information for dentists
For Dentists
Why Cervical-Cranio-Mandibular (CCM) complex?
The main role of the neck is to carry the head in order to serve its main functions such as sight, hearing, mastication (including taste) and correct its position in space according to the various demands and surrounding (proprioception).
This major role connects the neck-head-face and jaw into one major functional complex in which its components are inter-related and affect each other. Additionally, the modern neuroanatomy research demonstrates that there is a strong neural sensory connection between the various parts of this complex, such that noxious stimuli in a specific region (such as the right side of the upper neck) can easily lead to pain presentation in another region (around the right eye in this example) and vice versa.
In my PhD research project that was done at Tel Aviv University we characterized upper cervical spine musculoskeletal pain and related performance parameters, as well as assess the prevalence/incidence of cervicogenic headache among patients with Temporomandibular Disorders (TMD).
The trend we observed was clear and demonstrated significant specific upper neck impairments in patients with painful TMD, where over a third of them were diagnosed with Cervicogenic Headache versus 5% in the general population.
Therefore, the ideal rehabilitation of this region should also incorporate physiotherapy, which requires understanding of the whole Cervical-Cranio-Mandibular complex
How do Physiotherapists treat patients with Cervical-Cranio-Mandibular disorders?
One of the fortes of physiotherapists is the qualification and practice of stringent, thorough and comprehensive clinical assessment (and clinical reasoning) of various conditions and dysfunctions of patients and all related comorbidities and contributing factors such as one’s functional abilities, muscular performance, pain parameters, one’s perspective and belief system.
For the last two decades the physiotherapy profession has progressed greatly and is under continuous development in evidence informed clinical guidelines and practice, and in setting strong foundation for further research such as by developing valid and reliable tools for clinical and subjective assessment of patients’ progression.
Physiotherapy related research has also contributed greatly to the understanding of the relationship between the regions in the cervico-cranio-mandibular complex. In addition, there is emerging evidence as to the contribution and effectiveness of physiotherapy in the management of CCM related disorders, which have been published also in dentistry related journals.
The modern physiotherapist will perform a comprehensive assessment of the patient and will set measurable, meaningful, and realistic goals for the patient’s management based on their findings and clinical reasoning.
The following case study demonstrates a modern physiotherapist approach:
Patient seeks care with a CCM qualified physiotherapist with a main complaint left jaw pain while chewing bread or other firm food, with a VAS of 7/10. He expresses his concerns about this pain worrying him that it will prevent him from enjoying his son’s wedding next month.
In his assessment the physiotherapist finds mouth opening range of motion of 32 mm pain free and 41 mm with pain and intra-oral bruxism signs.
In specific upper neck mobility test a limitation to the left is noticed. In specific assessment of the deep neck flexors a relative weakness is present.
The main goal of the treatment is pain free chewing of solid food to achieve with a month (by the wedding of the patient’s son). Intermediate goals are to increase and develop the patient’s awareness of clenching during the day and his ADL, reduce overall pain and specifically where palpated in left masticatory muscles and provide re-assurance by educating the patient as to good expected prognosis.
In addition, there is room to train the deep neck flexors muscles and improve the mobility of his upper neck to the left side. Objective and subjective assessment are to be used throughout the treatment program until full recovery and are to be shared with the patient.
In the case described above, the goals stated were achieved within 4 weeks, of one session per week of 30 minutes long, and the patient has fully recovered and was able to attend his son’s wedding pain and worry free.
Is PT effective for people with CCM disorders?
There is vast evidence also of strong quality (such as systematic reviews and meta analyses) to demonstrate the effectiveness of physiotherapy interventions (manual therapy and exercise) as first line treatment for people with CCM disorders (neck pain, cervicogenic headache, TMD) (references).
This is similar to the role of physiotherapy management of non-musculoskeletal headache/orofacial pain (e.g., migraine or Tension Type Headache (TTH)) which is recognized complementary clinical practice as part of a multidisciplinary team (including for example neurologist, psychologist, physicians etc.).
How can dentists and physiotherapists collaborate in the management of CCM patients?
Similarly, to other chronic pain conditions, CCM is best managed by a multidisciplinary team guided by the biopsychosocial model. CCM certified physiotherapists and dentists are the first line of therapy for individuals with cervico-cranio-mandibular pain.
The role of a CCM certified dentist is primarily to detect and screen these patients as well as offer oral appliance as necessary, and the role of the CCM certified physiotherapist is to manage the rehabilitation of that patient.
This unique collaboration between these CCM certified clinicians is imperative for best care practice for patients with CCM disorders, as also supported by the science.
Which courses are offered for Dentists?
We offer 2 courses designed especially for dentists
* Orofacial pain for dentists (16 hours)
In this 2 days’ course, participants will learn an effective evidence informed assessment & practical dry needling therapy for patients with TMD’s and other forms of orofacial pain.
* Dry Needling for Orofacial Pain & Headache (9 hours)
A one-day workshop for dentists who use dry needling in their scope of practice who wish to expand their knowledge in the application of dry needling in orofacial pain and headache presentation.