Appliance Therapy Information and Consent Form

ORTHOTIC THERAPY

• The objective of this treatment is to allow for condylar repositioning and to allow the other involved tissues to heal.
• The treatment involves the alternate wearing of the appliances. There is one or two appliances worn for sleep and there is an appliance worn during the daytime (aka non-sleep hours). The daytime appliance is only to be removed when it needs to be briefly cleaned after eating or drinking or under the supervision of Dr. Freedman.
• This therapy is usually three months in duration. It sometimes can be up to six to twelve months in duration. The appliances are not designed to last longer than this.
• Appointment frequency will be determined by Dr. Freedman. In the beginning of the therapy, you will be seen on a more frequent basis for the evaluation of the appliances and adjustments to them as needed. At treatment progresses, you will be seen on a three to four week interval for monitoring examinations, appliance adjustments, occlusal analysis, computerized diagnostics, palpation testing, range of motion testing, etc.
• Pre and post therapy TMJ radiographs are essential to determine current osseus health and monitor any changes that may occur during treatment.
• Once you have reached maximum medical improvement, you will be weaned off the appliances. If a posterior open bite occurs and weaning is unsuccessful, we will discuss a next phase of treatment. This treatment commonly includes orthodontics or full mouth rehabilitation.

RISKS AND BENEFITS OF APPLIANCE THERAPY

• Your individual response to this therapy is unpredictable and as a result treatment success cannot be guaranteed.
• Many compliant patients have achieved maximum medical improvement with appliance therapy.
• It is possible that with appliance therapy any existing dental restorations may no longer function optimally and may change in the way they fit in your mouth. If this should happen, it is possible that these restorations would have to ne re-made to fit the new shape of the mouth, arches, occlusion, etc.
• As with any medical or dental treatment, unusual occurrences can and do happen. These possibilities could include minor tooth movement, loosened teeth or dental restorations, sore mouth, periodontal problems, muscle spasms, ear pain, neck pain, etc. Any of the mentioned complications are rare, but theoretically may occur. Additional medical and dental risks that have not been mentioned may occur.
• Appliance therapy may be uncomfortable when the soft issues (muscles and fascia) of the law and mouth are put into different positions. This has not been observed to be long-lasting in compliant patients.
• Speech may be affected by the wearing if the appliances.
• Eating may be challenging when wearing the appliances.
• Possible benefit of this treatment plan is resolution of the TMJ disorder.
• It is possible that during appliance therapy your teeth may no longer fit together as they currently do. This situation is usually known as a "posterior open bite". This has been observed as a positive treatment result in other patients. If this should occur, the teeth must be brought back together while supporting the preferred jaw position. This would be done in a second phase of treatment. Details for this next phase (type of treatment, fees, number if appointments, duration, risks and benefits, etc.) would be determined at the appropriate time.
• Recapture of a displaced TMJ disc may be ideal but may not always be possible.
• Elimination of joint sounds and/or pain through treatment may not be permanent.

I consent to the taking of photographs and radiographs before, during and after TMJ treatment as they are a necessary part of the diagnostic procedure and record keeping. I further give permission for the use of these photographs, radiographs and records to be used for the purpose of research, education or publication in professional journals.

I acknowledge that Dr. Freedman is not an orthodontist or oral surgeon but rather a general dentist who has taken numerous post graduate courses including but not limited to orthodontic, orthopedics, and TMD (temporomandibular dysfunction).

With any medical or dental treatment, the success depends to a large extent in the degree if cooperation of the patient in the prescribed treatment plan. Failure to comply with instructions could delay the treatment schedule and seriously affect the success if the treatment.

The responsibility for the cost of this program rests with the patient and payment is required to our office at the time of appointments. The fee for appliances is $2500, the fee for diagnostics in or office is $455, the estimated fee for specialty radiographs at Huronia Maxillofacial Radiology is $650 and the fee for follow up visits is $304 per visit. The frequency of required appointments will be determined by Dr. Freedman.

The decision to proceed with or discontinue any treatment is the patient's alone. We will attempt ti inform you of your options and potential risks regarding treatment.

I understand no guarantees or assurances as to the outcome of treatment can be made. The TMJ (jaw joint) is complex and subject to factors (postural, muscular, degenerative and recuperative) that may be beyond a clinician's control. The compete elimination of all symptoms is not always possible.

APPLIANCE THERAPY CONSENT TO TREATMENT

I certify that this appliance therapy information and informed consent to treatment contract outlining the general treatment considerations and the potential problems if orthotic therapy was presented to me and the I have read and understand the contents. I also understand that there could be other potential risks or problems not listed in this document that could arise. I further understand that, like other healing arts, the practice of TMD therapy is not an exact science and therefore cannot be guaranteed.

I hereby acknowledge that I have been informed to my satisfaction of all the treatment considerations, including benefits of treatment and proposed appliance therapy plan and the I now consent to treatment.

I understand and accept the fees for the TMD diagnosis and treatment are above the Ontario Dental Association fee guide.