Treatment Agreement for Oral Appliance Therapy: Temporomandibular Disorder (TMD)
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1 Treatment Agreement for Oral Appliance Therapy: Temporomandibular Disorder (TMD) What is TMD? Temporomandibular Disorders (TMD) are a group of conditions that cause pain and dysfunction in the jaw joint (temporomandibular joint) and the muscles that control jaw movement. What are symptoms of TMD? Some symptoms are: Pain Noises of clicking and grating from the jaw joint Restricted jaw motion, or jaw locking At what age do you develop TMD? TMD may occur at any time during one s life. It is more common in women and frequently begins in the late teens. In many instances, jaw muscle disorders are the cause of the pain, while in other cases inflammation (swelling that is painful, red and warm), shifting of the disk between the skull and jaw, and actual joint disease such as arthritis or tumors may be present. What causes TMD? Many people mistakenly think that TMD conditions are all related to how your jaw closes, or your bite. This is not true, there are many factors contributing to TMD, your bite may be only one. For example, there could be internal issues with the discs, ligaments, and bone within the jaw joints. Some TMD-related problems may also be related to your emotional and mental outlook and can only be helped by stress reduction, behavior changes, Department or unit name goes in the first page footer if not part of the logo - 1 -
2 psychological counseling, and relaxation training. For this reason, you may feel more discomfort with stress or depression and anxiety. Other illnesses have symptoms similar to TMD symptoms, so your doctor must make a careful diagnosis to determine which treatment approach is most appropriate. How is TMD treated? There are some cases where no treatment is necessary. Sometimes symptoms may be due to neurological, neurovascular, systemic disorders that mimic TMD. These cases may be referred to other medical specialists for treatment. Other therapies for TMD may include trigger point injections, muscle injections, electrical muscle stimulation, ultrasound, medication, hot and cold packs, and exercises to name a few. For some people, sadly, there are no solutions at this time. While waiting for new developments in treatment these people must learn to live with their problems. Surgery Most TMD conditions are treated non-surgically, but a few disorders require surgery on the TMJ (temporomandibular joint) itself. Surgery is reserved for correction of problems that were not helped by alternate therapies. Surgery is sometimes suggested when there is a disc displacement, a gross developmental abnormality, or a tumor. Surgery may also be considered when pain, damage from arthritis and joint inflammation are increasing, when jaw function becomes limited, or when joint, head, neck, or other pain becomes unmanageable due to TMD problem. Orthopedic jaw-positioning appliance An orthopedic jaw-positioning appliance may help to re-establish an area of normal function and comfort of the muscles and the temporomandibular joints. This TMD therapy may not cure the disease or disorder. Its purpose is to - 2 -
3 try to eliminate symptoms by placing the diseased and/or dysfunctional TMJ complex into a manageable orthopedic stable position. Frequently, detailed x- rays and tests or other modes of therapy will be necessary in addition to the orthopedic appliance therapy. The outcome of the orthopedic appliance therapy varies, and depends on your individual tolerance and response. Success of this therapy depends on the following factors: Type of disorders that are present Severity Amount of damage present Length of time the disorder process has been active If the disorder is progressive in nature Because of this, orthopedic appliance therapy may take several courses. It may be very simple and brief, or it may become quite complex and prolonged. Treatment time may range from 4 to 12 months or longer, depending on your individual response. As the joints normalize, the fit of your teeth may change. Most of these alterations of the bite occurring during appliance therapy are reversible, but some may not be. Most patients after active TMD treatment may need to wear the appliance at bedtime and during periods of stress, which may be sufficient to adequately manage their problems. How successful is the treatment with an orthopedic jaw-positioning appliance? Occasionally there are cases where treatment may be either ineffective or poorly tolerated. Some patients may remain the same, while in a few rare instances the disease and/or dysfunction may worsen in spite of everyone s best efforts. Because the lower jaw is shaped like a horseshoe and both joints are connected, in rare occasions the other side may compensate and cause changes that will shift the symptoms and/or discomfort to the other side. There are other individual responses to therapy that may lead to worsening of condition, but these are very rare
4 Due to the complexity of TMD problems we can t make any guarantee for treatment results. Fortunately, the vast majority of patients respond favorably to TMD orthopedic jaw-positioning appliance therapy. Most symptoms improve or may disappear, as the muscles are reprogrammed, the TMJ complex is stabilized and the true bite relationship is established. Some individuals may need to undergo one or more phases of finishing treatment. Orthodontics and/or restorative dentistry may be the next stage in this sequence if your condition cannot be managed with just wearing the appliance part time. This subsequent therapy, if needed, is intended to properly match the teeth, jaws, temporomandibular joints, and muscles at this orthopedically stable position. If this type of treatment is required, additional evaluation is required by your dentist or, possibly, an orthodontist and/or a prosthodontist. Who pays for TMD therapy? TMD problems are treated as a medical condition similar to an ailment in muscles or any other joints in the body. Depending on your insurance coverage, medical, or at times dental, insurance may reimburse you for the evaluation and treatment. Your insurance may not pay at all or may make only a partial payment to you. Therefore, it is your responsibility to see if you have insurance coverage for your particular temporomandibular disorders and the amount for which you may be reimbursed for each service. You are ultimately responsible for your bill. I understand the role of the orthopedic appliance and other TMD treatments (benefits, risks, and limitations), and I have had the opportunity of having all my questions fully answered. I have discussed with Dr. Ashman or one of his staff the dangers of wearing a splint without direct dental supervision. They have completely explained their concerns regarding using an appliance which is not being properly supervised or adjusted. I accept full responsibility for any adverse changes that may occur if I do not keep all my scheduled - 4 -
5 appointments, do not return for periodic checkups, or do not proceed with the next phase of treatment, which has been advised. Fitting for the oral appliance will be performed or supervised by: ID #:. I have read and understand the information on this form (and on page 2) before I signed it. My questions have been answered. I accept the risks listed above or discussed with my dentist or other health professional. Signature of Patient or Legal Representative Printed Name of LAR (proof of authority may be required) Relationship to Patient: Self Parent Legal Guardian Power of Attorney Next of Kin Other (specify) For Medical Personnel Only: Consent Obtained/Explained/Witnessed By (Signature) ID # Attending MD/DDS Resident Nurse PA Disclaimer: This document contains information and/or instructional materials developed by Michigan Medicine for the typical patient with your condition. It may include links to online content that was not created by Michigan Medicine and for which Michigan Medicine does not assume responsibility. It does not replace medical advice from your health care provider because your experience may differ from that of the typical patient. Talk to your health care provider if you have any questions about this document, your condition or your treatment plan. Patient Education by Michigan Medicine is licensed under a Creative Commons Attribution- NonCommercial-ShareAlike 3.0 Unported License. Last Revised 10/
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New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
DENTAL DIAGNOSIS AND TREATMENT
OFFICE POLICIES EXPECTED PAYMENT In order to keep our fees as low as possible we ask that co payments be paid at the time of service. For your conveniene an estimate for dental care will be prepared prior
RESPONSIBLE PARTY INFORMATION:
Practice Limited To Endodontics 113A Tavern Road, Martinsburg, WV 25401 (304) 263-9191 Fax: (304) 263-9659 PATIENT HISTORY: M.I. Patient s Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Gender: Male or
In-Network % of Negotiated Fee * % of Negotiated Fee * 100% 80% 50%
Dental Metropolitan Life Insurance Company Network: PDP Plus Coverage Type Type A: Preventive (cleanings, exams, X-rays) Type B: Basic Restorative (fillings, extractions) Type C: Major Restorative (bridges,
WELCOME PATIENT INFORMATION. Name Patient Prefers to be called Address. Home Address City State Zip Code How Long. Birth Date / / Month Day Year
14 North Hale Grantsville UT 84029 WELCOME Today s date: Thank you for entrusting your oral health care to our team of dental professionals. We are committed to serve you with the best in dental care while
PATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
PATIENT INFORMATION SHEET Referred By: Patient s Name: SSN: Date of Birth: Address: City/Zip: Phone #: Sex: M / F Marital Status: M / S / W / D No. of Dependents: Email Address: Emergency Contact Person:
THE TRUTH ABOUT THE TOOTH
THE TRUTH ABOUT THE TOOTH Gregory TarantolaDDS 559 West Twincourt Trail Suite 606 St. Augustine, Fl. 32095 www.tarantoladentistry.com DrT@TarantolaDentistry.com Thank you for taking the time to read this
Aetna Dental presents A Dental Benefit Summary for Michigan Voluntary Option 2; Freedom-of-Choice; No Ortho DMO
Aetna Dental presents A Dental Benefit Summary for Michigan Voluntary Option 2; Freedom-of-Choice; No Ortho DMO PPO Max Annual Deductible* Individual None $75 Family None $225 Preventive Service Covered