Information and Consent for Treatment

(a consent form for TMD splint therapy)

Here is some important information about plastic appliance (orthotic) therapy for jaw function problems (TMD, or temporo-mandibular joint dysfunction). The goal of this therapy is to a id in the relief of discomfort in the structures of the jaw joint and muscles.

TMD symptoms can include noise or pain in the joints, pain or spasm in the jaw muscle, locking of the jaw, headaches, neck-aches, and shoulder aches. An episode of TMD is much like a sprain in the ankle.

Research has revealed that the two most common predisposing factors for TMD are a previous forceful blow or injury to the face and tooth grinding or clenching habits. Dentists do not know the reasons why people grind or clench their teeth. Heredity may play a part.

The orthotic is a plastic horseshoe shaped device that we use to stabilize your bite, and to relieve unbalanced pressures on the joint structures. The orthotic device is not a cure for TMD, but may help relieve di scomfort. Such relief may be temporary. We do not intend for you to wear the orthotic more than 3 months continuously. For the long term, you may need to use it periodically to control discomfort. At first, however, you must wear the orthotic frequently, especially at night. After eating, you should remove it to brush your teeth and clean the appliance.

Besides orthotic therapy, we will often recommend other treatments for TMD: physical therapy, relaxation, regular exercise, a soft diet, and aspirin or Tylenol. Complicated or persistent problems may lead to a recommendation for stress management, extensive dental work, orthodontics, or grinding adjustments to the chewing surfaces of the teeth.

Orthotic therapy may not be effective. Pain or poor jaw function may continue in spite of correctly administered orthotic therapy. Some patients have persistent problems which involve actual damage to the parts of the jaw joint. This can only be verified with very specialized x-ray or sound wave imaging techniques. In cases involving pain that don't respond to lesser therapies, we might consider surgery on the jaw joint as a potential remedy.

Treatment Authorization

Dr. Nelson and Dr. Meyer have recommended orthotic therapy for me in the belief that it will help relieve my discomfort. I have read the above information and had my questions answered to my satisfaction. I authorize the recommended therapy, which includes laboratory construction of the appliance and all adjustment visits for a one year period. The fee does not include replacement of the appliance or any recommended diagnostic records, such as x-rays or study casts.

Signed (Patient Name)

__________________________________

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