Understanding defense of TMD cases.

• Author: Moses, Allen J.
• Position: Temporomandibular disorder

TEMPOROMANDIBULAR disorder, known as TMD, is of concern to lawyers, according to the recent correlation in both the dental(1) legal(2) literature of TMD as a sequelae to whiplash injury. TMDs seem to be as enigmatic to lawyers, however, as they are controversial in dentistry.

Pain and dysfunction in the orofacial region resembling temporomandibular disorder may originate at remote sites, such as dental problems or otolaryngologic, neurologic, vascular, neoplastic or infectious diseases. The location of the pain may not be the site of the pathologic lesion. Patients may have concomitant TMD and non-TM disorders or multiple TMDs. The quality and intensity of the pain may not relate to the extent and nature of the disease.

Because TMDs are stress related, the pattern of their appearance and evolution vary so greatly in different patients with the same pathological state that no single course of history typifies the expectations in all patients. It has been written in dental literature, "Clinical findings, no matter how accurately obtained, are not necessarily significant as they may represent benign conditions of normal variation."(3)

A search of the Medline database for TMD literature during the period from 1979 to 1992 discloses these variations:

* Epidemiologic studies of normal populations for TMJ dysfunctions ranged from 20 percent(4) 68 percent.(5)

* Epidemiologic studies of the prevalence of TMD signs in normal populations ranged from 43 percent(6) to 88 percent.(7)

* Epidemiologic studies of the prevalence of TMJ sounds in normal populations studied ranged from 20 percent(8) to 58 percent.(9)

* In one noninfectious chronic disease study in which 212 pain patients were matched with 212 controls free of pain, examination of the histories, physicals and radiographs revealed that the two groups were indistinguishable based on the illness criteria. The distinguishable difference was that the control subjects did not consider themselves sick and did not seek treatment.(10)

The problem of subjectivity

Assessing a patient's condition on the basis of subjective findings, rather than objective criteria, is a widespread custom in the diagnosis and treatment of TMD, and it leads to clinical disagreement. The use of such phrases as "patient feels better," "patient is improved" or "pain has subsided" as the basis for reporting therapeutic results in patient records makes no distinction between evidence and inference, criteria and conclusion. There are no quantitative and non-subjective methods of measuring the location, quality, quantity or other characteristics of the different types of pain produced by toothaches, headaches, face pain, migraines, etc., associated with TMD.

Pain on muscle palpation involves such subjective variables as the amount of pressure applied, the patient's subjective perception of pain and the patient's psychological desire to comply positively. Some doctors' only measure of success is relief of pain. Recognition of the subjectivity of pain and the psychological aspects of chronic pain leaves those doctors and lawyers at patients' whims in terms of determining success and termination of treatment or continued pain and the evaluation of impairment.

Thus, the dilemma if one buys into this paradigm is that a doctor or lawyer is faced in TMD with a chronic "disease" where it may be may more normal to have signs, symptoms and dysfunctions than not have them. If patients say they have them, based on a diagnostic standard using only patients' subjectivity as to what, when, where and how bad it hurts and...