Page 13 - GP Spring 2019

that the claimant reported that the tooth of dislocations, meniscus entrapments and and cervical support, as well as muscle
was damaged and an implant is required. TMJ derangements stemming from a host of weakness.
There are no supporting signs to go with conditions. These may include degenerative
the injury (facial injury, jaw injury) and joint diseases, laxity in the joint, prior In the case of TMD, I’m interested in
there is one mobile tooth. The injury was trauma or developmental conditions. Any knowing how the nature of the symptoms
not witnessed by anyone and the claimant of which could masquerade as an acute changed over time and if those changes are
does not want to have the tooth extracted injury to a clinician examining a joint for consistent with a known envelope related
because that removes the one item they are the first time. To begin the process of ruling to the disease. I want to know when the
claiming was injured. out the cause you will need as complete symptoms started and stopped, and of
a dental record as possible, diagnostic course, how the injury occurred and what
In recent years determining cause has imaging and a complete exam. 3 was the direction of force. Did a TMJ
become even more difficult for medication- become compressed or stretched? I want
induced hyposalivation cases. Medication To make complex determinations, such to know if the joint is now responding
induced caries (MIC) is a problem as TMJ syndrome, you must be secure as expected considering the impact of
stemming from the side effect of many in the fact that you can evaluate a joint, involved forces. A review of the anatomy
drugs that can cause decreased saliva read diagnostic imaging and test a joint to is important. A dry skull will remind a
production. Individuals who have had determine its condition and envelope of clinician of the paper thin bone between
work related injuries may be maintained on function. Can you determine the difference the ear canal and the posterior of the TMJ.
multiple medications over long periods and between subcortical cysts, surface erosion, A blunt force to the chin from a deployed
develop MIC. This can lead to an increase osteophyte formation and generalized air bag can have the effect of driving
in dental caries and, in some cases, require sclerosis and their potential contribution to the condyles into this delicate bone and
extensive oral rehabilitation. Careful a symptomatic joint? causing a host of symptoms from tinnitus
determination of dental caries caused to difficulty speaking.
by decreased saliva versus, say, dental This type of evaluation can be challenging,
neglect, poor professional treatment or any especially with a claimant who may have It is the IME investigator’s responsibility to
of a number of causes requires a thorough personal gain as a motivation (Table 2). identify behavior that can help to understand
understanding of how each etiology Here you have to assess your understanding the basis for an injury claim. In everyday
presents over time. Often a detailed of the anatomy and function of the TMJ as affairs the attending dentist generally
history, especially of on-going dental care, well as myofascial pain. Do you consider doesn’t scrutinize patient behavior for
is needed to prove that the depletion of your skills examing a joint good enough be malingering and catastrophizing. We trust
saliva is the cause. In many cases there are a subject of the scrutiny of others expert in that our patients are giving us honest
multiple factors that contribute to the cause the field when questioned? histories. However, in reality, people can
for hard tissue breakdown and each has to be motivated to seek claims for which
be considered. While doing an IME there is a difference they are not entitled and, in some cases,
between a health care provider (HCP) and to be assisted by HCP’s who don’t choose
Here, again, the patient history and an IME investigator. The IME investigator to question the veracity of patient claims.
clinical exam are essential. To differentiate is expected to have a heightened level Determining the veracity of claims in
between poor care versus MIC, can it of suspicion. The IME investigator many fields of medicine is a difficult and
be determined that even with normal needs to carefully evaluate all claims complex question especially when there is
home care and professional visits that the before accepting any claim as true. a financial gain to be had. 3
claimant continued to develop caries at This is especially true when confronted
an abnormally fast rate? Can the location with injuries to the TMJ or surrounding Identifying suspicious behavior isn’t
of caries be found to fit a pattern? Is the musculature in which imaging reveals part of our normal training, however, we
claimant still taking the medication causing no apparent breakdown but the claimant can comment on aspects of a claimant’s
hyposalivation and can the saliva production reports ongoing symptoms. behavior either as documented in the
be measured? Are there signs or history record or as part of the IME. For example,
of soft tissue changes associated with While both the HCP and the IME need to be during the interview the claimant was able
hyposalivation? And does the claimant’s aware of the classic presentation for TMJ, to speak comfortably for thirty minutes
history follow the pattern expected from the IME often has the benefit of having including a couple of open mouth gestures
a patient with hyposalivation versus, say, access to a more complete dental/medical when the dental assistant presented an
an office worker who sips carbonated soft record, including the histories of all HCP’s astonishing bit of glamor gossip. However,
drinks all day for eight years? who have seen this claimant. This allows when it came time for the intraoral exam the
the IME investigator the ability to compare claimant was only able to open a maximum
The problem of determining causation answers over time, retest specific findings of fifteen millimeters. And when asked to
versus pre-existing condition is even and to expand the scope of the testing. go into lateral excursions she could not
harder when it comes to TMJ injuries. This accomplish an excursion to the “afflicted”
can be due to the unique TMJ anatomy, our For TMD cases, I start with the record and side, yet she could do a full protrusive.
understanding of the condition, a lack of make a matrix of any physical testing that Yet, later in the exam when sensitivity
records to document a previous condition has been done. I use the matrix to repeat testing was done, she was able to open a
or the difficulty in getting a consensus testing and immediately see any pattern. full 35 mm to accommodate the important
on diagnosis. Thus, IME’s on TMJ cases I gather everything that has been done testing of where it hurt in her mouth. In
can be very challenging. Claimants can and place it in a matrix over time. In my this case the inability to translate to the
present with pre-existing conditions of exam, I auscultate and test joints for a full afflicted side and yet go into protrusive is
the jaws, TMJ and past injuries that can range of motion, palpate the joints during an unexpected outcome. The inability to
confound our ability to determine the cause motion, palpate the muscles of mastication open widely at first and then to do so later,
www.nysagd.org l Winter 2019 l GP 13