Since 3D imaging assesses the anatomy of patients more accurately than ever before, more patients than previously assumed are being discovered with compromised temporomandibular joints (TMJ) and airway system. While 3D imaging is vital to understand many presenting problems, dentists are often challenged when it comes to developing a practice model that allows for a reasonable fee to maintain practice profitability.
The traditional dental practice generates revenues from restorative procedures necessitated by tooth loss from decay. Yet, the knowledgebase of the profession has grown as such that the amount of decay in patients is decreased.
These days it's relatively routine for dentists to see patients with little to no decay, and who only need minimal restorative dentistry. However, many patients do have serious issues beyond restorative ones. Patients with significant alterations in normal joint anatomy, because of poor mandibular and maxillary growth, have a decreased oropharyngeal airway anatomy.
Compromised oropharyngeal airway space
George, a 57-year-old male, (Figure 1) has small condyles, which usually correlate to an injury to the TMJ occurring before growth was complete. In a 2006 journal article, Carlos Flores-Mir and Brian Nebbe1 discuss TMJ disc abnormality associated with reduced forward growth of the maxillary and mandibular bodies.
In many of the cases they studied, reduced maxillary and mandibular growth resulted in a compromised oropharyngeal airway space. (Figure 2)
To help a patient like George, a practice must create a diagnostic system that allows the practitioner time to evaluate both the TMJ and the airway. To do so requires obtaining additional diagnostic information different than those obtained in a traditional restorative practice model. Traditionally, restorative patients require mounted study casts with photographs to develop a treatment plan.
In patients with TMD and airway issues, more information is needed to develop a treatment plan. In most of these cases, it may be necessary to obtain an MRI, a CBCT and a sleep screening to understand the appropriate treatment options.
When treating these patients, significant time is required to post process and study the imaging and sleep screening. To obtain this information, and to have a sufficient period to study the information, it's necessary to create a multi-appointment process so there is enough time to treatment plan these cases.
The first appointment in this process is a typical new patient examination, designed to gather the data and to determine if additional diagnostic information (i.e., MRI, CBCT, sleep screening) is needed. If the findings in the history and clinical exam warrant additional diagnostic information, the case presentation for the diagnostic records and consultation occurs at the end of the new patient exam.
Diagnostic imaging acceptance
To increase the likelihood of case acceptance for diagnostic records, it's vital to have an organized approach in educating the patient about normal anatomy and how items reported in the history, or noted in the clinical exam, correlate typically to structural altered anatomy.
If a patient presents with a facial asymmetry, it's easy to explain normal anatomy leads to normal ramus length and a normal facial anatomy. An injury to TMJ in the growing years can result in a decreased ramus length resulting in a facial asymmetry and, in some cases, a compressed oropharyngeal airway space. It's important the patient understands diagnostic records are the best way for the dentist to make appropriate treatment choices for their individual case.
In addition to the clinical aspect of creating value for diagnostic records, it's necessary to discuss the financial aspects of obtaining them. It's important the patient understands that many, if not most, insurance companies limit the coverage for diagnostic records.
The patient must also understand it's not possible to make reliable treatment recommendations without the benefit of the information gained through the judicial use of diagnostic records. If patients understand the clinical need and the uncertain insurance reimbursement for them, they can decide based upon realistic information.
Fees for diagnostic workups
The fee should be determined by the number of hours of the exam appointment and the diagnostic records appointment. The combined time for the exam and records appointments can be multiplied by the hourly rate necessary to run the practice, and a fee can be set for the exam and the diagnostic records.
Over the years, I've allocated this fee between the exam and the diagnostic records. When discussing with potential new patients over the phone, I set a lower exam fee to remove the barrier of high fees. I make up the difference from the decreased exam fee in the diagnostic records fee once I've had the opportunity to meet the patient and create value for diagnostic records.
The consultation fee is included in the fee for the diagnostic records. The consultation typically lasts between 30-60 minutes and offers the opportunity to review normal anatomy, explain structurally altered anatomy, discuss treatment options, and choose the most appropriate treatment option. Once the most appropriate treatment options are discussed, the fee and any insurance information can also be reviewed with the patient.
In my experience, the model of a lower exam fee, along with a higher diagnostic records fee, leads to a predictable pathway for patients to benefit from a comprehensive treatment plan when it's necessary. This business model works well for both TMD and airway patients allowing a fair fee for the diagnostic workups necessary in these cases.
Jim McKee, D.D.S., is a member of Spear Resident Faculty
1. Flores-Mir C, Nebbe B, Heo G, Major PW. Longitudinal study of temporomandibular joint disc status and craniofacial growth. American Journal of Orthodontics and Dentofacial Orthopedics. 2006:130(3);324-330.