ORTHODONTIC CONSENT FORM

  • Pediatric Dentistry

    Ph.609-200-5437

    Ph.732-737-7336

    littleteethprinceton@gmail.com

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  • Informed Consent for Orthodontic Treatment

    Orthodontic treatment can improve your overall health, comfort, appearance, and self- esteem. Positive orthodontic results rely on the patient being cooperative and well informed. The following information is commonly supplied to patients considering orthodontic treatment. While recognizing the benefits of healthy teeth and a pleasing smile, you should also be aware of the risks and limitations of orthodontic treatment. These risks are rarely serious enough to forgo treatment, but they should be considered when deciding whether to pursue orthodontic treatment.

    Results

    While treatment usually proceeds as planned, results cannot be guaranteed, nor can all eventualities be anticipated. We will do everything possible to achieve the best results for your treatment, but we must take into consideration each individual's unique situation. We cannot guarantee that all benefits will be achievable for all patients, nor that you will be completely satisfied with your results.

    Purpose of Procedures

    Orthodontic treatment improves the bite via the management and placement of forces on the teeth. By distributing the forces of chewing and other normal wear and tear of the teeth throughout the mouth, we can minimize the stress placed on bones, roots, gum tissue and jaw joints. Orthodontic treatment may avert future dental or periodontal issues by facilitating good oral hygiene and preventing abnormal wear to your teeth.

    Risks

    There are inherent risks and limitations to all medical or dental treatment, including orthodontic treatment. Fortunately in orthodontics, complications are generally infrequent and minor. Nonetheless, you should fully consider all possibilities before undergoing treatment. The major risks of orthodontic treatment may include:

    Decalcification (permanent white markings), Decay, and Gum Disease: These issues may occur, especially if the patient eats a lot of sugary foods and does not maintain good oral hygiene. These issues can also occur if the patient does not pursue orthodontic treatment, but the risk is greater for individuals that wear braces or other orthodonticappliances.

    Root Shortening: In some patients, there may be some shortening of the roots of the teeth. These problems are usually minimal, however in some cases, they can affect the overall longevity, stability and mobility of theteeth.

     
  • Oral Hygiene: Bone and gum tissue that support the teeth may be affected by the movement of teeth during orthodontic treatment. Generally this is only an issue if the tissue was unhealthy prior to treatment, but in rare cases it can occur in apparently healthy tissue. In most cases, orthodontic treatment makes gum disease and tooth loss less likely. Gum and bone tissue may become inflamed if plaque is not removed daily.

    Post-Treatment Movement: Teeth may change position after treatment. Wearing a retainer as directed can prevent some of this movement. Many other factors can affect your bite, such as the eruption of wisdom teeth, growth, playing musical instruments, and other oral habits which are beyond the control of the orthodontist. It is possible that the tooth and jaw position shifts to the degree that additional treatment is required, which may include the replacement of braces.

    Temporomandibular (Jaw) Joints: Occasionally, problems may occur in the jaw joints, causing pain, headaches and ear problems. While these issues may arise with or without orthodontic treatment, if you experience these issues over the course of your orthodontic treatment, please let your orthodontist know immediately.

    UnusualDevelopmentandGrowth:Developmentanderuptionofteethisacomplexprocess. In some cases, primary teeth become fused to the bone and will not move. This is know as ankylosis. This is more commonly seen when there is not a permanent tooth underneath the primary. The fused primary tooth will remain lower than the normally developed teeth. This can alsohappenwithpermanentteeth,thoughitisamoreunusualoccurrence. Atypicalformation of teeth, or unusual changes in the growth of the jaw may limit our ability to achieve the desired results. At times, developmental changes after treatment require additional treatment or surgery. The development of the jaw and teeth is a biological process, and therefore beyond our control. Growth or changes that occur after treatment may adversely affect treatment results.

    Minor Injuries and Hazards: Orthodontic appliances are made of many small parts. These can come loose and be accidentally swallowed, aspirated, or irritate the mouth. Cheeks and lips may be scratched or irritated by broken appliances or blows to the mouth. Patients may inadvertently get scratched, poked, or receive an injury to a tooth, potentially resulting in damage to or soreness of oral structures. Abnormal wear of the teeth is possible if the patient grinds his/her teeth excessively.

    Post-Adjustment Soreness: After receiving an adjustment to your orthodontic appliance, some tenderness or pain should be expected. Generally, this goes away between 24 and 48 hours after the appointment, though this will vary depending on the patient and the procedure that was performed. If you have any unusual symptoms, broken or loose appliances, you should notify your orthodontist immediately.

    Headgear: If handled improperly, headgear can cause injury to the face and eyes, and in some rare cases, blindness. There have been a few reports of injury to the eyes of the patients from wearing

    headgear. Headgear should not be worn during horseplay or during competitive activities (particularly contact sports). While our headgears are equipped with safety systems, you should always exercise caution.

     
  • Oral Surgery, Tooth Removal, or Orthognathic (Jaw) Surgery: Surgery may be necessary in conjunction w/ orthodontic treatment, especially in cases of severe jaw imbalances or tooth crowding. Youshouldconsultwithyoursurgeonandgeneraldentistpriortoproceedingwith surgicaloptions.

    Treatment Length: The time required to complete orthodontic treatment may exceed the estimate. Unusual growth or lack of patient cooperation may increase the treatment time and negatively affect the quality of the end result. For best results, wear the appliances and elastics as directed by your orthodontist, maintain excellent oral hygiene, and keep all orthodontic appointments.

    Clear/Tooth-Colored Braces: When clear/tooth-colored brackets are used, there have been some reported incidents of patients experiencing breakage of the bracket and/or damage to the teeth. Possible issues include attrition, or damage to enamel, such as flaking or fracturing on debonding. Fractured brackets may result in remnants, which may be harmful to the patient (particularly if swallowed or aspirated).

    Allergies and General Medical Problems: The type, construction and material content of your orthodontic appliances may vary, depending on the desired result. Some patients may be allergic to certain component materials. Adverse allergic reactions could require alteration or cessation of the orthodontic treatment plan, which could limit the ability to achieve the desired result. Although exceedingly rare, medical management of allergies may be required. General medical problems such as bone, blood or endocrine disorders can affect your orthodontic treatment. You should keep your orthodontist informed of any changes in yourhealth.

    Additional Restorative Dental Treatment: Due to the wide variation in the size and shape of teeth, you may require additional restorative dental treatment to achieve the desired result. The most common types of restorative dental treatment are cosmetic bonding, crown and bridge restoration, and/or periodontal therapy. You are encouraged to ask questions about additional dental and medical care that may be required.

    Possible AlternativeTreatment

    For the vast majority of patients, orthodontic treatment is elective. For these patients, a possible alternative to orthodontic treatment is no treatment at all, choosing instead to accept your present oral condition. The specific alternative to orthodontic treatment for any individual depends on the nature of the teeth, supporting structures and appearance. Alternatives could include:

    Extraction versus treatment without extraction
    Orthognathic surgery versus treatment without orthognathic surgery
    Possible prosthetic solutions such as bridges, implants, partials or replacement teeth

    Possible combined approaches

    We encourage you to discuss possible alternative treatments or other questions about your treatment with your orthodontist prior to beginning your orthodontic care.

     
  • Surgical Considerations

    If the proposed treatment plan includes surgical movement of the jaws as well as orthodontic treatment, consider the following points before deciding to proceed with treatment:

    Prior to surgery, the orthodontic treatment is intended to position the teeth correctly within the jaw, not to correct the bite as it currently exists. During this phase of treatment, the appearance and bite may worsen, but after surgery the bite should improve.

    Electing to change from a surgical to non-surgical treatment plan can increase treatment time, and potentially compromise the final treatmentresults.

    Any change in treatment plan should be discussed with your general dentist and oral surgeon, as well as your orthodontist.

    Orthognathic surgery can create financial concerns. It is recommended you consult with an oral and maxillofacial surgeon before beginning treatment, to help you decide whether or not to proceed with the proposed treatmentplan.

    Acknowledgement of Informed Consent:

    I hereby acknowledge that the major treatment considerations and potential risks of orthodontic treatment have been presented to me. I have read and understand this document, and recognize that while it covers the most common risks associated with orthodontic treatment, there may be other problems that occur with less frequency or severity. I further recognize that while Dr.Iyer/Dr.Shah and the staff of The Little Teeth will do everything in their power to achieve the desired results, the final results may

    be different from the anticipated results.

    Dr.Iyer/Dr.Shah has discussed the orthodontic treatment for my child with me. I have been asked to choose whether to pursue the orthodontic treatment plan laid out by D r . Iyer/Dr.Shah , and have been presented with information to aid this decision. I have been given the opportunity to ask the doctor all questions I have about the proposed treatment.

    Consent to Undergo Orthodontic Treatment

    I hereby consent to the creation of diagnostic records, including x-rays before, during and following orthodontic treatment. I also consent to Dr.Iyer/Dr.Shah and appropriate staff providing orthodontic treatment for my child. I fully understand all of the potential risks associated with this treatment.

     
  • Authorization For Release of Patient Information

    By signing, I authorize The Little Teeth Workshop to use and/or disclose certain protected health information about me.

    This authorization permits The Little Teeth Workshop to use and/or disclose individually identifiable health information to other health care providers about
    my child, as deemed necessary for his/her orthodontic care. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer at:

    The Little Teeth Workshop NJ

    Surgical Supplement

    If the orthodontic treatment plan includes correction of the malocclusion by orthodontic appliance therapy in conjunction w/ orthognathic surgery, I understand that the oral surgery is a necessary component of my childs treatment. I authorize The Little Teeth Workshop to communicate with the surgeon and release information from my childs treatment record to the designated surgeon. I acknowledge the fees associated with the surgical component of the treatment are separate from the orthodontic treatment, and I will be responsible to the surgeon, hospital, or surgical center for all surgery-related expenses.

    I understand that if I do not complete the surgical component of treatment, the end result of treatment may be compromised, and other complications may arise. I agree not to hold The Little Teeth Workshop, Dr.Iyer/Dr.Shah or the staff responsible for any compromised treatment resulting from my failure to follow the treatment plan.

    Notes:

    The patient and family have been appraised of the importance and accelerated dental hygiene appointments and restorative follow-up visits over the course of and after completion of orthodontic therapy.

    Lack of compliance in the use of orthodontic appliances will compromise the ability to achieve the desired final results.

    Removal of selected primary teeth may be a necessary component of therapy.
    Excellent oral hygiene will be necessary to prevent decalcification and achieve optimal results.

     
  • In order to maintain the orthodontic results, retention therapy will be necessary for an indefinite period following the completion of the orthodontic treatment plan. Periodic follow-up visits will be required to monitor the patient's stabilization as well as to maintain the integrity of the retention appliances.

    All orthodontic treatment alternatives and potential risks have been covered. The patient and/or legal guardian has/have been given ample opportunity to ask questions regarding the treatment options and risks.

    I hereby give consent to Dr.Iyer/Dr.Shah for the necessary orthodontic treatment.