Given a treatment plan but feel it wrong - what next?
I developed TMJD this year subsequent to some bad dentistry which made my bite lopsided and lowered my molar height in January. I now have an unstable bite (since my molars are mostly too short and particularly so on the right) and malocclusion, I may also have a very slight open bite (which I have had for years however), not sure. Anyway, I've been slowly trying to deal with the teeth problems, persisting with going to a good dental clinic for what could be termed damage control (front teeth are becoming damaged from being pressed too hard together, swollen at gums etc.). I got a nightguard made to help the jaw joint relax after I was diagnosed with TMJD about 10 weeks ago, and the next stage was as far as I'm concerned just heightening the significant molars which is possible as I haven't lost my bite entirely, thus recovering my natural mouth shape and stabilising my bite. I was about to embark on this when the clinic I'm going to produced a young Mexican dentist (I'm from the UK and in Mexico City for a year where all this is happening, which isn't easy) who did some TMJD courses at NYU, this seemed fortuitous and I have spent some hours discussing my problems with him, many more hours writing out a dental history and detailed list of symptoms. Last Monday we met to discuss his treatment plan, supposedly based on the 'articulation model' with my teeth model in it, my tomograms, my history and symptoms and seeing my mouth. It became apparant as we talked that he has not read my history, he has suppositions re my teeth and bite that simply are not true and even the model he had of my jaw was (I believe, and I know my own jaw and how it was and is better than anyone) aligned wrongly with my lower jaw going slightly to the left which it does now if I bite down on the lower right molars. He was defensive agressive from the start, not prepared to acknowledge some of his premises were flawed, stating he appreciates my input and questions and that I have to agree to any treament plan before going ahead (of course) but in actuality not answering my questions, and belittling me (i.e. I ask if my jaw joint could have moved up displacing the cartilidge disc where the molars are lower -he replies 'did you read that on the internet?', snidely). His plan is simple and may work if his premises it is constructed on were correct, but as it is it's just not right for me, he wants to lower the molars further by filing slightly the left side of my mouth (equilibration), this idea horrifies me as if he does this work according to the way he has placed my top and lower teeth together in the model my bottom jaw would be irreversably misaligned going slighlty to the left for always. He would change the remaining molars on the left of my mouth which give me the reference point for where my teeth used to be, so that finding my orignal pre January bite again would be fairly impossible if I let him go ahead. The man reduced me to tears as I tried to just explain what I feel and how my jaw fits together, he finally he announced 'You are something else' which I had no idea how to take ... and talked subsequently to my friend in Spanish about how I want him to do what I want which is not what he can do as a professional. I don't want him, or anyone, to just do what I want, I need information, professional help, but I can't acquiesce to an irreversable treatment plan without discussion and answers, without feeling it is totally right and the facts re my mouth, history, teeth alignment, reasons for their malocclusion and so on correctly addressed. I require any professional I go to listen, to have the facts right (which this man absolutely did not and also did not acknowledge) and to work with me. I know I have a right not simply accept any diagnosis and proffered treatment straight off.
The solution may seem simple, just walk away and find another clinic/dentist. But this clinic (the other people there I've seen) have been so very professional, patient and helpful with me, I've trusted them and respected them. Now this one person has made it impossible for me to continue going there really. I have no idea what to do or where to go, the nightguard was expensive and needs adjustment, I'm in pain, and need help. I'm starting from scratch again.
I don't know if there are any neuromuscular dentists or TMJD specialists in Mexico. I know in the UK there are not many and those that do practice are prohibitively expensive (200 pounds per session just to talk). All of Europe is probably the same, I can't go to England anyway now because I have a cat here and need to plan out how to get her home. I feel bullied and wretched. Does anyone here know anything about TMJD? I think I'm pretty strong and I try so hard to be informed and to make good decisions, but ouf today's very uncomfortable encounter with a person I expected to be just - on my side- has subverted me totally. I'm afraid what I've come up against is a fairly defensive person out to prove himself and he has ruined my relationship with the only good dental clinic I know here. Almost a week later I'm still feeling so violated by this awful confrontation with a person I though would help me, I felt he was trying to beat me down and doesn't care about me at all, only about my accepting his treatment which I know is at the very least flawed. If he had just tried to attend to my concerns it would have been something, but he would not. Well, this is how it seems to me, I just don't know what was going on there and I hate ugly encounters so much, with anyone. I'm insecure, questioning myself, wondering how I have explained wrongly, how/if I could appear offensive, if I am wrong. But in a way I'm glad for the obvious clues, the dentist didn't know some very pertinant facts of my history (despite the fact I typed it out for him in detail) and verbally gave them, he was assuming causes/previous treatment/falsely premising reasons for certain teeth malacclusion I do know are false. I'd be an idiot to deny that and go along with his treatment just for the sake of harmony or because I so much want to find a viable, right solution. Trusting someone because it's upleasant to distrust them never really works, taking what is offered because it may help and is pushed at me and because someone is making me feel obstinate for questioning it would surely be so very passive and wrong.
[This message has been edited by Isobelj (edited 10-12-2003).]
I'm sorry the above is so long, maybe I should be more precise regarding information given to me by this dentist as I would love to hear the opinion of people here on it.
To start, I want to recover my pre January bite. I didin't have TMJ before January, though I may have had a predisposition to it and my bite even then wasn't ideal, but it was livable with and my mouth shape fine. It isn't impossible to recover that, I think I need to redo one left molar filling which is way too low and not even having contact with the molar above it, place a crown on a left cracked molar (at first a temporary crown not permanant as getting shape and height right before doing anything permanant is so important), and redo a 3 unit bridge on the right side which has made my right molars not touching, unless I force them altogether and when I do that my lower jaw slides slightly to the left and my right molars don't touch. I am convinced my molars are too low now, not only because I know of course that they reduced in January and are not their natural height (and also I do grind, so even my natural Jan molars were 'shorter' than they would have been if I didn't grind) but also because my front teeth are suffering because of being pressed too hard together, I need to relieve that.
Ok, what this dentist said is that this is now my bite and what he needs to work with. That if he does equilibration, touching the natural molars on the left and even the already really low bridge, that my bite will meet better, and I will feel I have my bite back and my tmj probs will get better. He also said my present nightguard will not work because it mimics my natural/present teeth (well, duh, I though the guard helped correct the present malocclusion and that was part of its funcion so this doesn't make sense to me) and I need to get another one made after the equilibration is done.
He did not listen when I told him my front teeth are suffering due to too short molars and if I 'cement' that by just keeping the molars low and letting him work on them to fit them better together I will continue to have gum issues and even an over bite I think. My bottom lower front teeth stick out a little on the right side, they cannot go smoothly into the teeth above, it I have to force them together as I do now to make the right molars meet then they slide to the left along with the jaw. It seems impossible for this man to understand this, he would be making my jaw slide to the left, as he has in my model, just lowering left molars and keeping that low molar height. I begin to despair of being able to explain this, am I at all comprehensible?
Then, the man said a top molar above the cracked tooth has surpraerrupted and there is no room for a crown anyway. I know it has not supraerrupted, I am so aware of every one of my teeth now and that tooth is the same height in relation to the teeth next to it and the 'twin' tooth on the other side of my mouth that it has always been. The reason he thinks there is no room for a crown is because he is pressing together the teeth on the model too much, which he can do if he misaligns the bottom jaw.
There's more but I'll spare you every detail!
What concerns me is;
I do need/want to heighten significant molars. I can do this without placing all crowns and without having such fragile teeth they will break, since I need just one filling redone not going over the natural tooth edge, one crown on a cracked tooth, and a redone bridge. If I don't do this my front teeth are in danger, plus my lower jaw sliding to the left when I press the molars together. Plus my mouth looks odd, not my mouth at all, compressed at the right corner, the lower lip going under more than it naturally does, not symetrical, I don't want to live with a distorted mouth. Plus, because the molars are shorter my jaw goes up slightly and back slightly when I bite, which can't be good for the joint and which again makes the jaw shape not my own.
The dentist told me to put my front teeth together, just the tips, he said if a person with a good bite does this the molars don't touch. If they do they are going to interfere with jaw movement partic at night when one grinds. He said this is happening with me. Actually if I put my front teeth together so they are just touching at the ends my molars do not touch, so he is wrong on this, but when he said it I believed him and wondered if my front teeth are too short (ground down?) and I have an open bite. I don't know. But if necessary I believe it would be better to put veneers on the front two top teeth rather than have all low molars and an odd mouth and jaw shape.
Then, finally, I have muscle spasms and a lot of strain in my jaw, face, neck and so on. Doing something permanant like equilibration now surely isn't advisable. After doing a lot of reading this week I think its better to try to relax the jaw, then place temporary crowns etc (maybe plastic) till height seems right. And to then only as a last stage do anything permanant. I'm trying to find actual tmj dentists to see, I know I don't want to even talk to the dentist I saw again. Others in the clinic are good, but none are tjm specialists at all.
As for the nightguard I don't know what to do with it. Last time I wore it my right joint ached, so I'm not using it for now. I am having, only when I poen my mouth not when I close it, increasing popping, slight cracking (not like the feeling if fingers click but a bit like the feeling you have if you pull a finger joint hard) and a slight sensation of deviation in my right joint which makes me think the disc is slipping down as a close my mouth, then when I open it is slips back into place (?), tomograms showed the bone is normal and condoyle unworn, but I don't even really know if the space between condoyle and fosse is ok or not as this unlikable dentist didn't interpret that for me (he asked me to get the lab to interpret and didn't tell me what they said). I also understood the articulation machine should show what the height of my teeth should be (measuring chin to nose distances etc.) and I got no feed back on this either.
Any opinions? Thank you, and thank you for reading all this!
[This message has been edited by Isobelj (edited 10-12-2003).]
[This message has been edited by Isobelj (edited 10-12-2003).]
A cardinal principle in treating TMJ and malocclusion is to fit the patient with a splint which corrects the malocclusion. The patient wears the splint for a few months with adjustments to the splint as necessary. Only after the patient has been completely out of pain and comfortable for at least three months does the specialist begin the finishing process which can be braces or crowns--whichever works best for the patient. This finishing process permanently adjusts the teeth so they are in the same configuration as the splint--since everything was working well with the splint.
If the specialist you are seeing does not plan to fit you with a splint before he does irreversible treatment--run as fast as you can to someone else.
I agree with Puzzled. GenDen is always so clear and right to the point.
GenDen, didn't you once say that it didn't matter whether the disc was recaptured? I'm looking at my treatment options and have come to the conclusion that my discs might always be displaced. I used to think that was important so that you didn't have future problems. So, I guess no pain, decompressing the joints (if condoyles are too far back) and a stable bite is what I should be hoping for then, right?
I have read research studies that say lots of people have displaced discs. Some have problems, most don't. My own opinion is that the body adapts very well. However, if there are too many problems going on at the same time, the body's ability to adapt is pushed over the edge. I think that is the reason why some of us with displaced discs have pain and lots of other people don't.
Your gut instinct tells you that something is not right with this dentist. I think you should trust how you fee inside. I agree with GenDen that you should be fitted with a splint and be symptom free before you start any reconstructive work.
You will have to keep looking for someone who can help you. I know nothing of Mexico City or UK. I wish I could help you out in that area.
I am in a similar situation. I had surgery to have my displaced disc put back in the proper position. I am mostly symptom free on one side but not the other. My surgeon wants me to start braces. The orthodontist and I have decided to wait awhile. I am scared to move my teeth when I am not symptom free. I don't know what I will end up doing. I guess what I am saying is that you are not alone in the fact that you feel you are in a mess, because so am I. I hope we both are able to find a solution. Have you asked the board if anyone knows of a dentist in your area?
Thank you all for the replies I'm fairly convinced now that doing anything irreversable at this point, particularly to my natural teeth, would be folly. My gut instinct re this dentist is really very strongly warning me to not let him even look inside my mouth again!
I've been reading about the damage an unstable bite can do to the joint (mostly on Dr Rebecca Griffith's website) and this so much fits my case. My bite is sliding all over the place on both sides of my mouth since January, it is only logical really that I developed tmj issues. I've decided the only imperative thing I do want to do straight away re dental work is heighten a much too low filling done in Jan (not making it higher than the natural sides of the tooth so this is not a large thing to do, it will just give me contact with the tooth above and help to give me stabilise my bite, and though it may sound so little I do feel doing this will help me feel better/help my jaw joint. And then I need to get someone to look at my present splint to see how useful it actually is, I hope it can be modified as it was awfully expensive. I'm not wearing it now as I know I grind with it in and I wake feeling worse than I do when I don't wear it.
I have found a clinic here which is part of an American chain, the 'Drdorfman' chain, has anyone heard of this? They have a tmj section on their website so maybe they would be some real help. They offer a free intial consultation anyway so I'll try to get to see them this week.