Every new patient exam requires a quiet Columbo or Sherlock Holmes voice in the back of the examining doctor’s head: What is really going on here? What’s missing?
And am I always right in my logical conclusion? Of course! Okay, maybe not, but I do let the Sherlock Holmes part of the brain in on the cogitation.
A recent case in point: A fifty-something very nice lady, Mrs. B, came in referred by her general dentist for sudden onset jaw clicking, jaw pain, and pain when chewing.
“When did this happen?”
“The same day I had this last tooth extracted. Same hour, even. Tooth came out and I was clicking and had pain.” She points to her lower right side and I see that the second molar is missing with the pink tissue of a recent extraction.
There’s a bridge just in front of that space, from #28 to #30 to replace missing tooth #29.
Sherlock whispers, Don’t like the looks of that bridge. Kinda ugly. But maybe it was a traumatic extraction.
A quick phone call and I find out the extraction was done by an excellent periodontist and that it wasn’t traumatic at all. Quick and easy, actually.
Joint x-rays show a slight posterior displacement of the right mandibular condyle. JVA (joint vibration analysis) discloses a high volume click on the right side upon wide opening.
The patient has right temporalis and right masseter pain, but no actual joint pain.
Sherlock whispering in my head says, What if the last molar provided the only holding cusps on the right side? What if that stupid bridge—sorry those were his words. I’d never talk that way!—was never in occlusion until the loss of the second molar? Collapse of the right side with that last tooth gone. Not a real joint problem at all.
I know it wouldn’t have been wrong to treat this lady with daytime and nighttime intra-oral orthotics to provide perfect joint position and bite. It would have worked. It would have proved a successful TMJ therapy case. But what if the whole exercise was not needed? Sudden onset joint problems with the loss of that one tooth meant only one thing to me and Sherlock: that old bridge was the problem. It was too low and always had been.
So I tried an experiment. With Mrs. B wearing JVA sensors I had her repeat joint noise testing, but this time with a 0.7 mm shim held on top of that lower right bridge. Lo and behold, the click disappeared.
I did my best to explain to this nice lady the concept of the support to the joint that should have been there but suddenly wasn’t. Proof lay in the fact that she knew her loud click was eliminated by improving the bite contact on that bridge.
“I’ll ask your dentist to replace that bridge and I think your problem will be solved with no actual TMJ treatment.”
She liked the idea.
I wrote her dentist a report and at the end said, “I can’t prove it, but I suspect the bridge on the lower right was never in occlusion. Losing #31 caused a collapse on that side. Replace the bridge. Provide good solid occlusion and I think her “joint problem” will go away—immediately.”
When I sent that report off I thought to myself, Gee, I hope he didn’t do that bridge! But then, I know the dentist, and know that his quality of care is better than what I was seeing here. Still, I wouldn’t want to tick him off by choice.
Was I going out on a limb? You bet. There are plenty of authorities who say occlusion can’t cause joint problems and some even say occlusion can’t cause pain. I think that anyone who says that ought to have a few high crowns or composite fillings placed so they can chew on that for awhile. Much like a rock in a shoe, it would not feel good.
On the other side of the coin are those who say pain and joint pathology are ALWAYS the result of occlusal problems. Sorry. I can’t get on board with that school of thought either. There isn’t any ALWAYS, except for the need to always be careful to weigh various possibilities during exams and have a little Sherlock inside one’s head playing detective while the doctor is assessing the objective findings.
A couple of months passed before I heard from her dentist but at last he let me know that he had taken that old bridge off and that he had replaced it with a new one. “The patient seems to feel better and her click is gone,” he told me.
I saw the patient a few days later. Indeed the TMJ problem was almost completely resolved and Mrs. B was happy. I saw that the bite on the new bridge was certainly an improvement, but I took a photo to show the dentist how it could be improved further.
He did the adjustment I recommended to remove a working side interference and the patient returned the next week with all pain resolved and the clicking gone.
This was a very satisfying result for all concerned, the patient, the general dentist, the periodontist, and me. It is nice when what looks like a possible joint dislocation that could take months of therapy to resolve is taken care of with a couple dental appointments.
We do have technology in our office that is beyond what is available in a typical dental office, so we are able to investigate some of these unusual oral/facial pain situations in greater depth than would be commonly available. Still, all of us can let a little bit of Sherlock whisper once in awhile.