the occlusion create an Active strain for the shoulder, neck, and head from your bite. It may come from holding the jaw in place or resisting the occlusion so that they can relax the shoulder.
The third condition is a Habitual strain. It is where long term strain is present. The strain has created a remodeling of the structures affected. This means that the low shoulder is more entrenched into this position. Normal structural balance cannot be achieved. This inconvenient
reality means that not all patients can have their final occlusion created in a moment. They might have some work to do to optimize their own circumstances.
Many times a patient presents with all three kinds of structural strain. While a correction of the occlusion may help, it will not remove the longer term habitual strain in the body.
Forward Head Posture (FHP)
Studies that show our tendency for FHP is to allow for more efficient breathing. If we bring our head more forward we can allow the oropharynx to become more patent or open. As well, FHP makes it easier to elicit the use of our emergency air hole, our mouth, to supplement air intake. Opening the mouth increases air intake, day and night.
There are many negatives of FHP. Studies have begun to show that there is increased alteration to the vascular system due to a FHP. FHP is accomplished with a straightening of the cervical vertebrae. This creates an abnormal alignment called a ‘Hypolordotic’ or ‘Kyphotic’ cervical vertebrae. This change in alignment can reduce blood flow to the brain. As well, heads are heavy. They weigh between 8 to 16 pounds. The moving of the head off of the center of postural balance created shoulders that roll forward, a winging of the scapulae, and an exaggerated rotation of the hips.
There can be a structural change with the alignment of the first thoracic (T1) to last cervical spine (C7). This connection is weaker than in other spinal areas and long term habituation here is hard to correct.
All of this is supported by the overuse of some muscles and the weakening of others to in effect, lock in the postural imbalance.
Abnormal Alignment of torso, hips, knees and feet
For the rest of the body, we see patients with structural strain creating a lack of chest flexibility, hamstring flexibility, hip flexibility and calf flexibility.
The patient may tip their body left or right. They may have a forward or backward lean in their posture with an increased lumbar lordosis (curvature) and hip rotation forward.
We have patients flex at their knees to see if there is a valgus (inward) or varus (outward) movement of the knee in strained posture. Compressive and tensile loads influence the feet as well and as dentists we need to figure out which direction is creating the pathology we see, so we can
understand the best way to intervene.
The real take home lesson is that no part of the body operates on its own. We are integrated beings and subject to a lifetime of postural strain. This strain is not free. It will exact a cost that may be important to our patients health. While we cannot treat necks, backs, hips and feet, we can observe strain, understand that we may have an influence on that strain, and collaborate and integrate with other health care providers to give better care to our patients.