TMJ, or Scamsville USA?

April 30, 2012 3:10 PM

How much would my mention of the phrase 'TMJ' (a jaw disorder) to a dentist affect his decision to attribute my toothache to grinding rather than to tooth decay? I am worried that I am about to be scammed, due to the fact that (i) my aching tooth (and that tooth alone) has obvious decay, and (ii) that a new dentist was able to attribute my toothache to grinding before actually looking in my mouth.

Background:

Last Friday, I developed a toothache. Because I'm in a new city, I went to a new dentist. So far so good.

In taking my history, I mentioned to the new dentist that I once had a problem with TMJ (namely, last summer I was knocked in the jaw hard enough to make me think my jaw had been dislocated. That blow caused my right TMJ to be inflamed and painful-as-hell for about two weeks). Unfortunately, I didn't fill in these latter details, and only mentioned TMJ as a prior condition.

The doctor at the ER I'd went to that summer -- since my aching jaw was in fact crooked and I'd never heard the phrase TMJ in my life -- told me that all of this was due to the grinding of teeth, and that the blow to the jaw merely set off the explosive pain. I was suspicious, but whatever. If that is what it was, though, my TMJ had never presented a problem before, and has not done so since.

Similarly, no dentist before today has ever been particulary concerned about the grinding of my teeth (or lack thereof). However, after this new dentist learned of my transient TMJ, he was able to diagnose the source of my toothache before even examining me. He even told me that he was probably going to be able to do just that.

I hastened to mention my suspicion that the source of my pain might be the very dark, rough spot on the back of the tooth in question, which I thought might be decay, and which is not a spot found on any otherwise off-white teeth.

However, the X-ray taken of the tooth showed nothing particularly zany, and tapping on it was not painful. The dentist then proceeded to say the word "grinding" approximately 30 more times in the next few minutes, getting me to bite down on a blue strip of paper in order to show me all of the terrible blue dye that was deposited on the teeth that touch, as though teeth are not in fact meant to touch. Diagnosis? Apparently I have a severe and hitherto undiagnosed problem with grinding my teeth :|

(He also attempted to attribute this grinding problem to end-of-term woes, despite my protest that I've been finished classes for over two weeks and my stress levels are at dizzying lows.)


My question, then:

I want to find a regular dentist, but am hesistant to go with this one [a multiple-AskMeFi-commenter endorsed one, no less] because of the possibility of ending up in scamsville. Has this sort of thing ever happened to you before -- i.e., a dentist explicit jumping to conclusions and sitcking to them, despite unseen evidence of tooth decay?

Alternatively, may the doctor in fact be correct in apparently jumping the gun? Any time I have ever had this sort of persistent pain previously, it has meant a cavity, and a filling has always solved it (hence my concern with the novel diagnosis), though I'd be more than fine with the fact that tooth decay is not the problem here.

Thanks!

posted by anonymous to health & fitness (16 answers total)

Does your jaw click/pop when you open your mouth? I went to a new dentist last year (hadn't seen one in over a decade) and after looking at my teeth she asked me to open wide (I try to avoid opening too wide because it hurts) and when my jaw popped she said that's what she was waiting for and that I grind my teeth in my sleep and that's why (at least partially) they're such a mess. She still filled the cavities though... what did your dentist suggest as treatment for your toothache? If he hasn't prescribed anything or made a follow-up appointment to fill the cavity, where's the scam? Unless he's suggesting a significantly more profitable treatment plan for the teeth grinding than he would get for a filling I don't see how he benefits from misdiagnosing you
posted by missmagenta at 3:25 PM on April 30, 2012

Bruxism is a very common cause of TMJ and the wearing down of teeth. It can be kind of serious, and you may not even be aware you do it at night. It may or may not be caused by stress. It can start up for no great reason. It could be caused by stress you're not even sure you're having, or some other non-specific reason.

It's weird that the dentist tried to diagnose you without first seeing the tooth, but he might have just been offering a speculation. He did examine the tooth, right? And found no cavity? Then it is very possible that certain wearing down of the teeth would be caused by bruxism. Often, teeth grinding isn't something that you realize you have until you're sort of well into adulthood. I, for example, had TMJ but didn't know it was caused by teeth grinding until I started sleeping with someone regularly and they were like, 'hey, you've got some serious teeth grinding going on.' I went to the dentist, and sure enough, my teeth were worn from grinding at night. I got a night guard and it is awesome, awesome.

I don't know what is up with the blue dye thing, exactly. He might have just been trying to show you what teeth were worn from grinding against each other (you can tell this by the impressions the teeth leave, I would guess).

I guess my advice is to get a second opinion if you're really concerned. That wouldn't be too hard. But if your dentist said you don't have tooth decay on the tooth you're concerned about, I mean, unless he is the shittiest dentist ever, I would be inclined to believe him. But, no hurt in seeing someone else if you're worried about it, but I don't think your dentist is probably 'scamming' you.
posted by Lutoslawski at 3:26 PM on April 30, 2012

Find someone you know in your new city that seems to be the practical, pragmatic type, and ask that person for a dentist recommendation. Or allow a mod to post your location and maybe one of us lives near you and can make a recommendation. Make an appointment and go to this dentist for a second opinion. Do not mention TMJ to this dentist. See what happens.

There are definitely scammy dentists. TMJ is also something that happens in lots of humans as a result of teeth grinding, and it can be painful. If the second opinion involves TMJ, follow the advice.
posted by aabbbiee at 3:45 PM on April 30, 2012

The blue strip is a common tool to visualize tooth to tooth contact. Your teeth fit together in a specific way, and if, for instance you get a filling, the dentist needs to shape the filling to mimic the original fit of your teeth. If you grind your teeth they wear down, and this can been seen with the blue strip test as there will be extra points of contact between your upper and lower teeth.

Like Lutoslawki said, grinding (bruxism) is a common cause of TMJ, so if you have TMJ grinding is likely. Therefor it's not unusual or unprofessional for the dentist to assume pain from grinding, especially if that guess is followed up with an actual exam.

The way this looks to me, you were suspicious of the ER doctor who diagnosed your pain as coming from TMJ, and now your suspicious of a dentist who diagnosed your toothache as the result of TMJ. You may have undiagnosed mistrust of medical professionals.
posted by grog at 4:01 PM on April 30, 2012 [1 favorite]

You said he took X-rays, and physically looked at the tooth? Why do you think he is lying about there not being a cavity then? It's possible that he is actually a really good dentist - one who communicates with his patients to look for the kinds of problems that don't present themselves immediately in clinic visits. This is exactly why he was taking your history - many conditions can cause the same symptoms.

You sound very distrusting of him because his diagnosis did not fit your pre-conceived notion of what the problem was. However, this is usually why we see medical professionals - any random person can learn to fill cavities, but doctors and dentists have years of training and experience to help them find the non-obvious solutions to and causes of many health problems.

I mean, if you like, go get a second opinion, but realize that your attitude might be doing you a disservice relative to your long-term dental health.
posted by newg at 4:05 PM on April 30, 2012 [2 favorites]

The "blue dye thing" is likely occlusal marking paper used to determine contact between teeth. It is my understanding that contact is good, but it has to be even and uniform. So if you have "terrible blue dye" all over your teeth with no gaps, that's should be a good thing. It means your teeth and jaw are aligned properly and you probably won't have uneven wear.

If, however, there are gaps in the blue markings, the dentist may have been trying to demonstrate how your teeth have worn down or eroded to a point where you no longer have contact. Or, perhaps related to your TMJ throwing off alignment. I know you mentioned that no one had mentioned bruxism before, but tooth wear is a gradual thing and sometimes people just don't notice.

Regarding sources of persistent pain, some depend on your health and eating habits. Sometimes the enamel gets worn away by acidic drinks like soda or coffee, which makes your teeth more "sensitive" to things. Sometimes the sensitivity is at the roots, exposed by gum recession.

As far as the dentist goes, I don't know the exact nature of your conversation with him. The way you describe it, it seems like he didn't have good bedside manners. Conversely, maybe he has excellent bedside manners, but without knowing exactly what you said to him in response, I can't tell if he was truly awful, or if the two of you were just combative.
posted by CancerMan at 4:05 PM on April 30, 2012

From the OP:

"(i) To my knowledge, I have no evidence of TMJ (no popping, no bruxism reported by partners sleeping in the same bed), and only mentioned it to the dentist when asked whether any doctor had diagnosed me with jaw issues before. My worry is that my mere mention of TMJ, rather than any actual finding, is fuelling a diagnosis [severe bruxism] that had never occurred to any other previous dentist.

And, again, I still think the initial diagnosis of TMJ from the ER doc was a misdiagnosis: a kick to the jaw which causes a severe two-week inflammation of the jaw-joint seems (to me) to be a much different affliction than chronic teeth grinding causing chronic inflammation of the jaw-joint. But alas.

This leads to the following upsell scam/concern:

(ii) The new dentist, in addition to offering to fill the decayed part of the tooth in question, is offering to refill fillings in the concave parts of some of my molars, which have (so he claims) also been severely worn by grinding -- again, despite the fact that these fillings have been fine for years (perhaps even decades, in some cases) of annual checkups."

posted by jessamyn at 4:06 PM on April 30, 2012

Well, you can and should get a second opinion if you aren't confident with the first one. But I do think that you need to be very careful that you aren't doing exactly what you're suspecting the dentist of doing -- looking specifically for a particular diagnosis and ignoring other evidence that might conflict with it.

If the x-rays didn't show decay on that particular tooth, it's probably not decay. At least not at that particular location. It could be something around the existing fillings though (at least that makes sense, and I've had that issue). So the offer to re-fill them is not an obviously bogus one on its face. Although I'm not sure I'd be jumping for that immediately either.

The only good thing about bruxism is that the treatment for it -- assuming you've caught it before it's gotten really bad and destroyed your teeth -- is pretty straightforward: you get a nightguard and wear it at night. Although I'm sure your dentist would be happy to make you one for a few hundred bucks, you can get passable ones (according to my dentist, about "90% as good at 10% of the price") at CVS. You soak them in hot water to soften the material and then bite down into them. I use one, and according to the dentist it has helped.

It's entirely possible that you have bruxism and don't know it, and don't make any sound at night. While it's talked about as "grinding," it can also take the form of simply clenching your jaw at night. I only made actual teeth-grindy sounds very occasionally (typically when going to sleep after drinking), but the wear to my teeth was consistent with near-constant grinding/clenching at night. Now, I wear a nightguard, and the wear has (apparently) stopped progressing.

So at the very least, the most conservative treatment would seem to be for you to get a nightguard and start using it, just on the off chance that you are grinding or clenching, and then get a second opinion from another dentist on the replacement of your existing fillings, if and only if they've been damaged and are causing the pain (and also assuming that the pain continues and isn't alleviated by the nightguard -- although I wouldn't stop using the nightguard if it doesn't stop the pain, as it could prevent further damage even if it doesn't stop the discomfort now).
posted by Kadin2048 at 4:24 PM on April 30, 2012

I had a scammy dentist after moving to a new city but I stayed with the office for far too long because I liked my hygienist. That's with whom you spend the most time, right? She was a character and, besides keeping me amused while I was in the chair, gave me some good tips on mouth care that I appreciated. The dentist would come in after and always, and I mean always, try and sell me on expensive solutions to problems I didn't think I had, a different one every time. He insisted that I had become a grinder though none of the people with whom I'd ever slept in the same room with had reported this and for which I had no other obvious indications. He said that I needed to be fitted for a custom night guard by his office, stat, and that OTC night guards were the devil. I finally thought to look up online reviews and it turns out that most of the online reviewers had had very similar experiences relating to various expensive procedures. I looked up my future spouse's dentist and the reviews were golden. I switched and am now told how great my teeth are. YM, of course, MV.
posted by Morrigan at 4:42 PM on April 30, 2012

From the OP:

"Three other brief clarifications:

(iii) There is in fact decay on the tooth. When I said that nothing was "zany" on the X-ray, I should've been much clearer: on the image, none of the decay appeared to the dentist to be near enough to the nerve to cause problems. It may just be an unfortunate coincidence that this is the only tooth that aches like hell.

(iv) I have lived in a few different cities and have seen dozens of generalists and specialists throughout my life, having multi-year relationships with most. I have only suspected the two doctors mentioned above of misdiagnoses, and I only suspect this because (a) they caught things that no other doctor had caught, (b) the things they caught seemed counterintuitive due to reasons specified, and (c) there were countervailing factors such as a speedy diagnosis in a hectic environment [ER doc] or financial compensation [dentist] that could confound things. I mean, I still find the "pain here = TMJ = teeth grinding" diagnosis after reporting a massive blow to the jaw to be a bit odd, and hope this feeling of oddity is not an oddity on my part.

(v) I am taking seriously your suggestions, and am far more sympathetic now to the idea that I may indeed have bruxism."

posted by jessamyn at 4:42 PM on April 30, 2012

these fillings have been fine for years (perhaps even decades, in some cases)

Do you have any evidence that these decades-old fillings are "fine," besides your lack of pain? Granted it does sound like he might want to repair some of this older stuff BEFORE it becomes a problem, but that's not exactly scammy -- the body needs routine maintenance, you shouldn't necessarily wait until these fillings fail before getting them reinforced. He might be saving you money in the long run.
posted by hermitosis at 4:53 PM on April 30, 2012

Get a second opinion, but my guess is that it will likely be similar to this opinion. Grinding teeth really does wear down fillings; it may be your previous dentist(s) who were giving you substandard (or at least not-to-the-gold-standard) care.
posted by Sidhedevil at 5:11 PM on April 30, 2012

Agreed that it would be worth getting a second opinion. One thing about dentists is they have different thresholds for when to take action - so a previous dentist may have noticed old fillings getting worn but decided to let it ride, whereas the new guy is a "take action immediately" sort. Or, of course, the new guy could be a hack. I've had this experience in reverse - gone from a "let's fill it just to be sure" guy to a "let it ride" guy, and it's unnerving. I think there are just a lot of judgment calls in dentistry and if you have an issue that's at the borderline, you'll see differences in people's judgment.

One thing you could try is getting a night bite-guard thing at the drug store. This will be something like $20 or $30 if I remember, and it's a clear plastic mouth-shaped thing that you can form to your own bite via a procedure described in the instructions. You can try sleeping with it and see if it helps anything, and if you notice it is getting worn down after a while. A dentist-created night bite-guard will be more durable and more expensive, so it's worth trying the cheap drugstore kind first.
posted by LobsterMitten at 5:48 PM on April 30, 2012

D/oh, totally missed Kadin's paragraph above suggesting the drug store bite guard thing and describing the procedure.
posted by LobsterMitten at 5:51 PM on April 30, 2012

I suspect what you're running into is that bruxism is very common and has predictable effects on teeth, so even before looking in your mouth your dentist is leaping to conclusions.

So this dissertation on My Jaw and Teeth is intended as anecdata showing that what you're hearing is consistent with one person's treatment for her very obvious jaw problems:

I have noisy, sore temporal-mandibular joints. I grind my teeth - I catch myself during the day sometimes, even, and I can see the wear. My last three dentists (in two different US states and Australia) have told me that some (but not all) of the old amalgam fillings are harder than the tooth itself, and have no flexibility, so grinding drives them deeper into the tooth and causes splitting (like using a wedge to split logs). My current dentist went ahead and replaced some of my fillings, after maybe fifteen years of watchful waiting with previous dentists.

I also have discoloration on one of my back teeth - 2 dentists have said it's a byproduct of the grinding resulting in a lot of tiny, tiny cracks in the tooth's surface, so that there's staining in each crack that can't be buffed out the way tooth stains usually are. As long as it's not actually decaying, we'll just watch and wait.

I have had (ye gods expensive) custom night guards. I haven't ever tried the OTC ones, mostly for the weak reason I'm afraid they won't fit or will make my jaw hurt worse. When I use a night guard my TMJs tend to be less sore all day. However I do wake up in a lake of drool. It's gross.
posted by gingerest at 6:20 PM on April 30, 2012

They actually make OTC nightguards that are very small, basically just bits that go between your molars rather than the whole football-mouthgard-style thing (supposedly not as good because they don't spread the force out across as many teeth, but "better than nothing") and they are nice because you can close your mouth normally around them. No drooling. Here is an example.
posted by Kadin2048 at 8:58 PM on April 30, 2012