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Dental products students are taught that amalgams are composed of a mixture of metals with varying composition of mercury, silver, zinc, tin and copper. They are told that these individual metals are all toxic, but when amalgamated their toxic effects are eliminated. …The facts, however, are at variance with these views.

Dental amalgam is still the most widely used restorative in dentistry. Dental students are taught that amalgams are composed of a mixture of metals with varying composition of mercury, silver, zinc, tin and copper. They are told that these individual metals are all toxic, but when amalgamated their toxic effects are eliminated. They are reassured that the most widely used and toxic of the five metals mercury, is bound in such a way that it is not released from the restoration and presents no hazards to patients. There are still many dentists who believe that these teachings still hold true and that the use of mercury amalgam is safe.

The facts, however, are at variance with these views. Research has shown that mercury and the other metals are released from amalgam restorations during their lifetime and can be absorbed from the lungs and the gastrointestinal tract; be distributed throughout the body and concentrated at varying levels in organs and tissues.

The issue currently being debated often with more heat than light is “are the amounts of mercury and other metals from amalgam restorations that reach the target organs and tissues below the levels at which toxic effects are detectable.”

The conventional view is that if amalgam presented a toxic hazard to the average patient any effects would have become evident by now as restorations containing mercury have been in use for over a hundred years. However, modern methods of analysis and diagnosis are many times more sensitive than they were only twenty years ago. Sensitive mercury detectors can pick up the mercury released from one filling after only two minutes chewing or brushing and neurophysiological techniques can detect significant deficits in central and peripheral neuronal function in dental personnel that can be correlated with their body burden of mercury.

The amounts of mercury found in the bodies of both dental workers and patients reflects the degree of exposure. Dentists who have worked extensively with amalgam restorations over long periods and patients with many fillings tend to have higher levels of mercury in their bodies and be at greater risk from its toxic effects. In some countries the authorities have decided that the health hazards from amalgam restorations are unacceptable and outweigh the benefits from them.

Sweden has banned the use of mercury amalgams in pregnant women as the mercury readily passes into the foetus which is believed to be particularly sensitive to the toxic effects of mercury. It is expected that this ban will be extended to cover the whole population by 1997.
Other countries such as Austria are planning to phase out the use of mercury amalgam by the end of the century and in Germany the drug regulatory body has signalled its intention to ban the production of amalgam.

Toxicity of Mercury

The distinguished Swedish toxicologist, Prof. Lars Friberg, who is an adviser to WHO on heavy metal toxicity, has stated that in his view mercury should be regarded like chemical carcinogens and that there is “no safe level of mercury”.

Modern techniques of amalgam preparation and taking effective precautions during removal of amalgam fillings can reduce the exposure to mercury for both the dental staff and patients. However, even under the best operating conditions the levels of mercury vapour present in dental surgeries is higher than considered healthy and in some cases has been shown to exceed the TLV (Threshold Limiting Value) for industrial environments. Although such cases are fortunately rare there are well documented cases of dentists dying as a direct result of mercury toxicity acquired as a result of exposure during their work.

One of the earliest signs of mercury poisoning is an adverse effect on fine muscular co-ordination resulting from a neurotoxic rather than a musculo-toxic effect. This effect is thought to be on the central rather than the peripheral nervous system. Recently mercury has been shown to inhibit the formation of the micro-tubules in cells of the central nervous system. This can affect their function and can lead to impaired brain function and eventual neuro-degeneration. Some patients can show a hypersensitivity response to mercury and this may be a factor in the development of oral lichen planus. Removal of amalgam fillings in these patients can result in elimination of the condition.

A recent collaborative study among three U.S. universities has found that oral and intestinal bacteria can show a degree of cross resistance to both antibiotics and mercury. The mercury resistant bacteria were also resistant to many of the widely used antibiotics including ampicillin, tetracyclines, erythromycin and kanamycin. This may be the first example of a non-antibiotic factor inducing antibiotic resistance in potentially pathogenic bacteria. The full implications of this finding have still to be fully explored.

The mechanism by which mercury exerts its toxic effects is still not fully understood but recent evidence suggests the involvement of toxic free radicals. These are short lived but highly reactive molecules containing oxygen produced within cells, examples are superoxide, hydrogen peroxide and hydroxyl radicals. These may be a by-product of metabolism, particularly lipid metabolism or produced specifically by certain white blood cells to destroy engulfed viruses and bacteria. Free radicals can also be produced by other dental procedures, X-rays, OV light used in resin curing and local anaesthetics may all produce free radicals and although the individual amounts may be small their additive effects may be of toxicological significance.

Protective Measures

The first and most important protective procedure is to minimise the exposure of mercury to the atmosphere during amalgam preparation. Mercury has a low vapour pressure and is highly volatile at the temperatures and atmospheric pressures found in the dental surgery. Modern containment procedures are designed to minimise the release of mercury vapour into the atmosphere and hence its subsequent inhalation and absorption. However, unless the dental team are prepared to dress in space suit type protective clothing while filling and drilling to remove amalgam, mercury vapour can transfer into the atmosphere of the surgery and this can then be inhaled. As mercury is only slowly excreted from the body the burden of mercury is likely to increase with exposure, the longer the exposure the more mercury is found in the body.

Intervention to minimise the toxic effects of mercury and other free radical inducers is feasible for both the dental team and patients. Probably the most effective protective agent against the hazards of mercury poisoning is the element selenium. This has the advantage in that it can combine with mercury to reduce the bioavailability of the mercury, possibly by competing with it for critical low molecular weight proteins used in metal transport. Selenium is a vital component of the metallo-protein enzyme glutathione peroxidase. This is a major component in the body’s free radical defence system. The availability of selenium is the limiting factor in the production of glutathione peroxidase, as modern day diets tend to be deficient in selenium its addition in the form of a nutritional supplement is the surest way of ensuring that adequate amounts are available for detoxification purposes.

Other protective agents that protect against free radical activity are the various anti-oxidant vitamins. The major antioxidant vitamins are Vitamins A, C and E and the vitamin A precursor, ß-carotene; these all are capable of quenching excess free radical activity and preventing their toxic effects. As vitamin A can be toxic if taken in excess the preferred form of this vitamin is ß-carotene.

Some dental teams already take nutritional supplements of selenium and anti-oxidant vitamins and have noticed significant improvement in their health, particularly in their increased ability to undertake procedures involving repeated fine movements. As the attitude of the health authorities in the UK towards the hazards from mercury toxicity appears to be lagging behind that of more progressive countries it is good policy to supplement the diet of the dental team with selenium and an antioxidant supplement. There is no evidence that the amounts of selenium and the other vitamins present in good quality nutritional supplements are harmful and it can be considered to be good insurance for the health of the team. Some dentists advocate the removal of all amalgam fillings as in many cases this has been found to benefit the health of patients and particularly in those suffering from disorders of the immune system such as M.E. Others believe that the removal of amalgam fillings increases the risk of exposure to a greater degree than that of leaving them intact. However, the evidence suggests that it is good practice to advise patients to ensure suitable nutritional cover with selenium and antioxidant supplements prior to removal of amalgam restorations and for some time after in order to minimise any potential mercury toxicity.

Selenium in its inorganic form is poorly absorbed by the body and most of the body’s selenium comes from organic sources, where it exists, combined with sulphur-containing amino acids, the commonest is L-selenomethionine. Some nutritional supplements contain the poorly absorbed inorganic selenium but for maximum absorption of selenium a formulation containing L-selenomethionine is the one of choice.

An organic combination of selenium with other anti-oxidants provides the best insurance against possible mercury toxicity and a preparation that combines Selenomethionine with the anti-oxidant Vitamins A, B6, C, and E together with Zinc in a balanced combination is Bio-Selenium+Zinc. This preparation originates from Denmark where many dentists who are exposed to mercury take this preparation as a preventive measure against mercury toxicity.

Introduction

My body has been steadily accumulating mercury through dental products amalgam fillings since I was about eight years old. The grand total of fillings was 13, collected over some 38 years. All this time I have been absorbing mercury in ever increasing amounts daily via different routes: chewing food; having hot drinks; breathing in the vapour; swallowing the saliva containing mercury; chewing of gum in my teenage years. Even brushing one’s teeth can cause the emission of mercury to increase by five to ten times, with this raised emission continuing for 1-2.5 hours afterwards. Over days, months and years that adds up to a lot of mercury. To alleviate this I used an amalgam blocking toothpaste and, since my symptoms of coldness did decrease to an extent, this did help to reduce the intake. Added to this is the constant leeching of the mercury into the circulatory system, bones and tissues. Mercury poisons all cellular functions and has a significant effect on the enzyme and hormonal systems. Figure 1 shows the proximity of the main facial arteries to the position of teeth, and how easy it is for this poison to move through the body, particularly to the eyes and brain. Removal of fillings only prevents a further increase in the absorption of mercury, so it is vital to follow removals with detoxification specifically for the removal of mercury, otherwise it will remain lodged in the brain and major organs of the body, as well as tissue and skin, and cause further problems.

Figure 1: Main facial arteries

At the age of 46, the seemingly unrelated symptoms steadily worsened to a level that I believe would have become life-threatening in the immediate future. Apart from the symptoms discussed later, I was finding it increasingly difficult to continue from day to day. It was as if all my systems were coming to a halt at an alarming speed. I had almost closed my practice, which had already been reduced due to parental illness the previous year. Now it seems silly not to have done something sooner, but I had approached doctors and dentists and been told there was nothing wrong, and ‘to pull myself together’. This left me not knowing where to turn. However, having read articles and books, and realizing that my life was deteriorating rapidly, I knew I had to do something quickly and found a sympathetic dental practice in Edinburgh. My initial appointment was in April to assess the treatment required. We agreed on removals in four sessions over six weeks. This allows the body time to adjust and clear any further release that may occur during removal but also means that the fillings are removed fairly swiftly and the detoxification process can begin properly. The removals were set for September/October. Despite having to wait all this time, it was good to know that something would be done. It was also a relief to meet someone who knew exactly what was wrong – I had gone there armed with copies of articles and reasons for the removals, and for once I had no need of them. I was talking to someone knowledgeable both of the havoc mercury can create in the body and also of the safety procedures required for such removals, which inspires great confidence.

Symptoms

The following symptoms were experienced throughout my teenage years and adult life to different degrees. I tried to alleviate them using essential oils, herbal and homeopathic remedies and diet, but these stood little chance in the face of such toxicity. I found a small amount of relief initially with some, but this did not last, presumably due to the increasing mercury in my system. The inability of such remedies to help also led me to realize just how widespread the problem was. It is interesting to note that since the removals I have used remedies and their effect has been good.

Mouth

The inside of my mouth was aggravated by the mercury. I would find myself biting the skin to such an extent that it would be torn, sore and inflamed. I would be fine until early afternoon and then I would find myself suddenly tearing at the inside of my mouth with my teeth as if something had to be released or removed. Sometimes I managed to prevent this with a lot of willpower, but it was something beyond my control. Amazingly, my body would have worked all night to repair the damage and the skin would be perfectly smooth the next morning. My gums looked pale and unhealthy and bled when I brushed them, and my teeth sometimes felt loose. The teeth did not really feel like part of me – they were separated by this toxic barrier. I was always aware of the fillings.

Eyes

My eyes have become increasingly light sensitive and easily tired. Over the past two years I have had the help of a vision therapist, and we have worked to improve my vision through exercises, palming and the use of eye patches to allow the eyes to work individually as well as together. But again this had limited effect since the cause was not being addressed.

Ears

The main problem was when descending in an aeroplane. I would suffer excruciating pain along my jaw and up to my ears and temples. My head felt as if it would split. I just sat in dreadful pain with tears pouring down my cheeks. Some pain would continue for several hours and I would feel unwell for two or three days after. Not surprisingly, I had decided that I never wanted to fly again after the most recent occasion. I also had recurrent bouts of piercing pain but with no evidence of infection. As my mother has had problems with her ears, I thought perhaps this was hereditary.

Nose

Over the past three years I have had small cuts inside my nose which would not heal and became infected on several occasions. The inflammation did clear from using tea tree and neem oils, but not the cuts, and I often felt as if I were getting flu.

Periods

In my mid-teens these became extremely heavy with a lot of clotting. In my 20s and 30s they were not so heavy but later again became heavy with increased clotting, cramps, fluid retention and mood swings. They were increasing to twice monthly but I managed to regulate them using a blend of essential oils, so in this case the oils did manage to break through the mercury blockade. Periods have become worse in recent years: very heavy with clotting, 6-7 days’ duration, mood changes beforehand, headaches, feelings of not being able to cope and fluid retention for 14 days prior combined with breast tenderness and sometimes sharp pains. There was very sharp, intense cramping always only on the right-hand side on the first day and night of the period, followed by more general cramping plus lower back pain. The whole process was rapidly affecting not just the duration of the period, but the weeks on either side, and also my relationships with my husband and daughter because of the effect on my health.

Sciatica

This began three years ago and always occurred at the start of the period and lasted for one day. It was so painful that I had to take painkillers during the day and before going to bed and I would feel tired and unwell the following day (perhaps due to the painkillers).

Circulation

As a schoolgirl I suffered from very painful chilblains every autumn through to Easter and I would become chilled waiting for the bus to and from school. My feet would be numb during gym class (we had to do this in bare feet on cold wooden floors) and it was painful to walk. The doctor suggested an operation but thankfully we declined this. Since then, the coldness in my body has increased, seeming to come from within, from the marrow of my bones and especially down my spine. My temperature control was either one extreme or the other and I disliked change – of temperature and of surroundings. Five years ago, I was diagnosed as having Reynaud’s disease, as my fingers and toes and the balls of my feet would easily become numb, white and painful, and take a long time to warm up. I had to wear thick bed socks and have a hot bottle at my back and double covers, but still I never felt really warm from within. In the daytime I wore thermal vests, layers and socks, but my feet still became numb, even in the house. I dreaded autumn, winter and spring, but also going on holiday to a warm climate as I would overheat. The problem of excessive sweating which began in my teens continued and was more of a nuisance than a physical hardship – finding the most suitable clothes’ styles and fabrics to avoid staining. In desperation I used a very strong antiperspirant once and it resulted in my being very ill for several days, with lumping under my armpits. I preferred to change my tops at least twice or more daily if necessary.

Fatigue

This became noticeable when I was in my 20s and was working in offices. I had difficulty getting going in the morning. I was never late for work but it took a great effort to get up; some mornings would be much worse than others but I could never work out the reason. My doctor thought I was just lazy. I did not want an excuse to stay off work; I needed to find out the cause so that I could remedy it. I had the energy to attend night classes and to complete a full day’s work, but at that time it was in the morning that I felt unwell. Our daughter was born 16 years ago. The birth lasted 12 hours and forceps were required, so afterwards I was badly bruised internally and in great pain but also very tired. I fed Jane myself for nine months so any fatigue then was put down to feeding during the day and often at night. I expected to feel an improvement as the years went on, but this did not happen. Tests have been carried out on a couple of occasions, but these proved negative and no helpful advice was given. I felt like a hypochondriac and was treated like one.

Having to get up at 6.45 am to ensure Jane got to school on time has kept me going. I am not sure that I would have had the determination to do that otherwise. Once I had my first shot of mercury via a hot mug of tea or two, I would feel much better. I altered my diet and became vegetarian over ten years ago to try to solve the mystery. No matter what I included or excluded there was no pattern emerging. Last year my energy levels became seriously low, which prompted me to find a mercury-free dentist. I was so exhausted all the time, to a point where resting for half an hour or even longer made no difference. There was no way to replenish the energy I was losing. This affected my spirit and I felt very light and not of this world at times, which was frightening. My thoughts were negative and I was reducing what I did rather than looking to expand my business and to the future ahead. I could see no future.

Brain

Over the past three years I noticed that I was finding it more difficult to take in information and to remember it. My brain seemed to be at capacity, or as if it were jammed. I began to notice slurring of speech and difficulty in finding words, which soon became a daily occurrence. We joked about it, but I was aware of how serious a problem this could be. Tingling in my fingers and a slight numbness in the arms occurred on several occasions. I was anxious that these symptoms might indicate multiple sclerosis or a similar disease, but I also knew it was the mercury fillings that were causing them. My fear was of my daughter having to visit a mother of 50-60 years old who was unable to communicate or recognizse her and for this to continue for many years instead of the close friendship we enjoy.

Mood Swings

Mood changes were outside my control. I would have planned to spend a morning with my husband and to have anticipated this all week only to feel on the day that that was the last thing I wanted to do and there was no way to change this. I would be stuck in that mind-set the whole day. It spoilt so many occasions. I always felt that it was like someone else doing it and deep down I did not want to be grumpy and bad company. There was anger inside, dissatisfaction with my life, with myself. I could see no logical reason for these feelings when I looked at them objectively, so why did I continue to feel and act like this? It wasn’t the real me.

All these symptoms could possibly be coped with singly, but together they engulfed me. On several occasions I felt that my husband and daughter would be better off if I were not living with them. They would not have had to put up with the fallout and the negative energy I must have been exuding. When giving treatments, I blocked out all the symptoms. I was totally committed to giving the best treatment I could and my concentration was centred on the client. My standards remained consistent and I am confident that no clients received lesser treatments at any point during this time. If I could not have maintained this, I would have closed In Harmony at once.

The Removal Process

The initial consultation with my dentist was to assess the level of leeching of the mercury and the state of the teeth, and plan a removal programme and the preventative measures both in the surgery and through supplements. We decided on four sessions at fortnightly intervals: three on the upper left, four on the lower left, three on the upper right and finally three on the lower right (see Figure 2). The gap between sessions allows the body to clear any mercury that may be absorbed during the extraction process despite the precautions taken. Any trauma to the gums has time to settle.

The sessions lasted two hours each. The extractions were fairly quick due to the drill, which allows chunks of filling to be removed, thereby reducing mercury particles. Any stray pieces in the mouth are easier to see and remove. A suction tube remains in the mouth during the extractions, removing mercury and saliva; a rubber dam around the teeth helps to prevent absorption during drilling; a protective nose mask reduces inhalation of mercury dust and vapour; goggles protect the eyes; a protective apron covers the body from neck to toe; an extraction fan removes air which may contain mercury particles and vapour, to protect the patient, dentist and staff, and further patients. The dentist herself wore a protective mask. I required extra local anaesthetic on two occasions to ensure total numbness of the areas. There should be no pain whatsoever. The numbness took a few hours to disappear, but two doses of Arnica tablets taken orally and Arnica cream massaged into the cheek area resulted in very little bruising. I also massaged the gum gently and washed out my mouth with chamomile tea regularly to soothe the gums, cheeks and teeth. The tea helped to calm my whole body and aid the healing process.

The refilling of the cavities is carried out once all traces of the mercury fillings have been removed. There was decay under almost all my fillings, which would have gone undetected until it became so bad that I needed them removed. The filling of the cavities requires skill and precision, as do the removals. The material used is a non-toxic composite, which is compatible with the teeth and has the added bonus of looking good. The cosmetic effect of white fillings should not be underestimated. I have admiration for my dentist who carried out the procedures with immense care and concentration over each two-hour session. The effect on my health and life cannot be calculated and I owe her so much.

Detoxification Programme

Prior to the Treatments

I took Essiac daily for three months, a herbal blend of burdock root, turkey rhubarb root, sheep sorrel and slippery elm bark. It rids the body of metabolic wastes, increases cellular metabolism by normalizing blood chemistry and rebuilds the immune system. This was to boost my body’s systems so that once the mercury amalgam was removed I could go straight into the cleansing tonics to clear the major organs of the mercury. On the day of removals I took charcoal tablets before and after to absorb the mercury and expel it from the body. Selenium and zinc are used up quickly by the body when dealing with heavy metals, so daily supplements were recommended: selenium 100mcg and zinc 15-20mg.

the Treatments

After all the removals are completed, cleansing of the vital organs must follow. One cleansing tonic should be used at a time. This process should be undertaken consistently to ensure success, particularly with the colon cleanse parts 1 and 2. These help to clear old faecal matter, allowing for easy removal, aid regular evacuation, and draw out poisons, toxins and heavy metals. It can seem awkward and unpleasant to keep to the programme at times, but the benefits are too great to abandon it. The daily amounts are small so that the body is not overloaded by the detoxification process and no healing crisis should occur. I have had a minor recurrence of some of the symptoms during the cleansing, but these have passed quickly. The other cleanses that followed were:

* Liver and gall bladder cleanse: dandelion root, cinnamon bark, liquorice, juniper berries, cardamom, bearberry leaf, cloves, ginger, milk thistle, Oregon grape root, Swedish bitters and colloidal silver. Freshly squeezed organic orange juice precedes the cleanse each morning;
* Kidney cleanse (preceded by fresh organic lemon juice): corn silk, bearberry leaf, dandelion, horsetail, burdock root, goldenrod, juniper berries and colloidal silver;
* Blood cleanse: red clover, chapparal, garlic, burdock root, gotu kola, cayenne, Echinacea, cat’s claw, gingko biloba, horsetail, poke root and colloidal silver;
* Brain tonic: gingko biloba, gotu kola, calamus root, rosemary, kola nut, cayenne and colloidal silver.

All these herbs help to cleanse the systems of the body while aiding the healing process. These cleansing tonics should ideally be taken in rotation throughout the year to cleanse the body of pollutants as well as poisons such as mercury. The courses last two to four weeks.

Recovery

I continued my vegetarian diet, including neem tea and kombucha tea, which both aid the immune system and detoxify the body. Energized water (two litres daily) is necessary to flush the toxins and wastes out of the body while hydrating it. It is easier to continue a well-established habit than to try to cope with several changes at once. There is much more likelihood of success without a healing crisis.

Mercury had been in my body for so long that I thought it would take months for any improvements to show. After just the first removals I felt much lighter, more positive and less tired. These changes continued, improving with each session. The difference made by removing just three fillings demonstrates the amount of mercury leaking into my body daily.

All of the symptoms listed above have been reduced or removed. I now have more energy and if I do become tired a short rest revives me. I wake up looking forward to the day ahead and have a positive outlook; I feel grounded; my eyes are less light sensitive and stronger; I have started up my business with new and existing clients and extended my product range; I can control my mood, so we have had many enjoyable occasions since October; slurring of speech and loss for words are improving; my brain feels clearer and does not race. We flew to Dublin for a few days and I was amazed to feel no pain at all when landing – it was marvellous. Period-related problems have greatly decreased – less fluid retention, lighter and shorter, very mild sciatica, mild headache, only slight grumpiness. Excess sweating has ceased. My body temperature has risen so I no longer feel cold in my bones – I feel constantly warm and have no need of bed socks and layers of thermal vests. I only experience numbness in one finger occasionally and it warms up quickly. Any coldness I may feel when outside seems external and easily dealt with. There has been no recurrence of tingling fingers or numbness of arms. The gums look pink and do not bleed; my teeth feel part of me. Of great interest to me is the regeneration of the tissue of my upper and lower lips, which has filled out. My facial skin has a pink glow even without make-up and the shadows under my eyes are now pink/brown not almost black as before. The cuts inside my nose healed up and have recurred only once. A fungal infection under my little toenail has totally cleared now and a new nail has grown up slowly. The best improvement is that I can enjoy life and look forward to the future and I know I am much more pleasant company now.

Introduction

The concept that good health is related in some way to posture is not new to Eastern or Western health philosophies. It has been established that dental health dental supplies can have an impact on general health., However, for many people, the possibility that their dental bite can influence posture and therefore their health is a thought-provoking idea.

The aims of this article are to present some of the key evidence that dental occlusion (bite) can influence an individual’s posture and put forward the case for making an objective postural assessment which includes evaluation of occlusion as an essential part of the clinical management of postural problems.

Figure 1. Image showing head and neck with groups of muscles.
M1 closing mouth. M2 Supra hyoid muscles opening mouth and head posture forwards.
M3 Infa hyoid muscles, opening mouth and head posture forwards.
M4 Neck muscles, head posture backwards.

Some General Thoughts About Posture

Good posture in humans is seen when the head is supported by the vertebral column which in turn is supported by the pelvis, legs and feet. The arms are suspended from the individual’s shoulders, which are level with respect to the pelvis and feet. The individual’s centre of gravity is situated within the body such that their weight is distributed evenly through all the vertebrae and the person is comfortable. The feet are at the centre of the physical forces acting upon the body whilst standing. Maintenance of an erect head posture depends upon the interaction between gravity and the muscles, bones and joints, all of which are coordinated by the individual’s nervous system.

In cases of poor posture, one of the patterns seen commonly involves the centre of gravity being projected forward, usually due to the head being held forward, anterior to the vertebral column. This places a strain on the muscles of the neck, shoulders and lower back and if symptoms occur they will be noted to involve the vertebrae of the neck and lower back. Whether symptoms occur, and their exact site, is dependant upon several factors that include the duration of the compensated posture and the individual’s ability to tolerate the adaptation.

What Drives Posture?

If one considers the human body as a closed mechanical system, the genetic make-up of an individual will dictate their body shape and musculo-skeletal composition. As a baby, posture is controlled by reflex coordination of the neuromotor system. These reflexes, which are developed in utero, are pre-programmed responses to stimuli and are designed to aid survival. As growth, development and maturation proceed there are underlying reflexes that provide support for body functions, and as they mature they provide the foundations for voluntary and coordinated movements to take place. If there are any imbalances, for example, if there is a problem with one of the joints, there will be some sort of compensation in order to maintain the overall stability of the system. So, any observed postural changes will result from the interaction between the genetic and environmental factors.

If an adjustment takes place in one part, for example as a result of a stone in your shoe, compensations will take place as you walk in order to maintain stability of your posture. If the stone is left in your shoe, the position of the stone in your shoe will determine the actual compensation that will result. This change in posture, which if maintained over any length of time, may cause symptoms distant to the foot under which the stone was placed. In addition, there may be a specific local effect, in this particular case, formation of a blister. This hypothetical situation can be considered as an ascending effect caused by an environmental factor. The possibility of descending effects, specifically the interaction between cranial factors including bite and changes in posture, must also be considered. The simplest explanation for a descending factor altering body posture is that it is caused by changes in head posture, as the head has to be balanced on the neck and supported by the pelvis, legs and feet.

An Overview of the Relevant Anatomy of the Head and Neck

Figure 1 shows a stylized view of the bones of the head and neck with the various groups of muscles involved in maintaining its posture and function. There are antagonistic groups of muscles that are responsible for the opening and closing movements of the mouth that facilitate breathing, chewing, swallowing and speech. The muscles responsible for closing the mouth are attached above the mandible, via tendons, to the skull. Those muscles below the mandible are anatomically described as being above or below the hyoid bone and together with gravity, are responsible for opening the mouth. The tongue is suspended from the inside of the mandible above the hyoid bone and has muscles with a range of different orientations. These facilitate changes in its shape and together with the surrounding muscles control its position.

The atlanto-occipital (A-O) joints are a pair of synovial joints contributed to by the occipital bone, which forms part of the base of the human skull and the first neck or cervical vertebra called the ‘Atlas’. This arrangement is unique in the neck as there are only two articular facets, whereas all the other cervical vertebrae have three articular facets. Both sliding movements and rotations take place at this joint.

The lower jaw or mandible articulates with the skull via the pair of tempempero-mandibular joints (TMJs) with the temporal bones, within which the sensory centres for hearing and balance (auditory and vestibular apparatus) are housed. The TMJs have a piece of cartilage interposed between the articular head of the mandible, the condyle and the base of the skull. The movement of the mandible involves not only hinge-type rotation but, also a sliding motion at the TMJs.

There is a considerable amount of standard anatomical literature that describes the 22 bones of the skull and the shapes of the joints (sutures) and the 106 different articulations. Kragt et showed that movement was possible at the sutures in macerated human skulls and Retzlaff at documented that the cranial sutures do not fuse with age. Prichard concluded that “it may be deduced from their mode of development and their histological organisation, that sutures form a strong bond of union between the adjacent bones, while permitting slight movement.” The possible association between motion of the cranial bones and restorative dentistry was reviewed by Libin, who concluded that the cranial mechanism offers dentists an added dimension for solving and avoiding clinical problems.

Tooth position is determined by the position of the supporting bone and pressure from the surrounding soft tissues. They occupy a ‘neutral’ zone determined by forces from the tongue inside the mouth and the cheeks and lips outside the mouth. Local factors such as sucking habits, for example a thumb or pencil, or wearing an orthodontic appliance will alter tooth position and can change soft tissue shape and function as well.

Linking Head Posture and Bite

Head posture and bite are intimately related. It has been shown that head posture can influence initial tooth contacts You can do an experiment by bending your head forwards, biting together and notice how your bite feels. Stop biting your teeth together, now tilt your head back fully and bite again. Notice the difference in how your bite feels. Maintenance of head posture depends upon the interaction between the effects of gravity and the balance between the muscles that stabilize the head. If we consider that the teeth provide the balancing contact for stability of head posture, it is possible that changes in our bite will have an effect as well. A non-ideal arrangement of the teeth is called a malocclusion. A normal bite of occlusion is called a Class I. When the upper jaw is more in advance than the lower jaw than average, this is termed a Class II, and if the lower jaw is positioned in advance of the upper jaw this is termed a Class III.

Using a balance platform it has been shown that subjects with Class II malocclusion exhibit an anteriorly displaced posture, whereas subjects with a Class III malocclusion exhibited a posteriorly displaced posture. When investigating the posture adopted by the cervical vertebrae, it was reported that nearly half the patients with a Class I or Class II had a marked cervical lordosis (arching forward) whereas Class III had abnormal kyphosis (arching backwards). The Class I and Class II patients benefitted from treatment but Class III did not

When comparing Class I and with Class III malocclusions, the position and inclination of the hyoid bone was found to be more anterior and it had a reversed inclination. The implications of this research were that malocclusion can influence supra- and infra-hyoid muscle function and affect the direction of mandibular growth.

Patients with severe malocclusions have most commonly been found to have a head and neck forwards posture. This forward head and neck posture has been significantly correlated with the Class II skeletal pattern.

A review of the dental literature carried out by Woda et al reported that mandibular position is constantly variable, and that mandibular posture greatly depends upon head posture.

Compensations in Head and Neck Posture That Can Cause Pathological Changes

Given that it is possible for movement to occur at the AO joints, temperomandibular joints, sutures of the skull and hyoid bone, it is not so surprising to find that compensations may occur which can lead to symptoms. Although teeth make micro-movements in their sockets, and the amount of movement at the cranial sutures is limited, most of the compensations that can take place tend to occur at the AO joints, in the TMJs, the hyoid bone, vertebrae or the surrounding soft tissues. Faulty position of the cartilage between the head of the condyles and the base of the temporal bones can lead to clicking or popping noises from the jaw joints when patients experience symptoms from their TMJs.

Altered head and neck posture is often the cause of TMJ problems. Patients with a malocclusion compensate by altering the normal masticatory muscle function, perhaps facilitating cervical spine disorders. Some of the other symptoms such as tinnitus and vertigo may be due to the fact that the vestibular (balance) and auditory (hearing) centres are located in the temporal bones. Other symptoms distant from the head and neck may be linked to descending problems but may not be apparent unless assessed specifically.

How to Assess Posture

To establish the correct diagnosis may involve a combination of conventional and complementary techniques. If the therapist or clinician assesses posture visually and makes a written record, this is a subjective assessment and, although it may not be fully detailed, can provide a reasonable assessment. It has been shown that photographs provide a reliable way to evaluate posture and this is an objective, repeatable method. With the introduction of affordable digital cameras this is likely to become the method of choice in the future. The general body postural assessment system that is used in my clinic involves two mirrors, one above and one at the side of the person being assessed. Both these mirrors are angled so that the digital camera, which is a fixed distance from the subject, can see the vertex and side view at the same time as a back or front view, and only two images are needed to evaluate the gross static posture (Figures 2 and 3). To carry out a cranial assessment, the patient’s head is placed in a cephalostat. This device uses short conical plastic tubes, which are inserted into the ears to produce a ‘relative’ horizontal plane, in turn making the ears parallel to the floor (Figure 4). All other facial planes are then measured relative to the ear plane. Once the postural images have been assessed it is then possible to decide if any other tests such as x-ray pictures may be appropriate to aid the diagnosis and help plan treatment.

Case Report: 1

An example of an ascending problem that was ‘locked in’ by the bite is shown in Figures 2, 3 and 4. This patient was referred by his osteopath, who reported that she could not correct this young man’s pelvis any further and wondered if his bite was contributing to his symptoms. The initial clinical assessment showed that the patient had major postural compensations. He had a deep bite and there was a pattern suggesting that his temperomandibular joints were involved. The effects of his dental splint therapy are shown following treatment for one month (Figure 5) and after three months (Figure 6). The dental treatment allowed spontaneous correction of the patient’s pelvis as there was no osteopathic input during the three months of dental splint therapy.

Management of Bite and Postural Problems

There is a growing awareness amongst healthcare workers that patients often require multi-disciplinary input to help them attain optimal health. The key issues are to ensure that the correct diagnosis is made and to integrate not only the provision of appropriate therapies but also to coordinate the way that the treatment is administered.

Although conventionally and complementarily trained clinicians and therapists are well qualified and may have many years of experience, they often concentrate on just their area of expertise. If a truly holistic approach were to be taken in relation to managing postural problems, regardless of the therapist’s speciality, ideally posture should be quantified before, during and after treatment. When evaluated before treatment this can help determine whether there is a postural component contributing to an individual’s symptoms, and which aspect of the posture is the key component. During treatment, a postural evaluation will ensure that the postural problems are being managed appropriately. Finally as maintenance of health is a very important aspect of optimal health, postural evaluation can provide motivation and feedback which will allow an individual to ‘help themselves’ and not rely entirely on further therapeutic input from others.

Correct treatment of any clinical problem must be based on making the correct diagnosis, the confirmation of which is then aided by the use of special tests such as radiographs and blood tests. The management of postural problems is no different. Often patients will be having their symptoms treated and this will provide some relief, but not actually solve their problems. Assessment of bite in relation to postural problems, prior to treatment, will ensure that the correct treatment is carried out.

For example, it has been reported that postural and muscle function abnormalities appeared to be more common in patients with temperomandibular disorders, and if they do not respond to dental splint therapy, the interaction between their posture and muscular function should be investigated.

Case Report: 2

An example of a descending dental cause of postural changes is shown in Figure 7, in which the patient’s head is tilted to her left. This 7-yearold girl presented with an abscess associated with her upper right first baby molar (Figure 8). Her postural pattern is what would be expected if she had altered her bite as a result of pain from the abscessed tooth. Her abscess had been present for several weeks and management had been based on the use of antibiotics alone. This had not completely resolved her symptoms, which included inability to chew on her right side. After resolving her abscess by removing the tooth and balancing the extraction by also removing the contra-lateral baby molar (Figure 9), the photograph taken at her follow up visit, four days later showed that her head tilt was resolved (Figure 10) and she was no longer experiencing discomfort from her mouth.