THERE IS NO SINGLE "BEST TREATMENT" FOR TMJ BECAUSE TMJ IS NO A SINGLE DISEASE OR PROBLEM. TMJ actually stands for TemporoMandibular Joint and it is a joint not a disease. Everyone has two TM Joints. TMD stands for TemporoMandibular Dysfunction but it is also a general term.
The following should help guide patients in finding the "right " doctor.
To receive the "Best TMJ Treatment" it is first necessary to have the "Best TMJ Diagnosis".
The diagnosis is actually the most complex part of treating this group of disorders.
The medical SOAP model is an essential part of arriving at the right diagnosis and treatment and is frequently not followed.
The "S" in SOAP is the subjective findings. These come from the patients history. Many dentists and physicians short change patients by not getting a thorough and complete history. Often, relevant facts about a patient's history are missed or revealed later by patients. I usually set aside a minimum of one hour for a first visit with a patient with chronic pain. My team will often schedule much longer appointments when a case appears complicated. The tentative diagnosis or diagnostic tree (differential diagnosis) is made from the patient's history and interview. It is the confirmed or reevaluated based on Objective findings.
The "O" in SOAP is the objective findings. Before objective testing is done the subjective history helps determine the proper testing that is appropriate for each patient. Objective testing includes Radiographs or x-rays. These may be plain film, cone beam, CT scans, MRI's. These are used to diagnose bony changes and soft tissue changes to the joints.
There are specific objective testing that helps determine the "Best TMJ Treatment" and confirms details of the working diagnosis. Neuromuscular Dentists use the following diagnostic tools to elucidate the complete nature of this disorder.
THE FOLLOWING OBJECTIVE DEVICES ARE USED BY NEUROMUSCULAR DENTISTS TO AID IN DIAGNOSIS AND TREATMENT OF CRANIOMANDIBULAR DISORDERS (TMJ, MPD, MPD,ETC)
EMG or Electromyography that is used to determine starting levels of muscle activity, symmetry of muscle activity, funCtional activity as it relates to posture and function. Spectral Analysis of EMG help to determine underlying physiologic sTatus of the muscles. EMG can also be used to fine tune bite corrections and to measure efficacy of treatment.
Sonography and/or JVA (joint vibration analysis) Can be used to measure the health of the joint and determine thru spectral analysis the amount of joint damage or changes.
MKG (mandibular kinesiograph) , CMS (computerized Mandibular Scans) are used to evaluate function and movement and in conjunction with ULF TENS to measure rest position.
ULF TENS is used diagnostically and as a treatment tool. The the dimensional position of the jaw is evaluated before and after muscle relaxation (as confirmed by EMG)
Blood Tests, urine chemistry, thyroid function are all objective tests that are used when appropriate. Sleep studies are an often under utilized diagnostic tool in finding the "BEST TMJ TREATMENT". Patients with morning headaches, snoring, high blood pressure and excessive daytime sleepiness should always be evaluated with polysomnography. The NHLBI (National Heart Lung and Blood Institute) of the NIH (National Institute of Health) considers Sleep Apnea to be a TMJ disorder.
Psychometric tests are also objective tests that are used in diagnosis. Unfortunately, many doctors believe that there are no real physical ailments and the TMJ is a "psychco-social" disease to be treated with drugs and psychotherapy. There are frequently psycho-social overlays to TMJ problems. Being in chronic pain changes patients in many ways. Psychometric testing often reveals the results of chronic pain rather than the cause.
The "A" in SOAP is the assessment, where all of the subjective and objective information allows the doctor to have a "working diagnosis" and to lay out an initial treatment plan.
The "P" in Soap is the PLAN or methods determined by the Physician or Dentist to be used to treat the patient. This may include use of medications, therapy or diagnostic orthopedic appliances. Many patients need numerous methods of treatment to address the disorders and problems diagnosed and revealed in Subjective and Objective examination. Frequently more than one practitioner will be involved in treatment.
DIAGNOSIS DOES NOT END WHEN A NEUROMUSCULAR DIAGNOSTIC ORTHOTIC IS PLACED IN A PATIENTS MOUTH!
It is essential to understand that diagnosis and treatment is an ongoing procedure and that a SOAP approach is used at subsequent appointments. The "BEST TMJ TREATMENT" is ongoing and as the patients improve it is frequently appropriate for the focus of treatment to change. It is important for the patient and doctor to be open and honest to achieve the best results.
I strongly believe that the Neuromuscular Dentistry approach is the best "TMJ" treatment but it is only a part of the total diagnosis.
Showing posts with label wrong diagnosis. Show all posts
Showing posts with label wrong diagnosis. Show all posts
Thursday, November 25, 2010
Wednesday, September 29, 2010
One in Six patients perceive that wrong diagnosis have been made.
An interesting study from the Archives of Internal Medicine (abstract below)reports that 1one in six patients percieve that their doctors have made wrong diagnosis. The study reported "Patients with chronic back pain, higher educational attainment, and poor physical health were at increased odds of perceiving mistakes".
This leads to two questions, were there actual mistakes in diagnosis and treatment or was this just a patient perception. Is it possible that there were multiple diagnosis and they were not yet all discovered?
I frequently see Headache and Migraine patients with numerous diagnosis and medications. I treat these patients with neuromuscular dentistry and their pain is rapidly eliminated. This does not mean that the previous diagnosis were wrong but rather treatment was ineffective. Typically patients with TMJ problems that lead to headaches have seen a minimal of six doctors prior to seeing the dentist, sometimes dozens of physicians. That is why TMJ Disorders are called "THE GREAT IMPOSTER" SEE http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor to read "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER"
Elimination of the headaches does not necessarily mean that other diagnosis were wrong but rather they were not the true cause of the pain. The expression "you can't see the forest for the trees" describes this type of problem. Relieving the headaches and Neuromuscular symptoms makes the patients feel great but frequently remaining symptoms not related to the Trigeminal Nervous system can also be discovered.
Dr Mercola of Mercola.com stated "One in Six Patients Report Getting Wrong Diagnosis
With each survey, study, and statistical review, the answer remains the same: Patients beware, because conventional medicine may inadvertently lead to you or your family's premature demise." It is important to note that this study was talking about patient perceptions about their diagnosis not actual diagnosis.
Solving chronic pain problems is like peeling an onion, as you relieve one layer of the onion you come to the next. Different layers of the onion may need different practioners or treatment. Sometimes it is necessary to treat one problem before progress can be made in other problems.
I frequently see patients who also go to chiropracters or osteopaths for spine adjustments that relieve their headaches but the adjustments do not hold. Combining a diagnostic neuromuscular orthotic with the chiropractic treatment eliminates the trigeminal system problems but also allows the spine to stabilize. Neither treatment works as well alone as the two treatment work combined.
I once had a patient who had constant daily headaches that were completely relieved by a neuromuscular orthotic with the exception of a pain in the right occipital area. The patient stated that was the first pain when the problem started, but did not remember that until the rest of the pain was gone. I could not find any trigger points in the muscle to duplicate the pain but the patient said that he first experienced the pain while playing golf and taking a back swing. When we had him repeat that motion the trigger point became active and we could locate, inject and eliminate it with complete relief of years of pain. That was probably the original injury but would never have been found without first getting him off of medications that masked the pain, correcting occlusal problems (TMD not TMJ this patient had no TM Joint problems just neuromuscular problems)
This patient had had several cat scans and an MRI and was told he has Multiple Sclerosis due to an abnormal MRI and symptoms. He refused to return to the neurologist but I explained that the MRI changes were real. When he revisted a new neurologist the MRI was still abnormal but because there were no symptoms no diagnosis of MS was made. The neurologist did say it could be a problem in the future but for many years the pain did not return. This case is one where the symptoms plus the abnormal MRI combined were used for the diagnosis but taken seperately a very different outcome. If there had never been pain the MRI would not have been taken and the accidental discovery of a questionable area on the brain would not be seen"
The study mentioned patients with back pain. Radiographic imaging of a patient with back pain frequently shows abnormalities which the pain is the attributed to. Patient with these same abnormalities are walking around pain free for years but no imaging is ever done until the pain occurs. Finding pain and radiographic changes does not always imply cause and effect. Studies have shown that the bell curves of pain and bell curves of radigraphic changes are not the same. Some patients with terrible arthritis have no pain and some with miserable pain have little objective evidence of pain. When the pain is labeled frequently other causes of pain are no longer even considered. The diagnosis of arthritis is correct but is just not the cause of pain. Arch Intern Med. 2010 Sep 13;170(16):1480-7.
Patient perceptions of mistakes in ambulatory care.
Kistler CE, Walter LC, Mitchell CM, Sloane PD.
Division of Geriatrics, Department of Medicin, University of California-San Francisco, USA. umanohone@yahoo.com
Arch Intern Med. 2010 Sep 13;170(16):1487-9.
Abstract
BACKGROUND: Little information exists about current patient perceptions of medical mistakes in ambulatory care within a diverse population. We aimed to learn about the perceptions of medical mistakes, what factors were associated with perceived mistakes, and whether the participants changed physicians because of these perceived mistakes.
METHODS: We conducted a cross-sectional survey at 7 primary care practices in North Carolina of English- or Spanish-speaking adults, aged 18 years and older, who saw a health care professional during 2008. Main outcome measures were 4 questions about patient perceptions of medical mistakes in the ambulatory care setting, including (1) overall experience with a medical mistake; type of mistake, such as a (2) diagnostic mistake or (3) treatment mistake, and its associated harm; and (4) effect of this mistake on changing physicians.
RESULTS: Of 1697 participants, 265 (15.6%) responded that a physician had made a mistake, 227 (13.4%) reported a wrong diagnosis, 212 (12.5%) reported a wrong treatment, and 239 (14.1%) reported having changed physicians because of a mistake. Participants perceived mistakes and harm in both diagnostic care and medical treatment. Patients with chronic back pain, higher educational attainment, and poor physical health were at increased odds of perceiving mistakes, whereas African American patients were less likely to perceive mistakes.
CONCLUSIONS: Patients perceived mistakes in their diagnostic and treatment care in the ambulatory setting. These perceptions had a concrete effect on the physician-patient relationship, often leading patients to seek another health care professional.
PMID: 20837835 [PubMed - in process]
This leads to two questions, were there actual mistakes in diagnosis and treatment or was this just a patient perception. Is it possible that there were multiple diagnosis and they were not yet all discovered?
I frequently see Headache and Migraine patients with numerous diagnosis and medications. I treat these patients with neuromuscular dentistry and their pain is rapidly eliminated. This does not mean that the previous diagnosis were wrong but rather treatment was ineffective. Typically patients with TMJ problems that lead to headaches have seen a minimal of six doctors prior to seeing the dentist, sometimes dozens of physicians. That is why TMJ Disorders are called "THE GREAT IMPOSTER" SEE http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor to read "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER"
Elimination of the headaches does not necessarily mean that other diagnosis were wrong but rather they were not the true cause of the pain. The expression "you can't see the forest for the trees" describes this type of problem. Relieving the headaches and Neuromuscular symptoms makes the patients feel great but frequently remaining symptoms not related to the Trigeminal Nervous system can also be discovered.
Dr Mercola of Mercola.com stated "One in Six Patients Report Getting Wrong Diagnosis
With each survey, study, and statistical review, the answer remains the same: Patients beware, because conventional medicine may inadvertently lead to you or your family's premature demise." It is important to note that this study was talking about patient perceptions about their diagnosis not actual diagnosis.
Solving chronic pain problems is like peeling an onion, as you relieve one layer of the onion you come to the next. Different layers of the onion may need different practioners or treatment. Sometimes it is necessary to treat one problem before progress can be made in other problems.
I frequently see patients who also go to chiropracters or osteopaths for spine adjustments that relieve their headaches but the adjustments do not hold. Combining a diagnostic neuromuscular orthotic with the chiropractic treatment eliminates the trigeminal system problems but also allows the spine to stabilize. Neither treatment works as well alone as the two treatment work combined.
I once had a patient who had constant daily headaches that were completely relieved by a neuromuscular orthotic with the exception of a pain in the right occipital area. The patient stated that was the first pain when the problem started, but did not remember that until the rest of the pain was gone. I could not find any trigger points in the muscle to duplicate the pain but the patient said that he first experienced the pain while playing golf and taking a back swing. When we had him repeat that motion the trigger point became active and we could locate, inject and eliminate it with complete relief of years of pain. That was probably the original injury but would never have been found without first getting him off of medications that masked the pain, correcting occlusal problems (TMD not TMJ this patient had no TM Joint problems just neuromuscular problems)
This patient had had several cat scans and an MRI and was told he has Multiple Sclerosis due to an abnormal MRI and symptoms. He refused to return to the neurologist but I explained that the MRI changes were real. When he revisted a new neurologist the MRI was still abnormal but because there were no symptoms no diagnosis of MS was made. The neurologist did say it could be a problem in the future but for many years the pain did not return. This case is one where the symptoms plus the abnormal MRI combined were used for the diagnosis but taken seperately a very different outcome. If there had never been pain the MRI would not have been taken and the accidental discovery of a questionable area on the brain would not be seen"
The study mentioned patients with back pain. Radiographic imaging of a patient with back pain frequently shows abnormalities which the pain is the attributed to. Patient with these same abnormalities are walking around pain free for years but no imaging is ever done until the pain occurs. Finding pain and radiographic changes does not always imply cause and effect. Studies have shown that the bell curves of pain and bell curves of radigraphic changes are not the same. Some patients with terrible arthritis have no pain and some with miserable pain have little objective evidence of pain. When the pain is labeled frequently other causes of pain are no longer even considered. The diagnosis of arthritis is correct but is just not the cause of pain. Arch Intern Med. 2010 Sep 13;170(16):1480-7.
Patient perceptions of mistakes in ambulatory care.
Kistler CE, Walter LC, Mitchell CM, Sloane PD.
Division of Geriatrics, Department of Medicin, University of California-San Francisco, USA. umanohone@yahoo.com
Arch Intern Med. 2010 Sep 13;170(16):1487-9.
Abstract
BACKGROUND: Little information exists about current patient perceptions of medical mistakes in ambulatory care within a diverse population. We aimed to learn about the perceptions of medical mistakes, what factors were associated with perceived mistakes, and whether the participants changed physicians because of these perceived mistakes.
METHODS: We conducted a cross-sectional survey at 7 primary care practices in North Carolina of English- or Spanish-speaking adults, aged 18 years and older, who saw a health care professional during 2008. Main outcome measures were 4 questions about patient perceptions of medical mistakes in the ambulatory care setting, including (1) overall experience with a medical mistake; type of mistake, such as a (2) diagnostic mistake or (3) treatment mistake, and its associated harm; and (4) effect of this mistake on changing physicians.
RESULTS: Of 1697 participants, 265 (15.6%) responded that a physician had made a mistake, 227 (13.4%) reported a wrong diagnosis, 212 (12.5%) reported a wrong treatment, and 239 (14.1%) reported having changed physicians because of a mistake. Participants perceived mistakes and harm in both diagnostic care and medical treatment. Patients with chronic back pain, higher educational attainment, and poor physical health were at increased odds of perceiving mistakes, whereas African American patients were less likely to perceive mistakes.
CONCLUSIONS: Patients perceived mistakes in their diagnostic and treatment care in the ambulatory setting. These perceptions had a concrete effect on the physician-patient relationship, often leading patients to seek another health care professional.
PMID: 20837835 [PubMed - in process]
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