WHIPLASH AND TEMPOROMANDIBULAR DISORDERS MEDICO-LEGAL ISSUES

The emerging recognition of whiplash and other traumatic events as precipitating factors for the development of temporomandibular disorders (TMD) has led to multiple disputes between insurance carriers and claimants. This is due in large part to the perpetuated supposition that temporomandibular disorders exist only as a subclass of chronic pain disorders and occur secondary to architectural dis-relationships, psychobiologic imbalances and other insidiously developing noxious influences. A substantial amount of research has developed a clearer picture of the pathogenesis of these disorders and has led to a paradigm shift in the diagnosis and treatment of TMD. This has included new classification systems as well as new treatment models and has been affected by evolution in diagnostic and treatment modalities available to the treating doctors. It is this paradigm shift that has led to many of the adversarial disputes which arise and which result in heated and costly litigation.

Widely diversified treatment models still exist in this field despite current research which substantially challenges the need for them and their efficacy. Further, this paradigm shift has not obviated certain of the older treatment techniques, but has placed them in a new perspective. Included in this group are oral orthotics, physiotherapy, stress management, chronic pain counseling, Phase II dentistry, behavioral modifications and exercise regimens. In many of the classic treatment models for temporomandibular disorders architectural dis -relationships were managed by oral orthotic therapy and permanent occlusal change. This was frequently orchestrated with spinal postural alterations via manipulation, spinal exercises, massage and home care instructions. Patients who demonstrated poor stress management techniques and tendencies toward bruxism where frequently given biofeedback training and medications such as the tricyclic antidepressants. The substantial body of these patients were considered to be victims of insidious decompensation of their adaptive capacity over time and, depending on the perspective of the discipline of the doctor in charge of the case, various combinations of the aforementioned therapies would be prescribed. A substantial portion of these patients would undergo permanent alteration of their developed occlusion. These treatment programs continue to date despite questions raised concerning scientific validation of these proposed pathogenic pathways as causative of temporomandibular disorders. Specifically highlighted issues of contention include malocclusion and bruxism. Over the past six years at least three authoritative studies have discounted malocclusion as related to the onset of temporomandibular disorders. Most recently a well orchestrated study by Pullinger et al has confirmed earlier studies which disclaim bruxism, with specific reference to nocturnal grinding of the teeth as evidenced by tooth wear, as a cause of temporomandibular disorders. Despite these findings treatment frequently proceeds as it has for decades addressing these issues as the driving force behind any temporomandibular disorder regardless of the history of its onset. There is no doubt that multifactorial, insidious decompensation produces a body of patients whose needs are met by these treatment programs, however, treating trauma victims within this model may produce rather than control chronic pain.

Patient history is the key to effective management of TMD and to effective medical/ legal assessment. The importance of this statement cannot be overvalued. Temporomandibular disorders are a substantial cause of chronic pain and these disorders result in billions of dollars of treatment each year and an inestimable amount of suffering. It is well agreed among the practitioners treating these disorders that early identification of TMD following its onset leads to more effective treatment as many of the chronic pain issues can be avoided. This is, in point of fact, the driving force behind the effort to identify causation or causations. As data surfaces which leads us to believe that trauma is frequently the precipitating event for the onset of many temporomandibular disorders, portal of entry doctors are being alerted to identify the onset of these disorders at the earliest possible opportunity. The hope is that this early identification will lead to effective referral patterns and early management patterns which will more effectively control these disorders and avoid the onset of chronic pain issues.

At the heart of this paradigm shift is the dispute over whether the majority of temporomandibular disorders are extracapsular (driven by psychobiologic and/or muscular phenomena)or intracapsular (inflammation/derangement within the joint). Prior to the advent of arthroscopic surgical techniques and investigation into the character of the temporomandibular joints proper, this distinction was somewhat problematic as there was no way of diectly addressing pathology within the temporomandibular joints without aggressive surgical technique. The somewhat quiet yet rapid evolution of arthroscopic surgical potential for the temporomandibular joints has changed this perspective substantially. We now have the capacity to enter the temporomandibular joints with a relatively nonmorbid technique and improve the environment of the temporomandibular joints so that the balance of degenerative and reparative phenomena is tilted toward the reparative process. However, this does not eliminate the need for many of the aforementioned techniques which are aimed at stabilizing function in this region and stimulating repair such as the oral orthotic, chiropractic care, physiotherapy and home care. When whiplash is suspected of causing intracapsular TMJ damage a course of appropriate conservative care should be initiated as early on as possible. Early intervention in these cases portends to minimize or eliminate the chronic pain formation which complicates the treatment issues and may well head off surgical necessity, allow for shorter treatment regimens, improve results and, when viewed in the long term, constrain costs.

These issues are of particular importance in a motorized society such as ours as the all too frequent phenomena of whiplash has been linked to the onset of symptomatic expressive internal derangement of the temporomandibular joints. There are an estimated 4 million reported whiplash injuries in the United States per year. This addresses only the whiplash injuries reported to the police following the collision and represents a fraction of the true number of cases which occur per year. When it is considered that referenced studies have estimated that as many as 50% of these cases result in a dysfunction of the temporomandibular joints the importance of this paradigm shift becomes obvious. It is hoped that linking the research which implicates trauma as a frequent precipitator of these disorders with accurate diagnosis will result in more timely and effective treatment as well as a decrease in chronic pain formation.

As trauma, especially trauma associated with motor vehicle accidents, becomes implicated as a frequent precipitating factor in temporomandibular disorders medical/legal disputes arise. This occurs specifically because of the separation between casualty insurance carriers and personal health insurance. The general topic of temporomandibular disorders has raised its own level of dispute within the world of personal health insurance secondary to lack of specificity in identifying these disorders and lack of standardization of protocol in treating them. This stands somewhat separate however from the issue of traumatic causation as casualty insurance carriers stand more vulnerable to responsibility for treatment delivered if causation is assessed to be a result of trauma to persons insured by these companies. While many of the same issues, e.g. diagnostic accuracy, need for treatment, specific treatment protocol and prognosis are enjoined responsibility is more firmly asserted in these cases as no exclusion clauses exist in these policies to allow the insurance company to deny treatment and financial responsibility. Thus, at one time or another all of these issues come to be argued.

The whiplash event has been implicated as a causation for temporomandibular disorders by epidemiologic studies of both whiplash patients and TMD patients. Imaging studies of post whiplash TMD patients have resulted in the same conclusions. Further, the proposed pathogenic pathway of whiplash induced TMD has been verified by computer model. In stark contrast to this, other proposed pathogenic pathways such as malocclusion and bruxism have failed epidemiological scrutiny and substantial statement has been made in the scientific community discounting the relationship between these factors and the development of temporomandibular disorders. This is not to say that these factors may not act as predisposing and perpetuating factors for a temporomandibular disorder, but the presence of these factors does not predict the eventuality of TMD and should not be used to discount the probability that a specific temporomandibular disorder onset following a traumatic event. Specific defense arguments against whiplash induced TMD claims from a causation perspective include: