Phase I Informed Consent Form

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

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: Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee that you will be completely satisfied with your results, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the orthodontist’s instructions carefully.

Length of Treatment: The length of treatment depends on a number of issues, including the severity of the problem, the patient’s growth and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if patient cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If treatment time is extended beyond the original estimate, additional fees may be assessed.

Discomfort: The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction of orthodontic appliances. Nonprescription pain medication can be used during this adjustment period.

Relapse: Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situations may require non-removable retainers or other dental appliances made by your family dentist.

Extractions: Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks associated with the removal of teeth, which you should discuss with your family dentist or oral surgeon prior to the procedure.

Orthognathic Surgery: Some patients have significant skeletal disharmonies, which require orthodontic treatment in conjunction with orthognathic surgery to achieve an ideal result. Orthognathic surgery presents its’ own risks/limitations which you should discuss with your oral surgeon prior to beginning orthodontic treatment. Please be aware that orthodontic treatment prior to orthognathic surgery only aligns the teeth within the individual dental arches. Patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment.

*Please Note: Patients who elect an orthognathic surgery treatment option will need to have the selected oral surgeon provide our office with proof of a signed financial commitment and/or approval from the patient’s insurance provider to perform the surgery before orthodontic treatment will be initiated.

Decalcification and Dental Caries: Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease, decalcification and/or early removal of braces. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient consumes sweetened beverages or foods.

Root Resorption: The roots of some patients’ teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth throughout life with severely shortened roots. If resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the appliances prior to the completion of orthodontic treatment.

Nerve Damage: A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases the tooth/teeth may necrose (tooth death), change color and/or ankylose (fuse to the bone). Treatment options vary, up to and including loss of the tooth. Restoration of the involved tooth/teeth by your dentist may be necessary.

Trauma/Root Canal Therapy: Teeth that have experienced trauma are at an increased risk for that tooth to spontaneously necrose (die) during orthodontic treatment. Tooth necrosis (and teeth that have had prior root canal therapy performed) are susceptible to the following sequelae during orthodontic treatment, including (but not limited to): pathology, a change in color of the tooth and ankylosis (fusion of the tooth to the bone). Treatment of traumatized teeth is unpredictable and may require extraction, prosthetic replacement and/or acceptance of a compromised result.

Periodontal Disease: Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to the lack of adequate oral hygiene. Periodontal diseases are serious bacterial infections that destroy the attachment fibers and supporting bone that hold your teeth in your mouth. These diseases can lead to tooth loss. You must have your general dentist, or if indicated, a periodontist monitor your periodontal health during orthodontic treatment every three to six months. It’s essential that you follow your general dentists or periodontist’s instructions on oral hygiene, medications and return for appointments. If you fail to do so, you risk losing one or more teeth. Although the chief cause of periodontal disease is bacteria that attack the gums and bone, there are other factors that can cause the disease to worsen. Tobacco in any form makes your gums much more prone to periodontal disease. You should not smoke or chew tobacco while undergoing orthodontic treatment. Stress, poor diet and genetics have also been linked to periodontal disease. Periodontal disease can interfere with normal tooth movement. If periodontal problems cannot be controlled, orthodontic treatment your teeth might not move on schedule, and/or may have to be discontinued prior to completion. If you periodontal disease is not controlled, your gums are prone to localized infections that are very destructive to the underlying bone. You might be prescribed antibiotics to take by mouth and/or apply to the infected area. Fixed appliances make through brushing and flossing more challenging. Your orthodontist might recommend additional oral hygiene aids to improve the health of your gums.

Injury From Orthodontic Appliances: Activities or foods that could damage, loosen or dislodge orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliances can be inhaled or swallowed or could cause other damage to the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when orthodontic appliances are removed. This problem may be more likely when esthetic (clear or tooth colored) appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.

Headgears: Orthodontic headgears can cause injury to the patient. Injuries can include damage to the face or eyes. In the event of injury or especially an eye injury, however minor, immediate medical help should be sought. Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.

Temporomandibular (Jaw) Joint Dysfunction (TMD): Problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or face), arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without orthodontic treatment. Current research suggests that orthodontics does not cause, nor cure TMD. Any jaw joint symptoms, including pain, jaw popping or difficulty opening or closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.

Impacted, Ankylosed, Unerupted Teeth: A tooth that is trapped within the surrounding bone is called “impacted”. In most cases, impacted teeth can be successfully aligned, however, impacted teeth are unpredictable in their behavior so you should be aware that any of the following situations might arise. Dr. Krieger might recommend additional diagnostic studies (special radiographic scans, etc.) to help determine the exact position of the impacted tooth and the surrounding teeth. Additional diagnostic studies may be necessary during orthodontic treatment to determine the position and condition of the involved teeth. In order to align an impacted tooth, a referral might be made to an oral surgeon or a periodontist (dental specialist who treats gum problems) to have the impacted tooth or teeth uncovered and/or a temporary attachment placed on the tooth or teeth. The fees for services performed by other specialists are separate and additional to the orthodontic treatment fees. If such a referral is made, you should speak with the specialist about possible risks and limitations of the procedure(s). There is a possibility that if a temporary attachment is placed on the impacted tooth or teeth, it might detach during orthodontic treatment. The oral surgeon or periodontist might have to replace it. This might require a additional surgical procedure(s). In rare cases, an impacted tooth might be fused to the surrounding bone (ankylosis) and might not move with orthodontics. If so, tooth removal might be necessary. In some cases, the space might be closed with additional orthodontic treatment after the ankylosed tooth is surgically removed. In other cases, the ankylosed tooth may need to be surgically removed and the resulting space filled by your dentist. The additional costs for tooth replacement are separate from the fee for your orthodontic treatment. An impacted tooth might have caused damage to adjacent teeth that is not evident until the tooth or teeth are moved. Additionally, if an impacted tooth is moved, it might push against the roots of the adjacent teeth and damage them. This complication might be unavoidable because of the position of the impacted tooth. The root of the impacted tooth might also shorten during movement. In severe cases, one or more teeth might be lost due to root shortening. During movement of an impacted tooth, the nerve of the impacted tooth or of the adjacent teeth might be damaged. This occurrence might be unavoidable because of the position of the impacted tooth. Root canal treatment might be necessary. The cost of root canal treatment is separate and in addition to the orthodontic fee. If the impacted tooth is brought into alignment, it might become evident that the tooth is a different shape or color than the adjacent teeth. You might choose to ask your general dentist to provide cosmetic correction. The cost of cosmetic correction of a tooth or teeth is separate and additional to the orthodontic fee. When the alignment of the impacted tooth is complete, the gum line along the formerly impacted tooth and the adjacent teeth might be uneven. Impacted teeth often experience some gum recession during alignment. If the appearance of the gum line can be improved, the service of another dental specialist may be required, the cost of which is separate and additional to the orthodontic fee.

Occlusal Adjustment: You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby “flattening” surfaces in order to reduce the possibility of a relapse.

Non-Ideal Results: Due to the wide variation in the size and shape of the teeth, missing teeth, patient compliance, jaw growth etc., achievement of an ideal result (i.e. complete closure of a space or ideal occlussal relationships) may not be possible. Restorative dental treatment including (but not limited to) esthetic bonding, implants, crowns, bridges or periodontal therapy, may be indicated. You are encouraged to ask your orthodontist and family dentist about adjunctive care.

Third Molars: As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist should monitor them in order to determine when and if the third molars need to be removed.

Allergies: Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan or discontinuance of treatment prior to completion. Although very uncommon, medical management of dental material allergies may be necessary.

General Health Problems: General health problems such as bone, blood or endocrine disorders, and many prescription and non-prescription drugs (including bisphosphonates) can affect your orthodontic treatment. It is imperative that you inform your orthodontist of any changes in your general health status.

Temporary Anchorage (TADS): 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. It is possible that the screw(s) could become loose which would require its/their removal and possibly relocation or replacement with a larger screw. The screw and related material may be accidentally swallowed. If the device cannot be stabilized for an adequate length of time, an alternate treatment plan may be necessary. 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 removal, surgical excision of the tissue and/or the use of antibiotics or antimicrobial rinses. It is possible that the screws could break (i.e. upon insertion or removal.) If this occurs, the broken piece may be left in your mouth or may be surgically removed. This may require referral to another dental specialist. When inserting the device(s), it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually these problems are not significant; however, additional dental or medical treatment may be necessary. Local anesthetic may be used when these devices are inserted or removed, which also has risks. TADs are constructed of medical grade titanium, a hypoallergenic material.

Laser Treatment: Lasers are sometimes used to remove excess gum tissue. Should laser treatment be needed results cannot be guaranteed. Generally, the use to a laser to treat the oral tissues is a safe and predictable procedure. If a soft tissue laser is used the level of the gum line might not be perfectly symmetrical. If needed, this can often be improved by additional laser treatment or by a periodontist. Damage to the oral tissues might result from laser treatment. This is generally a self-limiting short-term injury that usually resolves without additional treatment. In rare circumstances, additional dental and/or medical treatment might be necessary. Protective glasses must be work by all persons near the laser. Failure to do so might result in permanent eye damage. Laser treatment in areas near large blood vessels, could possible damage the blood vessels. If damage occurs, additional medical or dental treatment might be necessary.

Anesthetic Products: A topical anesthetic and/or local anesthetic will be applied to the gums before a laser or TADs procedure.

Use of Tobacco Products: Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.

The chemicals in tobacco can interfere with healing after a laser or TADs procedure.

Bisphosphonate Treatment: The purpose of this is to inform you of the general risks associated with orthodontic treatment of patients who are now taking, or have taken in the past, medications known as “bisphosphonates.” Bisphosphonates are medications prescribed by your physician for the treatment of a variety of difficult medical disorders. Bisphosphonate medication types that you may be taking, or have taken, can be: Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), Skelid (tiludronate), Didronel (etidronate), Aredia (pamidronate), or Zometa (zoledronic acid). There may be some additional brand names in addition to the above, but they are all known as “bisphosphonates.” Every medication has risks and benefits. All bisphosphonates inhibit osteoclastic (related to bone) activity. They have the ability to, and probably will, inhibit tooth movement during orthodontics. This issue may slow your response to orthodontic movement and lengthen orthodontic treatment time. The effects of these medications may be severe enough to stop tooth movement, which may cause braces to be removed regardless of favorable or unfavorable tooth position. No orthodontist can predict the effect bisphosphonates will have upon an individual’s tooth movement. Long-term bisphosphonate use has been observed to decrease bone healing. It is possible that tooth movement and any surgery procedures performed within the jaws or bone surrounding the teeth may be difficult, and, in some cases, no bone healing may occur. The risk for developing osteonecrosis is higher for cancer patients on i.v. bisphosphonate therapy.

Clear Braces: Ceramic braces on the lower teeth may cause wear of the opposing teeth if in contact, or if the patient is a heavy grinder or has parafunctional habits not seen at the initial examination. If you ever feel as if you are touching braces at any point during treatment you should let your doctor know as soon as possible. Enamel wear can also occur if the patient does not attend regular regular appointments and remains unsupervised. If damage to a tooth does occur, enameloplasty/reshaping and/or restoration of the involved tooth/teeth may be necessary.

Patient Compliance: Lack of patient cooperation is the most common cause for compromised results. Instructions must be carefully followed. Oral hygiene, proper elastic wear, care of appliances, headgear wear, and keeping regular appointments are situations where problems most often arise. We encourage you to see your dentist every 3 to 6 months during orthodontic treatment for cleanings.

Non-Vital or Dead Tooth: A non vital or dead tooth is a possibility. A tooth that has been traumatized by a blow or other causes can die over a long period of time with or without orthodontic treatment. A non vital tooth may flare up during orthodontic movement and require endodontic (root canal) treatment.

Growth Pattern: Unusual skeletal pattern and undesirable growth can affect final orthodontic results. Surgical assistance is often recommended in these cases.

Alternatives: For the vast majority of patients, orthodontic treatment is an elective procedure. One possible alternative to orthodontic treatment is no treatment at all. You could choose to accept your present oral condition and decide to live without orthodontic correction or improvement. Alternatives to orthodontic treatment for any particular patient depends on the specific nature of the individual’s orthodontic problem, the size, shape and health of the teeth, the physical characteristics of the supporting structure and the patient’s aesthetic considerations. Alternatives could include, but not limited to:

1. Extraction versus treatment without extraction;
2. Orthognathic surgery versus treatment without orthognathic surgery;
3. Possible prosthetic solutions; and
4. Possible compromised approaches. You may wish to discuss possible treatment alternatives or other treatment questions with your orthodontist prior to beginning your orthodontic care.

Two Phase Treatment: This phase of your child’s early treatment is completed when the braces and/or appliances are removed, then a resting phase will begin. If retainers are used, they will be worn for only a short period because they can interfere with the eruption of the permanent teeth. Progress x-rays may be taken at regular intervals and are vital for the orthodontist to monitor and guide your child’s development. This resting phase may continue over several years. Once all or most of the baby teeth have come out and all or most of the permanent teeth have come in, another exam and consultation will be scheduled to evaluate if a second phase of treatment will be needed. At this time we will discuss a new treatment plan and fees for any future treatment. I understand that this is a two-phase treatment.

Mouth Guard: When participating in contact sports, a mouth guard is an absolute necessity. Athletes are required to use mouth guards in a number of sports because failure to use them can lead to serious injury. Custom mouth guards allow for proper tooth and gum adaptation and are the most superior mouth guard available. They fulfill all the criteria for adaptation, retention, comfort and protection. They interfere the least with speaking and have virtually no effect on breathing. Young mouths will need to have new custom mouth guards created periodically as they do breakdown over time. Mouth guards move soft tissue away from the teeth to help prevent laceration and bruising of the lips and cheeks. Not only will your mouth guard protect you from being bruised or cut by your teeth, it may help prevent injury to another player. Mouth guards help to keep the lower jaw from getting jammed into the upper jaw, providing a level of protection against jaw fracture in this case. I have been informed that the mouth guard needs to be examined periodically and is good for one season. If myself/son/daughter is wearing braces, the mouth guard may need to be replaced every three months. The mouth guard is made specifically for myself/son/daughter and is not transferable. It is to be used solely for the purpose of helping protect my/his/her teeth and the surrounding tissues during athletic activities, events and practice and to help prevent concussions and reduce the probability of head, neck and oral injuries. I voluntarily assume any and all possible risks, including risks of substantial harm, which may be associated with any phase of this treatment in hopes of obtaining the desire result.

Special Circumstances

Unusual Occurrences: Swallowing appliances, chipping teeth, dislodging restorations, ankylosed tooth, abscess or cyst may occur but are rare.

Muscle Relax: When braces are placed the jaw muscles relax, allowing the lower jaw to seat into a correct position. This position may demonstrate a significant malalignment and require extractions and/or surgery to correct.

Tooth Size Problems: If the upper and lower teeth sizes do not coordinate, some slenderizing or filing between the teeth or restoration of small teeth may be necessary.

If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.

 

Acknowledgment: I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the undersigned orthodontist(s) and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the orthodontist(s) indicated below to provide the treatment. I also authorize the orthodontist(s) to provide my health care information to my other health care providers. I understand that my treatment fee covers only treatment provided by the orthodontist(s), and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment.

CONSENT TO UNDERGO ORTHODONTIC TREATMENT: I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment, and to the above doctor(s) and, where appropriate, staff providing orthodontic treatment described by the above doctor(s) for the above individual. I fully understand all of the risks associated with the treatment.

TRANSFERRING FROM OUR OFFICE: In the event you transfer out of our office or discontinue treatment, the amount of treatment rendered will be determined, and depending on your individual case, a refund to you or a final payment to us will be made based on a prorated amount.

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION: I hereby authorize the above doctor to provide other health care providers with information regarding the above individual’s orthodontic care as deemed appropriate. 

CONSENT TO USE OF RECORDS: I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for promotional purposes and/or professional consultations, research, education, or publication in professional journals.