INFORMED CONSENT by wanghonghx


 for the Orthodontic Patient
Risks and Limitations of Orthodontic Treatment
 Successful orthodontic treatment is a partnership        have treatment; however, all patients should
 between the orthodontist and the patient. The doctor     seriously consider the option of no orthodontic
 and staff are dedicated to achieving the best possible   treatment at all by accepting their
 result for each patient. As a general rule, informed     present oral condition. Alternatives to orthodontic
 and cooperative patients can achieve positive            treatment vary with the individual’s specific
 orthodontic results. While recognizing the benefits      problem, and prosthetic solutions or limited
 of a beautiful healthy smile, you should also be         orthodontic treatment may be considerations. You
 aware that, as with all healing arts, orthodontic        are encouraged to discuss alternatives with the
 treatment has limitations and potential risks.           doctor prior to beginning treatment.
 These are seldom serious enough to indicate that
 you should not

 Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis,
 prevention, interception and correction of malocclusion, as well as neuromuscular and skeletal
 abnormalities of the developing or mature orofacial structures.

 An orthodontist is a dental specialist who has completed at least two additional years of graduate
 training in orthodontics at an accredited program after graduation from dental school.
Results of Treatment                                            to beginning orthodontic treatment. Please be aware that      Headgears
Orthodontic treatment usually proceeds as planned, and          orthodontic treatment prior to orthognathic surgery often     Orthodontic headgears can cause injury to the patient.
we intend to do everything possible to achieve the best         only aligns the teeth within the individual dental arches.    Injuries can include damage to the face or eyes. In the
results for every patient. However, we cannot guarantee         Therefore, patients discontinuing orthodontic treatment       event of injury or especially an eye injury, however
that you will be completely satisfied with your results,        without completing the planned surgical procedures may        minor, immediate medical help should be sought. Refrain
nor can all complications or consequences be anticipated.       have a malocclusion that is worse than when they began        from wearing headgear in situations where there may be
The success of treatment depends on your cooperation in         treatment!                                                    a chance that it could be dislodged or pulled off. Sports
keeping appointments, maintaining good oral hygiene,                                                                          activities and games should be avoided when wearing
avoiding loose or broken appliances, and following the                                                                        orthodontic headgear.
orthodontist’s instructions carefully.                          Decalcification and Dental Caries
                                                                Excellent oral hygiene is essential during orthodontic
                                                                treatment as are regular visits to your family dentist.       Temporomandibular (Jaw) Joint
Length of Treatment                                             Inadequate or improper hygiene could result in cavities,      Dysfunction
The length of treatment depends on a number of                  discolored teeth, periodontal disease and/or                  Problems may occur in the jaw joints, i.e.,
issues, including the severity of the problem, the              decalcification. These same problems can occur without        temporomandibular joints (TMJ), causing pain,
patient’s growth and the level of patient cooperation.          orthodontic treatment, but the risk is greater to an          headaches or ear problems. Many factors can affect the
The actual treatment time is usually close to the               individual wearing braces or other appliances. These          health of the jaw joints, including past trauma (blows to
estimated treatment time, but treatment may be                  problems may be aggravated if the patient has not had the     the head or face), arthritis, hereditary tendency to jaw
lengthened if, for example, unanticipated growth occurs,        benefit of fluoridated water or its substitute, or if the     joint problems, excessive tooth grinding or clenching,
if there are habits affecting the dentofacial structures, if    patient consumes sweetened beverages or foods.                poorly balanced bite, and many medical conditions.
periodontal or other dental problems occur, or if patient                                                                     Jaw joint problems may occur with or without
cooperation is not adequate. Therefore, changes in the                                                                        orthodontic treatment. Any jaw joint symptoms,
original treatment plan may become necessary. If                Root Resorption                                               including pain, jaw popping or difficulty opening or
treatment time is extended beyond the original estimate,        The roots of some patients’ teeth become shorter              closing, should be promptly reported to the orthodontist.
additional fees may be assessed.                                                                                              Treatment by other medical or dental specialists may be
                                                                (resorption) during orthodontic treatment. It is not
                                                                known exactly what causes root resorption, nor is it          necessary.
                                                                possible to predict which patients will experience it.
Discomfort                                                      However, many patients have retained teeth throughout
The mouth is very sensitive so you can expect an                life with severely shortened roots. If resorption is          Impacted, Ankylosed, Unerupted Teeth
adjustment period and some discomfort due to                    detected during orthodontic treatment, your orthodontist      Teeth may become impacted (trapped below the bone or
the introduction of orthodontic appliances.                     may recommend a pause in treatment or the removal of          gums), ankylosed (fused to the bone) or just fail to
Nonprescription pain medication can be used during this         the appliances prior to the completion of orthodontic         erupt.Oftentimes, these conditions occur for no apparent
adjustment period.                                              treatment.                                                    reason and generally cannot be anticipated. Treatment of
                                                                                                                              these conditions depends on the particular circumstance
                                                                                                                              and the overall importance of the involved tooth, and
Relapse                                                         Nerve Damage                                                  may require extraction, surgical exposure, surgical
Completed orthodontic treatment does not guarantee              A tooth that has been traumatized by an accident or deep      transplantation or prosthetic replacement.
perfectly straight teeth for the rest of your life. Retainers   decay may have experienced damage to the nerve of the
will be required to keep your teeth in their new positions      tooth. Orthodontic tooth movement may, in some cases,
as a result of your orthodontic treatment. You must wear        aggravate this condition. In some cases, root canal           Occlusal Adjustment
your retainers as instructed or teeth may shift, in addition    treatment may be necessary. In severe cases, the tooth or
                                                                                                                              You can expect minimal imperfections in the way your
to other adverse effects. If retainers need to be replaced      teeth may be lost.
                                                                                                                              teeth meet following the end of treatment. An occlusal
after treatment, any additional charges will be the                                                                           equilibration procedure may be necessary, which is a
responsibility of the patient. Regular retainer wear is                                                                       grinding method used to fine-tune the occlusion. It may
necessary to retain your final result following orthodontic     Periodontal Disease                                           also be necessary to remove a small amount of enamel in
treatment. However, changes after time can occur due to                                                                       between the teeth, thereby “flattening” surfaces in order
                                                                Periodontal (gum and bone) disease can develop or
natural causes, including habits such as tongue thrusting,                                                                    to reduce the possibility of a relapse.
                                                                worsen during orthodontic treatment due to many factors,
mouth breathing, and growth and maturation that
                                                                but most often due to the lack of adequate oral hygiene.
continue throughout life. Later in life, most people will       You must have your general dentist, or if indicated, a
see their teeth shift. Minor irregularities, particularly in
                                                                periodontist monitor your periodontal health during
the lower front teeth, may have to be accepted. Some
                                                                orthodontic treatment every three to six months. If
                                                                                                                              Non-Ideal Results
changes may require additional orthodontic treatment or,                                                                      Due to the wide variation in the size and shape of the
                                                                periodontal problems cannot be controlled, orthodontic
in some cases, surgery. Some situations may require non-        treatment may have to be is continued prior to                teeth, missing teeth, etc., achievement of an ideal result
removable retainers or other dental appliances made by          completion.                                                   (for example, complete closure of a space) may not be
your family dentist.                                                                                                          possible. Restorative dental treatment, such as esthetic
                                                                                                                              bonding, crowns or bridges or periodontal therapy, may
                                                                                                                              be indicated. You are encouraged to ask your
                                                                Injury From Orthodontic Appliances                            orthodontist and family dentist about adjunctive care.
Extractions                                                     Activities or foods which could damage, loosen, or
Some cases will require the removal of deciduous                dislodge orthodontic appliances need to be avoided.
(baby) teeth or permanent teeth. There are additional           Loosened or damaged orthodontic appliances can be
risks associated with the removal of teeth, which you           inhaled or swallowed or could cause other damage to the       Third Molars
should discuss with your family dentist or oral surgeon         patient. You should inform your orthodontist of any           Your Orthodontist may or may not refer you for
prior to the procedure.                                         unusual symptoms or of any loose or broken appliances         extraction of you third molars (wisdom teeth). Your
                                                                as soon as they are noticed. Damage to the enamel of a        Orthodontist is not responsible for any long term
                                                                tooth or to a restoration (crown, bonding, veneer, etc.) is   complications associated with extraction or non-
Orthognathic Surgery                                            possible when orthodontic appliances are removed. This        extraction of wisdom teeth.
Some patients have significant skeletal disharmonies,           problem may be more likely when esthetic (clear or tooth
which require orthodontic treatment in conjunction with         colored) appliances have been selected. If damage to a                                      Continued on next page
orthognathic (dentofacial) surgery. There are additional        tooth or restoration occurs, restoration of the involved
risks associated with this surgery which you should             tooth/teeth by your dentist may be necessary.
discuss with your oral and/or maxillofacial surgeon prior
                                                                                                                              Patient or Parent/Guardian Initials _________
                                                               Patient _________________________________ Date__________

Allergies                                                    ACKNOWLEDGEMENT                                    CONSENT TO USE OF RECORDS
Occasionally, patients can be allergic to some of the        I hereby acknowledge that I have read and          I hereby give my permission for the use of
component materials of their orthodontic appliances.         fully understand the treatment considerations      orthodontic records, including photographs,
This may require a change in treatment plan or
discontinuance of treatment prior to completion.             and risks presented in this form. I also           made in the process of examinations,
Although very uncommon, medical management of                understand that there may be other problems        treatment, and retention for purposes of
dental material allergies may be necessary.                  that occur less frequently than those presented,   professional consultations, research, education,
                                                             and that actual results may differ from the        or publication in professional journals.
                                                             anticipated results. I also acknowledge that I
General Health Problems                                      have discussed this form with the undersigned
General health problems such as bone, blood or               orthodontist(s) and have been given the
endocrine disorders, and many prescription and                                                                  _________________________________
                                                             opportunity to ask any questions. I have been      Signature                                     Date
non-prescription drugs (including bisphosphonates) can
affect your orthodontic treatment. It is imperative that     asked to make a choice about my treatment. I
you inform your orthodontist of any changes in your          hereby consent to the treatment proposed and
general health status.                                       authorize the orthodontist(s) indicated below to
                                                             provide the treatment. I also authorize the        ______________________________________
                                                             orthodontist(s) to provide my health care          Witness                           Date
Use of Tobacco Products                                      information to my other health care providers.
Smoking or chewing tobacco has been shown to                 I understand that my treatment fee covers only
increase the risk of gum disease and interferes with
healing after oral surgery. Tobacco users are also more
                                                             treatment provided by the orthodontist(s), and
prone to oral cancer, gum recession, and delayed tooth       that treatment provided by other dental or         I have the legal authority to sign this on behalf of
movement during orthodontic treatment. If you use            medical professionals is not included in the fee
tobacco, you must carefully consider the possibility of a    for my orthodontic treatment.
compromised orthodontic result.
                                                             __________________________________                 Name of Patient
                                                             Signature of Patient/Parent/Guardian       Date
Temporary Anchorage Devices
Your treatment may include the use of a temporary
anchorage device(s) (i.e. metal screw or plate attached to                                                      ______________________________________
the bone.) There are specific risks associated with them.                                                       Relationship to Patient
 It is possible that the screw(s) could become loose which   Signature of Orthodontist/Group Name Date
would require its/their removal and possibly relocation or
replacement with a larger screw. The screw and related                                                               Notes
material may be accidentally swallowed. If the device
cannot be stabilized for an adequate length of time, an      ______________________________________                  _____________________
alternate treatment plan may be necessary.                   Witness                           Date
It is possible that the tissue around the device could
become inflamed or infected, or the soft tissue could
grow over the device, which could also require its
                                                             CONSENT TO UNDERGO                                      _____________________
removal, surgical excision of the tissue and/or the use of
antibiotics or antimicrobial rinses.                         ORTHODONTIC TREATMENT                                   _____________________
                                                             I hereby consent to the making of diagnostic
It is possible that the screws could break (i.e. upon        records, including x-rays, before, during and
insertion or removal.) If this occurs, the broken piece      following orthodontic treatment, and to the             _____________________
may be left in your mouth or may be surgically removed.
This may require referral to another dental specialist.
                                                             above doctor(s) and, where appropriate, staff           _____________________
                                                             providing orthodontic treatment prescribed by
When inserting the device(s), it is possible to damage the   the above doctor(s) for the above individual.           _____________________
root of a tooth, a nerve, or to perforate the maxillary      I fully understand all of the risks associated          _____________________
sinus. Usually these problems are not significant;           with the treatment.
however, additional dental or medical treatment may be                                                               _____________________
                                                             AUTHORIZATION FOR RELEASE OF                            _____________________
Local anesthetic may be used when these devices are          PATIENT INFORMATION                                     _____________________
inserted or removed, which also has risks. Please advise     I hereby authorize the above doctor(s) to
the doctor placing the device if you have had any            provide other health care providers with                _____________________
difficulties with dental anesthetics in the past.
If any of the complications mentioned above do
                                                             information regarding the above individual’s            _____________________
occur, a referral may be necessary to your family            orthodontic care as deemed appropriate. I
dentist or another dental or medical specialist for          understand that once released, the above                _____________________
further treatment. Fees for these services are not           doctor(s) and staff has (have) no responsibility        _____________________
included in the cost for orthodontic treatment.              for any further release by the individual
                                                             receiving this information.
Patient or Parent/Guardian Initials _________                                                                        _____________________

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