Chiropractic

Peter Varley BDSc, FDSRCS, DFHom(Dent.) and Jonathan Howat DC(USA), FICS. (profile)

Introduction

Chiropractic was founded in 1895 by Dr Palmer in the USA. It is now the largest natural healing profession in the world. It uses the inherent recuperative powers of the body for the maintenance of health through the normal balance of the nervous system and the spinal, muscular and skeletal structures.

General chiropractic treatment is in the form of spinal adjustments. Chiropractic care is gentle and natural; it responds to the body's needs and does not include drugs or surgery.

The Scientific Basis of Chiropractic

Chiropractic rationale developed from long-standing clinical and physical observations that distorted skeletal relationships cause nervous system dysfunction. It is based on the following three facts:

• Homeostasis enables the organism to remain vital.
• The nervous system controls and regulates homeostasis.
• Instability of the skeletal structure impairs the function of the nervous system.

Dural Meningeal System

The brain and spinal cord are protected and supported by the dural meningeal system. It covers the surface of the brain and forms the venous sinus system which drains the brain and spinal cord of cerebro spinal fluid.

The intracranial dural membranes consist of the falx cerebri, the falx cerebellum, the tentorium cerebelli and the diaphragma sellae. These membranes act as baffles within the cranium supporting the two cerebral hemispheres, and separating them from the cerebellum (see figure 1). No matter what position the cranium is in, the brain is at all times supported and stabilised.

Normal Dural Meningeal System

The spinal dura is firmly anchored at the foramen magnum, the ring of the atlas, the body of axis and to the body of the third cervical vertebra. From there the dural tube descends and has no further firm attachments until the second sacral tubercle where the dural meningeal system is firmly adhered.

Skeletal System

The skeletal system consists of the 22 bones of the skull, the sacrum and the coccyx. The sacrum is supported bilaterally within the pelvis by the ilia forming the sacro-iliac joints. These joints are supported entirely by ligaments. They cannot be protected voluntarily, and act as a safety valve for disrelationships within the pelvic-sacral and sacro-lumbar junctions.

The Lovett Brother Relationship

A biomechanical state, namely the Lovett Brother Relationship, describes the skeletal reciprocity between paired bones of the cranium, pelvis and spine. Atlas and L5 will move in an equal and opposite direction to one another in order to maintain a balanced vertical position against gravity. Similarly the ilia will reciprocate with the temporal bones and the occiput with the sacrum.

Diaphragmatic Respiration

The ventricles of the brain expand and contract on respiration. On inhalation the diaphragm forces the abdominal organs downward onto the pelvic floor, flaring the ilia into external rotation and decreasing the lumbar lordosis. This causes compression on the sacral bulb (the lower part of the dural meningeal system) forcing cerebro-spinal fluid up in a helical motion towards the foramen magnum. There is a reciprocal motion between the occiput and the sacrum provided by this diaphragmatic respiration and is known as the cranial-sacral pump

Chiropractic Considerations

Skeletal Dysfunction - Bilateral Sacroiliac Fixation

Trauma during the birth can lead to distortion and rotation of the pelvis. This can lock the sacroiliac joints and twist the dural meningeal system affecting the spinal and cranial dura. The biomechanical effects of a rotational pelvis, produces a relative discrepancy in the length of the legs. This discrepancy is a physiological adaptation and not a physical leg length discrepancy.

Bilateral Sacroiliac Fixation

The Lovett Brother Relationship produces a compensation in the cranium. Both glenoid fossae are now out of synchronisation affecting the translation of the mandible. Posturally this patient when observed in a standing position will move in an anterior to posterior direction in an attempt to enhance motion of cerebrospinal fluid.

Unilateral Sacroiliac Lesion

The relatively long or short leg discrepancy over a period of time puts pressure on the interosseous ligaments at the sacroiliac joint. The resulting subluxation means that the weight bearing joint is now unable to support the body. When this patient is observed on a postural distortion analyser, the movement will be from side to side in a lateral sway.

The Sacroiliac and Temporo-Mandibular Joint

The sacroiliac and temporo-mandibular joints compensate and adapt for one another all the time. We swallow 2,000 times a day creating light forces on the teeth. This is nature's way of balancing the cranium and all its components. However, if the swallow is unbalanced over a long period, cranio-facial distortions will result and affect the cranial physiology and hence TMJ and sacroiliac balance.

The Latissimus Dorsi Muscle

The latissimus dorsi contracts to support the sacroiliac lesion stretching the brachial nerve distribution into the shoulder and arm.

Over a period of time this constant muscle spasm gives rise to the likes of frozen shoulder, tennis elbow and indirectly, carpel tunnel syndrome. The irritation on the brachial nerve plexus can give rise to parasthaesia as far down as the fingertips.

To counteract the latissimus dorsi the opposing trapezius and sterno-cleido-mastoid muscles contract, creating a pull on the occiput and temporal bone, distorting the glenoid fossa and affecting the relationship of maxillae and mandible. The effect of spasm on the temporalis jams the cranial sutures. The pterygoid muscles contract, creating a distorted effect on the sphenoid bone.

Lumbar 5/Sacral 1 Discogenic Syndrome

The inability of the sacroiliac lesions to support the body against gravity puts a strain on the muscles surrounding the lumbar-sacral junction. As the sacroiliac joint becomes weaker the stress into the lumbar-sacral disc will produce a disc prolapse.

At this point there is a total breakdown in the dural meningeal system. The patient on a postural analyser will show very little movement. Although the problem appears to be at the lumbo-sacral junction, it may be a temporo-mandibular joint dysfunction being adapted for at this junction over a long period of time and being consistently reinforced by the swallow and chew mechanism.

Ascending Stress Major

The discussion so far has taken into account primary chiropractic considerations whereby the major lesion has been at the sacroiliac or lumbar-sacral joints. This is an ascending stress major because instability at the pelvis will ascend producing compensation at the temporo-mandibular joints

Cranial Considerations

The Anterior and Posterior Pivots

The sphenoid bone is the central bone of the cranium and pivots posteriorly at the spheno-basilar synchondrosis and anteriorly at the pterygoid plates. These points are commonly known as the posterior and anterior pivots respectively.

Forceps delivery at birth can distort the greater wings of the sphenoid affecting the anterior and posterior pivots. The posterior pivot can be directly influenced by a pelvic distortion. The anterior pivot will be influenced by a dental malocclusion.

Pituitary gland

Due to the position of the pituitary in the body of the sphenoid bone, distortions of this bone will affect the pituitary. As this gland is the master controlling endocrine gland, structural changes of the sphenoid bone can affect the endocrine system.

When assessing the cranium the craniopath has to consider the maxillary/mandible relationship, the occlusion of the teeth and the effect the maxillae is having on the anterior pivot. He also needs to ensure that the pelvic girdle and thus the posterior pivot is balanced structurally.

Dental Considerations

Class II - Division 1 and 2

The orthodox treatment for this situation is the removal of bicuspids followed by fixed appliances. A Class II Div 2 mouth is already retruding the mandible as the upper incisors are distalised. Retrusion of the mandible in the glenoid fossae creates irritation on the retrodiscal tissue, ultimately affecting the vestibular cochlear mechanism which results in vertigo, tinnitus and loss of equilibrium.

It is also useful to note that in embryological development, cells from the neural tube area control the brain, the spinal cord, the central nervous system, half of the pituitary gland as well as the premaxillae and four maxillary incisors. In a normal occlusion the incisors should not come into contact at any point on swallowing or mastication.

Arch Expansion

The alternative approach to Class II Div 1/Div 2 type children is to expand the upper and lower arches well before puberty. In this way the integrity of the system is maintained. No teeth are removed, the occlusion is maintained, the mandible is allowed to protrude normally without damage to retrodiscal tissue. Head posture is maintained so that cervical lordosis is also maintained. There is no interference to the reciprocal tension membranes, the venous sinus drainage, the diaphragma sellae or the tentorium cerebelli.

Wisdom Teeth Extraction

As the children who had bicuspid extractions become adults, the wisdom teeth appear and they too need to be extracted because of the underdevelopment of the maxillae and mandible. The result is that by the time these people are thirty years of age, twenty five percent of their natural dentition has been removed artificially and without any just cause, except for pure aesthetics.

The treatment required is expansion of the upper and lower arch, protruding the mandible, erupting the posterior teeth to increase the vertical and using bridgework or implants to negate the loss of the premolar dentition

Loss of Posterior Support

Loss of posterior support results in the teeth on either side of the space collapsing towards one another creating a loss of vertical and overclosing.

This results in damage to the retrodiscal tissue area and a jamming of the temporal bone. This type of malocclusion will affect the anterior pivot. As this is a major area of cause, it needs to be addressed prior to any changes made to the cranial vault.

Descending Stress Major

The malocclusions described ultimately affects the occipital-sacral pump mechanism producing a sacroiliac lesion. The malocclusion, is then defined as a primary descending stress major.

The treatment plan, as far as the dental malocclusion is concerned, has to be assessed for incisal interference, loss of dentition, premature contact and loss of vertical on the merits of what will create a normal occlusal contact. The muscles of the cranium need to relax and become bilaterally equilibrated. This can be done by use of a Tanner appliance (made of hard acrylic) on which the maxillae may slide across the mandible without any fixed reference point.

While this dental treatment is in progress it is imperative that the pelvis is balanced. It is important for the craniopath to ensure that the cranial sutures are free, movable and uninhibited. If these levels are not maintained, especially when a patient is in fixed upper appliances, distorted patterns can take place lower down in the spine.

It has been suggested that fixed appliances across the mid-line of the maxillae can and will cause a scoliosis when one maxillae is fixed in internal rotation and the other fixed in external rotation. A lower Tanner appliance should then be advocated.

An Interdisciplinary Approach to Treatment

The interdisciplinary collaboration between a dentist/orthodonist and a chiropractic craniopath indicates that with a good working relationship between the two disciplines the required results can be achieved.

When looking at skeletal balance it is vital to ensure that the arches of both feet are supported properly. A third discipline, in the form of a podiatrist, will be required to assess the feet and prescribe the correct orthotics to support the arch which in turn will support the pelvis and consequently support the cranium.

Many patients who require cranial/dental treatment are exhausted. Their energy level is low, their diet is sometimes harmful and, because of the pain, their medication level has been high. Nutritional supervision is needed to allow the body to re-establish some stability. Reduction of analgesics and anti-inflammatory drugs must be stressed. These patients are usually frequent coffee drinkers, with high levels of chocolate and sugar intake, artificially stimulating the adrenals and overloading the pancreas.

Conclusion

We have tried to demonstrate a need for an interdisciplinary relationship between chiropractor and dentist. The aetiology of a problem can then be defined and diagnosed early so that the correct treatment can be applied.

A descending major stress area is a primary dental problem requiring a chiropractic backup to ensure a return to biomechanical stability. An ascending major stress area is a primary chiropractic problem requiring dental backup to ensure that premature contacts of teeth, loss of dentition and incisal interference can be monitored and corrected while the sacroiliac lesion is stabilised.

The number of patients presenting with obscure and apparently unrelated symptoms is on the increase. A logical conclusion to this state of affairs, despite our sophisticated technology is the iatrogenic effects of dental extractions. Their long-term effect is exhaustion of the body from a structural standpoint. This chronically lowers the immune system and culminates in pathophysiology and a breakdown in homeostasis. These problems cannot be resolved by a conventional medical or dental approach. An understanding of the effects that structural instabilities have on the nervous system and their mimicking symptomatic pictures is essential.

It is inherent in these new holistic, multi-disciplinary treatments to address all the issues and challenge aesthetic irrationality for a rational functional protocol. These groups with the knowledge of dynamic structural change must persevere regardless of criticism, to influence orthodox thought for the benefit of all our patients in the 21st century.