by Professor Tipton, a highly respected Specialist in Prosthodontics.
Expert Witnesses are experienced in a particular fieldand are trained to review a case, identify thepertinent issues, and provide an independent opinion based upon the facts. The role of the expert is toultimately help out the court (judge and jury) andthey must understand the role of the single jointexpert, and possess the skills to produce a court readyreport and if required to do so, present theirevidence in the courtroom in the correct manner.
Dentistry is becoming more specialised with theintroduction of specialist lists by the GDC. Dentalexperts highlight issues that perhaps the solicitor isunaware of due to the specialist nature of Dentistry.Their examination establishes a baseline recording ofthe client’s current dental health status and an opinion, prognosis and estimated future treatment aredetermined. They can help establish quantum,liability and comment on best practice that is inthe best interest of the client. The ideal expert is aspecialist and can speak on his or her specialism withgravitas and certainty.
Equipped with an expert report, solicitors and theirclients can fully understand the strengths and weaknesses of their case, and then make an informed decision whether to proceed with litigation. Seeking adental expert’s advice at an early stage ensures that aclient receives appropriate advice, and a comprehensive service from their solicitor. Without appropriate advice a solicitor risks overlooking a genuineproblem and a potential large claim that may disadvantage his or her client.
Whiplash and Temporomandibular Joint Injuries
Besides direct dental injuries most solicitors may besurprised to learn that whiplash victims may developsymptoms that are dentally related. These symptomsmay contribute to a victim’s suffering, and can be diagnosed, and treated by a suitably trained dentist,Restorative Dentist or Prosthodontist.
The presence of temporomandibular joint dysfunction after cervical whiplash injury was first recordedby Frankle in 1965. Rear end collisions now accountfor over 1/3 of urban accidents and nearly 40% ofthese produce whiplash injuries. Sudden forward acceleration of a car results in a backwards thrust ofthe head, on the relaxed musculature of the neck,thus causing a violent hyper-extension of the headand neck. In modern cars head restraints aim to reduce hyper-extension injury but their value dependson the mode of installation and adjustment. A headrestraint that is too low may even create a fulcrum forhyper-extension. After the hyper-extension phasecomes a rebound or recoil injury in hyper-flexion,hence the use of the term whiplash. It is thus a rebound injury that often damages the temporomandibular joints leading to a diagnosis oftemporomandibular joint dysfunction.
Trauma to the TMJs resulting from direct blows tothe face and jaws, due to impact with hard structuressuch as steering wheels, dashboards and windscreens,is well documented. Injury to the TMJs from impactwith the automatic air bag has been reported andconfirmed using magnetic resonance imaging (MRI). However, Temporomandibular joint (TMJ) symptoms are also a common finding in motor vehicle accident (MVA) patients with cervical whiplash. Therelationship between whiplash and TMJ injuries hasbeen verified with magnetic resonance imaging(MRI), in individuals who presented with TMJ symptoms and had sustained no direct trauma to the face,head or jaw, and had no TMJ complaints prior to theMVA.
At the TMJ and facial pain clinic at UCLA approximately 700 new patients a year are treated for TMJdysfunction with almost 1/3 having been involved inmajor trauma resulting mainly from car accidents. Acomparable group of non TMJ disorder subjects reported an incidence of only 13 percent involvementin major trauma (car accidents).
An examination of the TMJs should therefore become an integral part of any comprehensivee valuation of post motor vehicle accident cervical whiplash victims. Solicitors can screen whiplash sufferers for injuries (jaw joints) after accidents veryeasily using this tailor made questionnaire:
After the accident did you experience any of the following?
Please indicate if you had a symptom beforeand/or after the accident.
Jaw Joint Clicking yes/no before/after
Limited mouth openingyes/no before/after
Painful jaw joints yes/no before/after
Muscle tenderness in face, cheeks and temples yes/no before/after
More frequent headaches yes/no before/after
Pain on waking in the morning (jaws, cheek muscles and teeth) yes/no before/after
Night-time tooth grinding yes/no before/after
Fullness of the ears yes/no before/after
Pain in around the ears yes/no before/after
Pain on chewing yes/no before/after
An orthopaedic surgeon is routinely instructed bymost solicitors to report for accident victims withwhiplash injuries. This report is essential and willevaluate the musculoskeletal aspects of the client’s disability. However, there may be additional dental disorders that a dental specialist could diagnose, ifinstructed in addition to the orthopaedic surgeon,which could substantially affect the quantum of theclaim if lengthy and expensive dental treatment wasrequired.
It is in the best interest of a client to recommend theyseek appropriate treatment as soon as possible. It isimportant that any treatment provided prior to examination by an expert is well documented. A dentalexpert can refer to these records later when the clientis examined.
Delay in treatment is a common problem. A numberof our clients could have benefitted greatly from earlytreatment. Many clients simply stated that they havebeen waiting for months for their solicitor to arrangean appointment for them. Inappropriate management can lead to unnecessary tooth loss, extensivebone damage due to infections that complicate futuretreatment, extended treatment times, increased costsand may have the potential to cause osteoarthriticchange in the temporomandibular joints (TMJs).
Claims of temporomandibular joint disorder (TMD)in individuals with whiplash are increasing. Whiplashsymptoms, including the early and late stages, include: Jaw pain, jaw joint clicking, pain in and aroundthe ears, headaches, pain on chewing, jaw joint dislocating, tenderness in the muscles around the head,changes in the bite.
The issues of diagnosis and establishing causation arecomplicated when it is appreciated that studies investigating jaw joint imaging (e.g. xray, computerised tomography scan, magnetic resonance imaging,arthroscopy) demonstrate many types of jaw joint abnormalities in subjects with no apparent symptomswhatsoever. Clinicians interested in this field appreciate that jaw joint disorders are common within a normal population, often with sub -clinical symptomsthat only manifest after accidental damage or stress.
Psychological factors and whiplash
Accident victims are generally in pain and distressand report genuine symptoms. Their psychologicalmake-up will determine their behaviour and patternof symptom reporting. These psychological factorsare amenable to treatment that can result in the reliefof physical symptoms as well.
An individual’s response to his or her injuries may beinfluenced by harboured resentment of a problemsomeone else created, and the stress of associated litigation. It has been demonstrated that the stress ofthe legal process could influence treatment outcomesin accident victims. Pre-accident sub-clinical problemscan become clinical after an accident. Clients may notregard these problems as new, or relate them to theaccident, especially if the problems develop some timeafter the accident (Late Whiplash Syndrome).
In many patients, however, the signs and symptomsof the whiplash injury go undiagnosed as there areoften greater problems that have occurred as a resultof the road traffic accident. This has led to what hasbeen called “Late Whiplash Syndrome”, where accident victims report symptoms arising several weeksor months after the accident. Temporomandibularjoint dysfunction is a term used to describe a multitude of signs and symptoms affecting the temporomandibular joint.
People who have suffered a motor vehicle accidentand whiplash have experienced a great deal of stress,especially in the first three months and this anxietytogether with stressful life events can lead to jaw painand TMD.
An Examination of the TMJ’s should have thereforebecome an integral part of any comprehensive evaluation of post-accident cervical whiplash victims. Thefact that most solicitors refer their car accidentwhiplash injury victims to orthopaedic surgeonsmean this very painful and prolonged problem goesundiagnosed creating misery for many patients.
Many researchers have described the relationshipbetween stress and increased jaw muscle activitycalled bruxism. Bruxism (night-time tooth grinding)becomes elevated in times of stress, and can causemuscle pain, tooth pain, and jaw joint tendernesswhich, if pre existing, can exacerbate the cervicalwhiplash injury.
Treatment is aimed at initially treating the TMD in aconservative manner by occlusal splint therapy torelax the muscles that move the jaw. The temporomandibular joint is the most complicated joint in thebody and acts as a hinge that articulates the lower jawwith the upper jaw and allows the lower jaw freemovement. When there is damage to the joint themuscles become tense, not allowing this free movement in an attempt to isolate the joint. However, if theposterior ligament of the joint has been stretchedthen the muscle spasm further stretches the ligamentcausing greater damage. The aim of occlusal splinttherapy is to relax the muscles and allow the articulator disc to slip back into its ideal position.
The success rate is expected to be in the 85% + region and greater relaxation and pain relief may begained from occlusal adjustment (reshaping of theteeth to create a better bite) and sometimes furtherrestorations or full mouth construction with crowns,to stabilise the bite. This final treatment modality istime consuming and technically demanding andclaims in the region of £50,000 or more are not uncommon. In extreme cases surgery may be involved.
It is important that your clients receive appropriateprofessional advice, and an accurate diagnosis is established. If your client is mismanaged, and inadvertently told that therapy may be needed for months oryears, with the possibility of permanent symptoms,their pain symptoms may be amplified and becomeresistant to treatment. In addition, if inappropriatetreatment has been provided, with the best intention,patients become disillusioned with health care professionals, and sceptical of the benefits of further treatment modalities, no matter how qualified, orbeneficial they may be.
In summary, expert witnesses are experienced in aparticular field. They identify the pertinent issues,and provide an independent opinion based upon thefacts of the case. Dental experts indicate whether acase is strong or weak, they highlight issues that asolicitor may be unaware of, and their examinationestablishes a baseline recording of the client’s currentdental health status.
Besides the obvious dental injuries, solicitors may besurprised to learn that whiplash victims may developsymptoms that are dentally related after motor vehicle accidents. An examination of TMJs should be anintegral part of any comprehensive evaluation of postmotor vehicle accident cervical whiplash victims. Solicitors can screen whiplash sufferers for dental injuries (teeth and jaw joints) after accidents using asimple questionnaire.
Claims of temporomandibular disorder (TMD) inindividuals with whiplash can be expensive. People whohave suffered a motor vehicle accident and whiplashhave also suffered a great deal of stress. Anxiety andstressful life events can lead to jaw pain and TMD. Inaddition, bruxism (night-time tooth grinding) becomes elevated in times of stress, and can cause muscle pain, tooth pain, headaches and jaw joint tenderness. If a patient is actively bruxing then an attempt toalleviate their symptoms with splint therapy is indicated. A suitably trained restorative dentist or aprosthodontist can diagnose and treat these symptoms.
Failure to refer a whiplash injury to the correctRestorative Dentist or Prosthodontist could result in aclaim for malpractice against the solicitor or classaction if dental whiplash is not part of a claim.
A highly respected Specialistin Prosthodontics, Professor Tipton has published over 100 scientificarticles in the dental press andis an expert lecturer in hisfield with Tipton TrainingAcademies in Manchester,London and Dubai (www.tiptontraining.co.uk).
After gaining his Masters Degree in ConservativeDentistry in 1989, he was awarded the Diploma inGeneral Dental Practice by the Royal College of Surgeons four years later and received Specialist status in Prosthodontics in 1999 from the GDC. He is currently Professor of Restorative and Cosmetic Dentistry at the City of London DentalSchool and BPP University, and President of theBritish Academy of Restorative Dentistry(www.bard.uk.com). An ex-professional cricketer withLancashire County Cricket Club.
He is one of the UK’s most successful dentists in theUK (www.drpaultipton.com) with specialist clinics inManchester and London (www.tclinic.co.uk) and regularly appears in the Dentistry Top 50 UK dentist’s poll.