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Patients suffering from craniomandibular joint (CMJ) disorders often need relief for their pain, and treatment doesn’t always have to involve surgery. Rehab facilities could play a large role in treating these patients. The Affinity Health System in Appleton, WI, has a special program for CMJ patients, called The Center for Craniomandibular Disorders. The program’s staff include oral surgeons who specialize in CMJ treatment and rehab staff who also work at the hospital system’s outpatient rehabilitation center.
The center, which is within St. Elizabeth Hospital, was launched in 1989 when it became clear to physicians that it was increasingly difficult to manage CMJ patients in the hospital because they had to go to so many different places for treatment, says oral surgeon Arthur Helgerson, DDS. Patients who are treated at the center don’t need to go anywhere else. Their therapy and doctor appointments all take place at the center. Helgerson, for example, sees patients at the center 2.5 days a week and spends the rest of his time at his private practice in Appleton.
The program built up slowly but has become very popular, and the center does not have to advertise. It often has a three- or four-month waiting list of potential patients. "Since we opened the center, physicians and dentists in the area have sent a lot of their patients to us," Helgerson says.
The center is the only one of its type in the region, so it has established a very good reputation in the community, says Susan Van Handel, CDA, program coordinator.
Helgerson, Van Handel, and other members of the center’s staff relate the steps the center took to build a successful market niche by treating CMJ patients:
• Overcome reimbursement obstacles. Business at the CMJ center increased by 35% to 40% in the two years since the state of Wisconsin passed a law mandating insurance coverage of the disorder, Van Handel says. Previously, many regular insurance carriers either offered no reimbursement or stringent limits, Van Handel says. "That insurance mandate really did make a big difference in the number of patients we treat throughout the year," she adds.
The law’s passage was no accident. The center’s patients joined the Wisconsin Dental Association and other health care professionals in writing letters to state legislators requesting that they pass such a measure, Helgerson says. "The idea for the bill was so patients could go to a family dentist and he could make a splint," he explains. "A lot of patients have early disease and can be treated with a splint, a soft diet, and no gum chewing, and it will get better."
The CMJ center’s patients are those people who have endured CMJ pain for a long time and have found no lasting relief from multiple prescriptions of anti-inflammatory drugs. "They have more complex disorders and pain over a long period of time, and it’s more difficult to manage, which is why we have put together this team," Helgerson adds.
Since the Wisconsin legislature passed the bill mandating CMJ coverage, insurance carriers have set up a variety of reimbursement policies. Some will pay for all of the services offered by the center, while others have set financial caps on how much they’ll reimburse for nonsurgical treatment.
A very small percentage of patients will pay out of pocket for their treatment, and Medicare typically pays 80% of the usual charge. Medicaid coverage is complicated and is not a significant source of revenue. The payers mainly are private insurers and health maintenance organizations, Van Handel says.
• Establish treatment protocol. "Typically the patients who are referred to us have symptoms of muscle pain surrounding their jaw and they hear clicking and popping in their jaw," Van Handel says. "Sometimes there are patients who will complain of crunching teeth and are having a lot of pain because of that."
So one of the first steps in the program is for one of the oral surgeons to evaluate the patient and make sure the problem is related to CMJ. The oral surgeon makes a diagnosis, and based on that diagnosis, the team will develop a treatment plan. For example, if a patient visits the center because of popping sounds in his or her mouth, but there isn’t much pain, then the patient might need only two to four visits with a physical therapist. The PT can show the person how to open and close the mouth in a way that will manage the problem, Helgerson says.
On the other hand, if the patient has difficulty with clenching his or her teeth, then the patient may be given a splint and sent to the occupational therapist to receive help with muscle problems, Helgerson adds.
Yet another case may involve a patient who has significant difficulty opening his or her jaw, and this patient may require basic surgery. "At this center we really try to do surgery only when there’s something we can fix and not just to do surgery for pain," Helgerson says, adding that about 3% of patients require surgery. Those who need surgery typically are covered by insurance carriers, and this type of treatment was well-reimbursed even before Wisconsin passed its bill, Helgerson says.
The physical therapist’s main goal is to help the patient maximize CMJ function through modalities and therapeutic exercise, says Mary Krueger, PT, a physical therapist for the center and the hospital’s outpatient rehabilitation facility. Physical therapists develop a treatment plan that addresses muscle and joint dysfunction and includes hands-on treatment, an exercise modality, a home exercise program, and education in the use of self-management techniques.
• Use technology to assist in treatment and treat pain. Van Handel generally begins the patient’s pain treatment by meeting with the patient and discussing various strategies the patient can implement to reduce pain, such as heat and diet recommendations.
When self-management methods are unsuccessful, the team will provide specific pain treatment. For example, there may be times when a patient is unable to exercise because the pain levels are so high, says Jane Steinbach, PT, a physical therapist for the center and the outpatient rehabilitation facility. "So we do modality treatment to reduce that inflammation and the swelling in the joint," Steinbach says. "And this may involve phonophoresis, which means administering an anti-inflammatory medication via ultrasound." Another method is iontophoresis, which is the process of administering an anti-inflammatory medication by electrical stimulation, Steinbach explains. "These are good alternatives to joint injection, and they are much more comfortable," Steinbach adds.
Some CMJ patients live with constant pain that greets them when they arise in the morning and stays with them as they go to bed at night, Steinbach says. Each time these patients visit the center, they are asked to rate their pain on a scale of zero to 10, with zero being no pain and 10 being the greatest imaginable pain. They also rate the duration and frequency of their pain.
"We are looking for the numbers to come down and for the pain to be intermittent," Steinbach says. "If a person has part of a day with zero pain, then that’s a huge breakthrough."
Patients’ pain also is treated through ultrasound without medication and through the use of the transcutaneous electronic nerve stimulator unit without medication. This home unit can be used to treat muscle tension pain and for regular pain management, Steinbach says. "If a patient needs a little more help at home, then we can send the patient home with a unit," she adds.
The center also uses biofeedback technology to monitor a patient’s pain and to help teach the patient how to reduce muscle tension and learn relaxation strategies, says Linda Nett-Duesterhoeft, OTR, an occupational therapy/ biofeedback therapist at the center and the outpatient rehabilitation facility.
"This helps to reduce episodes, duration, and intensity of pain flare-up," Nett-Duesterhoeft says. "We look at the patient’s autonomic nervous system and muscular system, and then look at the patient’s stress response, monitoring changes in hand temperature and hand sweating."
The patient’s muscle temperature in the jaw also is measured. The therapist gives the patient a print-out of his or her individual stress response. This demonstrates how the patient may clench his or her jaw during stress, an action that patients largely are unaware they’re doing. "If they can listen to signs of their stress response by knowing what those changes are, then they are empowered to do something about it, and that’s where relaxation skills are important," Nett-Duesterhoeft explains.
Patients respond well to receiving both visual and auditory feedback, says Shelly Vanness, OTR, an occupational therapist and biofeedback specialist for the center and the outpatient rehabilitation facility. "Many muscles are hypertrophied from clenching, and these patients clench more significantly than people who don’t have the disorder, so when they see what they’re doing on the computer screen, it’s very helpful," Vanness says.
• Provide therapy when needed. The CMJ center also offers patients therapy sessions when needed. "I come into play when the majority of the team feels that the patient has some personal problems that are leading to a more abnormal level of stress, and they need to talk to a psychologist to work out some issues," says Kathleen Clarke, PhD, rehabilitation psychologist. Clarke provides individual therapy and cognitive behavioral training in six to eight sessions. "I see maybe 30% of the patients," she adds.
About 80% of the CMJ patients are female, and the typical age range is from age 13 to 45, with the average patient age being 21, Helgerson says. "These are people in the early stages of the disorder," he adds.
Many of the patients have difficulty coping with stress related to a combination of work and family, Clarke says. "Generally a person is overstressed because she’s trying to handle too many things," she says. "She has children and is trying to get them to and from school, and she has a job and is overstressed with personal problems and from trying to handle it all at once."
• Educate patients.
Patient education is a crucial component of CMJ management because stress, diet, and other issues can affect the patient’s pain from the disorder, and education can make the difference between a short-term and long-term solution to the problem. "We want the patient to be independent in caring for chronic problems," Krueger says.
Physical and occupational therapists teach patients active relaxation techniques that they can practice throughout the day. These relaxation skills might take them 20 to 30 minutes of practicing in a reclined position in a controlled environment, Nett-Duesterhoeft says.
One small and easy technique is to have the patient repeatedly say the word, "emma," which automatically puts the jaw in a relaxed position. "I’ve had people joke about driving through the Rocky Mountains and wanting to clench their teeth, but instead are saying emma’ to themselves throughout the Continental Divide," Nett-Duesterhoeft says.
Teaching patients these relaxation techniques in a way that will sink in may take an hour a week for six weeks. However, Nett-Duesterhoeft says she often has to accomplish everything in one visit because of reimbursement constraints.
Van Handel educates patients about their own insurance coverage, giving them pointers on how to ask the insurance company questions in order to learn what the coverage is. She also explains how they will use splint therapy at night, when this is prescribed. The splint is a device worn on the upper teeth to take pressure off of the joint and prevent night-time clenching. "A lot of patients complain of waking up with stiff and sore muscles in the face," Van Handel notes.
Then Van Handel explains the oral surgeon’s orders and gives patients an idea of what they can expect from therapy. She also tells patients what the treatment team’s expectations are for the patient. "There is a time commitment with our program, and there is no quick fix," Van Handel says. "Our goal is to treat for four to six weeks so the patient doesn’t have to come back, and if the patient has a flare-up, she can handle it at home."
• Kathleen Clarke, PhD, Rehab Psychologist; Susan Van Handel, CDA, Program Coordinator; Arthur Helgerson, DDS, Oral Surgeon; Mary Krueger, PT, Physical Therapist; Linda Nett-Duesterhoeft, OTR, Occupational Therapy/ Biofeedback; Jane Steinbach, PT, Physical Therapist; Shelly Vanness, OTR, Occupational Therapist and Biofeedback Specialist, Affinity Health System, St. Elizabeth Hospital, The Center for Craniomandibular Disorders, 1506 South Oneida St., Appleton, WI 54915. Telephone: (920) 831-1442.