019: Missed Diagnosis

I want to share a story that highlights the importance of comprehensive evaluation and patient education when it comes to third molar pain. Imagine this scenario

A 17-year-old female presents with bilateral jaw pain. Exam reveals
Impacted third molars, no obvious pathology
No intraoral signs of infection or pericoronitis
Teeth are removed without complication

But at post-op visits, the patient reports
Pain persists or worsens
No response to anti-inflammatories
Headaches develop

What's going on? In this case, we may have missed an underlying diagnosis of TMD, specifically myofascial pain in the muscles of mastication.

Key signs of TMD to watch for
1. Headaches, often behind the eyes or at the temples
2. Tenderness at the temporalis insertion (near maxillary first molar)
3. Pain at the angle of the mandible (masseter attachment)
4. Pre-auricular pain (pterygoid involvement)
5. History of gum chewing, ice crunching, or other parafunctional habits

The problem: When we assume third molars are the sole cause of pain and remove them, we set ourselves up for trouble if TMD is the true culprit. The patient's pain persists, and they may blame us for their worsened condition.

The solution: Thorough assessment and clear communication
Palpate the muscles of mastication for tenderness
Document pre-existing TMD in the patient's record
Discuss the distinction between third molar pain and myofascial pain
Set expectations for potentially prolonged recovery due to TMD
Consider the necessity of third molar removal if no obvious pathology is present

I learned this lesson the hard way when a patient reported me to the dental board, claiming I had caused her TMD by "dislocating her jaw" during surgery. Thankfully, my documentation of her pre-existing condition exonerated me, but it was a stressful experience.

By sharing this story, I hope to help others avoid similar pitfalls. Remember, a thorough exam and clear patient communication can make all the difference in achieving optimal outcomes and maintaining trust.

As always, I'd love to hear your thoughts and experiences. Feel free to reach out at [email protected], and follow me on X @RussellKirkDDS for daily posts on all things oral surgery.

Talk to you next week!