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TMJ treatment properly diagnosed and documented should
start out with a thorough clinical exam which includes the following:
History and Physical Exam
We are looking to see if they have had previous trauma, surgery or any other treatments
for a condition that may have been overlooked and TMJ diagnosis was not considered. We
also may find a positive history of being treated for a TMJ disorder but was not handled
effectively.
Frequency and location of headaches
Many times patients have been treated for what they call sinus, stress or migraine
headaches when indeed they have TMJ.
Joint Sounds
Joint sounds can be heard in their early stages with the doppler. As the form and function
of the joint deteriorate further, then they can be heard with a stethoscope and eventually
by the human ear and feel it pop when the joint is palpated by the finger tip. Also at
what point the joint sound is made either in closing or opening may give some insight as
to the severity of the intracapsular condition.
Muscle Testing
Here we are palpating the mucles of mastication and associated muscles connecting to the
mandible, skull, neck and back. Positive muscle soreness is a sign of fatigue and spasm.
Muscles are designed to either be at maximum contraction or relaxation. When muscle has
been competing with its counterparts its is not able to reach a state of rest. This would
indicate that the system is not working in coordination and the cause should be found.
Range of Motion Measurements
The mandible has a normal range of motion that should be attainable in opening and
closing. It also has a normal range of motion that should be attainable in sliding to the
left and to the right. The mandible should also be able to opening and close in an up and
down path that is straight without a deviation to the left or to the right. Ranges that
fall below the norm are usually indicative of incoordinated muscle function but can also
be representative of an internal joint problem.
Airway Evaluation
This can be helpful in determining that an airway obstruction is causing a forward head
posture and altered form of breathing. If this is problematic then the forward posture of
the mandible could be causing unwanted symptoms on the back of the head.
Radiographic Interpretation
I routinely request a panagraph to evaluate for neoplasms, third molar difficulties,
abcesses, failed root canals, interference with the mandibular nerve or other structural
abnormalities.
Oral Cancer Screening
This is to rule out any abnormal causes of oral pain.
Current Stress Evaluation
The patients current stress level may indicate that other forms of stress coping
mechanisms are necessary in order for the patient to refrain from forceful clenching.
Stress can also lower ones natural immune system or ones lactic acid threshold limit.
Accurately Mounted Study Casts
These are probably the most important test evaluated to determine how much disharmony is
present in the masticatory system. It is a must that the models be mounted with an
accurate facebow and a precise duplication of the centric relation position of the joints
just prior to any tooth contact between the maxilla and mandible. Then these records are
precisely transferred to an adjustable articulator.
Loading of the Joint
This is done using the bimanual manipulation as per Dr. Pete Dawsons technique. When the
condyle is fully seated with the disc assembly and articulating fossa and the patient
experiences no discomfort then you can sucessfully load the joint. What this tells us is
that you are safe that there is not an internal derangement that is going to require
further tests like MRI or referral to the surgeon.
DIAGNOSIS OF TMJ
Usually by the time you have performed this evaluation and tests the patient tells you
that you have touched every sore spot in their head. This can be an indication that you
are on the right track as far as some kind of TMJ Disorder. With other positive signs in
your evaluation you are ready to tell the patient how we feel it is a TMJ problem. Now we
know that muscles change in length and pressure in the joint changes when we have
uncoordinated function, so we can not get on a hurry to prescribe permanent treatment
until we have muscles and joints that are in a more relaxed state. That is why that the
vast majority of times we recommend a reversible initial form of treatment. That is the
use of a properly made splint or mouth appliance.
Splint Construction
It is very important to construct an appliance properly and out of the right material. Yes
you can use a lot of different materials but how comfortable your patient stays and how
well your patient responds to this therapy depends on some critical factors. Those being
the fact that the appliance works better if it is made out of a softer acrylic that
polishes smoother and stays smoother in the patients range of motions. The object is to
decrease muscle activity and when the teeth find a rough spot then the muscle will
increase in activity. Also the splint must be constructed in centric relation and have no
incline interferences on the back teeth at any time. The splint should be constructed with
anterior guidance on the most anterior tooth that can handle the load with posterior
disclusion. As the patients muscles and joints reach a more normal state then the splint
will be adjusted regularly to accommodate the changes. When the patients system reaches a
static point for several months then no more adjustments will be needed and you can take a
new centric relation registration and determine the extent of permanent treatment needed
to attain longer term patient comfort.
TREATMENT OPTIONS
At the conclusion of splint therapy and with the achievement of patient comfort at a level
the patient is content with, then the option or combination of options that may be
necessary are as follows:
- Orthodontics
- Equilibration
- Orthopedics
- Occlusal Reconstruction
- Tooth Removal
VALUE of TMJ TREATMENT
A comprehensive examination and the minimum of tests should be attainable for $1000.
Sometimes patients require an MRI or other tests and this will cost more.
Proper splint therapy and construction should be another $1000.
Then if all that is necessary is an occlusal equilibration then another $500 should cover
it.
So a simple case should be fixable for around $2500.
It is when the patient needs a combination of treatment options that can run the cost up
into $10000-20000.
Or worse yet when the patient needs the most extensive and lets says they need surgery,
then orthodontics, then occlusal reconstruction and equilibration. Then you could easily
be faced with a total treatment cost of $50000 or more.
It is very easy for me to duplicate the treatment
needed and present it to you on a dental articulator so that anyone can easily see what is
needed. I show you one set of models of where the patient began and one set or more of
where we need to be in order for the patient to achieve the maximum level of comfort.
Therefore it benefits the patient greatly to find out the right problem and treat it as
soon as possible to limit the treatment needed to the most conservative forms available.
Please feel free to contact me so that I may help you and your client in any way get in
the hands of one of the few dentists highly proficient in the treatment of this often
misdiagnosed condition.
SUCCESSFUL DEFENSE OF TMJ CASES
In order to have a successful defense which I will call the minimum amount of treatment
necessary to achieve a longer term more permanent treatment is determining what caused the
TMJ disorder. The first thing that needs to be done is a full work up as shown in my
article the valuation of a TMJ case. There are many causes that can occur as the patients
system is constantly undergoing change. It could be related to an injury, improper dental
procedure, general anesthesia, increased stress, lowered immune system, decreased lactic
acid threshold, congenital defect, hormonal change or just the patients bodys inability to
adapt at the current level. It is my opinion that it is hard to prove that the injury or
malpractice did not cause any part of the patients symptoms unless you can document that
the patient had all of the same symptoms before the incident in question occurred. The
best way to do this is to ask them to fill out my attorney screening form and answer it
before the questioned occurrence. Another good form of defense is when the patient has
been told they already had these positive signs of TMJ by their doctor, ENT, Dentist, Eye
Doctor, Chiropractor, Neurologist or Psychologist. The age old defense that occlusion does
not have anything to do with TMJ is rapidly loosing ground. In my opinion when a country
boy like me can see the results work in his hands on hundreds of patients then there must
be something to it. There also needs to be a full work up as shown in my article the
valuation of a TMJ case. One would need to make sure that the treatment recommended by the
plaintiffs expert is the minimum necessary to achieve comfort. I have seen treatment plans
suggest full mouth reconstruction when all that was needed was an occlusal equilibration
after splint therapy. It is very important to be accurate with the dental study models and
to precisely register the bite record in centric relation. There is a 1:3 ratio from back
to front. So for every millimeter of error in the back there would be three millimeters in
the front and this would mean a totally different need of treatment. This is all very easy
for me to duplicate and have on the table so that anyone could see it. Please feel free to
contact me so that I may help you evaluate your case precisely.
By: Ronald
Neer, DDS E-mail: ronneer@nemonet.com
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