Record keeping adjuncts for TMD therapy

Proper record keeping is mandatory for any dental treatments, but perhaps it is even more important in temporomandibular disorder (TMD) therapy due to the nature of the problem. TMD treatment includes the management of pain and discomfort. It has been the author's experience that the patient's and the clinician's perception of progress are not frequently similar. Since pain is completely subjective, proper record keeping is even more difficult to maintain because it is not quantifiable by the clinician. This paper presents two record keeping adjuncts that the author has developed over the years, which have helped this record keeping problem. The first adjunct is to have a summary of the initial diagnostic findings located at the top of the treatment record. This summary makes it easy to refer back to the original signs and symptoms to measure the treatment progress. The second adjunct is the actual treatment chart for TMD therapy. This chart is filled out by the patient and utilizes the visual analog approach. Using this approach minimizes any misunderstanding between the patient and the clinician. Each entry is signed by the patient, which further substantiates the accuracy of this approach. This author has utilized this adjunct for the past few years and has found it to be significantly better than his former records.