Postural Stress & Exercise

Holistic Dentistry, Postural Stress & Exercise

• Overview
• Postural Stress
• Head forward Posture, Foot Structure & Leg Length discrepancy
• Podiatry & Dentistry - an interesting connection
• Exercise

Patients often ask, "What is Holistic Dentistry"? To me the term "holistic" refers to understanding of the way the body is interconnected. It also refers to the fact that as a holistic health practitioner we need to at least have an awareness of what other factors, other than our own professional interests impact on our patients health. We also need to be able some guidance and have a reliable network of other healthcare professionals who share a similar perspective.

So holistic dentistry recognises that interconnectiveness and realises that postural factors including exercise impact on our patient health in general and oral health in particular.

Postural Stress

I would define a postural stress as any movement or lack of movement of the body that impacts on our health. Whether we are looking at postural positions and there effect on headaches or jaw joints, or we are considering the effect of lack of exercise on the body in general and the health of the mouth in particular (see health model-anaerobic metabolism) we need to identify these factors.

This may take many forms.

Sleeping posture - we spend on the average 8 hours a day sleeping and the position in which we sleep can impact dramatically on the muscles of the head, jaw, neck and back. Stomach sleeping is the worst position and can result in headaches, neckaches or jaw aches. Retraining sleeping position is a simple, noninvasive and cost effective first step in a treatment regime and can of itself have dramatic impact on the level of pain, and the success of subsequent treatment.

Stomach sleeping - a problem

Working posture - the position in which we work, the subject of ergonomics has come a long way, yet still needs to be part of our history taking and patient awareness program

Trauma - muscles have " memory" which may last a lifetime. That " memory" occurs in the form of a soft tissue lesion (see headaches) and may be what is causing headaches and neckaches.

Traumas may include

• an accident
• whiplash
• a blow
• a general anaesthetic which may have strained the jaw and muscle of the back of the neck
• repetitive strain such as RSI, tennis elbow, shin splints, clenching or grinding of the teeth (See Headaches and NTI appliances)

Head forward Posture, Foot Structure & Leg Length Discrepancy

Anatomical VS Functional Leg Length Discrepancy

Anatomical leg length refers to an actual difference in the length of the bones.

Functional leg length refers to muscles pulling on joints giving the appearance of leg length difference.

Podiatry and Dentistry - an interesting connection

In 1987 an enlightened chiropractor working in Sydney invited me to work closely with him and a podiatrist to deal holistically with his patient's biomechanical problems including chronic pain and dysfunction.

I say enlightened because he recognised that the cases that he and other chiropractors, osteopaths and physiotherapists were having problems achieving a stable lasting result which could very often be helped by integrating biomechanical principles of dentistry and podiatry.

Thus began a 15-year association with Mark Ninio a leading podiatrist in Australia. This has led to 5 years of part-time research in the Department of Physiology in the Faculty of Medicine at University of NSW in Sydney, where we looked at the effect of.

Orthotic appliances in the mouth and for the feet on EMG activity of shoulder and calf muscles (May 1992) (See Downloads)

Clenching of the jaw on two neck and two trunk muscles ( June 1996). (See Downloads)

Above all it gave me an interesting insight into the similarities between the two professions and how much both professions have to offer to the treatment of chronic musculo-skeletal pain and dysfunction.

The similarity is the limited way people perceive both professions. Dentistry is often associated purely with fillings and cleaning of teeth and gums. Podiatry is associated with the treatment of corns and bunions. Both have a large biomechanical component, which the public, and indeed a large majority of health professionals, is not aware of.

While dentistry focuses its biomechanics on the temporomandibular joint (TMJ) podiatry focuses its attention on the sub-talar joint (STJ) between the talus and calcaneus.

As dentists we know the TMJ is a complex joint and much controversy surrounds the biomechanics of the joints and how best to achieve an ideal position often referred to as, dare I say it "centric relation". Controversy also surrounds the sphere of influence our treatment of the TMJ with many theories about how splints work and to what extent they we can influence the body in general.

Podiatry similarly uses orthotic appliances to control and support the sub-talar joint (STJ). Much controversy exists in podiatry about the best way to treat foot function and whether controlling foot function can have positive effects on the back and upper body.

I am not a podiatrist, nor can I do an accurate assessment of foot function and gait. Having a holistic approach means that we must be open to other, and often simpler, treatment approaches as well as building a team of other health professionals.


When podiatrists to whom we refer does a biomechanical assessment he is looking at posture and gait which includes:

• Head forward posture
• Head tilt, rotation
• Shoulder height
• Pelvic tilt
• Pigeon toed
• Knock knees
• Bow legged
• Foot function
• Leg length discrepancy
• A person's posture and gait, which includes an assessment of foot function, can have a significant effect on the balance of muscles throughout the body. There are two basic parts to our hypothesis on what causes tension headaches, that I believe are relevant to the discussion.

Firstly, that tension type headache is the result of soft tissue lesions, particularly in the posterior cervical muscles and the attachments to C1 and the styloid process. Soft tissue lesions are defined as tear or damage to muscle, tendon, fascia, joint capsule or most likely the periosteal attachment of the muscle to the bone, resulting in the release of chemical mediators, which activate the nociceptive system. Soft tissue lesions are caused by trauma, which may be macroscopic, such as an accident, a fall, whiplash or even a general anaesthetic. The trauma may also be microscopic in nature resulting from a sustained strain on the muscle such as postural stresses of a work or sleeping posture, clenching or grinding of teeth.

Secondly, that the jaw is a major perpetuating factor of soft tissue lesions particularly in the posterior cervical muscles and the attachments to C1 and the styloid process. That is when the you clench your teeth your neck muscles tighten as well and may lead to a headache.

Another similarity is that fact that these two joints, the TMJ and STJ are often overlooked as perpetuating factors in chronic musculo-skeletal pain. The aim is to heal the soft tissue lesion. The extent of the intervention varies from one individual to the other and is the challenge of a holistic practitioner.

Foot function looks at the forefoot and rear-foot, specifically on the sub-talar joint. Ideally when a person is walking and the heel strikes the ground the sub-talar joint is balanced when it is in a neutral position, neither pronating nor supinating.

Limb Length Discrepancy is another area of controversy that podiatry and dentistry need to have a clear position on. A discrepancy can be either:

Functional - relates to the effect that muscles have giving the appearance of a leg length discrepancy even if the bony measurement reveals no difference between the two sides

Anatomical - is determined from the femoral head (in the hip joint) to medial malleolus (in the ankle joint). We have used a CAT scan scout view and is believed to be accurate to 1mm

Combination functional/anatomical

Case Report 1

Case Report 2

Conclusion

The question arises in podiatry, as it does in dentistry, as to how important is symmetry, balance and an ideal occlusion or ideal foot structure is? Should centric relation of the temporomandibular joint and a perfect class 1 skeletal and dental relationship, together with a neutral position of the sub-talar joint without any functional or anatomical leg length discrepancy be our goal? If we take nature as our guide perfect symmetry and ideal balance are the exception and not the rule. Similarly what may be a postural stress to one person may be perfectly well tolerated by another.

The answer I believe is that each case should be treated individually. The paradigm that I discussed on head, neck and jaw pain emphasises the need to understand the difference between the diagnostic phase (establishing the problem, its extent and how much we need to intervene) and the treatment phase (the intervention itself).

Our treatment of patients holistically needs to recognise a hierarchy of treatment. Starting with minimal intervention and educating our patients as to the various stresses which impact on their health. It may involve the most elaborate treatment that we can provide, however before we reach that point we should understand that our main rationale for any advice or treatment is to recognise that the body has a tremendous capacity to heal itself. That capacity varies from one person to the other and it is our task to deal with each patient individually.

Exercise

Lack of exercise and poor nutrition are the biggest contributors to poor health.

Exercise works by increasing the sensitivity of insulin receptors so the insulin that is present works much more effectively and your body doesn't need to produce as much.

Blood sugar is only the symptom in most diabetics; the real challenge is to control your insulin levels. Once the insulin levels are stabilized it is common for the blood sugar to come back to normal levels.

Most people, especially doctors, tend to not appreciate how powerful exercise is. However, I believe it needs to be viewed like a drug - you have to be very careful with the dose. If the dose is not high enough, it will not work.

One of the keys in using exercise to normalize insulin levels with secondary benefits of weight loss and normalization of blood sugars, is to make certain minimum thresholds are met. It is my experience that most people are not exercising enough.

Many people have told me they thought they were exercising enough when they were actually seriously under-dosed. This may be because many have not previously competed in an aerobic sport, which allows you to understand the feelings of "training" and how hard you have to push yourself to obtain aerobic and insulin benefits.

There are three important variables with exercise:

• Length of time
• Frequency
• Intensity

Assuming people can exercise, I encourage my patients to gradually increase the amount of time they are exercising to one hour per day.

Initially the frequency is daily. This is a treatment dose until they normalize their weight or insulin levels. Once normalized, they will only need exercise three to four times per week.