THE READERS' CORNER

PETER M. SINCLAIR, DDS, MSD

Topics include TMJ and practice newsletters.

1. What percentage of your orthodontic patients would you estimate show TMJ signs or symptoms before treatment? during treatment? after treatment?

Responses can be divided into those reporting a low incidence of TMJ signs or symptoms (less than 10% of their patients), those reporting moderate incidence (10-60%), and those reporting high incidence (greater than 60%). For patients before treatment, 47% of the responses were in the low category, 38% moderate, and 15% high. For patients during treatment, the number of responses in the low category increased to 53%, while the high category decreased to less than 10%. For patients after treatment, the low-incidence category rose to 66%, the moderate category decreased to 25%, and the high category remained at less than 10%.

It is interesting to note that 46% of the respondents felt that TMJ signs and symptoms decreased during orthodontic treatment, 38% felt they remained unchanged, and 15% felt they increased.

What are your normal procedures for dealing with TMJ signs or symptoms that are displayed before treatment? during treatment? after treatment?

The importance of a thorough pretreatment examination and documentation was stressed by many clinicians. Diagnostic methods often included tomograms and the use of splints to determine the nature and extent of the patient's problems, particularly the presence of a CO-CR slide. Pain-relieving medications, physical therapy, and habit control were also mentioned as being helpful before treatment.

During orthodontic treatment, centric-occlusion splints, especially the "soft" type, were the most frequently recommended adjuncts. Many respondents said they would also cease active orthodontic movement for about three months while the TMJ signs and symptoms were dealt with.

Following treatment, splints were again the most popular therapy, often combined with some of the measures that might have been used before treatment. Occlusal equilibration was mentioned by several clinicians as a useful procedure at this stage.

Specific comments included:

"Treatment depends upon the signs and symptoms. An initial finding of joint noises with no other symptoms is noted, but not treated per se. Other symptoms-- e.g., popping, locking, mandibular shift, pain-- are addressed first with splint therapy and/or equilibration. Once symptoms disappear or a new mandibular position is seen, full treatment will begin. If needed, additional radiographs, MRI, and other consultations may be ordered."

"I inform the patient and parent before treatment, discuss conservative treatment (splint) before fixed appliances as an option, but typically go directly into fixed appliances since symptoms usually improve after initial banding. During treatment, I will inform the patient and treat conservatively if painful problems arise. After treatment, I use bite plates on maxillary retainers to help control signs and symptoms. If TMJ problems occur several years after orthodontic treatment, I handle the patient the same as a new TMJ patient."

"Before treatment, I make no guarantees about TMJ signs and symptoms and tell the patient and parent that orthodontic treatment may not alleviate these. If the patient has painful symptoms, I will on occasion fit a simple centric-relation splint. Full orthodontic treatment follows if the pain subsides. During treatment, if mild pain is present, I note it on the chart and proceed after informing the patient that it is usually transitory. If significant pain is present, I will stop the active mechanics and see if it stops the pain. After treatment, I may give them a night-time splint to relax their muscles."

"Before and after: If chronic and painful, I refer out. During treatment, I follow this sequence:

1. Patient education to modify their jaw use, such as avoiding clenching, avoiding opening wide, avoiding hard foods, and no gum chewing.

2. Minor occlusal equilibration in balancing and centric.

3. Jaw muscle exercises.

4. Change in treatment plan."

Do you treat patients who have disc displacements? If so, how do you differentiate among types of disc displacement, and what is your normal treatment regime?

Fifty-seven percent of the respondents said they treated disc displacements. The majority of these used a detailed clinical examination to differentiate among types of displacement, supplementing the exam with an MRI or the use of joint-unloading splints. Disc-recapturing splints were also mentioned as a useful treatment modality.

Some specific comments:

"I'm not certain I can differentiate disc displacement. I tend to anteriorly reposition the patient to the protrusive position, where they can open and close without popping or clicking, if there is a reciprocal click. I do not try to recapture a disc, but I try to unload the disc area so some remodeling or healing can occur. I consider successful treatment to be freedom from pain and adequate range of motion, not freedom from joint sounds."

"Specifically, I differentiate between anterior disc displacements and anteromedial disc displacements. The former reduces in vertical opening, while the latter reduces in lateral excursion. I primarily treat pain and limitation of movement. I will try to recapture a disc in a patient with a painful early-grade clicking with good disc morphology, as evidenced by a relatively loud click or pop. I usually do not try to recapture the disc in a pain-free patient, except early-grade clicks in Class II patients when I would be using a functional appliance anyway."

"If the dislocation is acute and painful, I refer to a physical therapist and will deliver an anterior-positioning splint. I only do this on recent dislocations. If the dislocation is chronic and nonpainful or of longstanding duration, I inform the patient that it may flare up and then I proceed with treatment. I do not attempt to recapture old or nonpainful disc displacements."

"Differentiation of displacement is from the clinical history-- range of motion, deviation, when the click occurs, etc. As to treatment, the literature supports the view that disc recapture is not likely. Treatment in our office involves palpating the case, and evaluation and treatment of precipitating causes when appropriate."

Do you treat patients who have neuromuscular problems? If so, how?

Sixty-seven percent of the clinicians reported treating neuromuscular problems. A detailed clinical examination, including muscle palpation and a centric-relation splint, was the most frequently used diagnostic procedure. Therapeutic regimes often included physical therapy, non-steroidal anti-inflammatory drugs, warm heat, spray and stretch, and muscle relaxants.

Responses included:

"Diagnosis is based on clinical palpation of the musculature and description of symptoms by the patient. If a patient has muscle myositis that leads to headaches, I usually start with an orthotic splint to try and stop parafunctional activity. Most patients improve with full-time wear of the orthotic. If muscle symptoms persist, I send patients to a physical therapist to help 'work out' the muscle inflammation."

"If the problem is due to a bruxing condition or severe deep bite as in division 2, I place fixed appliances on the upper arch initially, alone or together with a bite plate, which usually relieves muscle problems well. I then proceed with full treatment, but I consider a bite-plate maxillary retainer to protect against bruxism in the retention phase."

"I refer suspected neuromuscular patients for diagnosis and do minimal treatment to obtain a stable occlusion."

"I treat neuromuscular problems with a clinical exam consisting of range of motion, muscle palpation, mounted models, x-rays, and patient history. Treatment can include physical therapy, medication, and centric splints, with frequent outside referral for stress management, physical therapy, counseling, and (rarely) oral surgery or neurology."

2. Do you publish a periodic practice newsletter? If not, have you published one in the past? If you have discontinued a newsletter, what were your reasons?

Only 13% of the respondents said they currently published practice newsletters. However, one-third of those who did not have newsletters had published them in the past. Their reasons for discontinuing the newsletters included:

"Difficulty in continuing to provide timely, high-quality, meaningful information to the recipients. A positive became a negative, so we stopped."

"We discontinued our newsletter because of the cost-benefit ratio. Too much time and effort with little positive response from the patients."

"A change in staff and lack of feedback from our patients led us to discontinue our newsletter."

The orthodontists who did publish newsletters sent them to both active and inactive patients, as well as professional referral sources. Frequency of publication ranged from twice monthly to semi-annually. Newsletters varied in size from two to six pages.

Content generally included items about dental health, humor, patient news, and practice news. Artwork often consisted of clip art and photographs. Spot color was frequently used, and one practice used full color.

The practice's involvement in production was usually limited to writing and editing, basic layout, and generation of mailing labels, with other work being hired out. Either the orthodontist or a particular staff member was in charge of the newsletter.

JCO would like to thank the following contributors to this month's column:

Dr. Charles D. Atkinson, Greer, SC

Dr. H. Eldon Attaway, Irving, TX

Drs. James G. Barrer, Douglas White, and Warne White, West Reading, PA

Dr. Paul Batastini, Cherry Hill, NJ

Drs. J.H. Belofsky, L.J. Lowenstein, and Shari Lisann, Worcester, MA

Dr. Stephen D. Bosonac, Clark, NJ

Dr. Gene Brain, Renton, WA

Dr. Barry S. Briss, Chelmsford, MA

Dr. James E. Buckthal, Raleigh, NC

Dr. Kerry DaVirro, Westchester, CA

Dr. Dennis DeMuth, Lambertville, MI

Dr. David E. Drake, Chambersburg, PA

Dr. Devek K. Frech, Wichita Falls, TX

Drs. Daniel Grob and Mark Donovan, Tucson, AZ

Dr. Myron D. Guymon, Logan, UT

Dr. Jerome Levy, Smithtown, NY

Dr. Ronald A. Madere, Mandeville, LA

Dr. Phillip R. Parker, Norman, OK

Dr. Carmine N. Petrarca, Bethesda, MD

Dr. Donald R. Picard, Palm Beach Gardens, FL

Dr. Russell R. Schwindt, Manitowoc, WI

Drs. Terry A. Sellke and Donald J. Reily, Grayslake, IL

Dr. Jay R. Singer, Sunrise, FL

Dr. Robert F. Uible, Jacksonville, FL

Dr. Martin Van Vliet, Ramsey, NJ

Drs. William Wallert and M. Alan Bagden, Springfield, VA

Dr. Gene Wood, Fort Worth, TX

Dr. David W. Zemke, Minneapolis, MN

Journal of Clinical Orthodonics

THE READERS' CORNER

1. What percentage of your orthodontic patients would you estimate show TMJ signs or symptoms before treatment? during treatment? after treatment?

2. Do you publish a periodic practice newsletter? If not, have you published one in the past? If you have discontinued a newsletter, what were your reasons?

PETER M. SINCLAIR, DDS, MSD

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