What His Dentist Will Never Know

Dr. Halligan
Dr. Halligan

A young man came to see me yesterday with complaints of pain when chewing, jaw clicking and limited opening. He’d had prior orthodontics 10 years before but was sure that had nothing to do with his current problem.

He said he had mentioned the problems to his regular dentist who apparently had no answers. He was finally referred to my office not by his dentist but by a local oral surgeon.

Range of motion without pain measured 35 mm, but he could push it to 45 mm with some pain (normal opening is considered to be 42-52 mm opening without pain, depending upon which authority you read).

He had a slight deviation to the right.

Upon palpation he had pain in both masseters, the right anterior temporalis, and the right lateral capsule of the TMJ.

He had a slight click on closing.

Patient's biting force upon closing. Note harder occlusion left than right.
Patient’s biting force upon closing. Note harder occlusion left than right.
Left lateral excursion. Good canine guidance.
Left lateral excursion. Good canine guidance.
Heavy non-working side interference on right lateral excursion. That left second molar should not contact.
Heavy non-working side interference on right lateral excursion. That left second molar should not contact.

T-scan of occlusion showed significantly harder occlusion left than right and when he went into right lateral excursion–hard for him to do by the way–T-scan displayed a very hard contact on the left second molars.

Imaging of the temporomandibular joints showed normal joint architecture with both condyles well centered in the glenoid fossae with good translation on opening.

“Well, the good news,” I told him, “is that you don’t appear to have a TMJ problem at all. This is primarily a bite problem and it’s causing muscle strain. Your left side teeth hit too hard when you close, and your teeth don’t function smoothly side to side. I think your dentist could correct all of that.”

He confessed then that after orthodontic treatment he had worn his retainers for a year or two but had then stopped.

“Perhaps that caused a shift in the occlusion,” I told him.

“But I also had quite a bit of dental work recently, and all of it on the left side.”

“Well, that’s important,” I said, while thinking Okay, Dummy, you should have asked about recent dental work when you saw the occlusion!

“I told my dentist something didn’t feel right.”

“I’ll prepare a report of findings and send your dentist a copy including a print-out of T-scans. He should be able to fix this for you, especially if there are some high fillings. Make sure he looks at the left side teeth when you’re grinding on the right. That last molar shouldn’t be hitting like this.”

“Actually, do you know a dentist who’s good with bites?”

“Sure, but I’m positive your dentist will be able to correct this, especially after he sees the scans.”

“I want you to refer me somewhere else, and I don’t want my dentist to get a report.” He looked me straight in the eyes with a solid, I am not kidding, gaze.

Now, perhaps you can guess how I felt at that moment. I don’t know his dentist personally, but I still didn’t wish to step on his toes.

“I don’t have to send your dentist a report if you don’t want me to, but I think it would appropriate for me to do just that.”

“No. I’m not going back to him. Just give me another name.”

With HIPPA rules being what they are, I at least try to follow them. I think that if I had a personal relationship with this young man’s dentist, I’d be tempted to break the rules and make phone call and discuss the matter. As it was, I said Okay, and gave him a referral.

(By the way, Mr. President, would you please do us all a favor and issue an executive order striking down HIPPA? It has certainly become a giant PIA for every medical, dental, optometry, podiatry, etc. office in the land. Only the veterinarians have escaped. So far. Woof.)

So, somewhere nearby is a young dentist who will never see this patient again and will never know why. Maybe he has a busy practice and this one patient won’t be missed. Still, if this dentist misses a few too many of these occlusal problems–some of them his own making– I’d have to suspect his practice will suffer.

Should I break patient confidentiality and just give him a call? It’s a quandary for sure. Would you break the rules? Should I break trust with the patient?

The answer is this: after only a little consideration I’ve decided that I absolutely won’t. And the young man’s dentist will never know what happened.

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