Dwells TMJ Tests and Treatment

Orthopedic Testing & Acupuncture
Strategies: TMJ & Neck Pain
By
Dr. David Wells, D.C., L.Ac.
Leading Acupuncture CE Provider

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Orthopedic Testing & Strategies:
Head and Neck by David Wells
TMJ & Neck Pain
Dr. David Wells

D.C., L.Ac.
Lotus Institute Of Integrative Medicine

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Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715

Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine
Your Patients Have Teeth! The jaw isn't just for dentists
Course Outline Most dentists are focused only on the teeth.

The jaw isn't just for dentists
They are not trained in mandibular
Anatomy of the TMJ orthopedics.
Clinical presentation of occlusal
disorders They repair or straighten teeth, often without
Case studies
regard for the function of the TM joint.
How to treat using manual techniques We have the capacity to provide holistic
and acupuncture. integration of the bite with the rest of the
Coordination of care with dentists body.
The jaw isn't just for dentists Bony anatomy
Using acupuncture and massage, we can The upper jaw is the maxilla
normalize the muscles that allow the The lower jaw is the mandible
mandible to float in a normal glide path. The TMJ is the meeting of the
We can also normalize the motion of the temporal bone and the mandible
cranial bones, upper cervical vertebra
and supporting posture all the way down
to the feet.

Tel: 626-780-7182 Fax: 626-609-2929 Website: www.eLotus.org Email: info@eLotus.org
Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine. 1
Who has jaw problems? Who has jaw problems?
Males Females Johansson A, et al: Gender difference in
TMJ pain 6.7% 12.4% symptoms related to temporomandibular
Joint sounds 12% 16.5% disorders in a population of 50-year-old
Difficulty opening 8.2% 11.2% subjects. J OROFAC PAIN 2003; 17:29-35.
Bruxism 15.5% 20.2%
Chewing difficulty 27.2% 24.8%

Males Females Pow EH et al : Prevalence of symptoms
Jaw pain 33.4% 32.5% associated with temporomandibular
Clicking 30.2% 29.7%
disorders in Hong Kong Chinese. J
Difficulty opening 7.5% 8.9%
Bruxism 25.1% 24.0%
Orofac Pain 2002; 15(3):228-34.
In addition to the obvious symptoms Ear pain

listed above, other problems may be Tinnitus
attributable to TMJD. Nausea
Headache
Tooth pain
Eye pain
Neck and shoulder pain
Vertigo
Malnutrition

Clinical pearl How does this happen?
Knowing this can make you more

effective in treating these conditions.
By being able to offer these services, you
can add more to what you offer your
current patients.
How does this happen? How does this happen?
The diverse symptoms occur because The mandible needs to be level to chew.
the muscles that support the TMJ The eyes need to be level to orient to space.
transfer the tension of balancing the joint The inner ear, pelvic righting reflexes and
to other areas of the head and neck. proprioception in the feet all have to agree to
support normal movement through space.
Lack of agreement creates dizziness and
poor coordination.
Formation of dental arch Formation of the dental arch
The teeth erupt but from the mandible and

maxilla but are guided into place by usage.
Opposing pressures from the tongue, lips
and other teeth form the dental arch.
Thumb sucking or mouth breathing causes
Alveolar Prognathism. This affects only the
dental arch in the front, not the whole jaw.

Formation of the dental arch Formation of the dental arch
Maxillary retrognathism (upderbite) is a Mouth breathing

far more common condition. This generally results from airway
Both conditions are left alone unless they obstruction due to swollen tonsils and
interfere with speech and chewing. adenoids
Infants who are not breast fed are at higher
Surgery with orthodonture can be used to
risk for mouth breathing
treat extreme cases.
Mouth breathing reduces aerobic respiration,
lowers energy, leads to cravings for sweets
and other problems
Mandibular Prognathism or underbite AKA The quality of air produced by nose

Dick Tracy or Dudley Do Right is a breathing is better than by open mouth.
protrusion of the lower jaw. This appears Nitric oxide is produced in the nasal sinuses
to be a genetic trait that arose from (where it inhibits bacterial growth) and is
politically motivated inbreeding inhaled.
(Hapsburgs, Charles the II of Spain). It increases absorption of O2 in the lungs
and throughout the body.
It is a strong vasodilator and
neurotransmitter.

Mouth breathing leads to malocclusion, Overbite
mandibular retrognathism, narrow dental Overjet
arch and a long face.
Malocclusion includes over bite, over jet, Cross bite
posterior cross bite and open bite. Open bite
The upper and lower jaw growth is 90% Gummy smile
complete by age 12.
Venous pooling under the eyes,
Adult complications can include obstructive
aka allergic shiners
sleep apnea, heart disease and stroke.

Look at the teeth Look at the teeth - bruxism
Look at the midline. Normal chewing puts 20-80 psi pressure on

Look for over jet, over bite, dental teeth on the long axis. Grinding can put 300
crowding, cross bite, visible gums, long to 3,000 psi pressure in a horizontal axis.
face, etc. Grinding my be an attempt to move lymph
through muscular action.
Damaged teeth can indicate bruxism.
Check for tight Pectoralis Minor muscles and
teach postural exercise.
Refer out for a dental appliance.
Look at the teeth - overbite Questions?
Look at the face from the side. In over bite,

bring the lower jaw forward until the skin
above and below the lips is vertically
aligned.
Watch and feel the jaw open. The side that
comes forward first is often the identified
problem because of pain and popping but is
only compensating for the restricted side.
Treat the restriction.
Anatomy of the TMJ Anatomy of the TMJ

The posterior condyle of the mandible fits
into the articular fossa of the temporal bone.
The two bones are separated by the articular
cartilage.
Mandibular movement (opening and closing
the jaw) should glide anteriorly and
posteriorly on that articular cartilage.
Over-closure of the bite (retrusion) is the
most common occlusal disorder.

Anatomy of the TMJ Motion and Occlusion
Over-closure of the bite occurs because of a The normal jaw translates forward on
failure of the teeth to fully erupt, forcing the opening. (Hinging in place is not a normal
jaw to over-close to make the teeth meet for movement unless you are a crocodile).
chewing.
Prolonged lack of anterior translation
The articular disc separating the two bones causes wear and tear to the TMJ that
distorts it's shape to be anterior to the results in arthritis of the joint.
condyle. This causes the disc to pop or
click as it moves out of the way of normal Any occlusal dysfunction may cause TMJ
forward movement on opening. pain.
Motion and Occlusion Muscles of mastication
A tooth that is painful or protruding such The muscles that close the jaw are the
that it hits before the others (prematurity) masseter, medial pterygoid, temporalis
can cause the jaw to deviate to avoid and the superior division of the lateral
pain. pterygoid. These are the muscles of
interest as they are the ones that restrict
opening.
Muscles of mastication Masseter

The following slides show these muscles
and their associated areas of pain.
Acupuncturists may needle the trigger
points associated with the pain.
Chiropractors may spray and stretch
them. All providers may massage them or
use other muscle release techniques.

Masseter Masseter
Temporalis Temporalis
Temporalis Anatomy of the TMJ
The posterior condyle of the mandible fits

into the articular fossa of the temporal bone.
The two bones are separated by the articular
cartilage.
Mandibular movement (opening and closing
the jaw) should glide anteriorly and
posteriorly on that articular cartilage.
Over-closure of the bite (retrusion) is the
most common occlusal disorder.

Tooth pain Lateral Pterygoid
You may have noticed that many of these The most critical muscle in treatment of
trigger points also treat tooth pain. If you the TMJ is the lateral pterygoid. It has 3
are treating tooth pain with acupuncture, branches. The top branch blends with the
add St44, St 45, Li4. fibers that stabilize the articular cartilage
(disc). Lateral deviation of the jaw is
controlled by the lateral pterygoid.
Lateral pterygoid Lateral pterygoid
Lateral pterygoid Lateral pterygoid

Why over-closure? Practice watching occlusion
Weston Price traveled to pre-industrial societies Check the midline
and observed the teeth, jaws, occlusion and
Which side of the jaw moves first on
general health of people eating unrefined,
traditional diets. People he studied included opening?
Native Americans, Polynesians, Pygmies, Which side has the most muscle tension?
Aborigines and many others. In 1939, he Which side has the pain or clicking?
published Nutrition and Physical Degeneration.
He concluded that modern diets contribute to How wide is the opening (in fingers)?
poor development of the jaw and teeth.
Why over-closure? Why over-closure?

Francis Pottenger was extracting adrenal Meat study. Cats fed cooked meat did
glands from cats for research at a tuberculosis poorly compared to cats eating raw meat.
sanitorium in Monrovia, California from 1932
The raw group got two thirds of their
to 1942. He found that cats on different diets
had different health outcomes. His study diet was raw meat, one third raw milk and
ultimately included over 900 cats. cod liver oil.
Pottenger's research was flawed but still The cooked group got same diet except
offers insight into the effects of diet on dental that the meat was cooked.
development and general health.
Price's hypothesis was that unrefined In the cooked group, but the third generation,
food required more chewing, leading to the cats developed degenerative diseases early
in life. Some were born blind and weak and had
greater development of the jaw muscles a short life span. Many of the cats in the third
and teeth. He also believed that there generation couldn't reproduce. Kittens of the third
were a number of micronutrients in native generation did not survive six months. Bones
diets that are missing from refined food became soft or missing, particularly of the mouth
diets. and jaw. Males became docile while females
became aggressive.

Milk Study. Different groups of cats were Note that modern cat food includes the amino acid
fed raw, pasteurized, evaporated or Taurine, added after cooking, which was unknown
at that time. Cooking destroys half to two-thirds of
sweetened condensed milk plus raw Taurine.
meat. The raw milk cats did well, while Adult humans can synthesize Taurine from
the cats fed other forms of milk suffered Methionine and Cysteine.
similar degenerative changes as the Taurine is generally missing from a vegan diet and
cooked meat diet cats. is lower in the serum and urine of vegans, despite
the ability of the body to synthesize Taurine from
Cysteine & Methionine
Practice watching occlusion Why over-closure?
Check the midline. The implication is that our refined food

Which side of the jaw moves first on diet has led to poor development of the
opening? jaw and teeth, including dental caries and
TMJ conditions.
Which side has the most muscle tension?
The bite locks in the over-closed position.
Which side has the pain or clicking?
Leaving the teeth apart except when
How wide is the opening (in fingers)? chewing minimizes the problem.
How to treat How to treat?
The goal of TMJ treatment is normal

opening and closing of the jaw.
Our job is the release the muscle tension.
The dentist's job is to separate the bite
with an occlusal splint night guard or to
re-shape the bite.

How to treat? Palpation practice
The muscles of interest are the The muscles of interest are the temporalis,
temporalis, masseter, buccinator and masseter, buccinator and most importantly,
most importantly, the external pterygoid. the external pterygoid.
The latter requires massage inside the
The latter requires massage inside the mouth.
mouth. Local acupoints include Tai Yang, St 5 and
Local acupoints include Tai Yang, St 5 6, GB 3 and trigger points. Distal points
and 6, GB 3 and trigger points. Distal include St 44, GB 43 and Li 4.
points include St 44, GB 43 and Li 4. Adjusting upper cervicals can help.
Lateral pterygoid Case study Closed lock

Female, age 38.
S - "Jaw pain and contracture for 12 days after
extracting all wisdom teeth."
O - Can't get one finger into mouth. No
anterior glide in TMJ, just hinge movement.
Tx - Acu L GB3, R St5, Bi Tai Yang,
Li4. Massage ext. pteryg TMJ Cervicals
muscles.
Outcome - Could get 2 fingers into mouth.
Case study Closed lock Case study Closed lock

Visit 2 Visit 3
S - "Electric shocks in tongue went from 3 times per hour to "Getting better. Ate a salad last night. No longer using pad
once every 3 hours. Keeping gauze in left side of mouth to to separate teeth. Opening two fingers. Smiling and
prevent biting tongue and reduce shocks. Doing stretches and speaking normally.
cold. Talking better. Can get two fingers into mouth. Tx added insertion to lateral pterygoid
O - Left anterior glide restriction but some movement. Eating fine. Jaw ROM same. Still getting electric shocks,
T - L GB2, St5, Tai Yang, Li4. Massage lat pterygoid and though less.
masseter. 2.5 fingers opening.
Visit 4
Outcome - "Feels better. Fewer shocks, less numbness in Better. Tongue still numb. Opens three fingers with ease.
tongue.
Tx same.
same tx

Case study Closed lock Another closed lock
Male, age 25 "TMJ pain and immobility. Pain level = 4 out of
Dentist demonstrated that the lingual nerve 10, constant, worse with chewing. Can't open mouth. One week
was cut and the tongue sensation will never duration."
First visit, acupuncture St6 and 7. Tai Yang. Massage
be normal but he was amazed that she now pterygoid, masseters. Some pain relief but no functional change
has normal opening and anterior glide. (can only open jaw to admit one finger).
Three days later, "No change in jaw." Objective - could open to
admit two fingers. Tx St 44 and GB 43 immediate relief and
easier opening. Also needled external pterygoid.
Four days later. "Jaw is okay. Was popping initially. Hurts a
little on full opening - 75% normal." Objective - easily admits 3
fingers. Right TMJ muscles tight. Same points. No further pain
reported.
TMJ and headaches Case from JMPT

65 year old woman drove from Mineral Wells 41-year-old woman had bilateral ear pain,
Texas for treatment of chronic headaches tinnitus, vertigo, altered or decreased
greater than 10 years duration. hearing acuity, and headaches. She had a
She had been treated by neurologists, history of ear infections, which had been
allergists, gastroenterologists and treated with prescription antibiotics. Her
psychiatrists to no avail. complaints were attributed to a diagnosis of
Chiropractic and dentistry resolved her temporomandibular joint syndrome and had
issues within 6 weeks. been treated unsuccessfully by a medical
doctor and dentist.
Case from JMPT Case from JMPT
Intervention and Outcome: High-velocity, Chiropractic care of a patient with

low-amplitude adjustments (ie, Gonstead temporomandibular disorder and atlas
technique) were applied to findings of subluxation. Journal of Manipulative and
atlas subluxation. The patients symptoms Physiological Therapeutics. January
improved and eventually resolved after 9 2002 Volume 25, Issue 1, Pages 63-70.
visits.

Holistic case study Holistic case study
A 32 year old woman presented with What's the connection?

chronic pain in her right sacroiliac region.
Ice and adjusting to her sacroiliac and
lumbar spine resolved her pain.
She called from her car to report pain in
the left jaw and difficulty making her teeth
meet. I asked her to return.
Treatment of the jaw resolved her pain.
Holistic case study Holistic case study

On her way home, she called to report her Could I have solved that without the
sacroiliac pain returned. dentist?
I asked her to come in to the office again. I Could the dentist have solved that without
treated both conditions to good effect and
me?
examined her bite.
I identified the bite issue, called her dentist
and sent her directly (with cotton in her
mouth) to the dentist to equilibrate her bite.
Her sacroiliac pain did not return.
Holistic case study Working with dentists
What did I do as a chiropractor? Learn their language. Terms like

What could I have done as an translation, anterior glide,
acupuncturist? malocclusion, lateral deviation, lateral
pterygoid can help communication.
You free the bite. The dentist changes
occlusion.
Schedule the dentist after your tx. Send
the patient with a separator.

Working with dentists Cranial Manipulation
Lecture to dentists.
Besides dental societies, oral surgeons
and other specialists sponsor short CEU
seminars for dentists to get referrals.
Cranial work History of cranial manipulaton

Cranial bones retain some ability to move Cranial motion and manipulation was first
into adulthood. introduced to osteopathic profession in the
Assisting that motion can resolve a variety 1920's by William Sutherland.
of conditions. Prior to Sutherland publishing his findings,
This motion creates therapeutic effect Nephi Cottam, D.C., developed a method of
through it's connection with the dura. cranial adjusting that he called craniopathy.
The jaw is like a pump handle to the skull. Major DeJarnette, D.O., D.C., developed
Occlusal problems can and often will create Sacro-Occipital Technique (SOT).
cranial faults.
History of cranial manipulaton History of cranial manipulaton
Richard Van Rumpt, D.C., founder of George Goodheart, D.C., founder of

Directional Non-Force Technique (DNFT) Applied Kinesiology also developed a
developed his own system of cranial system of cranial adjusting.
adjusting, starting in 1940.
Richard Van Rumpt contended that
cervical adjusting would not hold if there
were significant cranial faults.

Cranial work Cranial work
We can observe cranial vault motion in Radiographic Evidence of Cranial Bone

the newborn. Does it persist in Mobility
adulthood? Sheryl Lynn Oleski, B.S., Gerald H.
The Radiographic Evidence of Cranial Smith, D.D.S., William T. Crow, D.O.
Bone Mobility study sought to answer From: Cranio: The Jornal of
that question. Craniomandibular Practice, January
2002, Volume 20, Number 1, pp 34.
Twelve adult patient charts were The degree of change in angle between
randomly selected to include patients who various specified cranial landmarks as
had received cranial vault manipulation visualized on x-ray was measured. The
treatment with a pre- and post-treatment mean angle of change measured at the atlas
x-ray taken with the head in a fixed was 2.58 degrees, at the mastoid was 1.66
positioning device. degrees, at the malar line was 1.25 degrees,
at the sphenoid was 2.42 degrees, and at
the temporal line was 1.75 degrees.
91.6% of patients exhibited differences in Temporomandibular disorder was also

measurement at 3 or more sites. This studied by Chinappi and Getzoff, (7) who
study concludes that cranial bone mobility concluded that the disorder was worsened
can be documented and measured on x- by an instability of the sacroiliac joint,
ray. specific thoracic and cervical vertebral
subluxations, and cranial suture restrictions.
It was improved by adjustments of the spine,
neck, and cranial sutures several times a
week.

Also, Gregory (6) noted that Cranial sutures (unless fused) exhibit
temporomandibular disorder (TMD) was slight motion at a regular rhythm
improved following chiropractic sacro- independent of breathing.
occipital technique treatment and that This motion creates therapeutic effect
concurrent chiropractic and dental through it's connection with the dura.
treatments may improve the success rate Manual manipulation combined with
of TMD resolution. breathing can unlock or facilitate normal
cranial and dural motion.
Cranial work Cranial Case Study
Cranial sutures (unless fused) exhibit 42 year old woman who was hit in the
slight motion at a regular rhythm side of the head with a Princess phone at
independent of breathing. age 18, resulting in chronic disabling
This motion creates therapeutic effect headaches.
through it's connection with the dura. Cranial and upper cervical adjusting
Manual manipulation combined with resolved her complaint within one visit.
breathing can unlock or facilitate normal Remember that patients have families
cranial and dural motion. when dealing with chronic problems.
Cranial Case Study Cranial Case Study
8 year old boy suffering from nightmares 17 year old male with severe dyslexia
and bedwetting. and a history of multiple head traumas
Cranial and other adjusting provided (jumping of the roof, flipping his bike
significant improvement to those and upside down, etc.)
some behavioral problems. He had serious problems in school and
difficulty reading.

Cranial Case Study AK Cranial Technique
7 year old girl with mirror writing. Inspiration/expiration assist.

Treated her while she was standing and Vagus test using pectoralis major muscle
writing at the counter. test provoked by deep breathing.
Temporal bulge
Frontal assist
Glabellar/sacral base.
Parietal spread.
Other (DNFT)
Questions? Break
Upper cervical movement Upper cervical movement
Anatomy and joint movements of the C1 is similarly mobile. It is typically

occiput, C1, C2 and C3. adjusted from the posterior lateral on one
The occiput typically subluxates side though it can subluxate laterally or
posteriorly (relative to C1) due to anteriorly as well.
prolonged head flexion of anteriorly due
to postural collapse.It can however,
subluxate laterally as well.

Upper cervical movement Upper cervical movement
C2 typically subluxates posterior-inferior C2 and C3 often subluxate together.

on one side. This is the most common When C3 is anterior on one side, it affects
cause of headaches and of restricted the SCM muscle and can thus cause
rotation on the side of posteriority.. nausea and dizziness. If it subluxates
anteriorly, it seems to affect the Vagus
nerve. Lateral subluxation limits lateral
flexion.
Mid cervical movement Lower cervical movement

C5/6 is the mid point of the cervical lordotic C7 often moves with T1 and the first rib,
curve. As such, it is most prone to injury in generally in the anterior superior
whiplash. Due to this and and to anterior direction. Shoulder shrugging is restricted
head posture/hyperlordosis, it is always wise when these are subluxated.
to check for anterior subluxation of these
vertebra.
Limitations of cervical extension may also be
alleviated by adjusting the spinous of C5
and/or C6 superiorly.
Correcting cervical movement Demonstration
Motion may be restored to these

joints using a variety of adjusting
techniques, including acupressure
and resisted range of motion.

Upper cervical anatomy Upper cervical anatomy
The vertebral artery

Suboccipital muscles
Vagus nerve
Head Syndromes Cephalgia

Conditions we will cover in this
section include:
Cephalgia G44.20
Vertigo R42.
Migraine G43.
Cluster headache G44.009
Trigeminal neuralgia 650.0
Bell's Palsy G51.0
Cephalgia Cephalgia
Cephalgia or Headache. Marked The most common mechanical cause of

discomfort in any part of the head, head headache is subluxation of C2 posteriorly on
and neck or face, not confined to a single the side of pain.
nerve distribution. Various muscles also refer pain to the head.
ICD10 R51 Some of these muscular imbalances are
related to TMJ dysfunction.
The most common is a tension headache,
Tension in the muscles that blend into the
characterized by constant, non-pulsing
scalp, such as the suboccipital muscles also
pain.
play a role.

Cephalgia Generic Case Study Cephalgia Generic Case Study
Office worker/student/laptop user/heavy Sub occipital muscles are tight, anterior

commuter complains of daily, diffuse cervicals are weak, rhomboids, mid traps
headaches, neck and upper back pain. and lower trapezius are weak and
Temporarily better with a hot shower or overstretched, i.e. postural collapse.
massage. Complains that neck is tight or
What to do?
in spasm. Can't get enough massage.
Better in the morning, worse as the day
progresses. Hopes acupuncture or adjusting
will finally relax those tight muscles.
Cephalgia Generic Case Study Cephalgia Generic Case Study
Release the tension in the upper cervicals Patients with postural collapse may also
to get the patient's attention and then have low blood pressure, be dehydrated,
teach exercise low thyroid, be generally deconditioned,
Plank rhomboid squeeze etc.
Supine chin tuck, shoulders back In addition to advice on diet and exercise,
Prone swimming such patients may also need Ginseng and
Astragalus or other tonics (per syndrome)
and possibly psychological help.
Cephalgia Generic Case Study Postural exercises
Patients with diffuse headache

accompanied by nausea often do well with
Pinellia and Magnolia Combination.
Patients with headache upon arising quickly
probably have postural hypotension. Check
two position blood pressure.
High blood pressure can also cause
headaches. This is your Yang Excess
patient.

Headache Red Flags Headache Red Flags
The American Headache Society Onset is sudden (thunderclap

promotes the mnemonic SSNOOP to headache).
remember red flags. Onset after age 40.
S Systemic symptoms such as fever or Previous headache history (This is
weight loss. the first or worst headache ever).
S Systemic disease such as HIV,
malignancy.
Neurologic symptoms or signs
Headache Case Study Headache Case Study
85 year old woman presented with recent I called her daughter and convinced her
onset of left sided, occipital, throbbing to go to the ER.
headache that she rated a 9 out of 10.
Adjusting the left upper cervicals and
acupuncture made no improvement.
What to do?
Vertigo Vertigo
Vertigo - The sensation of movement when not

moving. Can feel like spinning, swaying or being
on a boat. Can include nausea, vomiting or
sweating.
7.5 to 10% of people experience vertigo.*
Most common type is benign paroxysmal at 32%**
Next is Meniere's disease (12%)** and labryinthitis.
Rarely stroke, brain tumor, MS and toxins such as
alcohol.

Vertigo Vertigo
* von Brevern, M; Neuhauser, H (2011). Physical exam includes the Dix-Halpike

"Epidemiological evidence for a link test. In this test, the examiner takes the
between vertigo and migraine". Journal of patient from sitting to supine with head
vestibular research: equilibrium & extended 20 degrees and rotated 45
orientation 21 (6): 299304 degrees.
** Karatas, M (2008). "Central Vertigo The test is positive if nystagmus appears
and Dizziness". The Neurologist 14 (6): after 5-10 seconds.
355364.
Vertigo - BPPV Vertigo Case Study 1
Benign paroxysmal positional vertigo A 66 year old woman with a history of Benign
(BPPV) usually experience symptoms Paroxysmal Vertigo presented for episode that
lasting less than a minute that occur with began 2 weeks prior. Symptoms were worse
lying down or transitioning from lying to upright.
a change of position.
Palpation revealed misalignment of C1 and C2,
Theorized to occur due to a flake of left posterior with associated muscular tension.
calcium debris in the semicircular canal. Significant benefit at first treatment. 5
Usually treated with Epley's manauever. treatments required for complete relief.
Vertigo - Meniere's Vertigo Vestibular Neuritis
Recurrent, spontaneous episodes of H81.21(right ear) or H81.22 (left ear)

severe vertigo with tinnitus, a feeling of Severe vertigo with nausea, vomiting and
fullness in the ear, severe nausea, poor balance usually without hearing
imbalance and hearing loss. The hearing problems.
loss may progress. Persistent balance problems remain in
ICD10 H81.01(right ear) or H81.02 (left 30% of those affected.*
ear)

Vertigo Vestibular Neuritis Vertigo Case Study 3
* Neuhauser HK, Lempert T (November 71 year old woman with 5 year history of
2009). "Vertigo: epidemiologic aspects". dizziness. She had been to ENT's, the
Semin Neurol 29 (5): 47381. House Ear Clinic and a NASA test center
to no avail.
What reproduced the symptoms?
Vertigo Case Study 3 Migraine
A 7mm lift in her shoe effected complete

relief.
Moral of the story Take a good history
and treat the whole person.
Migraine Migraine
From the late Latin for hemicrania or 'half a Migraine does not mean severe headache,
head, migraine is a one-sided, pounding though they are often disabling.
headache, often preceded by a visual aura and Migraines most often begin between age 15
accompanied by nausea, vomiting, cold and 24 and are most frequent between ages
extremities, sensitivity to light, sound and smell. 35 to 45.*
In the United States, 6% of men and 18% of
Migraines with aura double the risk of
women get at least one migraine each year.*
ischemic stroke. Other risk factors include
Worldwide, approximately one billion people are being a young adult, female, smoking and
affected by migraines.**
use of oral contraception.***

Migraine Migraine Types
Migraines occur most frequently around ICD10 G43.0 Common without aura. To
menstruation. They also occur frequently distinguish this from a tension headache, 5
during perimenopause or from taking oral episodes are required for diagnosis. Must be
contraceptives. of at least moderate intensity and may
include nausea, photophobia and
Many report food triggers such as red
phonophobia.
wine, chocolate, MSG and a variety of
ICD10 G43.83 Probable migraine without
other foods.
aura is used when less than 5 episodes
have occurred.
Migraine Types Migraine references
ICD10 G43.1 Classic with aura. Bartleson JD, Cutrer FM (May 2010). "Migraine
Throbbing, unilateral headache of at least update. Diagnosis and treatment". Minn Med 93
moderate intensity that includes visual (5): 3641. PMID 20572569.
Vos, T; Flaxman, AD; Naghavi, M; Lozano, R;
disturbances and may include nausea Michaud, C; Ezzati, M; Shibuya, K; Salomon,
and phonophobia. JA et al. (Dec 15, 2012). "Years lived with
disability (YLDs) for 1160 sequelae of 289
diseases and injuries 19902010: a systematic
analysis for the Global Burden of Disease Study
2010". Lancet 380 (9859): 216396.
Migraine references Migraine references

* Lay CL, Broner SW (May 2009). "Migraine in *** Schrks, M; Rist, PM; Bigal, ME;
women". Neurologic Clinics 27 (2): 50311.
Buring, JE; Lipton, RB; Kurth, T (2009-10-
doi:10.1016/j.ncl.2009.01.002. PMID
19289228.
27). "Migraine and cardiovascular
disease: systematic review and meta-
** Stovner LJ, Zwart JA, Hagen K, Terwindt
GM, Pascual J (April 2006). "Epidemiology of analysis". BMJ (Clinical research ed.)
headache in Europe". European Journal of 339: b3914.
Neurology 13 (4): 33345. doi:10.1111/j.1468-
1331.2006.01184.x. PMID 16643310.

David's Migraine Theory David's Migraine Theory
Based on positive treatment results, I believe Why doesn't this mechanical constriction
that migraines occur in people who are on arteries cause a constant migraine?
predisposed because of mild vertebral artery
compression due to misalignment of the upper Hormonal changes or other triggers
cervical vertebra (C1, C2 and the Occiput). provoke the migraine in these
This decreased blood flow to the head results in predisposed individuals by lowering blood
compensatory vasodilation within the brain pressure.
which is mediated by serotonin and
inflammation.
David's Migraine Theory David's Migraine Theory
MRA studies have shown that migraines are Normalization of the upper cervical region
accompanied by mild vasodilation of the in conjunction with acupuncture (and
intracranial arteries. sometimes rest) provides immediate relief
Amin FM, Asghar MS, Anders H et al. and with repeated treatment prevents re-
(2013). "Magnetic resonance angiography of occurrence in chronic migraine sufferers.
intracranial and extracranial arteries in
patients with spontaneous migraine without
aura: a cross sectional study". Lancet
Neurol 12 (5): 454461.
Migraine treatment Migraine Case Study
Adjustment of C1, C2 and the Occiput. Patient/friend called me at home at 8:30

Acupuncture to the adjacent muscles (GB PM to say her husband had severe one-
20, UB 10, etc.) and to remote points sided headache, photophobia and
based on symptoms (such as 4 gates, P6, vomiting. I agreed to meet at the office.
etc.). He was crawling down the hallway to my
Postural correction and therapeutic office, under a blanket, vomiting every
exercise may also be needed. few feet.

Migraine Case Study Cluster Headache
Upper cervical adjusting, acupuncture

and Evodia Combination resolved his
symptoms.
He required 6 treatments to be free of
migraines from that point on.
Cluster headache Cluster headache
Cluster headaches are repeated episodes To be diagnosed as a Cluster, the headache

of severe, unilateral headaches, generally must be accompanied by at least one of the
focused around and above one eye, and following: drooping eyelid, pupil constriction,
in the temple. redness of the conjunctiva, tearing or runny
nose. Less commonly, blushing, swelling or
Typical episodes last from 15 to 180
sweating appearing on the same side of the
minutes. Most are under 75 minutes. head as the pain.
Pain is described as burning, stabbing, Restlessness, sensitivity to light, sound or
boring or squeezing. smells may also occur.

The pain of cluster headaches are more Cluster headaches frequently occur at the
severe than the most severe migraine same time of day, and clusters of headaches
and in fact may be the most painful often occur at regular times of year.
condition known to medical science. According to the International Headache
Matharu M, Goadsby P (2001). "Cluster Society, clusters of headaches that have a
Headache". Practical Neurology 1: 42. pain-free period of at least one month are
classified as episodic, while those clusters
that occur for more than a year without
remission are classified as chronic

Cluster headaches occur in about .2% of the There is no approved drug or medical
population, with males being affected two and treatment though acute attacks can be
a half times more frequently than females. diminished by use of Oxygen or a fast acting
The condition usually starts between age 20 triptan. Verapamil is used as a preventative.
and 50. Opioids may make the headache worse,
The cause and mechanism of the headaches suggesting that acupuncture may be
is unknown, though it is classified as a contraindicated.
trigeminal autonomic cephalgia. One case suggested that the homeopathic,
Bryonia Al. 30X may be helpful.
Facial nerve conditions Trigeminal neuralgia
Trigeminal Neuralgia ICD10 G51.0

Episodes of pain, numbness, tingling
and/or burning on one side of the face.
Provoked by touching or moving the face.
More common after age 50.
More common in women.
Tends to become more frequent over
time.
Trigeminal neuralgia Trigeminal Neuralgia Case Study
Treatment may involve correcting TMJ 42 year old man was exposed to cold wind
and resulting facial muscular tension. that resulted in headache and facial pain on
the right side 2 days prior to visit. He had mild
Dermatrol to control possible herpetic
clear nasal discharge and hearing loss in the
involvement. right ear.
Though it is considered an attack of Upper cervical adjusting and acupuncture
Wind Cold in TCM, heat makes it worse. relieved his facial pain.
He was sent to his primary for anti herpetic
medication but was given antibiotics instead.

Bell's Palsy Bell's Palsy
Trigeminal Neuralgia ICD10 G51.0

Unilateral facial paralysis caused by
damage to the VII Cranial nerve results in
drooping of the face and inability to fully
close the eye on the affected side.
Bell's Palsy Bell's Palsy
Generally thought to be caused by a viral Local points include GB 20, Tai Yang, ST
infection, most likely herpetic. 5 and 6 and Ah Shi points on the face.
Responds well to Dermatrol and Distal points include St 44, GB 43, 4
acupuncture. gates.
Most people begin to feel better within Adjusting to the upper cervicals on the
two weeks with or without treatment and affected side may also be beneficial.
recover completely in 3 6 months. An eyepatch is palliative as are lubricant
drops for the eye.
Bell's Palsy Case Study Bell's Palsy Case Study

41 year old male appeared with left-sided facial He was also given Dermatrol HV and
droop and inability to close left eye for one advised about a low Arginine diet.
week's duration. He was a performer and very Each acupuncture treatment included GB 20
concerned about his appearance. and Tai Yang (as points along the nerve
After the first treatment (see previous protocol) path) in conjunction with varying points to
he was able to better close his eye and move stimulate the remaining weak muscles.
his face. Some muscles remained completely
By the end of 2 weeks (5 treatments), his
flaccid.
condition had resolved.
He was advised to do facial exercise, use eye
drops and wear and eye patch.

Questions? Mid Cervical Syndromes
Mid Cervical Syndromes Cervical Sprain
S13.4 Cervical Sprain S13.4 Cervical Sprain aka whiplash.

M50.12 Cervical Disc Syndrome with 3 phases of healing
radiculopathy (applies to C4-7) Acute (inflammatory)
M47.014 Thoracic Outlet Syndrome Sub acute (repair)
M43.6 Torticollis (intermittent, spastic) Chronic (remodeling)
M44.2 Cervicalgia Acupuncture, ice, gentle manipulation,
transition to deep massage, gua sha,
therapeutic exercise.
Normal cervical lordosis Cervical sprain

Cervical sprain Cervical sprain
Cervical Disc Syndromes Mid Cervical Disc Syndromes
M50.12 Cervical Disc Syndrome with

Radiculopathy
M50.02 Cervical Disc Syndrome with
Myelopathy
M50.22 Cervical Disc Syndrome without
Radiculopathy
M50.12 Cervical Disc Degeneration
All of the above apply to C4 though C7
Cervical disc syndrome Cervical disc syndrome

Cervical disc bulge or rupture is common in Tests include:
cervical sprain injuries. Rust's Sign
Use acupuncture to relieve pain,
inflammation and some muscular tension. Cervical Compression and Distraction
Use Chiropractic or Tui Na to restore Bakody's Sign (Hand on head relieves
normal position and ROM pain)
Include traction with extension.
Goals restore normal range of motion and
eliminate radicular pain.

Orthopedic Tests Normal cervical MRI
Active and Passive Cervical ROM. Vertigo or
dizziness on rotation is Barre-Lieou Sign
(vertebral artery compression)
Reflexes and Dermatomes
Cervical compression Positive for disc
lesion or stenosis if pain radiates into arm.
Cervical distraction Positive for disc lesion
or stenosis if arm pain is relieved.
Cervical disc syndrome Cervical disc syndrome
Brachial Plexus Disorders Scalenes Anticus Syndrome
G54.0 Brachial Plexus Disorders

Code includes Scalenes Anticus
Syndrome and Thoracic Outlet Syndrome

Cervical brachial syndrome Brachial Plexus Diagnosis
Distinguish between Scalenes Anticus,

Cervical Disc and Thoracic Outlet
Syndromes.
Use history and orthopedic testing.
Brachial Plexus Tests Totticollis

Bakody's Sign Positive for Scalenes Ant. M43.6 Torticollis (intermittent, spastic)
Wright's hyperabduction test Positive for tight Assume it is a disc lesion and treat
pectoralis minor muscle if symptoms and loss accordingly
of pulse occur as arm abducts.
Do not treat the painful side with
Adson's test is positive if symptoms and loss of
pulse occur as arm extends back and neck tilts
acupuncture or massage.
away as head rotates towards extended arm. Goal of treatment is to return to upright
Shoulder Depression is a continuation of posture.
Adson's Test..
Cervicalgia Questions?
M44.2 Cervicalgia
May be a subluxated facet joint, muscular
tension, poor posture, etc.
Always correct ergonomics and give
postural exercise.
The overstretched, weak muscles do not
need acupuncture or massage.

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seminar/webinar schedule for this year,
please visit www.elotus.org More information on the classic formulas can be found
in the Chinese Herbal Formulas and Applications
Collection formulas can be found in the Lotus Clinical

Manual of Oriental Medicine
All the above texts are available through www.elotus.org
Herbs mentioned in this seminar/webinar,

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Orthopedic Testing & Acupuncture

Strategies: TMJ & Neck Pain

Dr. David Wells, D.C., L.Ac.

Leading Acupuncture CE Provider

Lotus Institute of Integrative Medicine

GENERAL POLICIES / GUIDELINES 2. Consent and Disclaimer Part II (Webinar Recording)

Like Lao-tzu's adage - when you do better, we all do better

Lotus OnlineCEU VIDEOS

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FREE Articles for Download

Dr. David Wells

Lotus Institute Of Integrative Medicine

Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715

Course Outline Most dentists are focused only on the teeth.

The jaw isn't just for dentists Bony anatomy

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Who has jaw problems? Who has jaw problems?

Who has jaw problems? Who has jaw problems?

In addition to the obvious symptoms Ear pain

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Knowing this can make you more

How does this happen? How does this happen?

Formation of dental arch Formation of the dental arch

The teeth erupt but from the mandible and

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Maxillary retrognathism (upderbite) is a Mouth breathing

Formation of the dental arch Formation of the dental arch

Mandibular Prognathism or underbite AKA The quality of air produced by nose

Formation of the dental arch Formation of the dental arch

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Look at the midline. Normal chewing puts 20-80 psi pressure on

Look at the teeth - overbite Questions?

Look at the face from the side. In over bite,

Anatomy of the TMJ Anatomy of the TMJ

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Motion and Occlusion Muscles of mastication

Muscles of mastication Masseter

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Temporalis Anatomy of the TMJ

The posterior condyle of the mandible fits

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Lateral pterygoid Lateral pterygoid

Lateral pterygoid Lateral pterygoid

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Why over-closure? Why over-closure?

Why over-closure? Why over-closure?

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Practice watching occlusion Why over-closure?

Check the midline. The implication is that our refined food

How to treat How to treat?

The goal of TMJ treatment is normal

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Lateral pterygoid Case study Closed lock

Case study Closed lock Case study Closed lock

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TMJ and headaches Case from JMPT

Case from JMPT Case from JMPT

Intervention and Outcome: High-velocity, Chiropractic care of a patient with

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A 32 year old woman presented with What's the connection?

Holistic case study Holistic case study

Holistic case study Working with dentists

What did I do as a chiropractor? Learn their language. Terms like