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“Whiplash” and “TMJ” Science or Opinion?

“Whiplash” and “TMJ” Science or Opinion?. Heidi C. Crow, D.M.D., M.S. Indiana University. Causality. Strength of association (relative risk ratio) Consistency upon repetition Specificity Time sequence Biological gradient Plausibility Coherence of explanation Experiment Analogy.

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“Whiplash” and “TMJ” Science or Opinion?

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  1. “Whiplash” and “TMJ” Science or Opinion? Heidi C. Crow, D.M.D., M.S. Indiana University

  2. Causality • Strength of association (relative risk ratio) • Consistency upon repetition • Specificity • Time sequence • Biological gradient • Plausibility • Coherence of explanation • Experiment • Analogy

  3. External causes • Direct vs. indirect trauma • Whiplash • low impact vs high impact

  4. Clinical Evaluation • History of onset • temporal relationship to a precipitating incident • previous injury to face/MVA • previous episodes of muscle/joint pain • Co-morbidities • Social history

  5. Life on the Internet . . . Or “information” easily accessible to your patients: • “Taking the mystery out of personal injury claims…how do I legally prove what happened?” • “Establishing a Medical Malpractice Lawsuit” • “How much is my personal injury worth?” • “What assistance can an experienced personal injury attorney provide in making my claim based upon TMJ Dysfunction?”

  6. “Whiplash” and “TMJ” Cervical extension-flexion injury (whiplash) and internal derangement of the temporomandibular joint. Weinberg and LaPoint, 1987. • 28 pts. post-whiplash, internal derangement 22/25. • Hyperextension, downward forward displacement of the mandible->hypertranslation of the mandible-> stretching and tearing of the posterior attachment • Hyperflexion-> “crushing” of the posterior attachment between the condyle and glenoid fossa

  7. “Whiplash” and “TMJ” Assessing neck extension-flexion as a basis for temporomandibular joint dysfunction. Howard, et al. 1991. • Cited Newton’s laws to discredit stretching/crushing theory • Compressive forces only would act on disk • Compressive forces encountered in cervical extension-flexion injuries should not exceed forces in normal chewing activities.

  8. “Whiplash” and “TMJ” Temporomandibular joint injury potential imposed by the low-velocity extension-flexion maneuver. Howard, et al. 1995. • Live human test subjects • 5 mph rear-end collision • Maximum forces that would be generated in the TMJ are much less than forces expected with normal masticatory function.

  9. “Whiplash” and “TMJ” MRI studies • Pressman, J MRI 1992: no control, group of whiplash + TMJ symptoms: claimed high incidence of internal derangement • Garcia, Cranio 1996: no control, group of whiplash + TMJ symptoms: claimed high incidence of internal derangement • Bergman, Am J Roentgenology 1998: matched control demonstrated no difference between groups

  10. “Whiplash” and “TMJ” Problems: • MRIs of individuals with symptomatic TMJs are likely to demonstrate deviation from normal. Whether the individuals had a previous MVA may be unrelated to the MRI findings. • Large percentage of asymptomatic individuals that demonstrate deviation from normal on MRI.

  11. “Whiplash” and “TMJ” In Lithuania, patients with whiplash (N=210) do not report an increase in TMD as compared to matched controls. (OOOOE, 1999) In Ireland, patients with whiplash (N=40) demonstrated more joint and/or muscle pain and limited opening than matched controls. (J Orofacial Pain, 1993)

  12. “Whiplash” and “TMJ” Problems: • Retrospective history of trauma in patients already presenting with TMD complaints at an Orofacial Pain Clinic. • Recall of signs and symptoms prior to the MVA.

  13. Poorer prognosis, higher number of interventions and treatments in post-traumatic groups Brooke, OOOOE 1978 Romanelli, Clin J Pain 1992 Kolbinson, JOP 1997 Same prognosis, same outcome with or without trauma De Boever, J Oral Rehab 1996 Greco, Clin J Pain 1997 Steed, Cranio 2001 Trauma and “TMJ”

  14. Trauma and “TMJ” The 10 Million Dollar Question: What differentiates patients who have transient myofascial or joint complaints following an MVA from individual who develop chronic complaints? • Stressors • Psychosocial factors • Sensitization

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