Download Informed Consent Form

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Informed Consent
Risks and limitations of Orthodontic Treatment
The American Association of Orthodontists recommends that you are provided with the following information if
you are considering orthodontic care. If you are a parent or guardian of the patient, you are agreeing that you have
read, understood and agreed to this information on behalf of the patient. Please take time to read this information
carefully, ask if you have any questions, and initial the boxes where requested to indicate you understand and
agree.
Benefits of Orthodontic Treatment
Orthodontics is an exciting treatment that can help to provide better dental health, hygiene, and comfort,
improved appearance, and an enhanced sense of self-esteem for the patient. As a general rule, an informed and
cooperative patient can achieve very positive results. To help ensure that this happens, we give the following
information to all patients considering orthodontic treatment so that, while recognizing the benefits of healthy teeth and
a pleasing smile, they are nonetheless aware that orthodontic treatment has limitations and potential risks. These
risks are seldom serious enough to indicate that treatment should be avoided, but they should be considered in making
the decision whether or not to undergo orthodontic treatment. Orthodontic treatment usually proceeds as planned;
however, as in all areas of the healing arts, results cannot be guaranteed, nor can all consequences be anticipated.
The purpose of orthodontic treatment is to improve the patient’s bite and to distribute the forces of chewing
throughout the mouth to minimize the stresses on the bones, roots, gum tissue and jaw joints. In this way,
orthodontics can eliminate certain dental problems, such as abnormal tooth wear, and reduce tooth decay and gum
disease by making normal brushing and flossing easier and more effective.
Risks of Orthodontic Treatment
All forms of medical and dental treatment, including orthodontics, have risks and limitations in addition to their
benefits. While orthodontic complications are relatively infrequent considering the thousands of people that undergo
orthodontic treatment every day, and even when they do occur are often minor, no medical treatment should be
undertaken without a full appreciation of the risks, from slight discomfort to occasional more serious complications.
While not all of the following risks may be relevant to your particular situation, you should understand them and accept
the possibility of such complications in your case so that you can decide whether the benefits of treatment for you
outweigh the possible risks. Please consider the following risks carefully and initial where requested to show that you
understand and accept the risk and understand what you can do, if anything, to minimize the risk:
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Hygiene
Tooth decay, gum disease, or decalcification (permanent white markings) on the teeth may
occur, particularly if you eat foods containing excessive sugar or do not brush properly and
floss frequently enough. Excessive drinking of soda (regular or diet), sports drinks, end even
fruit juice can cause or worsen decalcification. While this is a risk with or without braces, the
risk is greater to a person wearing braces and can be aggravated if you regularly drink only
well or bottled water rather than tap water, which is typically fluoridated. Children who do not
drink fluoridated water can be prescribed fluoride drops, and toothpaste containing fluoride
can help. To help you to avoid these problems, the bonding agents and cements we use
often contain fluoride to protect your teeth underneath and around the braces, though they
cannot, of course, protect near or below the gum line or between the teeth. When we bond
your braces to your teeth, we will provide you with an oral hygiene kit and instructions on how
to care for your teeth and braces. It is mandatory that you continue regular dental visits,
maintain good oral hygiene, and rinse with a fluoridated mouth rinse so that your teeth and
gums receive the best possible care. We may also require that you see your regular dentist
more frequently, especially if you have periodontal problems.
Remember, good, daily, oral hygiene is the responsibility of the patient and not the
orthodontist.
I understand this risk and what I need to do to minimize it.
Periodontal Disease
While orthodontic treatment overall tends to reduce the possibility of tooth loss or gum
infection due to the misalignment of the teeth or jaws, the bone and gum tissue supporting the
teeth may be affected by orthodontic tooth movement, especially when poor oral hygiene and
unhealthy conditions already exist, and even in some rare cases when there is no prior
indication. Inflammation of the gum tissue and loss of the supporting bone can occur during
orthodontic treatment, particularly if the bacterial plaque is not removed daily through good
oral hygiene. If you have pre-existing periodontal disease, or if such a condition occurs during
orthodontic treatment, your periodontist or dentist should monitor this condition throughout
your orthodontic treatment. Also, if the teeth were very crowded to begin with, the gum tissue
may not fill the space below the contact point of the teeth resulting in the appearance of a
triangular space. If the periodontal problem cannot be controlled, orthodontic treatment may
have to be discontinued and braces removed prior to completion.
I understand this risk and what I need to do to minimize it.
Root Resorption
In some patients, particularly adults and patients in treatment for a long time, the stress of the
treatment may cause the roots of some teeth to become shorter during orthodontic treatment.
This is usually minimal and relatively insignificant, but in more serious cases it may become a
threat to the longevity, stability, or mobility of the teeth. Also, impacted teeth (teeth that have
become blocked while pushing through the gum into your mouth) can sometimes resorb the
roots of adjacent teeth as well as those teeth with very small, thin roots. Because we cannot
predict which patients will have root resorption, we may require periodic x-rays to check that
the roots of your teeth remain healthy.
I understand this risk and what I need to do to minimize it.
Relapse
Orthodontics is about moving teeth in a carefully planned and monitored way. However, teeth
may continue to change their positions after treatment. For this reason, you will be provided
with retainers after your braces are removed, which you will likely wear for several years at
least and which should help the teeth to remain in place. Throughout life, as the jaw grows,
as new teeth (particularly wisdom teeth) come in, or as other changes occur, your bite may
change. This can be caused by genetic influences controlling the size of the tongue, teeth
and the jaws or by mouth breathing, tongue thrusting, playing musical instruments, and other
“oral habits” that are beyond the control of the orthodontist. Sometimes tooth or jaw positions
may change adversely following treatment to a degree that additional treatment or even
surgery is recommended.
I understand this risk and what I need to do to minimize it.
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Tooth Development, Eruption
The development and eruption of teeth is a complex processes. Sometimes primary (baby)
teeth become fused to the bone (ankylosis) and will not move. This is particularly true when
there is no permanent tooth to follow the primary tooth. The fused primary tooth then remains
lower than the rest of the teeth that continue to erupt during normal development. Often these
teeth need to be removed. This problem can also occur in permanent teeth, particularly if
they have suffered trauma, have an unusual eruption path, or require surgical exposure.
Sometimes, impacted teeth that require surgical exposure may be ankylosed and therefore
need to be removed. There is no way to assess ankylosis prior to attempted movement of the
tooth. Teeth requiring removal may need to be replaced with an implant.
I understand this risk.
Extractions
Some orthodontic treatment will require the removal 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.
I understand this risk and what I need to do to minimize it.
Orthognathic Surgery
Orthognathic surgery (surgical realignment of jaws) is sometimes necessary in conjunction
with orthodontic treatment, especially to correct crowding or severe jaw imbalances. There
are additional risks associated with these procedures which you should discuss with your oral
and maxillofacial surgeon prior to the procedure. If you require orthognathic surgery and elect
to discontinue the orthodontic treatment without completing the recommended surgery, you
may have a malocclusion that is worse than when you began treatment.
I understand this risk and what I need to do to minimize it.
TMD, TMJ
Occasionally problems may occur in the jaw (temporomandibular) joints (TMJ), causing pain,
headaches, ear problems, popping of the jaw, or difficulty in opening or closing the mouth.
These symptoms are more common in a patient who clenches or grinds his or her teeth,
chews on hard objects, has suffered trauma to the face or jaws, or has a poorly balanced bite.
These problems may occur with or without orthodontic treatment. Any of these symptoms
should be reported to the orthodontist immediately and may require treatment from a variety
of specialists.
I understand this risk and what I need to do to minimize it.
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, root canal treatment may be necessary. In severe
cases, the tooth or teeth may be lost. Similarly, a tooth that has been previously traumatized
by an accident or that has a large filling may have suffered damage to the nerve of the tooth
that orthodontic movement may, in some cases, aggravate and which may require root canal
therapy or even removal of the tooth. Often in such situations, root canal therapy or extraction
may have eventually been required even if orthodontic treatment had not been done.
I understand this risk.
General Discomfort
The mouth is a very sensitive area, so you can expect an adjustment period and some
discomfort due to the orthodontic appliances. Tenderness is normal and usually does not last
more than a few days. If you are suffering more than minor discomfort, you should call your
orthodontist immediately for an evaluation of your condition. Non-prescription pain relievers
such as ibuprofen may be used to relieve the discomfort, though their use is not
recommended for extended periods. Standard precautions should be taken not to mix
medications with alcohol consumption.
I understand this risk and what I need to do to minimize it.
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Injury from Orthodontic Appliances
Your orthodontic appliances are composed of very small parts connected together. They
could be accidentally swallowed, aspirated, or could irritate or damage your lips, cheeks,
tongue and gums, especially if they break unexpectedly. You should avoid activities and
foods that may damage your braces. Cheeks and lips may be scratched or irritated by loose
or broken appliances or by trauma to the face or mouth. If you are prescribed headgear as a
part of your treatment, and if headgear is handled inappropriately, pulled or caught
unexpectedly, or treated roughly, the appliance may cause injury to the face or eyes, even
blindness (there have been a few reports of injury to the eyes of patients from wearing
headgear). You should never play sports, roughhouse or engage in horseplay while wearing
headgear, and we urge caution at all times when wearing any orthodontic appliances. You
are encouraged to wear a protective mouth guard when playing sports or in activities where
there is a risk of injury. Ask your orthodontist what the best type of mouth guard is for you.
I understand this risk and what I need to do to minimize it.
Tooth Injury
Damage to a tooth, restoration, veneer, or crown is possible when your braces are removed
or in the event of impact or abuse while wearing braces. Abnormal wear of the teeth is also
possible if a patient grinds the teeth excessively. If a patient treats his or her braces without
proper care, the enamel of the teeth may be damaged since the braces are bonded to the
teeth. You should report any damage to teeth or tissue to your dentist or orthodontist
immediately and understand that restoration or other emergency treatment may be required.
I understand this risk and what I need to do to minimize it.
Third Molars
As third molars (wisdom teeth) develop, your teeth may change alignment. The orthodontist
will monitor them in order to determine when and if the third molars need to be removed.
I understand this risk and what I need to do to minimize it.
Materials Sensitivity
Most braces are made of stainless steel that contains nickel, though the type of appliance,
construction and material content may vary. Some patients may be allergic to nickel or may
have allergies to other components or bonding materials that may result in adverse reactions
and require alteration of cessation of orthodontic treatment with corresponding limits on the
success of the treatment. Although exceedingly rare, medical management of dental material
allergies may be required. Immediately inform your dentist or orthodontist if you experience
swelling, redness, hives, prolonged discomfort, pain, or any symptom of an allergic reaction.
I understand this risk and what I need to do to minimize it.
Occlusal Adjustment.
You can expect minimal imperfections in the way your teeth meet following the end of the
treatment. An occlusal equilibration procedure may be necessary, which is a grinding method
to use 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.
I understand this risk and what I need to do to minimize it.
Non-Ideal Results
Due to the wide variation in the size and shape of teeth, missing teeth, or abnormal position of
the teeth such as transposition, an ideal result (for example, complete closure of space) may
not be achieved. Restorative procedures may be required for a successful treatment. The
most common types of dental treatment are cosmetic bonding, crown and bridge restoration
and/or periodontal therapy. You should ask your dentist or orthodontist about the types of
adjunctive care recommended for you.
I understand this risk and what I need to do to minimize it.
Treatment Time
The total time required to complete treatment may be more than or less than the estimate you
have been given. Excessive or deficient bone growth, poor cooperation in wearing the
appliances including headgear and elastics for the prescribed time, poor oral hygiene, broken
appliances, missed appointments and other factors can lengthen the treatment time and can
adversely affect the quality of the end result.
I understand this risk and what I need to do to minimize it.
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Health
General medical problems, such as bone, blood or endocrine disorders, can affect the
orthodontic treatment. You should keep your orthodontist informed of any changes in your
health status.
I understand this risk and what I need to do to minimize it.
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.
I understand this risk and what I need to do to minimize it.
Temporary Anchorage Device (TAD)
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 these devices. It is
possible that a screw could become loose which would require its removal and possible
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. Please advise the doctor placing the device if you have had any
difficulties with dental anesthetics in the past.
I understand this risk and what I need to do to minimize it.
Possible Alternatives to Orthodontic Treatment
Orthodontic treatment is an elective procedure for most patients. One possible alternative to
orthodontic treatment is no treatment at all. You could choose to accept your present condition
and decide to live without orthodontic correction or improvement. Alternatives to orthodontic
treatment vary from patient to patient and may include, among others, extraction of permanent
teeth, orthognathic surgery, or prosthetics (bridge work or false teeth). You may wish to
discuss these treatment alternatives with your orthodontist before beginning
orthodontic care.
I understand the alternatives to orthodontic treatment.
Limited or Incomplete Treatment
If your treatment is terminated for any reason, whether or not it is your choice to do so, before
the course of treatment is complete, or if you seek treatment to address only a specific area
(e.g. aligning only the front teeth for aesthetic reasons), this may not result in a favorable
alteration of the bite or alignment of the jaw and may not lead to the result that you expect.
Therefore, selecting an option less than the ideal therapy may have less than ideal results.
I understand this risk and what I need to do to minimize it.
In any of the complications mentioned above does occur, a referral may be necessary to
your family dentist or another dental or medical specialist for further treatment.
Whether treatment for such complications is performed by us or by a specialist to whom
you have been referred, fees for these services are NOT INCLUDED in the cost you have
been quoted for orthodontic treatment.
I understand and accept this risk.
By signing this authorization where provided below, I hereby acknowledge that:
 I have read the materials provided to me in this “Informed Consent” detailing the Risks and limitations of
Orthodontic Treatment and fully understand the treatment considerations and risks presented and
discussed.
 I have had the opportunity to ask, and I have asked, any questions that I wish to ask, and I have received full
and satisfactory answers and explanations.
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
I understand that there may be other problems not covered in the materials with which I have been presented
because they may occur less frequently or are less severe.
 I understand and acknowledge that no specific result is guaranteed in my orthodontic treatment and that the
actual results of orthodontic treatment vary from patient to patient, are dependent on many factors beyond the
control of the orthodontist, and may be different from the anticipated results.
Consent to Undergo Treatment
 I have been asked to make a choice about my treatment and hereby give my fully informed consent to
orthodontic treatment.
 I hereby further consent to making and keeping of diagnostic records, including x-rays, during and following
orthodontic treatment and acknowledge that those records may be used by the orthodontist and dental staff in
connection with my treatment, for billing and collections purposes, for teaching or instructional purposes, and
to support insurance claims.
 I fully understand the risks associated with the treatment. Without limitation, I understand the relationship
of orthodontic treatment and the following: Hygiene, Root Resorption, Periodontal Disease, Retainers,
TMJ/TMD, Tooth Development/Eruption, Traumatized Teeth, Orthodontic Discomfort, Tooth Injury,
Headgear, Jaw Surgery, Growth, Occlusal Adjustment, Treatment Time, Ceramic Braces, Material
Sensitivity, Tooth Variation, TAD, Nerve Damage, Use of Tobacco Products, Allergies and overall
Health, Limited or Incomplete Treatment.
Authorization for Release of Patient Information
I hereby give my permission for the release of my records to other health care providers as deemed appropriate by the
treating doctors in accordance with the HIPAA Privacy Act. I understand that once released, the releasing party has
no responsibility for any further release by the recipient.
I am either a patient over the age of 18 years (“Patient”) or, if the patient is under 18, I am the patient’s parent,
guardian, or authorized representative with legal authority to sign on behalf of the patient (“Responsible
Party”). If I am the Responsible Party, I understand that I am giving consent, for the patient and I am fully
responsible for all fees, costs, and charges exactly as if I were the Patient.
AUTHORIZATION
Signature of Patient (if over 18)
Date
Signature of Orthodontist
Date
Witness
Date
Responsible Party (if not Patient)
If you are consenting to the care of another: I have the legal authority to sign on behalf of the Patient.
Name: _____________________________________________Relationship to Patient: ________________________
Signature
Date
Witness
Date
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