COMMON INJURIES IN CAR WRECKS: TMJ
INTRODUCTION TO TMJ
Increasingly, the medical and legal profession is encountering personal injury cases that focus on the temporomandibular joint.
(TMJ); the jaw joint located in front of the ears connecting the lower jaw to the skull. (see illustration above).
Because this TMJ dysfunction represents another dimension of medical proofs in any case involving a blow, direct or indirect, it is gaining attention in claim valuation and a focus in many trials today.
The Disorder - temporomandibular joint disorder (TMJ) - can occur as a result of injury and may or may not result in permanent impairment.
TMJ can cause pain, eating and sleeping disorders and exact multiple dollars in treatment.
Trauma to the TMJ and related structures may be overlooked, unless the patient complains of a specific jaw complaint.
Further, some physicians may not recognize that a TMJ injury could be contributing to and perpetuating post-traumatic headaches, ear pain and even cervical symptoms.
To complicate matters further, there may not be any pains directly in the jaw joint itself.
In reality, many post-traumatic headaches, earaches, and jaw pains, which appear to be resistant to treatment, can be traced to the temporomandibular joint as a contributory factor.
The legitimacy of the TMJ injury has been questioned and insurance carriers have become increasingly skeptical.
WHAT IS TMJ
The structures that make it possible to open and close the mouth are very specialized and work together when you chew, speak and swallow. These structures include muscles, ligaments, bones and jaw joints. Your jaw is held in place by the muscles and ligaments of the jaw as it attaches to your temporal bone (small skull bone above the ear).
The joint that is formed by these two bones is called the "temporomandibular joint", or TMJ for short. Actually, the TMJ is considered two joints in one. Separating each joint into two parts is a fibrous disc; above the disc the joint works as a sliding joint and below the disc it is rotational.
A healthy joint is pain free with a full range of motion functioning quietly (no clicking, popping, and grating).
The TM joint is the most complex joint in the body. In addition to allowing you to move your mouth in a normal way for purposes of eating and speaking, there are other important jobs performed by this very special joint.
Many dentist and doctors of chiropractic for example have discovered that the blood circulation to the skin, pain fibers, muscles and internal tissues of the neck and head is very strongly influenced by proper alignment of the TMJ.
Misalignment of the TMJ can seriously affect the blood flow, muscle tension, spinal balance and the proper working of the nervous system in the upper body.
This can result in many complex symptoms and ultimately disease unless the misalignment is correct by someone with special training and experience in this field of health care. The fibrous disc and its related ligaments are major anatomic structures influencing TMJ function.
In traumatic events such as motor vehicular accident, this disc may become unstable or even dislocated.
Symptoms then can included
~a clicking, popping, or grating sound in the jaw;
~painful jaws with restricted range of motion; difficulty in opening one's mouth; ~jaws that "get stuck," "lock," or "go out";
~tenderness of the jaw muscles; or
~dull aching facial pain; and
~possible neck complaints.
The disc displacement can also occur in a whiplash type of injury without the claimant sustaining a direct trauma to the jaw.
Due to the close and interrelated qualities of the TMJ and the upper spinal nervous system, the greater portion of TMJ problems is linked to misalignments of the vertebra in the upper spine.
The integrated network of nerves between the TMJ and the upper spine forms a complex system which strongly influences the muscle tension, blood flow and local organs of the upper chest, head, neck and face.
WHAT CAN CAUSE TMJ
According to the American Dental Association: More than fifteen percent of American adults suffer from chronic facial pain.
Factors that contribute to TMJ injuries fall into three categories:
1) Predisposing factors, which over the years have put an excessive strain on the TMJ,
i.e., malocclusions (bad bite), developmental jaw discrepancies, loss of teeth, oral habits (cleaning or grinding of teeth), stress, etc.
2) Precipitating factors, usually specific traumatic events that can initiate TMJ symptoms,
i.e., blunt trauma, automobile accident, whiplash, prolonged mouth stretching that may occur with long dental procedures, or the administration of a general anesthetic for surgery.
3) Perpetuating factors, which have been insignificant after the trauma but must be corrected to resolve the injury.
When muscles and joints do not work properly the muscles will often go into a spasm (cramp). This spasm can become part of a cycle that results in tissue damage, pain, muscle tenderness and more spasm.
TMJ INJURY Injuries to the TMJ Fall into two major categories:
1) Extracapsular: Primarily muscular injuries sustained outside the TMJ proper, commonly related to the soft tissue. Although treatment may be required, these injuries are usually self-limiting and will resolve over time with no resulting long-term permanent disability.
2) Intracapsular: trauma affecting the structures inside the joint including the disc, ligaments and neurovascular structures. These injuries are often more serious, require more prolonged treatment, and the possibility of a permanent condition is more frequent.
IF I HAVE TMJ, HOW IS IT TREATED?
The Council on Dental Care Program of the American Dental Association has divided TMJ treatment into two basic phases.
Phase I therapies are procedures that can usually be performed by a physician or a dentist. Treatment involves relieving the patient's symptoms through reversible, non-invasive methods. The Phase 1 procedures include examination and x-rays, orthotic appliances (intra-oral splints), physical medicine (moist heat, ice, ultrasound, TENS, galvanic stimulation, etc.), and medications. Applying moist heat to the face, using prescribed medications, eating soft, non-chewy foods are among the techniques used to reduce spasms and pain.
Bite plates can be worn to eliminate the harmful effect of clenching or grinding the teeth. Biofeedback, a relaxation technique that teaches people to control tension throughout various parts of the body with the aid of an electronic monitoring device, can also be helpful in reducing muscle tension in the jaws.
When emotional stress is identified as a factor contributing to TMJ problems, psychological counseling may be successful in reducing or eliminating the stress causing tooth grinding or clenching.
Phase II therapy includes irreversible procedures which will usually permanently alter the patient's occlusion (bite).
These consist of treatment modalities that only a dentist is licensed to perform, i.e. orthodontics, dental reconstruction, TMJ surgery, etc.
Phase II treatment is to control the perpetuating factors, which prevent resolution of TMJ symptoms. No Phase II irreversible treatment should be initiated until Phase I therapy has been successful and the patient is in a stable comfortable condition for four to six months.
Long term studies document that 85 to 95% of TMJ patients respond to Phase I conservative treatment.
Phase II therapy is usually not required if the occlusion can be returned to an acceptable state. Surgery is indicated in only a very small percentage of cases.
HOW DO I GET TMJ COVERED WITH WORKER'S COMPENSATION?
Elements of damages in a TMJ injury are comparable to that of any other workers' compensation or personal injury action where a specific joint in the body associated structures were traumatized.
Settlement depends on the extent of injury, degree of permanent impairment, pain and suffering, and necessary and reasonable medical/dental fees actual and anticipated. Disability and impairment cannot be considered permanent until, in the clinical judgement of the health care providers, maximal medical improvement has been reached.
The defense attorney and the insurance company will be on the look-out for instances where diagnostic, therapeutic, and anticipated medical/dental expenses and disability ratings appear unreasonable or excessive.
Fees for examination, x-rays, physical therapy modalities, office visits, etc. should be comparable to those fees charged by other health care providers such as orthopedists, rheumatologists, physical therapists, etc. for treating other joints in the body.
Confronted with what is perceived to be an over utilization of diagnostic procedures and treatment modalities with inflated fees, independent medical examinations (IME) frequently are being obtained.
If a defense attorney and his witnesses can convince an Administrative Law Judge in the case of workers' compensation, or a jury in a personal injury action, that there has been an inflation of fees, excessive treatment and exaggerated disability rating, the judgment may be low as the true extent of the alleged injury will become suspect.
TMJ can be a very painful and disruptive ailment. It can have an impact by creating headaches, difficulty in chewing, sleeping, or even by have "referred pain" (meaning referred from your jaw area) down into your neck and even into your shoulders or arms.
Many general physicians or even specialists do not readily diagnose TMJ, because it is a relatively new process, and TMJ has not gained wide acceptance in the medical community. Dentists are more often able to diagnose TMJ and to 'spot it'.
Doctors of Chiropractic specialize in the evaluation and non surgical, drug free treatment of structural imbalances in the body, with special emphasis put on the spine and its effects on the nervous system.
REFERRAL: You should get a referral to a dentist who is familiar with and works on TMJ patients, from an informed medical doctor. It is best if you can get one of your treating physicians to refer you to a TMJ doctor.
EARLY DETECTION OF TMJ DYSFUNCTION
1. Do I have headaches which do not respond to medical treatment?
2. Do I have unexplained dizziness, visual disturbances, hearing difficulties?
3. Do I have pain or stiffness in the jaw or temples?
4. Do I feel frequent muscle tension and strain in my face, head, shoulders or upper chest?
5. Do I suffer from unexplained tension, anxiety, depression or high blood pressure?
6. Do I have frequent sinus infections, bronchitis or other respiratory symptoms?
7. Have I been using sinus or cold medicine with little or no improvement?
8. Have I been examined by my chiropractor and dentist recently and been told I have spinal misalignment or TMJ problems?
9. Do I wear dentures that fit improperly and put pressure on my jaws in a painful way?
10. Have I injured my jaw, face, head or neck and had symptoms of TMJ dysfunction or spinal misalignment that I ignored?
YES to five or more of these questions indicates that you may suffer from TMJ dysfunction/spinal subluxation syndrome.
Please see your Denist as soon as you can.