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Dynamic Chiropractic – June 20, 1990, Vol. 08, Issue 13

TMJ Syndrome Signals Referral

By Dennis Semlow, DC
Facts:

Karen Adams' jaw had been bothering her for about five years. "It isn't really painful," she told Dr. Ted Regent. "It just clicks when I eat. But I have been getting a lot of headaches lately."

Karen, age 35, had a history of prior problems including numbness in her hands and arms, arthritis, headaches, and a stiff neck.

Dr. Regent took a full spine, 14 x 36 inch x-ray, which showed a loss of cervical curve and slight scoliosis of the upper thoracic spine.

The doctor recommended a sugar-free diet and instructed Karen to take calcium/magnesium for her headaches. He did not offer a specific diagnoses of the condition.

His recommended treatment included diathermy, cervical traction, intersegmental traction, and manipulation.

"No complications were noted with therapy or manipulation," the doctor remembered. "The patient had good cervical range of motion without fixation or restriction of motion."

Over a 3 month period, Karen received 26 manipulations.

"After that Karen asked to discontinue treatment for a couple of weeks," Dr. Regent continued. But it was six months before he heard from her again.

"She came in asking for her x-rays because she was planning to consult a neurologist for occipital pain," Dr. Regent explained, adding that he gave her the x-rays.

Two months later Adams' lawyer contacted Dr. Regent, alleging that "as a result of your misdiagnosis, Mrs. Adams suffers from myofascial pain syndrome of the neck and thoracic region. She now experiences chronic pain in her neck, has trouble sleeping at night, and requires medication for pain."

Under threat of a lawsuit, the letter demanded $125,000 in compensation for future medical treatment, loss of income, and "unbearable pain and suffering."

Results:

The insurance investigation revealed that instead of getting better, the patient had developed serious pain during the course of Dr. Regent's treatment. Medical records from her other treating physicians substantiated this.

Also, a dispute had arisen over Dr. Regent's bill. Unfortunately, Dr. Regent's advertising practices (which included several large billboards claiming to "guarantee pain relief") had alienated the local chiropractic community, and defense counsel was unable to locate a chiropractor to testify in his defense.

The investigator learned that after terminating treatment with Dr. Regent, Adams had obtained medical evaluations from several doctors, including neurologists, pain specialists, orthopedists, and, ultimately, a dentist. None of the doctors reported any anatomical relationship between her pain and physical condition.

"Our review of these evaluations leads me to believe that no connection between the plaintiff's pain and Dr. Regent's treatment could be proven in court," the investigator reported.

"The plaintiff's medical expert (a dentist), however, will testify that the manipulation of the mandible and the temporomandibular joint by Dr. Regent caused the problem," the report continued. "The expert has radiographs that show the mandibular condyles jammed against the patient's skull. These also show a torn and damaged articular disk bilaterally."

There was no indication in Dr. Regent's records that he intended to refer the patient to a dentist skilled in the treatment of temporomandibular joint syndrome (TMJ).

Karen Adams' chart contained only a treatment record and no progress notes or examination form.

According to an expert from the American Board of Chiropractic Orthopedists, who reviewed the case for the plaintiff, "The case history and examination were insufficient by today's standards of chiropractic care. According to the other doctors' medical records, the patient was getting progressively worse. There is no indication in Dr. Regent's records that this was the case."

"The negative testimony and evaluation of the case by other doctors is significant," the defense attorney concluded. "We believe there is a risk of an adverse verdict in this case."

Four years had passed since the claim was made and more than $20,000 had been spent on investigation and legal fees. In order to avoid further expenses and the risk of a high jury award, the decision was made to seek an out-of-court settlement of $75,000 and was finally agreed upon.

Prevention:

No x-rays of the temporomandibular joint were taken. A full spine x-ray does not show adequate pathology in this case. An upper cervical of at least two views would have been appropriate.

When a patient fails to respond to mandibular therapy, the treating doctor should refer the patient to a dentist trained in treating TMJ. Dr. Regent failed to make such a referral.

Even though Dr. Regent said he took a history, performed an examination, and completed range of motion tests, he failed to record any of these activities in the patient's chart. Adequate record keeping in this case would have provided a much stronger defense.

Disputes over payment of fees can often aggravate otherwise manageable disagreements with patients.

Had Dr. Regent used fair and straightforward advertising practices, the defense of his case could have been enhanced by an expert witness willing to testify in his behalf.


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