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By David A. Szwak
Temporomandibular joint syndrome [TMJ] is a notable myofascial pain-
dysfunction syndrome. TMJ is a painful condition often misidentified
and mistreated.1 Some experts believe that 80 percent of the American
population or approximately 10 million people have some form of
abnormality of the temporomandibular joint, however only 40 percent or
approximately 5 million Americans suffer symptoms severe enough to
require medical treatment.2
TMJ: Injury, Disease or Both?
The etiology of TMJ includes trauma to the head,3 systemic disease,
dental malocclusion, stress and/or some joint malalignment resulting
from and abnormal relationship between the spine, pelvis and other
extremities and the base of the skull. Some experts have adopted a
theory known as the "TMJ Triad" which sets out factors found in most TMJ
victims. The "TMJ Triad" factors are: (1) a predisposition, genetic or
acquired; (2) alterations of the bony and/or soft tissues; and (3)
personality traits which predispose to a psychological dependence.4 The
primary cause of TMJ is dental malocclusion which is the improper
juxtaposed upper and lower teeth.5 The malaligned teeth cause
displacement of the mandibular condyle and, through chewing and other
dental movements, excessive and misdirected stress and pressure is
placed on the soft tissue around the temporomandibular joint. Spasm
results in the masticatory (chewing) muscles.6 Trauma-based spasms
associated with TMJ tend to be of short duration while serious
malocclusion can result in a chronic condition.7 Emotional problems can
lead to bruxism. Bruxism results when the victim unconsciously develops
an uncontrollable clenching and grinding of the teeth.8 Bruxism can
result in severe damage to the teeth, the condyle and muscular balance
around the joint. Further bruxism can result in fatigue in the joint.9
Though not primary, the stress factor cannot be overlooked as it can
result in physical damage and thereby be a substantial component of the
Identification of TMJ symptoms is crucial. The most common symptoms
include: pain in and around the joint, crepitus of the joint, presence
of trismus and related difficulties, middle ear disorders, headaches11
and difficulties in speaking.12 Pain is the most common symptom.13
Pain is usually localized in and around the joint, however it can be
diffused in adjacent areas and even in areas as remote as the back and
shoulders. Pain associated with TMJ is usually quite severe and can be
the primary cause of attendant headaches. Crepitus14 is the customary
popping and clicking experienced in the joint. Trismus often occurs and
the TMJ victim experiences spasm in the masticatory (chewing) muscles.
This symptom includes difficulties in opening and closing the mouth,
with associated pain. Victims also tend to develop middle ear problems.
Tinnitus, dizziness, balance problems and feelings of fullness are
directly connected to middle ear. The victim often experiences
difficulties in swallowing and speaking. Occasionally the joint may
lock in the open or closed position.15 Other related conditions which
can develop include odontalgia, diplopia, and vertigo.
The temporomandibular joints are located just in front of each ear.
Each joint contains a condyle16 that fits into the condylar fossa17 and
a meniscus is situated between the condyle and the temporal bone. The
interrelated portion of the temporal bone provides a disk-like surface
upon which the joint pivots. Muscular movements cause the disk to move
back and forth to allow the mouth to open and close.
Diagnosis of a TMJ disorder can be complicated as many other conditions
cause similar symptoms. Other conditions which must be ruled out
include parotid gland dysfunction, myofascial pain dysfunction, otologic
dysfunction, arthritis, ear, nose, throat and bone diseases, abnormal
tumors in the area, migraine headaches, vascular anomalies and side
effects of various drugs. Diagnosis of TMJ may only be made after
reference to x-rays and radiographs of the joints.
No one method of treatment has proven successful in every case of TMJ.
A variety of therapeutic methods have been developed. Oral treatment
and surgery, physical therapy and medication are the most common type of
treatment used. Physical therapy is the preferred treatment
particularly in trauma-based TMJ cases. Appliances, such as mouth
splints, are used to adjust the malocclusion and prevent bruxism.18 The
splint actually pushes the jaw into the correct position. Oral surgery
is a "last resort" means of attempting to reduce the effects of TMJ.19
Stress management treatment can be helpful by eliminating an aggravating
factor which tends to amplify the symptoms. TMJ which is trauma-based
will usually correct itself if diagnosed early and treated. If the TMJ
results from other causes, it is likely to produce chronic and severe
pain and treatment should be designed as to minimize discomfort and
reduce risks of aggravating the condition.
TMJ has been recognized by Louisiana courts as a compensable injury when
the disorder results from the fault of defendant. In Molaison v. Denny,
Inc.,20 plaintiff was eating a salad at the restaurant when she
discovered the chef misunderstood her order and delivered fishing bait
in her salad. Apparently, she had eaten part of her salad when she
spotted worms. Thereafter, she began to develop psychological
problems21 and bruxism.22 Plaintiff developed TMJ. The Court awarded
Plaintiff her medicals of $3,800.00, general damages of $25,000.0023 and
$25,000.00 for future medical needs.24
The plaintiff in Merrill v. Jones,25 sustained serious facial and knee
injuries in a car wreck. Plaintiff lost several teeth and subsequently
developed TMJ. Despite oral surgery, Plaintiff's disorder was diagnosed
as permanent.26 Plaintiff was awarded damages, including general
damages of $68,000.00 for the TMJ disorder alone.
In Hardin v. Munchies Food Store,27 plaintiff was assaulted in a parking
lot of a convenience store. Plaintiff had a pre-existing TMJ disorder.
The Court summarized plaintiff's injuries as: TMJ aggravation, mental
anguish and post-traumatic stress syndrome. Plaintiff required surgery
for disc displacement of the right temporal mandibular. She was awarded
future medicals of $13,531.05 and general damages totaling $20,000.00
The future medical award included the past medicals incurred.
Plaintiff suffered a broken jaw, several damaged teeth, TMJ disorder
and cervical strain, in a bike accident in Clement v. State, Ex Rel.28
Plaintiff required six (6) root canal treatments. Plaintiff was awarded
general damages of $68,033.00; past medicals of $15,749.06; future
medicals of $5,000.00; and lost income of $855.0029
In Kimble v. Wal-Mart Stores, Inc.,30 plaintiff slipped and fell in the
store. Plaintiff suffered TMJ disorder, headaches, syncope, neck and
arm numbness, pain and swelling in the back. Plaintiff was awarded
general damages of $50,000.00; past medicals of $8,033.57; future
medicals of $2,500.00; lost income of $25,000.00; and loss of consortium
In Lejuene v. Cook,31 plaintiff suffered headaches and TMJ disorder as a
result of an auto collision. He was free from pain about one (1) year
after the wreck. His headaches resolved several weeks after he began
using a prescribed plastic mouth splint. He was awarded his medicals of
$5,100.00 and general damages of $12,500.0032
An auto collision led to Fonseca v. Hall,33 where plaintiff aggravated
existing orthodontic, incurred a TMJ disorder and insignificant back
injuries. Continued pain and TMJ-related problems continued for over
one year. The jury awarded general damages of $18,000.00, but the Court
granted a JNOV raising the award to $50,000.00 On appeal, the Court
affirmed the awards of past and future medicals of $28,500.00 and
general damages of $50,000.0034
In Peterson v. State Farm,35 plaintiff sustained an ulnar nerve lesion,
TMJ disorder and a rotator cuff impingement injury in an auto wreck.
The total award was $77,300.00
The plaintiff in Adamson v. City of Lafayette,36 aggravated of her pre-
existing TMJ disorder, incurred back injuries and damage to her teeth
which required root canal procedures in an accident. She also suffered
a slight knee contusion. She was awarded medicals of $5,000.00 and
general damages of $40,000.0037
In years past, the TMJ injury has been often overlooked, misdiagnosed
and mistreated. When symptoms are presented the careful practitioner
should have his client evaluated for TMJ injury. Though medical
causation appears difficult, from a practical standpoint, the
appropriate expert testimony should provide the key. Louisiana courts
have recognized the TMJ injury as compensable and general damage awards
have been substantial in this evolving field of damage. At the
September meeting, the Honorable Stephen Callaway's team of the Harry V.
Booth Inn of Court will be presenting this topic along with experts in
the field discussing aspects of proving a TMJ injury.
1. "TMJ Disorder": A Real Condition Often Falsely Accused," Mayo
Clinic Health Letter, vol. 6, p.1 (October, 1988).
2. A. Toufexis, "Treating an 'In' Malady: Some 10 Million Americans
Suffer From TMJ," Time, vol. 131, p.102 (April 25, 1988); R. Gray,
M.D., and L. Gordy, M.D., "Attorneys' Textbook of Medicine," vol. 1B,
par. 10.48(4), p. 10-96.3 (3d ed. 1988).
3. Some experts surmise that TMJ is trauma induced in "25 percent of
patients with minor trauma, even without any physical contact with the
face or jaw." M. Bouret, "TMJ Disorder: Emerging Criteria For Defense
Counsel," Defense Counsel Journal, p. 542 (October, 1993), citing Dewey
A. Nelson, "Thoracic Outlet Syndrome and Dysfunction of the
Temporomandibular Joint: Proved Pathology or Pseudosyndromes?," 33(4)
Perspectives in Biology & Medicine 567, 573 (Summer, 1990), citing C.A.
Helm, et al, "Internal Derangement of the TMJ," 1 (San Francisco:
Radiology and Research Foundation, 1983).
4. R.Gray, M.D., and L. Gordy, M.D., Attorneys' Textbook of Medicine,
Vol. 1B, para. 10.48, p.10-96 (3d ed. 1988).
5. M. Bouret, "TMJ Disorder: Emerging Criteria For Defense Counsel,"
Defense Counsel Journal, pp. 535-536 (October, 1993).
6. R.Gray, M.D., and L. Gordy, M.D., Attorneys' Textbook of Medicine,
Vol. 1B, para. 10.48, p.10-95 (3d ed. 1988).
7. See Clement v. State, Ex Rel, infra; Green v. Industrial
Helicopters, Inc., infra.
8. Molaison v. Denny, Inc., infra; M. Bouret, "TMJ Disorder: Emerging
Criteria For Defense Counsel," Defense Counsel Journal, pp. 541-542
9. R.Gray, M.D., and L. Gordy, M.D., Attorneys' Textbook of Medicine,
Vol. 1B, para. 10.48, p.10-96.1 (3d ed. 1988).
10. J. Frouman, "Stress Can Be a Jawbreaker," Business Week, p.128
(September 11, 1989); Molaison v. Denny, Inc., infra; Hardin v. Munchies
Food Store, infra.
11. See Maloney v. State Farm, infra; Lejuene v. Cook, infra.
12. R. Gray, M.D., and L. Gordy, M.D., Attorneys' Textbook of Medicine,
Vol. 1B, par. 10.48(3), p. 10-96.1-96.3; J. Zimmerly, M.D., Lawyers'
Medical Cyclopedia of Personal Injuries and Allied Specialties, vol.6,
par. 40A.16b, pp. 233-234 (1991); M. Bouret, "TMJ Disorder: Emerging
Criteria For Defense Counsel," Defense Counsel Journal, pp. 541-542
13. "TMD Spells Jaw Pain, " The University of California, Berkeley
Wellness Letter, vol.10, p.6 (March, 1994); L. Kaufman, "Oh, My Aching
Jaw," American Health, vol.10, p.31 (May, 1991); C. Sears and J.
Lawrence, "Jaw Pain: How to Navigate the Treatment Minefield," American
Health, vol.12, p.62 (Nov. 1993).
14. Crepitus is due to the lack of coordination between the condyle and
meniscus of the joint.
15. See Friedrichs v. State Farm Fire and Cas. Ins. Co., infra.
16. The condyle is located at the end of the mandible.
17. The condylar fossa is located on the lower end of the temporal bone
of the skull.
18. See Wyble v. Allstate, 581 So.2d 325 (La. App. 3d Cir. 1991),
(splint treatment); and Murray v. Sapp, 573 So.2d 495 (La. App. 1st Cir.
1990), (mouth splint); Stoutes v. GMAC, 598 So.2d 654 (La. App. 3d Cir.
1992), (splint therapy).
19. M. Bouret, "TMJ Disorder: Emerging Criteria For Defense Counsel,"
Defense Counsel Journal, p. 539 (October, 1993).
20. 592 So.2d 916 (La. App. 5th Cir. 1991).
21. Plaintiff "experienced insomnia, nightmares involving babies and
worms, became obsessive and compulsive about personal and housekeeping
cleanliness, entertained suicidal thoughts and eventually withdrew from
society." She was diagnosed with "post-traumatic stress syndrome,
compulsive-obsessive disorder and depression." Id. at 917.
22. Teeth clinching, grinding and grating.
23. The Court noted that "TMJ cases range from $25,000.00 to $68,000.00
depending on whether other injuries existed and the severity of the
problem. [footnoted citations omitted]." Id. at 920.
24. Plaintiff's future needs included having "al of her teeth capped,
at a cost of $16,000.00, because the teeth are wearing down due to the
grinding." Id. at 919.
25. 552 So.2d 466 (La. App. 4th Cir. 1989).
26. Id. at 469.
27. 521 So.2d 1200 (La. App. 2d Cir. 1988).
28. 528 So.2d 176 (La. App. 1st Cir. 1988).
29. Compare: Green v. Industrial Helicopters, Inc., 560 So.2d 684 (La.
App. 3d Cir. 1990), where plaintiff suffered injuries to his ribs,
chest, neck, shoulder and jaw in a helicopter crash. He returned to
work one month later but continued to treat for 3-1/2 years. He
incurred a TMJ disorder due to a jaw injury. His neck and shoulder
injuries did result in permanent impairment. He was awarded his
medicals of about $15,000.00 and general damages of $40,000.00
30. 539 So.2d 1212 (La. 1989).
31. 563 So.2d 1218 (La. App. 1st Cir. 1990).
32. In similar settings, the jury in Maloney v. State Farm, 583 So.2d
12 (La. App. 4th Cir. 1991), was faced with a plaintiff suffering a TMJ
disorder, frequent headaches and chronic soft tissue injuries due to an
auto wreck. The jury denied the TMJ claim. On appeal, plaintiff was
awarded medicals of $500.00 and general damages of $30,000.00; and
Stoutes v. GMAC, 598 So.2d 654 (La. App. 3d Cir. 1992), where plaintiff
sustained a neck injury and a TMJ disorder in an auto wreck. Painful
splint therapy lasted for a year. Future dental expenses were estimated
at $5,000.00 The jury awarded plaintiff general damages of $2,500.00
for the TMJ injury, cervical strain and psychological injuries. On
appeal, the award of general damages was increased to $10,000.00; and
Friedrichs v. State Farm Fire and Cas. Ins. Co., 496 So.2d 496 (La. App.
1st Cir. 1986), where plaintiff incurred injuries in an auto-bicycle
accident. Plaintiff suffered pain in the jaw, headaches and
intermittent locking of the joint. The trial court entered a JNOV
granting plaintiff an award of $25,000.00 for future pain and suffering.
33. 555 So.2d 42 (La. App. 1st Cir. 1989).
34. Compare the similar cases of: Breaux v. Martin, 619 So.2d 174 (La.
App. 3d Cir. 1993), where plaintiff sustained a TMJ disorder due to an
auto wreck. Two and one-half years of treatments by dentists,
orthodontists and a chiropractor followed. The jury awarded general
damages of $20,000.00 In the same case, a second victim sustained a TMJ
disorder. The jury denied her an award of general damages. On appeal,
the Court awarded that plaintiff general damages of $25,000.00 Her
medical totaled $6,600.00; and Rossito v. Jenks, 576 So.2d 1115 (La.
App. 3d Cir. 1991), where plaintiff suffered a long term cervical strain
and a TMJ disorder due to an accident. Her total award was $107,000.00;
and Girard v. Price, 606 So.2d 990 (La. App. 3d Cir. 1992), where
plaintiff received a broken nose and TMJ disorder in a trip and fall,
during her drunken stupor. Her nose was corrected by medical procedure.
Plaintiff was assessed 60% comparative fault, after the Court reduced
the trial court's assessment of 75%. Plaintiff was awarded general
damages of $35,000.00, subject to the reduction.
35. 543 So.2d 109 (La. App. 3d Cir. 1989).
36. 521 So.2d 1258 (La. App. 3d Cir. 1988).
37. Compare the similar cases: Wyble v. Allstate, 581 So.2d 325 (La.
App. 3d Cir. 1991), plaintiff incurred a TMJ disorder, loss of several
teeth, chronic back pain and headaches due to an auto collision.
Painful splint treatment followed. Plaintiff was awarded medicals of
$9,500.00 and general damages of $25,000.00; and Murray v. Sapp, 573
So.2d 495 (La. App. 1st Cir. 1990), where plaintiff sustained TMJ
disorder and chronic cervical and lumbar sprain due to an auto wreck.
The TMJ disorder was long term. Mouth splint was the course of
treatment. Pain was extreme. The back pain appeared permanent. Also,
she had six (6) visits to a psychiatrist. She was awarded his medicals
of about $9,500.00 and general damages of $125,000.00.
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