THE READERS' CORNER

1. Do you treat patients in your practice who require TMJ treatment only? If so, what percentage of your active cases are they?

Exactly half of the respondents reported treating patients for temporomandibular disorders only. These patients averaged 3% of their cases, although the most commonly reported figure was 1%.

Do you treat patients who have combined orthodontic and TMJ problems? If so, what percentage of your active cases are they?

A vast majority (91%) said they treated combined orthodontic-TMJ patients. The average was 6% of the case load, while the mode was 5%.

Do you normally treat TMJ problems before orthodontic problems, or do you treat them concurrently?

Seventy-three percent of the clinicians replied that they normally treated TMD first; 27% were more likely to treat TMJ and orthodontic problems concurrently.

Specific comments included:

"I usually try to treat TMJ problems/symptoms first. If I can reduce their pain and other symptoms, then I feel confident I can finish them orthodontically. If they don't respond, I send them to other professionals."

"We routinely resolve acute TMJ/MPD problems prior to definitive orthodontic therapy. We may refer out problems of a chronic nature, depending on the severity and duration of the dysfunction as well as the expectations of the patient."

"I always treat the joint first. You cannot develop an orthodontic treatment plan without knowing exactly where you stand with joint health and function."

"I treat them concurrently unless the patient is experiencing acute pain or is having a significant problem with function. It also depends on the patient's understanding and attitude about the problem."

What is your regular adult case fee for orthodontic treatment only? for orthodontic treatment plus TMJ treatment? for TMJ treatment only?

The mean adult orthodontic fee in this sample was $3,575 (very close to the 1993 JCO Orthodontic Practice Study mean of $3,549). An additional $527 on average was charged for combined orthodontic and TMJ treatment, raising the mean fee to $4,102. The range of this fee increase was from 0 to $ 1,800. For TMJ treatment only, the mean fee was $ 1,289, with a range from $600 to $3,580 (the latter being the same as the practice's regular orthodontic fee).

How successful do you feel you are at treating TMJ problems? Do you feel you can achieve final orthodontic results that are as good as those in conventional orthodontic cases?

Excellent success in treating TMD was reported by 45% of the clinicians, with the rest reporting only moderate success. However, 75% of the readers felt they could achieve orthodontic results in TMJ patients that were as good as in conventional cases.

Comments included:

"I get 100% success (defined as relief of all TMD symptoms on a full-time basis) about half the time. I get varied degrees of success 45% of the time, and no TMD relief in 5% of the cases."

"I am successful because I pick my cases. If they are long-term, chronic problems, I refer them to a university setting where they can get a multidisciplinary approach."

"We routinely advise our TMJ patients that a 100% cure is unrealistic due to probable irreversible alterations in joint morphology. However, we are able to realize significant improvement for most of these patients."

"A very high percentage of patients with TMJ problems appear to have underlying skeletal deformities. Consequently, most of these patients are treated by a combined surgical and orthodontic approach. Taken as a group, the results are very successful and are significantly more beneficial when compared to a group treated by orthodontic means alone."

"The final results of the orthodontic treatment usually are equal to the non-TMD patients. However, the stability of the TMD cases over the long term may not be as good as the non-TMD cases, because of changes in the joints themselves."

"Basically, the final orthodontic result is good if patient cooperation is excellent, if they can tolerate elastic wear, and if they agree to needed skeletal and/or joint surgery (e.g., orthognathic procedures, arthroscopy, etc.)."

2. Do you have every patient sign an informed-consent document? If so, which form do you use?

A little more than 90% of the practitioners reported having every patient sign an informed-consent document. About half of those who used informed consent generated their own forms; 20% used the AAO form; 20% used forms from the local or state society (in particular, "You and Your Orthodontist" from the California State Orthodontic Society); and 10% used various commercial forms.

How is your form generated?

The largest group of practices (43%) used preprinted booklets or forms that they had purchased. Another 40% checked applicable sections on preprinted forms, and 17% customized their forms with computer software.

Do you give a copy to the patient? Where does the patient or responsible party sign or initial the form?

Of those who had informed-consent documents, 90% gave a copy to the patient. Ninety three percent asked the patient or responsible party to sign only at the end of the form; the other 7% asked for signatures on each line or paragraph.

Do you have a staff member witness the informed-consent?

This was standard practice for 73% of the respondents.

If you use informed consent, do you believe it has been helpful as a reminder to patients? Do you believe it has been helpful in avoiding misunderstandings?

Three-quarters of the readers felt the informed consent had been helpful, both as a reminder and in preventing misunderstandings.

Do you record your consultations? If so, how?

Only 7% of the offices said they recorded consultations. Several mentioned that summaries of their consultations were entered in patient records.

Some specific comments:

"I realize that the informed-consent document does not take the place of good verbal informed consent during the consultation."

"The booklet has not helped avoid misunderstandings, but has been helpful to me in explaining misunderstandings should they arise. It gives me support for my side of a disagreement."

"We have a staff member witness the informed consent if the patient is not fluent in English."

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

Dr. Edward M. Bancker, Jr., Stevens Point, WI

Dr. Jeffrey Berger, Windsor, Ontario
Drs. Michael A. Blau and Robert N. Petrosino, Cambridge, MA

Drs. Donald A. Bronsky and Theodore W. Graff, Endicott, NY

Dr. William H. Brown, Kinston, NC

Dr. Joe L. Cannon, Memphis, TN

Dr. Fidel E. Cantu, San Ysidro, CA

Dr. Russell E.K. Chang, Los Alamitos, CA

Dr. Philip J. Corbin, Amarillo, TX

Dr. Larry D. Cross, Clovis, CA

Dr. Mark L. Dake, West Plains, MO

Dr. Richard A. Drummond, Shreveport, LA

Dr. Robert J. Edenfield, Macon, GA

Dr. Joel E. Elfman, Philadelphia, PA

Dr. Joseph C. Forsman, Lubbock, TX

Dr. John E. Freeman, Houston, TX

Dr. Richard Frei, Las Vegas, NV

Drs. Girard A. Gugino and Kevin J. Hanley, Buffalo, NY

Drs. Richard H. and Scott D. Hamilton, Topeka, KS

Drs. Anna and Bruce Hartley, Sunnyvale, CA

Drs. Richard C. Hayes and Malko E. Karkenny, Ridley Park, PA

Dr. William Hyman, Malibu, CA

Dr. Roger G. Johnson, Lawton, OK

Drs. Frederic S. and William R. Kreul, Waupaca, WI

Dr. Vincent A. Labruna, New York, NY

Dr. Hugh V. Leggett, Jr., Brookhaven, MS

Dr. Terry Loeffler, Fresno, CA,

Dr. Gary McMullen, Citrus Heights, CA

Dr. David W. McSurdy, Manahawkin, NJ

Dr. Ernest M. Mendeloff, Bridgeport, CT

Dr. Bruce I. Meyer, Stony Brook, NY

Drs. Robert A. Miller and James P. Soderquist, Charlottesville, VA

Dr. Alan B. Montgomery, Roseville, MN

Dr. Irwin K. Ornish, Dallas, TX

Orthodontic Associates, Inc., East Providence, RI

Dr. Manfred Quentel, Humble, TX

Dr. Ronald R. Sepic, Uniontown, PA

Dr. Martin L. Sherling, Dallas, TX

Dr. Donald F. Shoff, Red Bluff, CA

Dr. Robert E. Sutter, Lodi, CA

Dr. Stephen J. Vogel, Killeen, TX

Dr. John W. Vornholt, Lewiston, ID

Dr. Ray Walton, Beaumont, TX

Dr. Richard P. West, Lakeport, CA