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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 overall syndrome.10
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 of $10,000.00
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 (October, 1993).
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 (October, 1993).
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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