A 17-year old girl experiences chronic headaches and her dentist recommends braces.
History of headache
The dentist of 17-year girl, Ms. B, discussed treatment for her headaches with her mother. Ms. B was fit and well with no significant medical history and had been fitted with braces three years ago, achieving an acceptable cosmetic result before they were removed. She did not wear her retainers provided to her by her orthodontist and her teeth had recently begun to become very slightly crowded again.
She had recently began to experience headaches to which her doctor had prescribed painkillers. Her dentist felt that the headaches would be improved by re-straightening her teeth with “Invisilign® braces”.
Although Ms. B. wasn’t keen on braces having experienced them previously, the dentist felt that this was the only way forward and felt it worthy of performing. They proceeded and the headaches did initially improve. However, after a few months the headaches returned, “worse than before”, and the dentist suspended treatment and instructed her to leave her braces out. The pain diminished slightly and the dentist said he’d only charge the mother for the cost of the diagnosis and manufacture of the braces. The mother spoke to a lawyer who in turn suggested obtaining an Expert Witness’ Report.
Investigation of facts
Ms. B was examined and a report prepared. The investigation illustrated that her headaches had in fact commenced following her original orthodontic treatment some time ago; when teeth were removed and her crowded teeth straightened. Her history went on to show that these earlier low-grade but chronic headaches had worsened into “migraines” (as described by the mother) but there was no connection made with the orthodontics – and the orthodontist had blamed them onto stress.
The worsening of her initial headaches relating to her orthodontics did seemed to coincide with exams at school which were therefore considered their cause.
The Expert Witnesses’ report indicated that these might indeed be tension type headaches but felt that chronologically, physiologically and from his own anecdotal experience, there was most likely a connection between the initial orthodontics and headaches.
With no evidence that orthodontics would manage headaches, the general dentist chose to refund all monies to the mother.
A discrepancy between Ms. B’s bite (jaw position) when her teeth were apart and then by comparison when her teeth were closed together was noted, appearing as a shift of her lower jaw backwards and to the side, upon tooth ‘closure’. This was considered as significant, as literature does support this as a ‘possible’ factor in precipitating headaches.
Clinical Case Review
The orthodontist refused to consider that his treatment might be related to Ms. B’s headaches. The report made recommendations as to present and future options which included a short-term splint to align her jaws according to their correct position (not where her teeth fit together). This alleviated the pain immediately and it was suggested that she wear it, decreasing wear each week.
Recommendation to close the case
In this case the Expert Witness suggested that the chance of winning the case was compromised due no precedent of s successful action, despite widespread publicity against the removal of teeth – it was said, “to give enough room for the remaining teeth”.
Legal questions arising
It may be possible to prove a cause and effect relationship (despite the strong belief held by orthodontists that their treatment cannot cause headaches and/or dysfunction) because the judge is not an orthodontist, however the orthodontic fraternity is a strong one and the case, unfortunately and unreasonably though it may seem, was likely to be robustly and aggressively contested and defended in order that there be no precedent despite the chronologic evidence.
The role of the Expert Witness is to give honest and impartial evidence, but where science is not involved his (or her) opinion and recommendations should be based on likelihood. In this case it is extremely unlikely that the case would have received a successful outcome for the plaintiff.
Author – Stephen Bray DDS