Opinion
CLAIM NO. E206699
OPINION FILED DECEMBER 14, 1994
Upon review before the FULL COMMISSION in Little Rock, Pulaski County, Arkansas.
Claimant represented by the HONORABLE JAMES GERARD SCHULZE, Attorney at Law, Little Rock, Arkansas.
Respondents represented by the HONORABLE J. MICHAEL PICKENS, Attorney at Law, Little Rock, Arkansas.
Decision of Administrative Law Judge: Reversed.
OPINION AND ORDER
The respondents appeal an opinion and order filed by the administrative law judge on January 24, 1994 In that opinion and order, the administrative law judge found that the claimant's problems with her mouth and jaw are causally related to her compensable injury of April 3, 1992. After conducting a de novo review of the entire record, we find that the claimant failed to prove by a preponderance of the evidence that her temporomandibular joint problems are causally related to her compensable injury. Therefore, we find that the administrative law judge's decision must be reversed.
The claimant was involved in an automobile accident on April 3, 1992, which admittedly arose out of and in the course of her employment with the respondent employer. She was transported to the emergency department of Baptist Hospital by ambulance. The emergency room records indicate that the claimant was complaining of shoulder pain going down into her lower back, left elbow pain, and neck pain. In addition, her head apparently hit the windshield during the crash, and the emergency room records note a small abrasion on her left check. However, the records also note that she denied any temporomandibular joint pain, and there was no sign of injury to her teeth or mouth as a result of the accident. Cervical x-rays did not reveal any abnormality. Also, a CT scan of her head was performed to assure that there were no head injuries, and this was also normal. Likewise, a lumbar MRI was also normal. After her condition was thoroughly evaluated, the claimant was released from the emergency room with a diagnosis of an acute cervical strain and right hand contusion.
Approximately one week after the April 3, 1992, automobile accident the claimant woke up one night with "excruciating" pain in her mouth and her left jaw inside her mouth. She attempted to call several dentists that night, and, ultimately, she saw Dr. Sam Beavers the next day. Dr. Beavers' report indicates that the claimant advised him that she broke a tooth in the automobile accident. Dr. Beavers determined that the claimant needed a crown, and he advised her that she needed to have a root canal or to have the tooth pulled. In addition, the claimant had not been to a dentist for over 15 years, and Dr. Beavers found that the claimant had gum disease. He advised her that she was in danger of losing her teeth if she did not take appropriate actions immediately.
The claimant was financially unable to have the loose crown repaired by Dr. Beavers. However, she sought treatment from Dr. Creighton Wilson, the uncle of one of the claimant's friends, and Dr. Wilson pulled the tooth after the claimant made arrangements to pay for the treatment over time. Dr. Wilson also referred the claimant to Dr. Shelby Woodiel, a dentist. Dr. Woodiel has treated temporomandibular joint syndromes for seventeen years, and his practice has been restricted to the treatment of temporomandibular joint syndromes for the past seven years. After conducting diagnostic studies, Dr. Woodiel determined that the claimant was suffering from temporomandibular joint pain.
Dr. Wilson testified that the claimant's condition was not a true temporomandibular joint syndrome. According to Dr. Wilson, a true temporomandibular joint syndrome involves actual damage to the temporomandibular joint itself. However, he testified that the claimant's temporomandibular joint is not damaged. Instead, he opined that the claimant's is suffering from a cervical musculoskeletal dysfunction, and he opined that this dysfunction is causing the muscles to position the lower jaw in the wrong position.
This Commission has a statutory duty to decide the issues before it by determining whether the party having the burden of proof on an issue has established it by a preponderance of the evidence. Ark. Code Ann. § 11-9-704(c)(2) (1987); see, Gencorp Polymer Products v. Landers, 36 Ark. App. 190, 820 S.W.2d 475 (1991). In determining whether the party having the burden of proof on an issue has established it by a preponderance of the evidence, we must weigh the evidence impartially, without giving the benefit of the doubt to either party. Ark. Code Ann. § 11-9-704(c)(4) (1987); Wade v. Mr. C. Cavenaugh's, 298 Ark. 363, 768 S.W.2d 521 (1989); Fowler v. McHenry, 22 Ark. App. 196, 737 S.W.2d 633 (1987). In this regard, the claimant has the burden of establishing her entitlement to the compensation sought by a preponderance of the evidence. Bates v. Frost Logging Co., 38 Ark. App. 36, 827 S.W.2d 664 (1992); Lybrand v. Arkansas Oak Flooring Company, 266 Ark. 946, 588 S.W.2d 449 (1979); Bates, supra. Consequently, the claimant must establish a causal relationship between the employment and the condition for which she seeks compensation. Lybrand v. Arkansas Oak Flooring Company, 266 Ark. 946, 588 S.W.2d 449 (1979); Bates, supra.
In the present claim, we find that the claimant failed to prove by a preponderance of the evidence that she suffers from temporomandibular joint problems which are causally related to her employment. In this regard, Dr. Woodiel testified that the claimant's temporomandibular joint pain is not caused by the trauma of the claimant's head hitting the windshield and frame of the car, and he has opined that the claimant did not sustain a temporomandibular joint injury. Instead, as discussed, Dr. Woodiel has opined that myofascial pain in the claimant's neck and cervical area is causing referred pain in her face and producing referred headaches. On the other hand, the respondents obtained opinions from Dr. Fredrick G. McFall and Dr. J. R. Graham, dentist consultants for ADC-NCC in Marietta, Georgia. These dentists conclude that the findings submitted to them do not justify the contention that treatment of the temporomandibular joint is needed as a result of the compensable injury. In the regard, Dr. McFall notes that there is no displacement or improper functioning of the temporomandibular joint indicated by x-rays. Dr. Woodiel agreed with this reading of the x-rays. However, he again reiterated that his opinion is based on the effect of the cervical spine injury to the jaw and this his opinion is not based on an injury to the temporomandibular joint itself.
Consequently, Dr. Woodiel's opinion is based on his evaluation and assessment of the physical injury to the claimant's cervical spine. However, Dr. Woodiel is a dentist, and we are aware of no authority which suggests that the practice of dentistry includes the examination, diagnosis, and treatment of physical injuries to areas other than the oral cavity, teeth, gingivae, and jaw. See, e.g., Ark. Code Ann. 17-82-101 (1987). Instead, it is commonly accepted that the examination, diagnosis, and treatment of physical injuries to other areas of the body, such as the cervical spine, is limited to those licensed to practice in areas such as medicine, chiropractics, and osteopathy. See, Ark. Code Ann. 17-93-201 17-93-202 (1987). There simply is no evidence in the record establishing that Dr. Woodiel, as a dentist, is qualified to render an opinion regarding medical matters such as cervical strains and cervical muscle spasms. Such medical matters may affect dental conditions, and, when this occurs, the evaluations and opinions of dentists, as well as the evaluations and opinions of medical practitioners may be important in determining causation.
In the present claim, there is no opinion from a medical practitioner suggesting that the cervical injury is responsible for the claimant's dental or temporomandibular joint problems, and there is there is no suggestion in the medical records that a medical practitioner has ever suspected such a relationship. When the claimant was examined in the hospital, she denied any temporomandibular joint pain, and an examination of her mouth did not reveal any broken or avasculed teeth. Also, Dr. Edwin Barron, a general practitioner, was the claimant's treating physician for her cervical and low back complaints. Although Dr. Barron's records briefly note tenderness over the temporomandibular joint in his initial notes, there is no indication in his records that the claimant subsequently complained of temporomandibular joint pain to Dr. Barron or that Dr. Barron was aware of the claimant's treatment by Dr. Woodiel for this or any problem.
We also note that Dr. Woodiel could not say that this problem was a direct result of the compensable injury. In this regard, his testimony suggests that the pain is actually caused by other causes, such as structural abnormalities including the crowding of the lower anterior teeth, flaring of the upper anterior teeth, inclination on lower posterior tooth, a high roof, and evidence of uneven stress on teeth. Dr. Woodiel testified that any of these conditions, as well as the gum disease, could be the cause of the claimant's pain, although he concludes that the stress of the cervical muscle spasm triggered the onset of the symptoms. Interestingly, although Dr. Woodiel asserts that these problems are the result of the cervical muscle spasm, he also asserts that orthodontic treatment and the restructuring of the overlays is needed for treatment of the problem.
In short, the evidence establishes that the claimant did not actually injure the temporomandibular joint during the accident. In addition, the evidence establishes that several preexisting conditions were present which could have produced the temporomandibular joint pain which the claimant contends she experiences. Moreover, the only evidence connecting the compensable accident with the temporomandibular joint is Dr. Woodiel's statements regarding the effect of the muscle cervical muscle spasm on the temporomandibular joint. However, we find that the weight which should be given to Dr. Woodiel's opinion in this regard is minimized by the lack of evidence suggesting that he is qualified, as a dentist or otherwise, to examine and evaluate injuries to the cervical spine and to render opinions based on that evaluation. Aside from Dr. Woodiel's statements, there is little evidence suggesting that the claimant is suffering from temporomandibular joint pain which is causally related to the compensable accident.
Accordingly, based on our de novo review of the entire record, and for the reasons discussed herein, we find that the claimant failed to prove by a preponderance of the evidence that she is suffering from temporomandibular joint pain which is causally related to the compensable accident. Therefore, we find that the administrative law judge's decision must be, and hereby is, reversed. This claim is denied and dismissed.
IT IS SO ORDERED.
DISSENTING OPINION
I must respectfully dissent from the opinion of the majority finding that claimant failed to prove by a preponderance of the evidence that her jaw difficulties are causally related to a work-related injury.
The opinion of Dr. Woodiel that a causal connection exists in this case is entitled to great weight. First, Dr. Woodiel is a recognized specialist in the treatment of TMJ and myofacial pain. He has practiced exclusively in this field for the last seven years. Dr. Woodiel repeatedly opined that claimant's jaw difficulties were caused or aggravated by the work-related musculoskeletal dysfunction of her head and neck. Additionally, Dr. Woodiel is in a better position to render a opinion because he has personally examined claimant over a period of time. Moreover, in my opinion, a dentist is certainly qualified to diagnose and treat injuries to the body which affect dental conditions. One definition of "practicing dentistry" is "[t]he diagnosis, the surgical and adjunctive treatment of the diseases, injuries and defects of the human jaws and associated structures." (Emphasis added). Ark. Code Ann. § 17-82-102(1)(A)(ii) (1987).
Therefore, I find that claimant has proven by a preponderance of the evidence that her jaw difficulties are causally related to the compensable injury and the well-reasoned opinion of the Administrative Law Judge should be affirmed.
PAT WEST HUMPHREY, Commissioner