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The cervical spine,

Stomatognathic System
and Craniofacial Pain:
What is the Connection?
Susan Armijo-Olivo, BScPT, MScPT, PhD
Faculty of Rehabilitation Medicine
University of Alberta
Canada
susanarmijo@gmail.com

Why is this
Connection
Important?

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Introduction
DENTISTS
PHYSICAL THERAPISTS
PSYCHOLOGISTS
SPEECH PATHOLOGISTS
PHYSICIANS....

Craniomandibular
System

Types of Connections

Anatomical
Biomechanical
Neurological
Pathological
Pathophysiological
Clinical

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Anatomic and Biomechanical

Connection

Body Systems and

Craniomandibular system

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Craniomandibular System

Head,
Neck, and
.
shoulder Girdle,
work anatomically,
physiologically, and
biomechanically
together.

Gillies G et al.,. A biomechanical model of the craniomandibular complex and cervical spine based on the inverted pendulum. Journal of Medical Engineering & Technology. 1998;22(6):263-269.
Gillies GT, et al.,. Equilibrium and non-equilibrium dynamics of the cranio-mandibular complex and cervical spine. Journal Of Medical Engineering & Technology. 2003;27(1):32-40
Rocabado M. Biomechanical relationship of the cranial, cervical, and hyoid regions. The Journal Of Cranio-Mandibular Practice. 1983;1(3):61-66.

Craniocervical Equilibrium

Inverted Pendulum

Craniocervical equilibrium
- Importance of Cervical
Muscles

Gillies G et al.,. A biomechanical model of the craniomandibular

complex and cervical spine based on the inverted pendulum. Journal of
Medical Engineering & Technology. 1998;22(6):263-269.

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Craniocervical Equilibrium

Importance of cervical Muscles

Global muscle system

Upper trapezius

Splenius capitis

Splenius cervicis

Semispinalis capitis, and

Sternocleidomastoid

Local muscle system.

Cervical multifidus,

Longissimus capitis,

Longissimus cervicis,

Intertransversus,

Longus colli,

Rectus capitis,

and the suboccipitalis muscles at upper cervical level

Superficial Multifidus

Craniocervicomandibular Relations

Deep Multifidus

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Craniocervical posture is
related to the position of
the mandible and facial
structures
Makofsky HW. The influence of forward head posture on dental occlusion. Cranio: The Journal Of Craniomandibular Practice. 2000/1 2000;18(1):30-39.
Makofsky HW, Sexton TR, Diamond DZ, Sexton MT. The Effect of Head Posture on Muscle Contact Position Using the T-Scan System of Occlusal Analysis.
Cranio-the Journal of Craniomandibular Practice. Oct 1991;9(4):316-321.

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Sliding Cranium Theory

11

Changes in head posture

produce a change in the
position of the jaw and
consequently a modification
of teeth contact and
muscular activity
Makofsky H. The effect of head posture on muscle contact position: the sliding cranium theory. Cranio: The Journal Of
Craniomandibular Practice. 1989/10 1989;7(4):286-292.

Cervical Flexion

12

Anterior mandibular
displacement
First contact in the anterior
zone ( Schwarz, 1928; Preskel, 1965)
Increase of the
electromyographic activity of
digastric muscles (Fumakoshi, 1976)

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Cervical Extension

13

Posterior mandibular displacement

The first contact is in the posterior zone (Schwarz, 1928; Posselt
1952; Preiskel, 1965)

Increases in the activity of the temporal and masseter

muscles (Funakoshi and Fujita, 1976)
Increases the tension of the suprahyoid muscles,
masticatory muscles and cervical muscles (Yamabe, Yamashita
and Fuji, 1999)

Mandibular retrusion (stretching ) (sollow and Tallgren , 1976;

Golsdtein 1984; Gonzalez and Manns 1996; Kohno et al. 2001)

14

During Mouth Opening head moves

toward extension and during mouth
closing moves toward flexion
Kohno S, Kohno T, Medina RU. Rotational head motion concurrent to rhythmical mandibular opening
movements. Journal Of Oral Rehabilitation. 2001/8 2001;28(8):740-747.

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Craniocervicomandibular Relations

Forward head posture required more

masseter muscle activity when compared
with a corrected posture (21.7% MVC) (in
sitting position).

Slouched posture increased the activity of

masseter muscle in 21.9% MVC in standing
position compared with the other studied
postures (corrected posture, habitual posture

15

and forward head posture).

The increase in masseter Normalized EMG in

forward head posture and slouched
posture was clinically significant

McLean L. The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. Journal of Electromyography and Kinesiology.
2005;15(6):527-535.

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Neurological Connection

Cervical spine

18

(C1, C2, C3)

Trigeminocervical
Nucleus

Craniofacial
Pain

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Trigeminal nerve

19

Convergence

Trigeminocervical Nucleus

20

Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic

mechanisms. Current Pain And Headache Reports. 2001/8 2001;5(4):382-386.

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Trigeminocervical Nucleus

21

Pain from any structure innervated by

C1, C2, and C3 can be perceived in
regions innervated by trigeminal nerve

Bogduk N. cervical causes of headache. In: Grieves BJ, Palastanga N, ed. Grievess Modern Manual Therapy: The vertebral
Column. Edingburg, London, Madrid, Melbourne, New York, and Tokyo: Churchill Livingstone; 1994:317-332.

Structures Innervated by C1, C2, and C3

22

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Trigeminocervical Nucleus

23

Some recent evidence has proposed that subnucleus caudalis (SC) and C1 and C2 dorsal horns
may act together as one functional unit to process nociceptive information from craniofacial and
cervical tissues

Pain coming from orofacial region or cervical spine could be interpreted as coming from either
region (i.e. orofacial or cervical spine) since sensory information coming from both areas is
integrated at the trigeminocervical nucleus,

Thus responses to this pain could be directed to either place (i.e. orofacial or cervical spine).

Morch CD, Hu JW, Arendt-Nielsen L, Sessle BJ. Convergence of cutaneous, musculoskeletal, dural and visceral afferents onto nociceptive neurons in the first cervical dorsal horn.
European Journal of Neuroscience. 2007;26: 142-54.
Hu JW, Sun KQ, Vernon H, Sessle BJ. Craniofacial inputs to upper cervical dorsal horn: Implications for somatosensory information processing. Brain Research. 2005;1044: 93.

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Experimental
Evidence :
Neurological
Connection

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Animal Experiments

25

First 3 levels of the cervical spine and Trigeminal Nerve merge into a
single column of gray matter (Kerr , 1961; 1972)
Craniofacial inputs ( tooth pulp, mucosa, tongue muscles, larynx, TMJ
and neck) converge in Nucleus caudalis of the trigeminal nerve in cats
(Sessle et al. 1986).

Stimulation of afferents from jaw , tongue muscles and neck muscles

excited WDR and nociceptive neurons in Pars caudalis nucleus (Sessle et al.

1986)

Animal Experiments

26

The irritation of TMJ caused an increase in the activity of masticatory

and cervical Muscles in rats. ( Yu et al. 1995)

Irritation ( bradykinin) of the TMJ caused changes in the sensitivity of

muscles spindles in cervical spine. ( Hellstrom et al, 2002)

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Animal Experiments

27

Stimulation of cervical
paraspinal tissues ( mustard
oil) caused increase in the
Masticatory muscles as well
cervical muscles EMG (Hu et al,
1993)

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Cervical Joints , their

Nerves and Craniofacial
Pain

30

Cervical Joints
(C2-C3 and C3-C4)

Atlantoaxial Joints

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Experimental Evidence

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Zygapophysial joints Pattern

33

Cervical Joints
(zygapophysial joints)
pain patterns obtained in
healthy volunteers (Dwyer et.
al. 1990)

Pain more spread in

patients than
healthy subjects

34

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Patterns of pain evoked in a volunteer by stimulating the Zygaphophyseal joints at

segments C2-C3 to C6-C7 ( Dwyer et al., 1990)

36

Pain similar to
reported by patients.
Cervical blocks
(nerves and joints)
caused relief of
symptoms

Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal

joint pain patterns. II: A clinical evaluation. Spine. 1990/6
1990;15(6):458-461.

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Patterns from Joints C2-C3, extended

further into the head, toward the ear,
vertex, forehead, or eye.
Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain. Spine. 1988/6 1988;13(6):610-617.

Atlantoaxial joints pain patterns

38

Atlantoaxial joint
blocks caused relief
of pain in patients
with occipital
headache

Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral atlantoaxial (C1-2) joint. Cephalalgia: An International Journal Of Headache. 2002/2
2002;22(1):15-22.

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Symptoms reproduced by injection of contrast medium into cervical

joints ( C0-C1; C7-T1) or by electrical stimulation of the dorsal rami (C3C7) with a larger number of patients
Fukui S, Ohseto K, Shiotani M, et al. Cervical zygapophyseal joint pain patterns - Pain distribution determined by electrical stimulation of the
cervical dorsal rami*. Pain Clinic. 1996;9(3):285-293.

40

Cervical Medial
branches blocks
and cervical joints
relief referred
symptoms

Bogduk N, Marsland A. On the concept of third occipital headache. Journal

Of Neurology, Neurosurgery, And Psychiatry. 1986/7 1986;49(7):775-780.

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Cervical Muscles, Myofascial

Pain, Muscular pain models
and Craniofacial Pain

42

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Myofascial Syndrome: Trigger Points

43

Myofascial Pain Syndrome ( MFPS):

Pain that is derived from myofascial
trigger points, which are highly
localized and hyperirritable spots in
a palpable taut band of skeletal
muscle fibers

Pain, stiffness, weakness

Restricted Movements

Cervical Myofascial Pain : Evidence

44

Referred pain to the cranial zone ( Fricton 1985, Davidoff 1998,Travell and Simmons 1999,

Wright, 2000)

Muscles innervated by C1, C2 and C3 commonly refer pain to the facial

region (Fricton, 1985, Travell and Simmons; Wright, 2000).

Active TPs in the cervical and shoulder muscles of patients with headache
and orofacial pain are usually found (Wright, 2000)

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SCM Myofascial Pain Syndrome

45

The SCM causes pain in the

fronto-temporal region,
occiput, vertex, forehead,
and the orbit

Upper Trapezius and Splenius Myofascial Pain Syndrome

46

Trapezius muscle refers pain to

the head, neck, orbital, and
preorbital regions.

Splenius capitis and splenius

cervicis refer pain to the vertex
of the head, behind the head,
behind the eye and the
occiput

Simons D. Travell & Simons Myofascial Pain and Dysfunction :The Trigger point Manual. 2nd ed. Baltimore: Williams and
Wilkins; 1999.

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Cervical Myofascial Pain and Craniofacial Pain

47

Patients with MFPS of the upper trapezius

decreased their pain and EMG activity in masseter muscle after injecting upper Trapezius
TP (Carlson et al, 1993)

Splenius capitis and the splenius cervicis TP treatment caused relief in patients
occipital neuralgia (Grad-Radford et al, 1986)

Stimulation of the TPs during an headache attack exacerbates or intensifies the

headache.

TP Inactivation relief the symptomatology (Davidoff, 1998; Wright 2000).

Cervical occipital Myofascial Pain and Craniofacial

Pain

48

TPs from suboccipital

muscles cause referred
pain in patients with
occipital neuralgia
(Davidoff, 1998)

Davidoff RA. Trigger points and myofascial pain: toward understanding how they affect headaches.
Cephalalgia. 1998;18(7):436-448.

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Cervical Myofascial Pain and Craniofacial

Pain

49

Lower cervical intramuscular

anesthetic injections have
demonstrated good results in relief of
symptoms in patients with intractable
head or face pain (Mellick and Mellick, 2003)

Map of referred pain generated by palpation

50

The most common referred pain

source in the craniofacial region
was from palpating the trapezius
muscle ( Wright , 2000)

Wright EF. Referred craniofacial pain patterns in patients with temporomandibular disorder.[see comment][erratum appears in J
Am Dent Assoc 2000 Nov;131(11):1553]. Journal of the American Dental Association. 2000;131(9):1307-1315.

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Muscle Pain Experimental

Models

Experimental Pain Models: Muscular Pain

52

Glutamate injections on the splenius capitis

muscle referred pain to:

The ipsilateral neck and occipital region,

And in some subjects, toward the ipsilateral upper
head and temporal region (46.15%). (Svensson et al.

2005)

In one subject, the reference pattern reached

the teeth and masseter region (Svensson et al
2004)

Svensson P, Wang K, Arendt-Nielsen L, Cairns BE, Sessle BJ. Pain effects of glutamate injections
into human jaw or neck muscles. Journal Of Orofacial Pain. 2005;19(2):109-118.

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Experimental Pain Models: Muscular

Pain

Hypertonic saline in Upper Trapezius caused

pain at the base of the neck in 83% of the
subjects, infra-auricular zone in 50% and 42% to
the retro-auricular zone ( Komiyama et al, 2005).

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Greater spread of pain to the temporomandibular joint

region

Experimental pain in upper trapezius caused a

significant decrease in the mean maximum
mouth opening (54 to 47.8 mm) ( Komiyama et al,
2005)

Komiyama, O., et al. (2005). "Pain patterns and mandibular dysfunction

following experimental trapezius muscle pain." Journal of Orofacial Pain
19(2): 119-126.

Experimental Pain Models: Muscular Pain

54

Upper trapezius referred pain after experimental pain model ( Madeleine et al.
1998 and Ge et al. 2003)

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Experimental Pain Models: Muscular Pain

55

When glutamate was injected into masseter, the EMG activity of the
masseter as well as the activity of the SCM and Splenius was
increased ( Svensson et al. 2004)

Muscle Pain Sensitivity in TMD

56

Significantly increased masticatory and cervical

muscle tenderness and pain sensitivity in the hand
in subjects with TMD when compared with healthy
subjects.
Moderate to high effect sizes showed the clinical
relevance of the findings

Silveira A, Armijo-Olivo S, Gadotti IC, Magee D. Masticatory and cervical muscle tenderness and pain sensitivity in a
remote area in subjects with a temporomandibular disorder and neck disability. J Oral Facial Pain Headache.
2014;28(2):138-146.

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Cervical Discs and

Craniofacial Pain

Cervical Discs and Craniofacial Pain

58

Disc is innervated
and as a result can
cause Pain

Bogduk N. Innervation and Pain patterns of the Cervical Spine. In: Grant R, ed. Physical
therapy of the Cervical and Thoracic Spine. St Louis: Churchill Livingstone; 1988:61-72.

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Cervical Discs and Craniofacial Pain

59
Cervical Disc

Sites

C3-C4

Mastoid, temple, temporal, parietal,

occiput, jaw, temporomandibular joint,
craniovertebral junction, neck, throat,
back ,trapezius muscle, top of the
shoulder, and upper extremity

C4-C5

Mastoid, temporomandibular joint,

parietal, occiput, craniovertebral junction,
neck, throat, back ,trapezius muscle, top
of the shoulder, upper extremity, anterior
chest , and upper back.

C5-C6

occiput, craniovertebral junction, neck,

throat, back ,trapezius muscle, top of the
shoulder, upper extremity, anterior chest ,
and upper back.

C6-C7

Neck, upper back, scapula, shoulders,

trapezius muscles, upper extremity, and
anterior chest

Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine. 2000/6/1 2000;25(11):1382-1389.
Schellhas KP, Garvey TA, Johnson BA, Rothbart PJ, Pollei SR. Cervical diskography: analysis of provoked responses at C2-C3, C3-C4, and C4-C5. AJNR.
American Journal Of Neuroradiology. 2000/2 2000;21(2):269-275.

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Cervical Spine
Dysfunction and TMD

Cervical spine Dysfunction:

Collective term

Clinical problem

Musculoskeletal structures (cervical spine)

Pain is usually aggravated by moving the head or adopting certain

62

head positions.

Neck pain main symptom

Dysfunction related to acute (macrotrauma) or chronic ( microtrauma)

affecting the joints or periarticular tissues surrounding the cervical spine

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Cervical Spine Dysfunction and TMD

63

Symptoms of the stomatognathic system overlap in patients with TMD

and CSD, and symptoms of the cervical spine overlap in these
patients (De Wijer et al. 1996 a, b)

Patients with TMD more often suffer from cervical spine pain than
subjects without TMD (Visscher et al, 2001,Stiesch-Scholz et al 2003 Fink et al,

2003)

Cervical Spine Dysfunction and TMD

Patients with internal derangement showed more cervical symptoms

such as tenderness in cervical muscles and shoulder muscles

alteration of the mobility of the upper cervical segments

64

than healthy controls (Fink et al, 2002)

Facial pain has an association with reported pain in the neck and tenderness in the
neck- occiput area (Sipila et al. 2002)

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Cervical Spine Dysfunction and TMD

Positive relationship between neck pain and temporomandibular

disorders (Ciancaglini et al.1999)

Patients suffering TMD had more than double the odds (odds ratio of
2.33) of suffering neck pain than patients without TMD. (Ciancaglini et al.1999)

Individual symptoms such as facial and jaw pain were significantly

associated with neck pain with odds ratio of 2.09 (Ciancaglini et al.1999).

Cervical Spine Dysfunction and TMD

66

Patients with myogenous TMD had increased resting EMG activity of

the upper trapezius muscles as well as the SCM muscles when
compared with control subjects (Pallegama et al. 2004)

The presence of pain over the SCM and trapezius muscles was
significantly associated with masticatory muscle pain without disc
displacement.
Pallegama RW, Ranasinghe AW, Weerasinghe VS, Sitheeque MA. Influence of masticatory muscle pain on
electromyographic activities of cervical muscles in patients with myogenous temporomandibular disorders. Journal of Oral
Rehabilitation. May 2004;31(5):423-429.

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Relationship between Cervical Spine and

TMD

67

Neck pain was the most strongly associated with TMD

Plesh O, et al. Temporomandibular joint and muscle disorder-type pain and comorbid pains in a national US sample. Journal of Orofacial Pain.
2011;25(3):190-198.

Relationship between Spinal pain and TMD

68

The prevalence of frequent spinal pain increasing

with increasing frequency/severity of TMD symptoms.

The operational definition of 'spinal

pain' was pain in the neck, shoulders
and/or low back.

Wiesinger B, Malker H, Englund E, Wnman A. Does a dose-response relation

exist between spinal pain and temporomandibular disorders? BMC
Musculoskeletal Disorders. 2009;10.

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Relationship between Spinal pain and TMD

69

Wiesinger B, Malker H, Englund E, Wnman A. Does a dose-response relation exist between spinal pain and temporomandibular disorders? BMC
Musculoskeletal Disorders. 2009;10.

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Discussion

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71

There is evidence in the literature

that supports the connection
among cervical spine,
stomatognathic system and
craniofacial pain
Moya et al., 1994; Rocabado, 1983; B Solow & Tallgren, 1976; B. Solow & Sandham,
2002a; Zuniga et al., 1995; Kohno, Kohno, & Medina, 2001; Kohno, Matsuyama,
Medina, & Arai, 2001; Torisu, Yamabe, Hashimoto, Yoshimatsu, & Fujii, 2001; C. M.
Visscher, Slater, Lobbezoo, & Naeije, 2000; Yamabe, Yamashita, & Fujii, 1999;
Yamada, Ogawa, & Koyano, 1999; makosfsky, 1989.)

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Anatomic, neurological
biomechanical,
physiological and pathological
connections between
craniocervical region
and craniofacial pain exist
(Escolar, 1948; Hellstrom et al., 2002; F. W. L. Kerr, 1972; Sessle et al., 1986; X.M. Yu et al., 1995). (Anonymous, 2004; Aprill et al., 1990; Bartsch T, 2003;
Benoliel & Sharav, 1998; N. Bogduk, 1982; Bogduk & Marsland, 1986; BorgStein, 2002; R. A. Davidoff, 1998; Dreyfuss et al., 1994; Dwyer et al., 1990;
Edmeads, 1990; Steven B Graff-Radford & Newman, 2002; Grubb & Kelly, 2000;
Hack et al., 1995; J. W. Hu, Sessle, Amano, & Zhong, 1984; Kuhn et al., 1997;
Mackley, 1990; Mellick & Mellick, 1109; Piovesan et al., 2001; Schellhas et al.,
2000)

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However.....

Levels of Evidence

74

Sackett D et al. Evidence-Based Medicine. How to Practice and Teach. Edinburg, London, New York, Philadelphia, St Louis, Sydney,
Toronto: Churchill Livingstone, 2000.

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Levels of Evidence

75

Level

Characteristics

Expert opinion

40

Case series and poor quality of cohort and case

control studies

45

3b

Case control-studies ( cross sectional studies)

13

3a

Systematic Reviews of case control studies

2b

Individual cohort studies and low quality of RCTs

2a

Systematic Reviews of cohort studies

1b

Individual RCTs with narrow confidence interval

1a

Systematic Reviews of RCTs

total

Number of
references

101

76

This is the information that

we have, So

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The Advice:

Do not consider this information useless.

The evidence pointed out a tendency to link cervical spine, neck

structures and craniofacial pain. This tendency should not be
undervalued.

Analyze carefully the studies results.

It is necessary more well designed studies to strongly conclude

We have to evaluate and treat patients based on this knowledge

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Questions
?

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