The primary goal of this website is to provide surgical and imaging information concerning orthopedic pathology of the jaw joint.  That has been our purpose since going on line. Also see (ASTMJS.org)  Similarly, it is a call for dismissal of the generic term “TMJ syndrome”, “ TMD disorder” and other non specific but commonly used “catch-all” categorizations of physical issues that can impact the TMJ or jaw joint as any other synovial joint system of the human body.  The problem with such categorizations with the TMJ has unfortunately led to generic treatment modalities and provider bias of understanding….or that pain in the face and jaw joint region (particularly in young and growing patients)  are exclusively  linked to muscular or dental bite relationship problems.   The following is a 22 year old patient who exhibits a history and eventual treatment that represents such a paradigm clash.

JT was seen for second opinion related to “My TMJ”.   Her history was that she had problems “since about 10 years old”.  It had impacted her jaw growth (crooked or asymmetric mandible) and because her joint disease was likely to have been present during her growth and development years, she now had significant malocclusion and facial deformity.  Traditional orthodontic treatment and orthognathic surgery was recommended and carried out  as the philosophy of both the treating orthodontist and surgeon was that such treatment would correct the problem. .

When JT would open her mouth, it would make a loud popping and grinding noise that was easily audible by anyone.  Mechanical locking and significant pain had been present for many years.

Below are Coronal MRI images of JT’s joints.

A

Image A is the patients symptomatic joint.  B is the normal joint.  In the lateral most compartment of the symptomatic joint (A), an image that is much darker than the remaining disc/capsule is seen.  This represents a calcified stone or often what is referred to as “loose bodies” by radiologists when commenting on atypical calcium deposits in cartilage tissues of joints.  This “loose body” in this TMJ image is embedded in the lateral attachment of the  disc/capsule of the joint complex.  Fortunately, frictional wear and tear had  not yet destroyed the joint boney surfaces at JTs young age.    It is not quite the character of bone, but nevertheless is partially calcified which will impair joint function significantly.  Compare with the homogeneous signal from the joint space in B.  

The clinical  term for this is “synovial chondromatosis”.  Another term is “pseudogout”.  The mechanisms for development of these calcified bodies in synovial joints is due to biochemical abnormalities in synovial tissues and  with normal joint fluid production and/or a combination this and cartilage growth and development. In younger patients there may be genetic issues in play. This condition can also  occur in severe and longstanding  osteoarthritic disease of synovial joint as an end stage pathology.  The condition is more prevalent in larger joints such as the knee, but can be seen in the TMJ nevertheless.

B

  Space does not allow inclusion of sagittal images in this case.  The absolute size or volume the patient’s symptomatic right joint A, is approximately 50% that of the left.  These growth differences are likely to have contributed to the crooked jaw that has developed as JT and her parents relate joint symptoms present well before puberty and skeletal growth advanced.  Though orthognathic surgery would be required to correct this consequence, the primary joint disease  would have to be addressed as well.  Many “TMJ” patients are simply evaluated imaging wise with a traditional dental “panorex/panoramic” film.  These films are generally of little value compared to tomography, CT or MRI.  

Conditions such as synovial cysts, tumors, ankylosis or joint fusion, avascular necrosis (AVN), stress fractures, and joint impingements occur in the TMJ as in other joints of the body. MRI is the appropriate examination for these conditions.  Most of all, “TMJ”  is not always “TMJ” .  Contrary to published editorials in dental professional journals, imaging is of upmost importance in diagnosis, particularly in younger patients with facial growth anomalies and provide much more insight than just talking to the patient, taking their history, and providing dental related or stress management therapy. ( 1 ) 

See Blog (this website), published 8/20/2010. “A Response to a “New” orthodontic standard of care.

1.  Greene, CS, editorial: “Managing patient with temporomandibular disorders: A new “standard of care”. American Journal of Orthodontics and Dentofacial Orthopedics, 2010, 138;  3-4.

This blog contains motion  video of MRI imaging of the jaw joint.  It is intended to give the viewer an example of the complex mobility of the joint as static MRI pictures that are present in this web site may at times be difficult to conceptualize relative to orthopedic function.

To supplement this blog, review of the following  previously posted blogs on this site may help the viewer to better visualize the complex orthopedic biomechanics of TMJ function.  Please refer to the archives section for reference prior to viewing:

1. The disc/capsule complex
2. The Wilkes/Schellhas/Piper stages of TMJ derangement
3. A Picture of TMJ Pain

NORMAL JOINT RANGE OF MOTION AND FUNCTION.

As addressed in previous discussion of biomechanics of the TMJ, this is perhaps the most complex orthopedic system in the body.  It has both rotation and displacing gliding function (translation) where the condyle/disc/capsule leave the fossa (socket) in front of the ear and glide together as a unit with mouth opening.  Computer finite element studies have shown that physical loading of this joint system is greatest during mouth opening, as this is this orthopedic system’s most dynamic, viable, and stressful function.

In this video, notice how the disc/capsule functions with  the condyle during this  translation function.  The basic nature of the “cartilage” of this joint system is that it naturally has highly flexible and elastic properties that allow the shape of the disc/capsule to actually change its entire shape to adapt to the curvature of the boney structures of the joint structure during function.  Note in this video how this particular joint  functions  as the disc/capsule is  functionally adapted  to the condyle of the jaw during the gliding sequence of mouth opening.

Click Here for Video

A WILKES III  DERANGEMENT IN ATTEMPTED MOUTH OPENING FUNCTION

This video shows complete detachment of the disc/capsule from the condyle of the jaw.  (Wilkes III derangement { “non reducing disc”} ).  Movement is painful and guarded.  From the beginning of the mouth opening sequence, the disc /capsule never re-locates or adapts  to the gliding function.  Painful mouth opening is due to progressive tearing and detachment of ligaments that are designed to maintain the functional integrity of the  moveable parts.  Progressing  distributed shear throughout the soft tissue cartilage portions of the joint create progressive tissue destruction.  Such long term destruction is shown in surgical examples in other blogs of this website.

Click Here for Video

Final Comments:

Increased levels of shear and other damaging physical forces distributed throughout the disc/capsule in abnormal TMJ orthopedic function are responsible for progressive destruction of this orthopedic mechanism.  To that degree, orthopedic dysfunction of the TMJ and its consequences mimic progressive destruction of tearing seen in the rotator cuff of the shoulder, progressive destruction and evolution of arthritic processes in unstable knees etc.

It is a principle that cannot be ignored, but unfortunately is in much traditional clinical management of “TMJ Syndrome”, or “ TMD” patients or any convenient catch all categorization that often leads to tangential treatment of this clinical problem.  Often, the orthopedic problem within the joint is the last thing that is addressed after years of misdiagnosis, no imaging, or other forms of investigational neglect in long term symptomatic patients.  This can eventually lead to progressive development of chronic  pain mechanisms that are difficult to manage and are eventually the overwhelming  impairing issue.    In the end,  continuous  dysfunctional instability of this joint system can lead to progressive tissue destruction and worsening of derangement states (Wilkes III –V) and development of destructive arthritic processes in select patients.

Historically, many individuals with TMJ pain and dysfunction seeking treatment have been told by health providers that the condition is a psychological condition, brought on by stress.  In 31 years of surgical practice, I do not recall a single patient, with true and legitimate problems  who did not actually resent that opinion, particularly when they had true impairment of jaw movements and pain when trying to eat a meal.

In the late 60′s and into the 70′s,  dental and medical education did place much attention on the associated psychological state of the  “TMJ” patient.  This was because of large studies which showed positive subjective improvement to experimental treatment “placebo” therapies.  This suggested then and is true today that many early pain issues are transient and self limiting.  As a consequence then and now, many people who consulted providers were counseled that if they could just eliminate stress from their lives and not succumb to depression of chronic pain,  and perhaps go on antidepressants, that their “TMJ”  issue would magically disappear .  Unfortunately, there were many people who found that not to be true in their own experience.  That type of  professional “management” still goes on today.  It has also introduced a specific bias toward understanding a cause and effect relationship that a majority of health care providers were “brought up” with in their education process. This website is dedicated to education relative to true orthopedic pathologies of the human jaw joint and impairing conditions.

Much of the “psychological stress” component of this complicated clinical issue is serendipitously connected to the real physical  phenomenon of bruxism, or jaw/teeth  clenching.   If this were the total story of cause and effect relative to  pain and orthopedic dysfunction of the jaw,….well…..all of us would have a problem to deal with because a reality is that probably  all of us brux from time to time.

Bruxism is mentioned many times in Biblical writings.  It was observed and commented on by ancient Egyptian, Greek, and Roman empire physicians.  Most of us will brux during sleep.  It particularly occurs in specific levels of sleep when an individual can be quite physically active, yet in a deep sleep state and is totally unaware and unable to control such.  Jaw clenching does occur when humans are stressed.   It is so common in a human population as acknowledged by simple visualization that it ranks up there as something that is truly “nothing new under the sun” as it reflects the history of mankind.

The problem with psycho/physical ailments   are that there are cases when this truely is the real problem behind the “clinical condition”.  For providers, this phenomenon is a real frustration to deal with because there are people out there who enjoy going to doctors with complaints that are imagined.    These encounters, make it easy to label groups of patients with  a perceived condition as a “stress ailment”.  This is very common in the “TMJ” population and daily  patient encounters. Unfortunately, many individuals with true orthopedic disease of the jaw joint are often lumped into this category and suggested to seek treatment with stress counselors, biofeedback therapists, general dental providers (who will then turn this into a malocclusion/bite alignment problem) and a muscle spasm disorder due to stress from clenching again assumed to be dental or tooth related phenomenon.

BRUXISM PARADOX

True and isolated muscular pain ailments must be separated from true joint orthopedic problems. Also, bruxism can accelerate with oral and dental pain conditions.  Classic controlled studies in earlier eras showed conclusively that if a simple dental filling in a tooth was “too high” and contacted before other teeth contacted, bruxism was seen to increase.  It is nature’s way of trying to self adjust the fit of the teeth. Consequently, this type of bruxism is an acute exacerbation, totally related to an abrupt and  recent change in oral physiology or the status quo if you will.   This reality is why your dentist must be and can be  so obsessed with “getting the bite right”.

Bruxism can indeed be increased during stress.  There are certain human personality types that do physically target stress reactions in this way and end up with sore and painful jaw and neck  muscles do to this issue.  So it can not be completely dismissed as a relative  and significant issue requiring periodic management.

The most severe types of bruxism are seen in individuals with history of brain injury,stroke, or other central nervous system pathologies.  Here, true and constant jaw  closing muscle spasm  and no ability to separate the teeth can be seen. The same conditions can sometimes be seen in individuals receiving medication for certain  psychiatric conditions.  Various neurologic conditions associated with physical dyskinesias or involuntary uncontrolable  muscular movements are common in this subset and are difficult to manage.

Finally, bruxism can be a significant modifying factor in long term success for people who have true orthopedic problems of the jaw joint and it must be accounted for.  When bruxism occurs, individuals can load an injured or deranged jaw joint with longer periods of time and with forces that are greater than when we eat a meal.  It is this group of patient that can truely benefit from the constructed oral orthotic or bite splint.  The splint will accomplish two main objectives.  It can be constructed to an xray confirmation that the disc/capsule is not under physical loading to the degree that when the teeth are in contact.  Also, it will decrease the ability of muscle groups to generate their maximum amount of isometric muscle contraction force during involuntary jaw clenching maneuvers.  For this reason, I advise all surgical patients to have a custom orthotic constructed for night time  and indefinite use.

Bruxism tendencies can never be totally eliminated, only attempts at decreasing intensity, frequency,  and duration of the phenomenon can ever be attempted or accomplished in my clinical experience and that of others.

Readers of this blog site might come to the erroneous conclusion that I only advocate surgery for management of TM joint derangement.  Nothing could be further from the truth as many patients can find significant pain management assistance with physical therapy.  Physical therapy took its rightful place in TMJ management when Dr. Mariano Rocabado first introduced physical therapy modalities employed in conventional orthopedics to facial pain and orthopedic problems of the jaw joint in the early 1980s.  In those days, the TMJ region was usually ignored in the training of physical therapists.  Thankfully today, it is part of many physical therapy training programs along with physical therapy for associated neck pain issues.  (1,2,3)

This author was the first to publish in the oral and maxillofacial surgical literature, a clinical evaluation of patients undergoing physical therapy for “TMJ” problems.  In that paper, our practice analyzed  68 consecutive patients with 87 collective joint derangements. We analyzed two separate clinical responses…joint function and pain response.  An overall improvement in joint function (improved or eliminated joint locking, joint instability etc) of 86% was achieved with this group .  Pain response improved in 82% of patients. Bite splints or orthotics were also used in many patients to help reduce joint loads during treatment.  All therapy was completed with two sessions per week for 3 to 6 weeks at which time they were subjectively re-evaluated.  No medications other than external applications of anti-inflammatory medications used with ultrasound muscle massage therapy were used with these patients as part of pain management.  (4)

Patients who responded well, were basically a group of patients with joint instability that occured very early in the mouth opening maneuver and had experienced symptoms for a year or less.  Physical therapy was not successful in patients who showed joint instability much later in the mouth opening sequence or with side to side jaw movements.  Many of these patients had subjective symptoms for greater than 2 years and included cases of Wilkes II and III derangement (“reducing and non reducing disc displacements”  as they were once referred to.)  Physical therapy functional and pain management is not very effective in Wilkes III derangements or greater for a significant period of time.  This is due to many of the inherent joint pathologies that impact orthopedic joint function as presented elsewhere in this blog.  In general, patients with significant lateral impingements will not respond well to physical therapy.

ADVANTAGES OF PHYSICAL THERAPY MANAGEMENT

1.  The biggest advantage is its obvious non invasive qualities.  It also uses hands on manipulation and patient jaw opening exercises to attempt to educate patients in biomechanics aimed at limiting  joint loading, hypermobility etc. and other potential damaging functional movements.

2.  Avoidance of long term use of anti inflammatory medications which can cause stomach irritation and risk other organ toxicity.

3.  Improvement in removal of various biochemical pain mediators in both the joint capsule and associated musculature, reducing reflexive muscular spasm of  muscles that are part of  jaw opening  and  closing.  Since neck musculature can also be impacted and neck therapy can be employed simultaneously. Physical therapy directed to muscle spasticity can avoid use of various medications used to combat muscle pain that often create sedation and are not compatable with work etc.

4.  It is non invasive and often rapid response to treatment with a skilled therapist with interest in TM joint dysfunction is achieved.  It is very cost effective.  This applies not only to the concept of surgical invasiveness, but also expensive and sometimes irreversible dental reconstruction procedures that are costly and often take significant time to assess efficacy.

A WORD ON BOTOX

In recent years, Botox injections into the muscles of mastication (jaw muscles) has become used frequently.  Botox is a powerful paralytic agent that is injected directly into musles to reduce spacticity.  It is very effective in true rigid muscle spasticity conditions such as conditions similar to spastic torticollis and other musculoskeletal muscle rigidity conditions.  Its problem is that the medication wears off in a couple of months with need to re administer.  It is a very expensive treatment and many patients can find themselves “on retainer” in various pain management centers and medical/dental offices.

A recent controlled, double blinded study evaluating Botox in the management of myofascial TMD pain showed it to be no more effective than injection of normal saline into muscular tissues.  There was a slight improvement in pain response with Botox, but  not significantly.  The authors concluded the costs of Botox outweighed any predictable and consistent clinical outcome and that much of the positive response was felt to be placebo, as similar scoring by patients occured when saline was injected.  (5)

1.  Rocabado M:  Diagnosis and Treatment of Abnormal Craniocervical and Craniomandibular Mechanics, Tacoma,WA, Rocabado Institute, 1981

2. Rocabado, M: Arthrokinematics of the temporomandibular joint.  Dent Clin North Am 27:586, 1983.

3. Wing ML Phonophoresis with hydrocortisone in the treatment of temporomandibular joint dysfunction. Phys Ther 62:32, 1982.

4. Kirk, WS and Calabrese, DK:  Clinical evaluation of physical therapy in the management of internal derangement of the temporomandibular joint. J Oral and Maxillofac Surg. 47: 113-119, 1989.

5.  Ernberg M, Hedenberg-Magnusson B, List T, Svensson P:  Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD painL  a randomized, controlled, double-blind multicenter study,  PAIN  (2011) ,  doi:10.1016/j.pain. 2011.03.036.

Previous blogs have discussed orthopedic injury and other intrinsic mechanisms which create orthopedic impairment of the human jaw joint.  Systemic degenerative disease or arthritic processes can attack the TMJ as they do other joints of the body.  The above photographs are clinical occlusion example above and a panoramic radiograph below of a patient with bilateral rheumatoid arthritic destruction of both TM joints.  The resultant bite relationship pattern is called an open bite.  It is caused by collapse of the vertical height of the posterior supporting aspect of the jaw called the ramus.  The ramus becomes shortened due to destruction of the boney mass of the condyles of the jaw.  The same destructive pattern is seen in other joint systems where the entire boney architecture of joint structures is lost due to destruction of the joint.  The jaw is uniquely designed but its tell tale dysfunctional state is the collapse of the jaw vertically and horizontally and the bite limited to dental contacts only of the very back molar teeth.  This patients has 28 teeth available for chewing and eating function.  Unfortunately,dental contacts available for function are limited to only 6 teeth.  In the radiograph (x ray), note how the condyles are resorbed and now resemble little sticks.  They are roughly 5-10%  of what would be expected of normal bone size and mass for a mature adult.

Many rheumatologists underestimate damage to the TMjoint caused by autoimmune arthritic diseases such as rheumatoid arthritis, psoriatic arthritis, and other connective tissue diseases of the body.  The most important diagnosis to make is jeuvenile rheumatoid arthritis as it can impact facial growth significantly.

There are two important clinical parameters with rheumatoid arthritis of the TMjoints…pain management and correction of the malocclusion component.  The treatment can differ significantly between adults and adolescents who develop jeuvenile rheumatoid arthritis. 

In adults, a total joint replacement can be a viable option in that the malocclusion and joint destruction can be managed with joint replacement and reconstructive jaw (orthognathic) surgery which realigns bone and tooth segments back into alignment for chewing function.  In the past, before the development of reliable prosthetic joint replacements such as the TMJ Concepts and Biomet prostheses, ribs were often transplanted with the same objective of joint replacement.  Unfortunately, the disease process can continue on and attack the transplanted rib causing a relapse of the malocclusion.  So, in the adult patient, total joint replacement has to be an option.

Below is a before and after result of a patient with jeuvenile rheumatoid arthritis.  In this particular case, the patient had excellent range of motion of the jaw and very little joint pain.  Her disease destroyed the joints of her hands and feet and TM joints….all smaller joints of the body.  The disease struck quickly and was active for 3-4 years and then subsided.  Since she had little joint pain or range of motion difficulties, no surgery of the joints were performed, rather she had orthodontic and  orthognathic surgery alone with no relapse of her condition 20 years after surgery.  In the case of rheumatoid arthritis, development of malocclusion is very rapid.  Both joints are not always involved to the same degree and asymmetries of the lower jaw can develop rapidly.  Most rheumatoid arthritic joints are quite painful in their active states. Orthotic appliances (bite plates) applied to the lower jaw in order to decompress the painful joint(s) can be used in pain management until definitive joint replacement takes place.   The development of malocclusion with generalized osteoarthritis  is generally much slower and insidious with varying degrees of adaptation.  The worst case scenario for any arthritic joint is fusion or ankylosis of the joint which will always require surgery to restore movement of the jaw.

This syndicated photograph details issues that are not for the faint of heart….but it is the reality of what happens during all kinds of jaw and facial trauma at the point of impact whether it be sustained in an auto accident, fall, playground accident in the case of children, domestic trauma, industrial/work related accidents etc. Past blogs published in this series also serve as a basis for further discussion of injuries that occur to the temporomandibular joint (TMJ) soft tissues during jaw trauma. The consequences of facial/jaw trauma or long term consequences of any TMJ hyperextension injury (sprain) are poorly understood by most physicians and dentists….through no fault of their own, it rarely if ever is part of their formal educational curriculum….but unfortunately the following realities and consequences are rarely considered by most healthcare providers….particularly after acute injury. Some homework is necessary. Please refer to the following as a background for the science that follows with this discussion :

TMJ and Whiplash Injuries (12/8/09)
The Disc/Capsule Complex ((9/2/10)
A “new” orthodontic standard of care (7/9/10)
A Response to an orthodontic standard (8/10)
Wilkes/Schellhas/Piper Staging of TMJ Derangement (11/14/10)
A Picture of TMJ Pain (2/15/11)
A Patient’s Perspective (3/10/11)
Genetic Factors Not Likely (5/31/11)

THE BIOMECHANICS OF ACUTE TMJ HYPEREXTENSION INJURY

We have all viewed sporting events on television and likely seen the unfortunate consequence of an athlete who has sustained a knee injury…sooner or later the announcers inform the viewing fans that immediate and preliminary examination and MRI have revealed a cruciate ligament or other ligament tear or injury to the joint. To repair the injury, that athelete will undergo repair as soon as possible to repair and protect the integrity of the supporting ligament injury and the function of the joint itself. This is the orthopedic standard of care or paradigm and is well accepted based on evidence based experimental and practical clinical research. Unfortunately it is not an accepted parameter of care in significant ligamentous injury to the jaw joint that remains dysfunctional after a similar event.

Refer to the photograph above and look right in front of the ear of the boxer receiving the blow. Through the distortion of the face and the kinetic injury causing such concussive distortion, one can see the condyle of the jaw dislocating laterally. This lateral hyperextension occurs to the opposite joint to the side of the jaw to which the blow is delivered. If the blow is severe enough, the jaw will fracture, generally in two places because of the design and distributed forces throughout the curvature of the mandible. One of the most common places of the jaw to fracture is in the region of the condyle and these statistically make up the most common site of fracture.

There is one significant difference between a professional boxer and the average child or adult….the boxer wears a large, rigid, mouth piece that the upper and lower teeth both fit in and from the time he begins to learn his craft… it is his most important piece of equipment……he knows how important it is to keep the jaw closed tightly into this mouthpiece….if he doesn’t, he will have a short career as there is a neurophysiologic mechanism referred to as the trigeminal/vagus reflex….that is, there is a nervous system interconnection between the 5th Cranial nerve which supplies the brain information that when the jaw (basically a floating bone with two joints ) is displaced violently from this area… another cranial nerve called the vagus nerve….immediately activates and rapidly slows the heart rate among other things. (immediate nausea for instance). This and other concussive kinetic energy force waves through the brain create the famous “knockout punch” . The more stability the boxer provides to the jaw while receiving the blow, the better trained he is to prevent this from happening. You can see the amount of displacement that occurs in this trained professional who is still engaged with his mouthpiece. Imagine the potential of displacement that will occur in any human being with no such device stabilizing the jaw and TMJs at the moment of impact.

Biomechanical data tells us that it takes an average of 620 Newtons of force to break the jaw at the condyle. (1) An important contribution (though unfortunately ignored by many “TMJ” clinicians) from Ben Amor and associates in Paris (2) has documented that it takes roughly 10% of the force delivered to the jaw required to fracture the condyle to cause lateral detachment or rupture of the disc/capsule of the human TMJ from its attachments to the condyle. There are other mechanisms of hyperextension injury other than lateral dislocation of the condyle. An anterior subluxation or hyperextension sprain or injury can occur when the disc/capsule and condyle transtlate or glide forward too far forward during mouth opening. This mechanism exceeds the capabilities of another ligament attachment system posteriorly in the joint between the ear and the condyle of the joint. Regardless, ligament detachment, tearing or rupture can occur in this joint as in any other of the body.

Children can sustain significant jaw impact during falls and not sustain a fracture. This is because their developing bone tissues have more inherent elasticity or resistance to fracture than mature adults. The tale tell sign of a playground or bike accident creating a deep laceration to the chin is not too uncommon. The amount of energy created during impact of the chin directly on a hard surface and capable of cutting or tearing the soft tissues of the chin are above those in terms of Newtons of force that can cause detachment of the disc/capsule from a developing child’s mandibular condyle. The paradigm is to go to the ER, sew up the injury. It is not necessarily the present paradigm or standard to image to determine potential for injury or bleeding of the joint…..this is a project necessary to be studied in OMS academic centers before the paradigm becomes standard of care. However, Dr. Schellhas in Minneapolis and Dr. Piper in St. Petersburg have shown this to be a significant finding in published data in the medical radiology literature. They and others have also shown that those children who do sustain significant joint injury to one or both joints are at potential risk to have significant disturbances in jaw and facial development growth (short lower jaw) as a consequence. (3,4,5 )

Fortunately, many of these occurances may not lead to immediate progression of problems and impairment…in children, favorable growth and development adaptations (often referred to as remodeling…especially after fracture) can provide remarkable functional recovery. However for those pediatric and adolescent patients who are referred by the medical community to the dental community to the orthodontic community to correct a worsening “TMJ” problem….it is necessary to first inquire about potential for early injury….and to at least image these patients if they are becoming impaired with chronic pain and joint dysfunction. (See Wilkes/Schellhas/Piper staging of joint derangement). Unfortunately, this parameter has been slow to catch on inspite of MRI technology availbility for the past quarter of a century (Blogs of July and August 2010). In place of this approach, often the problem is described as a “neuromuscular disorder, stress, tooth clenching or grinding, or a malocclusion or the way the teeth fit…naturally requiring orthodontic or bite changing intervention”.

Biomechanic research also tells us that the jaw joint is loaded most during attempted mouth opening. After injury, the natural forces distributed throughout the disc/capsule are shearing and damaging to the integrity of the joint…just like that athlete who has the knee injury….the joint function can not support the demands of routine normal function, not to mention athletic competition. A focus on the way the teeth fit together as the cause of the problem ignores the science of pathologic biomechanics of an injured joint. It is an area in healthcare that must undergo significant change in perspective. (6,7 )

The unfortunate consequence of much of all this is that it has been ignored as a fundamental cause of “TMJ”….that nebulous diagnostic term that is too much of an expansive diagnosis to provide any meaning of cause and effect…after all that athlete who is injured is not reported to now have “knee syndrome” or “knee”….heck, even the average sports fan is astute enough to understand his or her favorite athlete’s past cruciate ligament knee or rotator cuff shoulder repair and long term consequences to his or her career if the injury is severe enough. The fundamental question has to be asked as to why medicine and dentistry have not provided didactic information during educational training of providers to mirror these accepted paradigms.

In people with chronic conditions, pain researchers, clinicians, and patient advocacy groups are steering research to all corners of the “research” paradigm to explain what “TMJ Pain” might be. There is almost no funding of important studies that are needed to document actual degrees of injury sustained to the joint itself soon after hyperextension injury. This is a research paradigm that is 40 years behind the research which describes consequences of other orthopedic joint injuries scientifically. To the credit of pain researchers, they have done a masterful job of describing the complex biochemical and neurological activities in the body and nervous system that create chronic pain….and this research helps produce drugs for chronic pain managment and other modalities. But the paradigm of what initiates the TMJ injury and tissue destruction in the first place has been ignored….it is an approach of collective negligence that needs to be adapted relative to the known science presented by orthopedic biomechanics and the consequences of injury damage potential in any age patient.

BIBLIOGRAPHY

1. Hylander, WL: The human mandible, lever or link? Am J Phys Anthropol 1975; 43: 227-42.
2 Ben Amor F, Carpentier P , et al: Anatomic and mechanical properties of the lateral disc attachment of the temporomandibular joint. J Oral Maxillofoc Surg 1998; 56: 1164-7.
3. Schellhas KP, Pollei SR, Wilkes CH: Pediatric internal derangements of the temporomandibular joint : Effect on facial development. Am J Orthod Dentofacial Orthop , 1993, 104:51-9.
4. Defabianis P: Post-traumatic TMJ internal derangement: impact on facial growth (findings in a pediatric age group), J Clin Pediatr Dent 2003, 27(4): 297-303.
5. Sanroman J, et al: Relationship between condylar position, dentofacial deformity and temporomandibular joint dysfunction: an MRI and CT prospective study. Jnl Cranio Maxillofac Surgery (1997) 26: 35-42.
6. Tuijt M, Koolstra JH et al: Differences in loading of the temporomandibular joint during opening and closing of the jaw. Jnl of Biomechanics, 43(2010)1048-54.
7. Gallo LM: Modeling of Temporomandibular Joint Fuinction Using MRI and jaw-tracking technologies-mechanics. Cells Tissues Organs (2005); 180:54-68.

This patient came for consultation this week. She is 38 years old. In her chief complaint, she described her issues….”I have had symptoms for greater than 20 years….My pain is now constant and I am battling extreme headaches on a daily basis” . This was another patient who had traced her symptoms back to her developmental years.

This radiograph is called a panoramic radiograph. It is quite common in general and specialty dental offices. The physics of the way this film is taken make it a film that that is not as accurate as films of the jaw joint itself (radiographic and 3-D digital tomograms for instance, Maxillofacial CT or MRI for example). However, some pathologies are so striking that the panoramic film can be clearly diagnostic as this one. Note that the condyle on the left side of the film (patient’s right side of her face) is markedly smaller than that of the condyle on the right. Aslo, if you look closely, there is a marked uneveness of the jaw or an asymmetry with the chin off to the patient’s right. A film taken in the 3rd dimension, revealed that indeed the boney mass volume of the patient’s right condyle is less than 50% of the one on her right.

A surgical specimen of a condyle of the jaw with AVN is pictured above the radiograph. A photograph of a normal condyle and its divided disc/capsule is also presented. Note the significant surface structural integrity differences between the two condyles.

This patient arrived with 4 or 5 different splints, all created by dental or facial pain specialists over the years. She reported she had never been imaged, CT or MRI, both which will be definitively diagnostic. Rather, her diagnostic management lately had been with the use of Botox injections aimed at a muscular source of pain.

This condition mimics a condition in orthopedics called avascular necrosis (AVN). This condition is a progressive loss of healthy bone particularly in supportive condyles of joint systems due to longstanding degenerative or osteoarthritis and the attendant inflammatory destruction of bone and blood supply nourishing bone. When this condition occurs in hips or knees, the integrity of those systems is such that they collapse, there is bone on bone contact, it is painful if not impossible to function very effectively. It is a slow and insidious process which generally requires joint replacement in those systems.

Because the jaw is the only orthopedic system in the body with two joint systems that operate simultaneously and complimentary to one another, AVN of one condlyle creates significant functional problems for patients. Undiagnosed AVN generally is associated with longstanding joint pain and progressing limited mouth opening. When it occurs in one joint an asymmetry or crooked jaw develops, biomechanical problems can develop in the opposite joint and impingements develop . This is because the work of jaw opening is forced to the one un-involved joint. When AVN occurs in both joints, dental contact patterns change. Patients who could previously contact the edges of their front teeth and incise food can no longer do so. The lower jaw recedes backward, an “open bite” malocclusion occurs and the only teeth which contact will be the molar teeth. This can be a very impairing acquired state. Obstructive sleep apnea can develop. A similar condition can occur in patients with other types of systemic arthritis such as rheumatoid, jeuvenile rheumatoid, psoriatic arthritis, and other auto-immune connective tissue disease processes of the body.

In orthopedics, muscular pain issues generally follow injury or arthritic destruction of joints and are managed secondarily and not assumed to be the primary cause of pain and impairment. Physical therapy after management of the inherent joint disease can be successful in managing the secondary mmuscular pain component, which occurs from muscle groups involved in operating a diseased joint.

On the contrary, in dentistry, the myofacial pain model of disease is often the predominant paradigm practiced and taught in dental education. It presumes that much TMJ and mandibular pain with jaw function is due to muscular pain issues, always difficult to repeatedly visualuze and scientifically measure on a day to day basis. It trumps an orthopedic model. Unfortunately this patient has experienced this paradigm for 20 years. Imaging can detect much earlier conditions that can be managed earlier preventing progression to this state. However, many practicing dental pain management specialists are reticent to suggest imaging for unknown reasons. (See previous blog, August 2010 that appeared in a specialty journal of dentistry, suggesting that imaging was of limited value)

There is one other source of pathology in this patient’s jaw….and that is a failed attempt at complete removal of a 3rd molar or wisdom tooth which was attempted to be removed in her early 20′s. There is bone destruction from chronic bone infection or osteomyelitis. Sometimes in the world of chronic facial pain management of supposed muscular origins, tunnel vision can impact even the best of intentions or paradigms.

Avascular necrosis of the human jaw joint is a significant challenge. It is a condition that can impact patients 20-30 years younger that the same condition that occurs in knees or hips. When it gets its start in skeletal developmental years, facial asymmetry or developmental deformity, and jaw deviation is generally associated.

The functional problem with AVN of the jaw is that when it attacks a jaw joint and destruction is rapid, bite or dental contact problems can occur quickly. Many with a dental treatment paradigm view will alter the teeth with dental filing or expensive bite adjustments including orthodontia, dental caps or crowns etc. …or subjucting patients to continuous wear of dental splints adjusting them on a regular basis. Symptoms may not improve due to the severity of the destructive joint disease. These dental occlusion changes or potential for them will dictate surgical treatment plan. Joint replacement can be an option when restoration of the occlusion or the bite is a simultaneous goal of treatment.

Previous blogs addressed the mechanisms of chronic headache with this condition. A disc from a patient with AVN has been demonstrated in earlier blogs.

Biomedical research today has identified certain disease states with high genetic penetration of occurance. Almost all epidemiologic studies consitently show that females have significant dysfunction of the jaw joint at greater freqency than males. This is consistent in multiple studies and the average ratio is 4:1. This has led to research that has investigated a gene for “TMJ”.

Genetic studies to date have not identified such a gene. Genetic studies have shown no statistically significant finding suggesting such a relationship in controlled studies. A recent study by Kim et al suggested that rather than genetic factors, issues such as ligament laxity, trauma, and other factors are more likely than any other genetic factor. (1) This paper offers a good discussion of the state of the art of this topic and bibliography of studies relative to this questioned relationship.

This web site has presented a biomechanical argument as to why women develop problems more than men. (See TMJ Surgery and the female patient. Posted 12/4/09) Also referenced blogs relative to pain and other issues in women that differ in men can be seen in blogs posted 3/4/10 “TMJ Surgery, Oral Contraceptives, and complications with osteoporosis in young women”…….9/15/10 TMJSurgeon.com…”Chronic Derangement and Associated headache. Part I. ”

There appear to be genetic factors in play with all autoimmune diseases such as rheumatoid arthritis that can attack the TMJ sometimes requiring surgeries to correct mobility problems as in other joint systems. But for the majority of patients with joint pain and dysfunction, genetic issues do not appear to be responsible for mobility or dysfunctional problems.

Genetic studies do suggest there can be some racial differences among human groups. Studies of European and caucasian races show a higher incidence of penetration than in Asian races for instance.

Response to pain has been attempted to be linked to estrogen levels or lower levels at times in women than men. Estrogen mediation of inflammation or bone metabolism may explain levels of activity or bone destruction in the face of significant osteoarthritis of the TMJ. Previous blogs have discussed relationship of estrogen precursor imbalances and the incidence of associated headache and complication after surgical orthodontic treatment which requires further study.

Parents or family members often question such a relationship concerning a genetic connection due to another family member with similar TM joint orthopedic dysfunction and pain. Research indicates this is not likely. Even the researchers of this field conclude that it is more likely that issues inherent to the unique orthopedic biomechanics of the human jaw joint are more likely in varying levels of penetration in a human population. This is significant in that an evidence based research and observation approach to this disorder is stronger considering the perspective of data presented throughout this website.

In the United States, the research in the literature is contrary to much of which patient advocacy groups would like to politically suggest. Many of these groups advocate cause and effect relationships to any and all conditions except those that are orthopedic or biomechanical in their basic nature…which is becoming the common conclusion of gentic research to date.

1. Kim, B-S, Kim, Y-K et al: The effects of estrogen receptor alpha polymorphism on the prevalence of symptomatic temporomandibular disorders. J Oral Maxillofac Surg 68:2975-2979. 2010.

OBAMACARE

This is the last essay on the specialty of Oral and Maxillofacial Surgery (OMS) and the difficulty patients with significant impairment  have in finding a qualified surgeon when  non surgical management has failed. 

 OMS is an interesting health field to study in relation to economics , particularly relative to cause and effect of market forces, supply and demand capitalistic business model versus a socialized governmental control model endemic to US medical care delivery today.  OMS is the only surgical specialty where a provider can have both a dental and medical degree.  This is a standard credentialing process in Europe, Asia and other countries, and since the `1980s, many young US  surgeons choose to go to medical school after dental school.  It expands the knowledge base as well as the scope of the field.  The cost of such training must be borne personally and often the debt owed is in the 100-200 thousand dollar range…..4 years of college, 4 years of dental school, and 5-6 years of maxillofacial surgical training place the time spent in formal surgical training on a time basis that is similar to that of a cardiothoracic surgeon.  A young surgeon is generally assuming his first employment in his or her early to mid thirties.  When finally practicing, third party insurance compensation is provided in part by dental insurance and in part by medical insurance. So part of his or her care faces restrictions from both medical and dental insurance restrictions (yearly maximums in case of dental extraction procedures and medical insurance restrictions ERISA etc as previously discussed….. along with Medicare and Medicaid socialization payment systems).  It is an interesting balancing act when trying to construct a provider’s business model of economic viability…let alone debt service.   And the  patient bases are generally a patient base most impacted by important quality of life healthcare decisions and treatments…as opposed to life and death healthcare decisions faced by other medical specialties, particularly those involved with late in life heathcare management.

One of the most interesting aspects of today’s  ”evidence based healthcare” investigaton methodology, is how payers of healthcare look at data relative to its benefit to  the general public.  The specialty of OMS self funded and produced one of the most well received and extensive evidence based cause and effect models of recommended heathcare treatment…a study to determine the “medical necessity” effectiveness of removal of impacted teeth (wisdom teeth), the traditional bread and butter procedures of the specialty.  This was a well controlled 10 year study that basically determined that impacted teeth are a common cause of oral infection, creating pain, swelling and other unpleasantries….and that removal is legitimate therapy from a medically necessary beneficial standpoint.  This was really nothing new that the lay public, through their own collective experiences, already understood. The conclusions were no different than those from the literature of the OMS specialty published for the previous 50 years or so prior to this large formal study following the alogarithms of a formal “evidence based” epidemiologic study.  It was just that the formalization of such a study and including all kinds of clinical situations, presentation, age parameters and controls ….and satisfied academics and those demanding such studies (third party payers of such services)….in the end, creating an “evidence based model” of care and declaring  “institutionally” and  universally that the service was a legitimate human healthcare service.  The project itself , its design, and 10 year study are a testimony to the specialty and how to design as study of this magnitude.  From a cynical viewpoint, it was an expensive confirmation of a basic healthcare service….one that not performed in the days before development of antibiotcs….was often a lethal infectious  disease process at its worst case scenario.   

Once such studies are created, it then becomes necessary for acturarial analysis relative to cost of providing that care.  Statistics show that over 80% of humans will have diseased impacted teeth or other problems with their 3rd molar teeth (commonly referred to as wisdom teeth) creating medical necessity of need to remove them.

After acceptance of such a concept by payers,  an actuary looks at results of a well designed health care evidence based study, and determines what  a given company or payer can afford to provide that care.  Evidence based methodology that prooves the benefit of a certain treatment, in the end depresses payments accross the board….because the system is only willing to subsidize so much money for any given benefit.  It is not a marketplace supply and demand economic depression factor….but rather a statistical actuarial  application of a fixed supply of dollars available to be spread over a population to compensate for a given service.  As more “evidence based medical” studies and models are produced, they will have the same economic impact as the third molar removal study produced in OMS….all payers of healthcare will cut back on individual case compensation per capita….because there are now so many future statistically predictable recipients in the mix….and the result is a created depression of prices based on demand and statistical probabilities of need.  With only a fixed amount of circulating capital available to be applied to employee or government recipient  healthcare services available (without tipping the balance for other expenses in life) .

What this does, for younger people anyway,  is to increase their own personal investment in healthcare for services as co pays and percentages of coverage for a procedure to compensate for payments  decreased by a third party payer.    This differs significantly from a Federally mandated government paid healthcare program where current services are covered as they occur regardless….such as Medicare funded life extension, end of life medical therapy where procedures are compensated regardless of whether they make financial sense or not, or really necessary in adding to overall management, may be performed with medico-legal concerns in mind….or do much to improve anything about the quality of an individual at the ending of life as we know it. 

 Healthcare financing studies in the US conclude that approximately 15% of the US population consumes 85% of US healthcare costs.  This includes those with significant disease processes with multiple system complications such as diabetes and cardio-vascular disease, the disabled from disease and accident, those with congenital defects and the elderly drifting in and out of hospitals receiving life extending therapies only to return to nursing home environments.

How to pay for this…Obamacare’s solution is to decrease payment to doctors and introduce a new tax levied on real estaste transactions…..Americans are OK with the first but like Congressmen who did not read the legislation….are unaware of the second cost saving  aspect.  Unfortunately, the legislation does nothing to address what we all must face as a culture…quality of life services and their application while we are young and productive versus a limitless credit card account to engage miraculous but expensive healthcare services, Government funded, at the end of our lives or when we are faced with the difficult choices forced on those inflicted with terminal diseases.

What does this have to do withthe majority of  patients seeking common healthcare services?  Understand that costs have been cut and that personal investment in one’s own health care services are the trend that generation X and Y will have to plan for.  Your peers who choose medical training will incur tremendous debt to earn the privilege to help humans with disease and dysfunction.  Many difficult choices are in store for all relative to quality of life healthcare expenses spent while young, versus almost out of control end of life expenditures covered by Medicare.  Despite all the rhetoric and emotions, Obamacare does nothing to solve this underlying economic morass and moral delemma. 

 Since impairing TM joint dysfunction can impact a much younger group of patients compared to other orthopedic problems, much of the provider’s services must be borne by the patient since they are not compensated by third parties.  Going forward, this reality will be likely for all individuals and a personal economic financial life model will have to include allowances for basic and common  health care issues, many that have evidence based scientific cause and effect benefit but  pushed out of the way by these other unresolved macro health issues.

In summary, the complexities of the American macro-economic  healthcare  model  is mirrored in the micro-economic model endemic to the surgical field of oral and maxillofacial surgery.  Presently, there are two major market forces in play, a capitalistic, laissez-faire model based on delivery of cash fee for service procedures such as dental implants, cosmetic facial surgery, office based anesthesia services (provided by the only surgical specialty which continues to obtain anesthesiology training in residency training) providing non 3rd party covered and compensated procedures.  The other model is  one based on insurance compensation from Federal or Corporate insurance self-funded regulated markets that mirror that exclusive to medical services save that of those seen in cosmetic plastic surgery .  OMS providers will provide care at both levels.  However, the disconnection of supply and demand natural economic marketplace forces in play in the aspect of delivery of dental implants, a huge public need and want that is not provided by traditional 3rd party payer models….is contrasted by other provided services in the field such as management of facial fractures, facial deformity adn TM J orthopedic surgery…all compensated by  Federal or other 3rd party payers at regulated fee structures created by government as a basis for determining service worth.  These issues become more complicated, paradoxically, when the response to good research and evidence based methodology relative to direct cause and effect of disease and statistical penetration of incidence within the public patient base (payers reduce compensation for reliable beneficial services in a population where services help with quality of life concepts ), particularly in a young productive public patient base or workforce.   In the United States, 85% of healthcare costs paid for by 3rd parties or payers other than the patient, are spent on 15% of the population fortunate to have insurance or Federal (Medicare/Medicaid) benefits.  Much of the funding of this discrepancy is made by workers who themselves find legitimate and beneficial quality of life services denied or significantly diminished by those very payers they help to fund.

This discrepancy is unsustainable. We all know that.  Obamacare, pushed through by Congressmen and women who did not even read the legislation and based now on coercian and mandatory obligation of Americans to purchase insurance is to be questioned.  It does nothing to address the difficult moral questions we as a culture have not been seemingly willing to address relative to the disconnects in the system that we have all personally experienced.   The solutions to fund our financing needs for healthcare are based on increased tax revenues from taxes hidden from the public (real estate transaction taxes), increases in Medicare tax rates , and significant reductions in payments to doctors for services.  With this as a background, and the fact that few providers obtain government sponsered bailouts for their debt (unless they serve the government in some way),  the solution to our “healthcare crisis” will likely in the long run impact younger Americans disproportionately in the future as they are victimized by the law of unintended consequences because of the limited access to certain specific healthcare needs, especially sub-specialized “niche” care few providers  are trained to provide  or interested in delivering in the first place.  In plain English, the attrition of one of America’s greatest natural resources, its medical healthcare providers who refuse to be held hostage by a dysfunctional system based on coercian will escalate.  When that happens, access to care and the wait to find a qualified specialty care provider will create waiting for care that exists in certain countries where healthcare resources are much less than ours.  What will be left will be all the American invented machines of healthcare.  What will be lost is the human interest to competently run those machines. 

Given a choice, an OMS will generally choose a market based business model of direct mutual contract with a patient….because he or she has all the services to provide within an office setting, at less overall cost, than services offered with many middlemen and artificial cost controls that do not compensate for the direct costs, time or risk to deliver that care.  Today, access to care for certain services are becoming harder to find for the public.  TMJ surgical services are some of those difficult to  services.   Consult ASTMJS.org  for a list of subspecialists with interest , qualifications and skills to  provide these services.

                                                             ERISA

Two previous editorials argue  that indeed the United States functions under the guise of a socialized model of healthcare delivery….one a governmental model and the second a corporate health employee benefit model.  The second model will be discussed here in more detail. The purpose is to explain why Americans have great difficulty in obtaining care for “TMJ” and must educate themselves to argue their problem.

Corporate  employee healthcare benefits are under federal regulation via a law called ERISA, which stands for Employee Retirement Income and Security Act of 1974.  The year is significant and we will discuss that further in a bit.

ERISA governs corporate America relative to their employee retirement benefits as well as healthcare benefits that employed Americans receive during their working years as as part of a work compensation package .  ERISA was established during the Nixon/Ford presidency years and in spirit was created as a governmental regulatory oversight relative to  retirement pensions and other benefits.  It applies to  US corporations that offer retirement and health benefits but very few Americans realize that the law and its mountains of regulations address voluntary  agreements by Corporate  America to agree to promise  these  benefits as part of a work compensation reward process…..  Americans and many other citizens of the world  have become accustomed to the notion that a retirement plan and healthcare are entitlement benefits that seem to begin at birth.  All countries of the world are discovering problems with this notion…and many believe all shoes have not collectively dropped relative to this thought process. (not part of our discussion here but “it is what it is”….and the thought process is a big part of our problems…..regardless…..

  ERISA does not mandate that empoyers must provide these fringe benefits…it only regulates protocols when they do.  Since the enactment of ERISA in 1974, Corporations were governed by the Federal Government relative to their management of these voluntary benefits…and when companies collectively bargain with worker unions relative to change in benefits, ERISA law has to be followed by both sides.  Any changes to ERISA are under the oversight of Congress and the Federal Courts.  These days, most HMO and other healthcare benefit problems that Americans face are actually complaints towards how insurance companies, which are hired by Corporate America to  administer or supervise these healthcare benefit dollars that are voluntarily set aside to pay various  healthcare claims, are managed.

The year 1974 is significant relative to healthcare standards.  Since the spirit of ERISA is voluntary and literally requires an act of Congress to change or the Sumpreme Court to review relative to change…well change is hard to come by and this is one reason this regulatory bureacracy has not been tweaked in 37 years.  Most all individual states have individual commissioners of insurance…but this applies only to traditional insurance that a comsumer would personally buy….since ERISA is a Federal law that involves companies performing inter-state commerce;   it trumps all state laws….therefore various state insurance commissioners have no say relative to whether an ERISA healthcare product, funded voluntarily by an employer, must meet requirement of coverages mandated by certain states and their regulatory agencies or state legislatures .  This is critical to the specialty of oral and maxillofacial surgery which has undergone significant transformation in scope since 1974.  If one were to dig deep into what ERISA regulates relative to health coverage, it deals with scientific health parameters that were generic to 1974 as a basis.  Employers and HR departments enter into a fiduciary agreement with an insurance company to administer funds (costing 30% at least relative to administration, based on estimates)  and to provide information relative to items of “medical necessity”.  Insurers hire doctors, PhDs and others to review medical literature and advances relative to what is called “evidence based medicine”….that is to say legitimate practice and delivery of diagnostic and health services that have good basis of relationship to cause and effect and good evidence that a certain recommended treatment is legitimate in all possible ways of evaluation…..or at least that which someone who is paying for your healthcare must be convinced that their money is not wasted on say….snakeoil.

A previous blog recognized contributions of Oral and Maxillofacial surgeons in this era, post Vietnam, and the scientific progress made in those days….with that conflict ending in the early 70′s- 1974 timeframe.   In those days, “TMJ syndrome”  was understood to be a disorder, developed in the 1930′s by an ENT physician Dr. Costen”  (history found in earlier parts of this website) , to suggest a disorder of the fit of the teeth or other things.  Relative to this,  a disorder of the “teeth” is not considered an ERISA sanctioned  “medical” condition( In those days, the American Dental Association wanted nothing to do with any insurance funded services of any type)….therefore with misinformation and bias cooked into the system and a tremendous advancement of the knowledge base, provided by advance abilities to diagnose functional and subtle arthritic disease of the human jaw joint….this area of health care has been trapped by the unusual circumstance of cultural misinformation and other issues  for many years…..as a benefit, it is excluded from many ERISA health products.

CUTTING TO THE CHASE….THE PROBLEMS WITH ORAL AND MAXILLOFACIAL SURGERY CARE AND ERISA. 

1. Orthognathic Surgery 

 Most major advances in maxillofacial surgery have occured post ERISA implementation, 1974.  These include surgeries to correct facial disfigurement due to facial growth and development problems that require both orthodontic care and surgery to render one with the ability to perform one of life’s most basic function…proper ability to masticate or chew food. Often insurers will site these treatments as “cosmetic” in nature….though they have the ability to change the appearance of an individual, their functional significance is to place the teeth in a position to chew food in the first place.

2.  Orthopedic surgery of the jaw joint.  

With the development of superior imaging modalities such as MRI which reveal orthopedic problems of the jaw joint that are similar to what is seen in other joint systems of the body, actual surgery of the joint has been acknowledged among various insurance fiduciaries and an evidence based medical evaluation concept…that is, similar problems (rotator cuff tears in the shoulder) are very similar problems to what initially can occur in the TMJ.  Surgeries can be covered but other ancillary and necessary items such as a bite splint, necessary to unload the joint for pain management or healing after surgery (analagous to knee brace, or other joint supporting device) are not….due to the fact that these are considered “dental” devices. Various coverage dependent on what an employer may have chosen on the advice of the insurance fiduciary.

3. Volunteer principles

As OMS research advanced and it became clear that an impairing arthritic jaw joint should not be extracted from the human body and a special discriminating identification diagnosis tag “TMJ Syndrome”, TMJ , TMD etc or that this was a disorder of the way teeth fit (occlusion);  national and state professional OMS societies took it upon themselves to argue before committees created by insurance commissions, insurers, regulatory agencies, state health care legislature committees,  etc. that it was health care discrimination to not cover severe orthopedic disease of the jaw joint….particularly if an insurer had no problems with the same concepts of disease treated in any other orthopedic system of the body.  This was a good news/bad news outcome.  States that agreed (there were approximately 30-35) created legislative bills requiring coverage….however, ERISA trumps all state regulations….and coverage can be available…..well…..only if the employer (HR department responsible for benefits) understands the magnitude of the problem or the disease…..and by a benevolent volunteer basis…agrees the employee could benefit from treatment.

So we are back to where we started……it’s the luck of the draw and the knowledge/benevolence of your HR personnel….and their decision to pay for treatment.

4.  Some good news (Depends on your perspective)

Insurance companies, as a fiduciary, have many responsibilities and this is expensive oversite on behalf of Corporate America.  Several years ago, it was not uncommon for any treatment surgery, non surgery, or imaging to be denied as “not medically necessary”  (Federal ERISA law allows insurer to tell patients this on their rejection for services notices if it is anything that may have not be a “parameter of care” in 1974)….and this includes any and all healthcare issues….we have all seen those and been amazed, frustrated, and angered.

Relative to “TMJ” issues, many major insurers have developed specific parameters of care relative to TMJ surgery and site the scientific literature as a basis of why something will or will not be covered.  This is the ‘evidence based medicine” part that requires review of effectiveness and medical necessity.  In the US, most major insurers site the Guidelines of the American Society of TMJ Surgeons….ASTMJS.org…see Guidelines…..as the basis of advice to corporations relative to coverage.

If you have your own HR battle relative to this issue, copy those guidelines and argue your impairment in terms relative to problems seen in other joints of the body….perhaps your battle will be assisted.

Finally, socialization implies concepts such as collective group behaviors, oversites , and manipulations  based on powers that control the group.  The American healthcare debate needs to come to grips with the reality is that we really are socialized…microsocialized at the work place level with “benefits” that are extracted from an individuals pay check….and a “macro-socialized” system in Medicare and Medicaid.  For all the debate that has taken place in this country relative to what the public “wants”, the public must first understand what it really “has”.

The 4th and final  of these “editorials” will be comments on what the United States refers to as “Obamacare”….which like Frankenstein’s monster, has developed a life of its own in the past couple of years….