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….

When President Clinton was running for election, his campaign adviser, James Carville, always reminded him to focus on what the public was most interested in, always reminding him: “It’s the economy, stupid!”  That was nearly 20 years ago and things have intensified to be sure.  Let’s look at some basic economic facts about why a patient may have  trouble finding an oral and maxillofacial  surgeon  (OMS)  if they have a problem that has gotten worse and they feel they require surgery because non surgical treatment has run its course.

There are two words that summarize the practice and economic state of affairs in oral and maxillofacial surgery (OMS)….”dental implants”. 

 These are remarkable devices capable of solving many difficult dental problems or tooth replacement issues that  people have had …with few options for improved function….through the years.   For those who argue the US leads the world in medical technologic creativity and advances…..well they have missed the boat on this one…..as the prototype R&D and development goes to …..well…….that honor goes to Sweden and to an orthopedic surgeon no less,….not a dental researcher. …..that’s right…..something that has revolutionized a major aspect of American healthcare came from…..yes…….another country.  Inventive American manufacturing changes have simplified various dental implant systems to the degree that they are so excellent now that today’s systems can also be placed by generalists and other dental surgical specialists in a dental office setting.  Think of it…..a major advancement in this country that was created out of a country with socialized health care….@#%&   !!!  Wow, how could that have happened ??!!

If one looks at what  current basic free market supply/demand forces (and complimentary insurance company set fee rates ) will compensate a contracted dental provider to surgically place a single dental implant….one that replaces a single tooth ….those fees for compensation range from $1704   to $2010..(cost of the implant the provider pays is roughly 1/4 to 1/3 of the cost).depending on the insurance company( and the regional marketplace….these ranges are for the writer’s  market).   This is a procedure in skilled hands that can take 30-60 minutes tops depending on the tooth being replaced  and other factors that impact degree of difficulty to perform.  It can be done conveniently in a private office setting with minimal bureacracy compared to a hospital setting. It is generally fee for service which at best means the office will as a courtesy file a dental insurance claim, but the patient will pay the fee and be reimbursed by the insurer or doctor when the insurance portion is paid.  There are some but very minimal risks compared to….let’s say performing a total jaw joint replacement,  skeletal jaw or orthognathic surgery,  or other major maxillofacial surgical hospital based procedure and paid for as a “medical” expense.  Removal of a set of  impacted teeth, the bread and butter procedure of an OMS (like tonsils, adenoids and ear tube placement for an Ear, Nose, Throat physician) can parallel the insurance compensation for placement of a single dental implant.  These are services that are not paid by Medicare or other federal services…..entrepreneurs with ideas of improvement and a competitive capitalist model among manufacturers of dental implants have now made a product that the public has benefited from….and now actively seeks……particulary when dental esthetics/and functional improvement for people compared to removable dentures replacing teeth,  etc.

On the other hand, medical/surgical fees for services for physicians/providers are set in one way, shape, or form by the US government.  The government, through Medicare sets base rates.  Insurance companies  borrow from these Medicare base rates and base  their medical fee payments to doctors on  this system that is called a relative value system…..that is to say, groups of people in a think tank once got together, created a point system that scored things such as degree of work anticipated that would be required, technical difficulty, time to accomplish the task, risk of procedure, need of a specialist to perform , and a host of  factors…..starting an IV and administering medications carries a relative value…..performing open heart surgery has a relative value number…..  A number is created and multiplied by a standard dollar amount  multiplying  factor….and presto, a magical number/fee is produced that reflects what a bureacracy (non active patient managing human beings …or someone like an actuary) thinks a procedure is worth.  Insurance companies, borrow this data from Medicare, and increase the fee by a percentage, say 20-35%….to determine their fees to be paid for care.    The increase is necessary to lure doctors into participating in a “network”  so as to allow insurance companies to sell their products in each of the states or to employers providing healthcare benefits…..a “network” has to be created to assure governmental regulators that the insurance company has the manpower to deliver the health care that they….as a profit motivated stock company…..can sell to employers or individuals.  Currently, one of the  suggested solutions to pay for healthcare in this country is to decrease payments to doctors by 20%…..and this is a fundamental aspect of the solution that Obamacare offers the country for healthcare cost containment…..so an artificial system is always vulnerable to continued manipulation in order to control costs….this represents a socialized concept of health care delivery…..there is no free market….and hence, no competition…..it is impossible to implement otherwise…..because the government is the originator of the logistics of the system in the first place. 

The Medicare relative value for a basic arthroplasty  (procedure to correct a TM joint which is painful and chronically locks to where the patient can not open the mouth to eat….or it gets locked in the full open mouth position ) of the human jaw joint is approximately $1120.  This is a procedure generally done under general anesthesia, in a hospital or surgery center . Depending on degree of difficulty, the procedure can take up to 1.5-2 hours to perform, the doctor will be away from his/her office for at least 3 hours.  These procedures are not covered under dental insurance, as dental insurance is restricted to tooth related work of some sort. ….and payment for such services is paid by the government or an employer out of medical insurance funds.

For a total joint replacement of the human jaw joint, the Medicare limit (For Medicare payment) that a doctor can charge is $1704.  This is an extremely complicated and precise surgery, it involves two separate external to the mouth incisions, is a hospital procedure…..and few surgeons have the desire or assumption of the responsibilty to perform…..it is a much longer and more difficult procedure than an arthroplasty as well….and the government “rewards” this complexity on a par with placement of a single dental implant placed by any dental provider…..in a dental office.

It is no secret why patients have trouble finding a  provider willing to perform TMJ surgery…..During the past 10-15 years, OMSs have been leaving the hospital environment because of these reasons……when the government deems that performance of surgeries such as this is on a compensation par with placement of a single dental implant for replacement of a single tooth…..it does not take a PhD graduate from Harvard Business school to connect the dots relative to choice of business/surgical risk model in decisions concerning agreement to perform certain procedures….or how that doctor would choose to make his or her living.    Plus, with the anesthesia training that OMSs receive in residency….it is the only  surgical specialty where the surgeon himself has had anesthesiology training in residency….hence, there is no need for a hospital based practice when the doctor takes a financial hit to perform procedures there…..the logical and rational choice is to make his/her living in what the  insurance and government controlled  marketplace  forces he or she to do.  

The OMS, in the majority,  is the  only surgical specialty with  surgical training for management of orthopedic disease or dysfunction of the jaw joint.  With such discrepancies and lack of logic relative to reasonable compensation performed by the few providers who do this work….it is no secret why an experienced provider is hard to find.

This is a crash course in healthcare economics 101 for American Society…and we have talked about only one situation impacting a small area of healthcare…..every medical  surgical specialty has comparable situations in its field that mirrors issues like this that have evolved in American healthcare……so multiply this many times over and presto…one has the chaos that is known as the American medical  healthcare economic system.  Is it any wonder that skilled specialist providers of all types are no longer willing to perform very specialized work, leaving their surgical specialties, retiring or changing or modifying their careers and choosing to simplify their personal and professional lives?

For US citizens, consult the web site of the American Society of Temporomandibular Joint Surgeons…ASTMJS.org for a list of providers who welcome patients with these needs.  These members are a mix of institutional (University)  and private providers who continue to welcome patients and who can be assured that they are seeing a provider with significant experience in this field.  They are also individuals who are committed to this area and providing these hard to find services.

Over the past year, I have received many emails expressing interest in insurance issues and difficulties that patients have in obtaining care.  In all of healthcare, this is one of the more bizarre areas to have to deal with relative to healthcare financing whether it is through employer funded insurance coverage, or the federal government payers (Medicare/Medicaid).  The current state of affairs in the United States impacts us all.  Frankly, in talking with my surgical colleagues from other countries, my perception is that patients in other countries have much less difficulties than do Americans in this area of healthcare. 

 This and the next  blogs  are    ”Editorial Comments” which I hope will help with understanding of the problems providers and patients face with obtaining help with this  very common human ailment.  The underlying theme here is that Americans have the mistaken perception that they do not live in a country that has socialized health care…..they are wrong as they misinterpret the word “socialized”.  When government directs,funds, pays, authorizes, and controls the delivery of healthcare (Medicare/Medicaid) it is socialized and easier to understand as a “socialized” concept.  When corporate America self funds healthcare as an employee benefit, hires an insurance company as a fiduciary to write coverages of benefits (like choosing food in a cafeteria…what’s covered, what’s not…)  this is corporate employee benefit socialization….albeit in a smaller group context but a group socialization nevertheless.   A patient is still not free to choose an insurer or product, or even sometimes their choice of doctor, that fits their needs and there are layers of review and authorizaton to go through. It’s not a governmental or publically acknowledged  socialization, but regardless,  is a cultural capitalistic socialization of work compensation benefits.  Abuses of this system have created the need for government to step back  in to police this part of the  process with multiple layers of complicated bureaucracy for providers and the healthcare “industry” ….laws like  (HIPPA and many others) to protect the public from abuses from HMO behaviors etc.  So regardless of perception, we are socialized, just to different degrees and disguises.   The agents of socialization are just identified and interpreted differently for some reason.  Make no mistake, if there was no money to be made by insurance companies in American Healthcare administration…..there would not be the emotional debate and defensiveness  concerning mechnaisms of payment by third parties, be they governmental or corporate insurance based….and hence the debates  that enrage the public such as “single payer” concepts and the emotions that are created.

People somehow  believe there is freedom and fairness in this process….there is not.  It is ironic in the country that science, research and development has created much of the modern world’s healthcare discoveries and advancement….that its own people contend with such a dysfunctional product for their own healthcare financing.  

  If one were to choose a healthcare specialty to study the bizarre system and consequences that have evolved to create the healthcare system of the US, a good starting point would be the specialty of oral and maxillofacial surgery……which is the surgical specialty which will manage “TMJ Surgery”.

A perception of non-surgical clinicians is that surgery of the human jaw joint is to be the absolute last resort to management of orthopedic problems with the jaw joint.  Unfortunately as also seen in a previous blog reporting  recommended standards of care reported in the orthodontic literature (See August, 2010), even MRI imaging in symptomatic patients is rarely performed or recommended by some  professional societies which represent those groups of providers.  This model is contrary to the standards of orthopedics in management of other orthopedic systems of the body. Some of these societal parameters categorize this as a psychological or stress disorder.  As shown in this web site with both MRI and surgical images of disease, nothing could be further from the truth in some cases.

 Unfortunately, there can be patients with undiagnosed surgical disease, who develop chronic pain states that become much more difficult to manage when all dental related therapies applied have proven unsuccessful.  Often these patients are subjected to non surgical treatments that can take years to complete before any outcome is known or definitive imaging ever obtained.

As suggested in previous blogs with MRI examples of significant problems in adolescent patients, significant problems can occur in younger groups of patients.  The National Institutes of Health in the US estimate that on the average and at any time, 10 million US citizens have issues of severity meriting management and 10% of these have advanced surgical disease.  MRI Studies of adolescents undergoing orthodontic treatment have shown to levels of statistical significance that younger, growing patients in their adolescent years undergoing orthodontic treatment will have a 10% penetration of significant “TMJ disorder” and numbers identical to adult populations.(5)   Preventing progression to disability and functional impairment is paramount in these patients as well.

A previous blog discussed the Wilkes/Schellhas/Piper staging criteria when MRI examination is performed.  Long term post operative studies are clear that the Wilkes II derangement has much higher success rate than Wilkes III.  This has proven to be the case with both arthroscopy and open surgery (arthroplasty).   (1,2)  In some instances, the reason for this diminished success between these stages may be due to the presence of joint impingement that was unappreciated preoperatively. (6)

There are many reasons for decreasing success among surgical/MRI stages as  a recent report has indicated that time plays a very important role in surgical success.  After 6-12 months of continuous joint instability and pain, arthroscopic surgery begins to become less successful, according to a recent report delivered to a joint meeting of American, British, and European TM joint surgeons.  Pain improvement and functional  results drop significantly with arthrocentesis and arthroscopic surgery within the group of patients who had unmanaged joint impairment for 6-12 months and greater than 1 year prior to arthroscopic intervention. (3)

  A complimentary and separate study published in 1994 revealed that advancing arthrosis begins in Wilkes Stage III.  In a study of MRI characteristics of condyle degenerative processes, only 2 of 18 patients with Wilkes II derangement  had condyle arthrosis or early stage of degeneration.  In Stage III, 22 of 26 did.  In Wilkes stage II,the patient reported time frame of constant pain and joint instability  was less than 1 year in 14 of 18 cases.  Wilkes III patients reported unmanaged symptoms in for greater than 1-2 years in 24 of 26 instances (7).  Therefore, gross sustained orthopedic instability with this time frame is long enough for cartilage of the joint to become significantly damaged due to advancing inflammatory destruction of cartilage from unstable and damaging shear forces.

A study of Wilkes II cases revealed a 98% surgical success rate in Wilkes II cases, but success decreased to 85% in Wilkes III and patients with longer standing dysfunction in separate and independent evaluations  of arthroscopy and arthroplasty (1,2).  The fundamental reason is that the quality of elasticity in the joint is much better in earlier stages.  Advice to prolong surgery in the face of significant and progressive joint instability that does not respond to reasonable non surgical treatment for 6 months is a reasonable indicator that definitive diagnosis with MRI or diagnostic arthroscopy be made and in advancing cases, and definitive joint repair procedures considered if derangement is advanced. 

Specific conditions merit specific surgical procedures.  A prospective designed multicenter study evaluating 4 different surgical  procedures showed good results of 95% or greater relative to pain and  improvement in dysfunction to levels of statistical significance when a specific procedure was applied to a specific pre-operative condition. (4)

As in orthopedic surgery, definitive diagnosis and interceptive management to correct significant pain and joint dysfunction is very important and age is an independent variable to consider.  The most important factors are becoming clear that  duration of symptoms, appropriate staging and application of the operation to match the level of disease.

Time is of the essence in this orthopedic joint system.

1.  Kirk, WS Jr:  “Risk factors and initial surgical failures of TMJ arthrotomy and arthroplsty:  a four to nine year evaluation of 303 surgical procedures. Jnl Craniomand Practice (Cranio) 1998;  16(3):  154-61.

2.  Murakami K.  Five years results of TMJ artroscopic surgery correlated to stage of internal derangement.  Lecturre, American society of Temporomandibular Joint Surgeons. Palm Desert, California.  February 28, 1997.

3. Machon, V:  Chronic closed lock of the TM Joint.  Comparison of two therapeutical methods:  arthrocentisis and arthroscopical lavage”  Lecture:  European Society of Temporomandibular Joint Surgeons, Rome, Italy,  April 16, 2011.

4.  Hall, HD, Indresano AT, Kirk, WS, et al:  Prospective multicenter comparison of 4 temporomandibular joint operations.  J Oral and Maxillofacial Surgery, 2005;  63:  1174-9.

5. Nebbe B, Major PW. “Prevalence of TMJ disc displacement in a pre-orthodontic adolescent sample.  Angle Orthodontic, 2000, 70: 454-63.

6.  Kirk W and Kirk B:  Indications for primary arthroplasty of the temporomandibular joint.  OMS Clinics of North America.  September, 2006.

7. Kirk, WS Jr:  “Sagittal Magnetic Resonance Image Characteristics and Surgical Findings of Mandibular Condyle Surface Disease in Staged Internal Derangements”  Jnl Oral/Maxifac Surg.  1994  52: 64-68.

Total Joint Replacement System of the TM Joint

Biomet, Inc.

This prosthesis, manufactured by Biomet, Inc. is one of two prosthetic systems which borrows from bio-mechanical principles and lessons learned from the experiences of Charnley’s hip orthopedic prosthetic development.  A second system is produced by TMJ Concepts, Inc. of Ventura, California .  Both systems employ an onlayed prosthetic condyle to the mandible  to replace a severely diseased or destroyed condyle.  It articulates with a high density polyethelene fossa component and both are fixated to their respective sites as shown.  The difference between the two systems is that the TMJ Concepts product (see TMJconcepts.com) is a custom made prosthesis, constructed from a CT scan of the patient to precisely fit the nuances of variable anatomies.  Both systems have followed FDA developmental protocols and are now marketed world wide for specific indications.  Both systems have been developed by surgical pioneers who faced their own particular and private “Charnley learning curves” as discussed in the previous blog on alloplasts. 

A difficult history

Modern Maxillofacial surgery and surgeries developed to correct significant facial disfigurement benefited from both from the understanding gained from facial injuries sustained during wartime (Vietnam) and the fact that animal studies, particularly those studies which researched blood supply and proposed surgeries on humans, could indeed be performed with confidence.  Until the decade of the 60s, maxillofacial surgeries performed to correct unfortunate victims of accidents and other forms of injury, birth defects and other causes of distorted facial skeletal development were risky and fraught with complications.  Certain world centers could achieve acceptable results, but by in large these were not  frequently performed surgeries.

In the heroic attempts to save life and improve quality of life, surgeons in wartime often are forced to adapt basic techniques or attempt new ones, particularly in reconstructive surgical efforts.  During the Vietnam conflict, US military surgeons made tremendous strides in refining techniques such as bone grafting and other reconstructive facial surgical techniques.  When the war ended, many returned to academic careers to perfect the full spectrum of the science that allowed this specialty to explode upon the health care scene, and provide a new era of services.  The decades of the 70s and 80s saw remarkable advancements.  It included the use of animal studies to test the feasibility of developing jaw and facial surgery technique improvements. 

Unfortunately, the decade of the 80s saw the attempted development of an artificial cartilage or “disc” material to replace diseased TMJ  cartilage.  There were two main problems with its development and use.  One was ignoring history (which seems to be a world wide epidemic phenomenon in many aspects of life these days) and the other was lack of ability to employ animal studies (primates) to test whether such products were suitable prior to use in humans.  This  material was a sheet like material with teflon on one side and another material made of a material designed of poly carbon and other hydrocarbon materials designed to allow scar tissue to surround it and stabilize it.  Politically to this day, animal rights activists create the difficulty to study new surgical techniques and materials in animals.  This fact circumvents a huge necessity in surgical  sciences…..and that is to observe the response of such efforts to improve human life, in an animal first.  Though I do not wish to debate with animal rights activists, their efforts are responsible for significant problems and the reality that there were many things developed in the 80s and 90s without the ability to test in animals first.   The artificial TMJ disc development was such a disaster.  Developers ignored Charnley’s experience in the hip.  He had significant failure with the attempted use of teflon lining the artificial cup of the hip socket.  The “theory” of its use in the first place was to somehow reduce friction during rotation function in the hip.  In the  jaw, it was to reduce friction during the sliding or gliding function and prevent scar tissue from preventing this gliding function.   Lack of animal studies led to use of a product without  knowlege of how the second component of the replacement would react in the unique environment of a synovial joint system ( a critical immunology field not to be taken for granted).

In this light, the product (used over a period of 3-5 years ) created its own aggravation of the arthritic process and was rightfully recalled by the FDA and its use prohibited.  Development of the total joint replacement to manage severe problems was put on the fast track by surgeons and a surgical field that  needed a total replacement system.  This  history parallels Sir John Charnley’s in the hip.  The end of the story is the development of prosthetics based on good surgical science from other fields, employment of bio-mechanical and biomedical engineers who did the appropriate R&D and the use of materials well tolerated by the body’s immune system.  They serve a unique purpose in the surgical armamentarium in the attempt to make impaired and disabled humans better.

A total replacement should be placed by an experienced surgeon.  There are basic  indications:

1.  Gross arthritic, injury, or pathologic destruction of the human jaw joint which has created a lower jaw deformity, asymmetry, etc and has created a severe malocclusion .

2.  Ankylosis or fusion of the jaw joint from a severe arthritic process.

OTHER OPTIONS

Maxillofacial surgeons have historically debated the use of prosthetic joints for TMJ replacement versus other reconstructive attempts using one’s own tissues, mainly rib grafting to substitute for  diseased or destroyed  TMJ condyles in an attempt to reconstruct an arthritic joint.  Rib grafting definitely has it place in the growing patient.

Rib grafting has its advantages and disadvantages.  The use of one’s own natural tissues appeal to many patients and surgeons.  However, taking a rib(s) is not always a benign procedure either, particularly with chronic pain issues from the surgery site and  risks of chest complications.  Also, in cases of systemic arthritis (rheumatoid, psoriatic, juevenile osteo and rheumatoid arthritis conditions), the risk of using a rib is that the systemic arthritic disease process can lead to long term complication with or frustrating  destruction/ankylosis (fusion of joint) of the rib graft.  In this light, alloplastic TMJ surgery has its rightful place of consideration, particularly if associated with significant jaw deformity, an agressive arthritic joint, tumors, trauma reconstruction  and all associated with  malocclusion.

Of greatest concern to any patient is the expected lifespan of the prosthesis.  The  present prototypes of total TMJ replacement, (using Charnley protocols of dissimilar articulating materials of the condyle and fossa)  have been in use for over 15 years.  For both systems, long term failure rates are currently reported  less than 3%.  The greatest risk of these devices is infection, and an infection is most likely to occur within the first 2-3 months of placement.   Such issues are similar to placement of knees and hips.( Less than 1- 1.6%)  (1) (2).  Westermark has reported on the Biomet prosthesis with 8 year follow up.  There is no untoward reaction of tissues seen microscopically suggesting any unfavorable reaction .  (4,5).  Mercuri has reported similar acceptance of body tissues and the TMJ Concepts with a 12 year follow up. (6) The Biomet prosthesis was developed at the University of Pennsylvania. Of greater than 650 that were placed at that institution and tracked by Biomet, there have been only 9 requiring removal due to issues such as infection or some mechanical failure. (8)

 Failures due to wear and tear is much less of a risk in the TMJ with the prostheses discussed here,  than a knee or hip, mainly due to the realities that compressive loads are not in play relatively as much as those in knees or hips.  Charnley’s and later orthopedic failure experience included the use of cements for fixation which created their own immunologic reaction problems.  The total TMJ replacement systems do not use a fixating cement.  Rather, elements such as titanium which is “bone friendly” and bone fuses to it for stability, eliminating the need for use of cements.  The total TMJ replacement prosthesis however does not have the potential degree of translation or “gliding” that a natural joint has.  By necessity, a total TMJ replacement must be a much simpler biomechanical design than the most complex joint of the human body….paradoxically to increase lifespan and wear and tear of the prosthesis.  Its main benefit is to restore most joint function but with a more simple hinge or rotation function….and to correct facial asymmetry and disfigurement  due to arthritic destruction of a jont(s).  A total TMJ replacement results in less mouth opening potential than normal ranges of motion.  But the improvements from the pre-operative state can be remarkable particularly in cases of joint fusion or ankylosis. Post operative jaw mobility can improve significantly from less than a centimeter of mouth opening (barely large enough to fit a spoon, fork, or brush one’s teeth) to 3.5 cm or a range of mouth opening large enough to place 3 fingers between the front teeth. (4,5,7)

Early technical failures in the hip led to a better understanding and advancement in “biophysics”.  The same advancements and knowledge data base  are  now being accumulated in this field. 

As an alternative to alloplasts, Biomechanical engineers and other bioscientists are researching developmental growth of biologic joint replacement transplantable “parts” using stem cell research from umbilical cord stem cells.   This is remarkable work and may present as an alternative in the future .  This work is being conducted by some of the finest bioengineers in the world at Rice University, The University of Kansas, Columbia University, and U. of California.  (3)

Presently, in the United States , companies and surgeons which use these alloplastic joint replacements  are under company and FDA reporting criteria relative to use and failure (as is the case will all orthopedic prosthetics) and this is not going to change in the foreseeable future.  Other countries of the world are employing  what are called patient registry systems….where tremendous data is being generated for long term follow-up.  Such a system is likely to come to the United States  eventually. Nevertheless and currently, there are numerous steps along the way to assess these developments and uses.   In my view, low risks of infection will continue to be the problematic issue with these devices (as in any prosthetic joint system)….and that current risk with these total TMJ replacement systems  is low based on published data.

.

Refer to ASTMJS.org to find US and international surgeons who will perform these cases in selected circumstances.  Readers can also google British Asssociation of Temporomandibular Joint Surgeons, European Society  of Temporomandibular Joint Surgeons for qualified surgeons.

1.  Wolford, LM, Rodrigues, DB and McPhillips,A:  Management of the Infected Temporomandibular Joint Total Joint Prosthesis.  Journal Oral/Maxilofac. Surg.  68:2810-2823, 2010.

2. In current Publication:

Mercuri,LG and Psutka, D:  Perioperative, Postoperative, and Prophylactic Use of Antibiotics in Alloplastic Total Temporomandibular Joint Replacement Surgery:  A Survey and Preliminary Guidelines.  Jnl of Oral and Maxillofacial Surgery, 2011.

3.  2nd TMJ Bioengineering Conference.  U. of Kansas.  Dr. Michael Detamore, PhD. Chair.  Broomfield, Colorado.   October 17,18 2009.

4. Westermark,A:  Total reconstruction of the temporomandibular joint.  Up to 8 years follow-up of patients treate with Biomet total joint prosthesis”,  International Journal of Oral and Maxillofacial Surgery, 2010,39:951-955.

5.  Westermark, A. , Leiggener, Aagaard, and Lindskog:  “Histological findings in soft tissues around temporomandibular joint prostheses after up to eight years of function” International Journal of Oral and Maxillofacial Surgery,  2011, article in press.

6. Mercuri  LG, Edibam NR, Giobbe-Hurder:  14 year follow-up of a patient fitted total temporomandibular joint reconstruction system.  J Oral Maxillofac Surg 2007:  65: 1140-1148.

7.  Wolford, et al: “TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5 year follow-up study.  Int J Oral Maxillofac Surg 2003: 32: 268-274.

8. Biomet Corporation, Personal Communication.

An alloplast is an artificial material used to replace body tissues. An artificial joint is an alloplast. In modern orthopedic surgery, the development of the artificial hip was pioneered by English surgeon Dr. (Sir) John Charnley in the 60′s and a colleague from the same facility pioneered the development of the artificial knee. The history and politics of all of these developments are as fascinating as the study of the people who saw the need and committed their professional lives to the bioscience. Politically, medico-legally, and socially, artificial joint replacements face many challenges. Charnley himself was labeled a quack in England and was delegated by the health service there to practice in an old tuberculosis hospital, out of the mainstream. His patients were the sickest and most impaired. Charnley, though, was one of those rare individuals who saw a need and the scientific and developmental talent….not to mention the will… to pull everything together. In today’s world, it is not likely the risk of the tort system and healthcare politics would ever allow a Charnley to exist, much less create a significant advancement in orthopedic medicine.

The Charnley hip development process served as the prototype to prosthetics of today, primarily due to two important concepts: function of a metal artificial “ball component” against a strong molecular weight, dense “ plastic” cup or socket replacement and a way to “fixate” the prosthesis to withstand the body’s weight over time.. In efforts to always try to improve things and create a better mousetrap, changes in format are often the rule. Theories of different biomaterials and their ability to provide better use and lifespan, manufacturing techniques to reduce material wear…. are always being researched. His first designs failed due to material wear, fracture of the metal neck that was cast and part of the metal ball component, and because of fixation problems. Failures though led to better biophysics and biomechanical understanding improving his next generation of prosthetics.   His pioneering work still stands today as the basics for bioengineering understanding of the modern hip prosthesis. 

If one makes a critical review of today’s modern “failures” …….findings can be  surprisingly consistent…there has been a variation of a system in some way that it violates the biomechanical principles that Charnley’s early failure taught his researchers.  Often they can be traced back to significant variations of one of Charnley’s premises….that any prosthetic system must be consistent of two dissimilar substances….particularly the cup or socket component performs best long term  if it is the high density “plastic” component or similar type substance against the metal ball component.  This is because substances of similar makeup and particularly metal against metal have shown microscopic wear and element breakdown……”metallosis” or microscopic breakdon of metal against metal creates localized reactions in joints that combined with other factors lead to loosening….but there is now published literature which reveals release of metallic ions at least into surrounding tissues.  This is not to say that the other systems do not wear also…..they do, but the localized reaction seems to be more of an inert event in surrounding tissues.  Somewhat a lesser of two evils concept when a surgeon makes a choice as to what type or design to employ.

In the 1960s, the learning curve was to take an eventual 100% impairing and crippling human condition and improve it significantly, offering humans an alternative to a life  of permanent pain, and eventual use of  crutches or a wheel chair. Charnley’s pioneering work and basic improvements of systems he advocated served a tremendous need.  The field of maxillofacial surgery faces significant similar needs as well, in selected circimstance.

Two Current total joint replacement systems of the human jaw joint use materials similar to knees and hips…the high weight bearing “plastic” fossa and the metal condyle replacement system. TMJ Concepts, Inc and Biomet, Inc. are the developers of these systems. Oral and maxillofacial surgery has had its “Charnley moments’ developmentally and professionally as we will see in the next blog.

Note: I operated this patient two years ago. Below is her own account of her personal experiences. It is published in this blog with her permission. I know that all of my colleages in the American, British, European, Asian, and Austrailian Societies of Temporomandular Joint Surgeons see such patients on a daily basis. .

“At about age 12, I began to have joint pain in my TMJ on the right side. At first, it mimicked a chronic ear ache. My parents took me to ENT doctors but no ear problems were seen. This was the first experience with the diagnosis “TMJ”. My dentist noted that my bite was off and drifting to my right side. To correct this, an appliance was placed in the roof of my mouth. My “bite” was never on target and dentist after dentist filed my teeth down to try to ge a proper occlusion. I had many bite splints and other dental treatments, including dental caps to correct my worsening occlusion but with no improvement in my pain.

Starting in my 20s, headaches and incredible muscle pain in the head, neck and shoulders began. Debilitating pain returned in my right joint in my 30s and never went away. At age 35, an orthodontist finally took an xray which showed that the condyle in my right TMJ was much smaller than my left. My jaw was shifting to my right. Orthognathic surgery or jaw repositioning surgery was recommended. My insurance company denied this surgery. Now I am thankful this was the case because my TMJ problem was due to severe arthritic disease in the joint and this operation would not have dealt with that problem.

When suffering with TMJ, a patient feels lost. My dentist tried to have all of the answers, but after much experimentation, you realize that he doesn’t. Your try an orthodontist and after everything they have to offer, you are still in pain and lost. Folks would say “Find a TMJ Specialist”. I had no idea who that might be or where to find one- much less a reputable one! A friend finally called a surgeon in Pittsburgh and asked for a recommendation.

At the age of 45 and after 33 years of difficulties, pain of many and confusing types…..I finally had a diagnosis made. This was the first time any provider suggested definitive diagnosis with an MRI.

I cried in Dr. Kirk’s office the day he showed me pictures of what my right TM joint currently looked like. Compared to normal images that he showed me, I could see for myself with clarity that this was a terrible case of degeneration, arthritic degeneration from years of wear and tear. It is likely that my problem began due to a growth malformation of the right jaw joint. The right side was smaller than the left causing the jaw to pull off to the right side and wear the joint out. An MRI is what finally led to solid answers for the first time in my life !!

My surgery was a success. I did not experience as much pain from the procedure that I expected. The worst of my chronic pain of 33 years is now gone and I can now function as a happy mother of 2 little ones. Due to the longstanding problem, I still have headaches at times but they are managed very well with physical therapy and exercises I have been taught to control chronic muscle issues. Before, nothing would help headache.

In my case, headaches, neck pain, shoulder pain, ear ache, ringing in the ear, dizziness, pain in all facial muscles,and chronic sore throat can all be related….I had all of these symptoms at one time or another during 33 years!

For 33 years, what was missing was an accurate diagnosis and imaging provided that. One can not put a price on your health..and one must be educated about their own health issues. A specialist who will actually suggest imaging a patient before treatment is my most important recommendation to you.

D. Agnone
Charlotte, NC
February 4, 2011

COMMENTS:

I think most surgeons who encounter patients like Deborah become frustrated when they encounter patients like this who report such histories. It is frustrating. MRI of the TM joints were reported in the medical and dental literature back in the 1980s. It became very clear that this would become the gold standard for imaging any joint in the body, but its employment in TM joint work was very important. Despite publications in the dental literature, most “TMJ Specialists” rarely employ it unless they are teamed with a surgical specialist who can direct the patient to hospital or other imaging centers. There are pockets of providers scattered in the US who will image patients and even base their non surgical treatment on simulated therapeutic intervention based on what MRI predicts…but these are few and far between.
Also note that this patient’s known history of problems began at a young age. The assumption that her TMJ issue was related to occlusion issues was unfortunately misguided…..the occlusion issues were a consequence of an early degenerative process alive and well during the period of skeletal growth and development. It can not be emphasized enough that the cause and effect in growing patients with significant malocclusion and a crooked growing jaw may just indeed be an abnormality impacting joint development, the growth center of the lower jaw.

WSK
Charlotte, NC