As you all well know, I like to document our treatment by using an MRI to determine if the discs in the jaw joints are out of place, and to what extent they are out of place. This gives us a great way to track progress and determine if the discs have improved over the course of a year in treatment.
Recently, I had a patient who was one year in treatment and it was time for a new MRI to see if the discs had improved in position to make sure we were on track basically. Her symptoms were most certainly a lot better- i.e. much less pain and better range of motion. Unfortunately, the original MRI showed very prominent displacement of the discs in both joints- i.e. it was bad. The day that we reviewed that MRI I told her that her risk of needing the microsurgery to fix the damaged discs was relatively high, but we needed to ‘work the joints’ as I call it, for about a year to see what can improve.
The original MRI showed the right disc had ‘prominent medial’ displacement which is about as bad as it gets. And the left joint had both ‘prominent anterior’ and ‘prominent lateral’ displacement- again really a lot of displacement. Both discs did not reduce on opening – i.e. they were stuck there and probably had been like that for many years. Another thing that I order on my MRI’s is the angle of the jaw relative to the central axis to determine how out of alignment the jaws were. Those angles came in at 76 degrees on one side and 62 degrees on the other- again, not a good situation but very important information to have to compare for the future.
Back to the story at hand. At one year into treatment, I ordered the new MRI for comparison purposes and told the lady to go back to Novant imaging- the same people who did the first MRI so that we could get a good comparison done. You already see where this is going: She went to a different imaging center for the new MRI and the report came back stating there was no longer any displacement, nothing was out of place, all was well. Hey folks- I think I am pretty good at this, but not that good! In all the years I have been doing this work, I have never had such severely displaced discs go back into proper position completely- in other words it’s simply not likely. It’s the same odds as winning the lottery, imho.
This is why good data is so very important. When using an imaging service for the MRI’s, it is really important to maintain consistency and use a company that does these images all day long. Most imaging companies only do MRIs of the TM joints once in a while, whereas I send oftentimes 3-4 patients daily to this one place- and they have become very good at reading and producing good data. So when I got this new report for this woman, I knew right away that the results were nearly impossible and if indeed the report was correct, this classifies as a small miracle! And since I have not seen such a miracle in the past, it was not likely that the discs recovered as much as the report stated- i.e. they did not read it well.
As I sat back and thought about this turn of events, I understood why the lady went to another location for the imaging- it was near her home and they were in network- i.e. insurance paid more. But then as I further reflected on the situation, it made me realize how easy it can be to entirely misdiagnose a TMD case. If the radiologist cannot read an MRI properly, that means there are many cases out there that are being misdiagnosed. So imagine if this lady had originally gone to a TMD doctor more near her home and if she had the imaging done at the same place as she had done, then it is likely they would have missed the problems and her course of treatment might have gone a lot differently.
This is why TMD treatment seems to be a ‘hit or miss’ kind of thing. Over the past years I have had countless new patients show up here telling me they have been to ‘dozens and dozens’ of specialists- Mayo clinic, Harvard, UCLA, and Hopkins as well. A good MRI proved that the discs were displaced and allowed us to begin proper treatment. Without that MRI to prove what I thought to be true, treatment would never have begun. So therein lies the rub as they say- taking a shortcut on diagnosis does not benefit anyone.