informed consent form - phase I appliances

Patient’s informed consent and agreement regarding phase I orthodontic treatment

Your doctor has recommended Phase I orthodontic treatment for you/your child. Although orthodontic treatment can lead to a healthier and more attractive smile, you should also be aware that any orthodontic treatment has limitations and potential risks that you should consider before undergoing treatment.

Device description

Phase I treatment could include appliances such as Twinblocks, Superscrew expanders, Space maintainers, etc., which could be either fixed or removable. These appliances may contain Nickel, Stainless Steel, Titanium and other metals. Please let us know if you are allergic to any metals or alloys.

Procedure

You may undergo a routine orthodontic pre-treatment examination including radiographs (x-rays) and photographs. Your doctor may also take impressions or intraoral scans of your teeth. The recommended appliance will be placed after a thorough prophylaxis (clean). This insert procedure can take up to 30minutes and can cause some discomfort. Unless instructed otherwise, you should follow up with your doctor every 12 weeks; these appointments are generally made in advance at the practice.

Patients may require additional impressions/techniques to help with regular orthodontic treatment.

Benefits

Most people consider orthodontic treatment for a great smile. But added benefits include better bite (to chew your food), ease of cleaning (it is a lot easier to clean teeth when they are straighter, tooth brushes are manufactured to clean your teeth while they are straight), good joint health, to improve speech.

Risks and inconveniences

Like other orthodontic treatments, the use of Phase I appliances may involve some of the risks outlined below:

• Failure to maintain the appliances, not using the product as directed by your doctor, missing appointments, and erupting or atypically shaped teeth can lengthen the treatment time and affect the ability to achieve the desired results
• Dental tenderness may be experienced from time to time
• Gums, cheeks and lips may be scratched or irritated
• Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages that contain high sugar levels, do not brush and floss their teeth properly after snacks and meals, or do not use proper oral hygiene and preventative maintenance
• The appliance may temporarily affect speech and may result in a lisp, although any speech impediment caused by the appliance should disappear within one or two weeks
• Phase I appliances may cause a temporary increase in salivation or mouth dryness and certain medications can heighten this effect
• Fixed appliances can come off throughout your treatment if you eat hard and sticky foods, if this happens you will be required to have it replaced as soon as an appointment is available
• The bite may change throughout the course of treatment and may result in temporary patient discomfort
• At the end of orthodontic treatment, the bite may require adjustment (“occlusal adjustment”)
• Atypically shaped, erupting and/or missing teeth may affect the ability to achieve the desired results
• General medical conditions and use of medications can affect orthodontic treatment
• Health of the bone and gums which support the teeth may be impaired or aggravated
• Oral surgery may be necessary to correct crowding or severe jaw imbalances that are present prior to using braces. If oral surgery is required, risks associated with anesthesia and proper healing must be taken into account prior to treatment
• Product breakage is more likely in patients with severe crowding and/or multiple missing teeth
• Orthodontic appliances or parts thereof may be accidentally swallowed or aspirated
• In rare instances, problems may also occur in the jaw joint, causing joint pain, headaches or ear problems
• Allergic reactions may occur
• Teeth that are not at least partially held by the braces may undergo supraeruption
• In rare instances, patients with hereditary angioedema (HAE), a genetic disorder, may experience rapid local swelling of subcutaneous tissues including the larynx, HAE may be triggered by mild stimuli including dental procedures

Informed consent

I have been given adequate time to read and have read the preceding information describing orthodontic treatment with Phase I appliances. I understand the benefits, risks, alternatives and inconveniences associated with treatment as well as the option of no treatment. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about orthodontic treatment with Phase I appliances with my doctor from whom I intend to receive treatment.

I understand that I should only use the appliances after consultation and prescription from an orthodontist and I hereby consent to orthodontic treatment with a Phase I appliance that has been prescribed by my doctor. Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor has not and cannot make any guarantees or assurances concerning the outcome of my treatment.

I authorise my doctor to release my medical records, including, but not be limited to, radiographs (x -rays), reports, charts, medical history, photographs, findings, plaster models or impressions or intra-oral scans of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my doctor’s possession (“Medical Records”) (i) to other licensed dentists or and organisations employing licensed dentists and orthodontists for the purposes of investigating and reviewing my medical history as it pertains to orthodontic treatment (ii) for educational and research purposes.

I understand that use of my Medical Records may result in disclosure of my “individually identifiable health information” as defined by the Health Insurance portability and Accountability Act (“HIPAA”). I hereby consent to the disclosure(s) as set forth above. I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure. I acknowledge that use of my Medical Records is without compensation and that I will not nor shall anyone on my behalf have any right of approval, claim of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of any use such that comply with the terms of this Consent.

A photostatic copy of this Consent shall be considered as effective and valid as an original. I have read, understand and agree to the terms set forth in this Consent as indicated by my signature below.