Quality of evidence

Sir, a few weeks ago, I examined one of our junior dental nurses who has recently joined the practice. She has a long history of migraines throughout her late teens and now, aged 20, has a severe bilateral click on opening. As we often hear, her migraines began following the removal of all four first premolars and fixed orthodontics in her mid-teens. Her GP has also been aware of her migraines and has been prescribing her amitryptyline for some years. On examination, there was indeed a hefty click on opening and non-working side interferences on both upper second molars. Some very simple occlusal adjustments removed the interferences and three weeks later her TMJ click had gone and so had the migraines. I urge us all to be in closer contact with our patients’ GPs in such cases. This poor girl has (I think) been prescribed powerful tricyclic antidepressants needlessly for several years. J. Critchley Totnes DOI: 10.1038/sj.bdj.2013.537