Download Patient Information and consent to begin orthodontic

doyle & baker, PSC
chris baker, RN,DMD
kenny nusbacher, DMD
Patient/parent information and consent to begin appliance treatment
The following paragraphs are meant to inform and advise
you of what procedures are recommended for your child,
and why they are important, of the benefits and risks of
the treatment and possible treatment alternatives. Your
understanding, approval and comfort with the treatment
plan is of the utmost importance.
Your presence
Parents - always stay with your child – we insist!
We believe pediatric dentistry is an opportunity to
transform the quality of life. Beginning with the area of
emotional support and parental involvement, the goal for
your child is to make the dental visits comfortable and fun
and to make sure anything difficult is made as easy as
possible, and with the most support possible. This
always includes having the parents/family with the
patient.
Your child’s dental problems and
recommended treatment:
Your child:__________________’s recommendations::
_____Bluegrass appliance for habit and adverse
tongue position
fee__________________
_____MEA/quad helix appliance for crossbite
fee__________________
_____chin sling for Class III (underbite)
fee__________________
_____facemask for Class III (underbite)
fee__________________
__
other_____________________________
Safety
Your child’s safety is first and foremost. A young child
does not understand that unexpected movements or
grabbing can be very dangerous, and a young child does
not understand that when sharp instruments are used, or
placed in the mouth, that he/she could be inadvertently
scratched or poked, especially with sudden movement.
As necessary, safety will be provided through:
-your presence during treatment; you will hold
your child’s hands, so your presence and touch is
constantly felt, and at the same time, so safety of hand
position is assured by you.
-a head support person will help by supporting
your child’s head and preventing sudden dangerous
movements, and by holding a tooth pillow, allowing your
child’s teeth to rest on it, rather than having to hold open.
-a papoose cuddle coat, cuddling your child and
preventing sudden dangerous movements, so that
excellent, safe treatment can be done for your child.
Emotional support
One of the most important opportunities dental treatment
provides is the opportunity to provide love and caring to
your child and to you.
Each child responds in his or her own way to a
dental visit. It is perfectly normal for your young child to
be worried about new experiences. Crying is the normal
way a young child communicates worry. Through
explaining, coaching, your participation and even fun, we
offer love and caring to both of you.
Treatment descriptions and information
______Bluegrass Appliance (BGA) helps your child
stop the habit. This helps stop adverse growth caused
by the habit. The appliance starts training the tongue
toward a normal posture, which also helps the growth of
the face. This works because the appliance beads are
present for the tongue to “play with,” which strengthens
the tongue musculature.

Certain speech sounds will be different, and will
improve within time after appliance placement.
Even though sounds are different, the tongue is
strengthening and actually can improve its’
ability to enunciate sounds over time.

The BGA is very successful in most children.
Every child is different, and there a few with very
resistant habits who have habit reduction
without cessation. The younger your child is
when the BGA is placed, the more chance of
cessation.
_____ MEA (Maxillary Expanding Appliance)
_____Quad helix MEA
Both take advantage of the open area between
the two halves of the palatal bones. By separating these
two bones, the maxilla (upper jaw) is made wider, and
the midline space fills in with bone.

You may see a space developing between your
child’s two front teeth.
Quad helix MEA

has 4 (quad) loops (helix) which build in
automatic expansion. You do not need a key.

is used for younger children who need less force
to expand the maxilla.
_____Chin sling appliance and facemask appliance
take advantage of growth and helps redirect the growth,
altering the ultimate shape and size of the lower jawbone
(the mandible.)

It can create incredible changes in the beauty of
your child's face and in the future health of
his/her bite and TMJ (TemporoMandibular
Joint.)

The more the appliance is worno the quicker and greater your child’s
effect
o the shorter the total treatment time.
Potential problems and risks
The following paragraphs are meant to advise you of
some of the problems that can be associated with
orthodontic treatment. While recognizing the benefits of
a pleasing smile and healthy teeth, you should also be
aware that appliance therapy, like any treatment of the
body, has potential risks and limitations.
Perfection

Perfection is our goal; however, in dealing with the
human body and problems of growth and development
and patient cooperation, achieving perfection is not
always possible. Often a functionally and esthetically
adequate result must be accepted.

Oral Hygiene/Plaque Control
If you do not control plaque well in your child’s mouth,
permanent scarring of the teeth (decalcification, white or
brown spots,) decay, or breakdown of the supporting
gum and bone can result. Dental and orthodontic
appliances do not cause decay – bacterial acids
cause decay. Thus, proper brushing, flossing and
keeping your teeth and braces clean, along with few
acidic, sweet, sticky foods for the bacteria to feed on, and
regular checkups can negate or minimize these risks.
Your child’s POH (Preventive Oral Hygiene) visits should
be maintained every 3 months.


mouth, it is possible that the patient may be
inadvertently scratched or poked, especially if the
patient moves at a critical time during the procedure.
It is possible for a foreign object to fall in the back of
the mouth, and if it is far enough back or if the
patient reflexes at that instant, the object may be
swallowed or inhaled. Great care is used in placing
and removing the braces and bonded attachments.
Extra-oral (external) appliance instructions must be
followed carefully. A chin sling or facebow that is
pulled outward while the elastic force is attached,
can snap back and injure the face or eyes. Be sure
to release the elastic force before removing the
appliance from your child’s teeth.
Allergic reactions to some of the materials used
during treatment have occurred on very rare
occasions.
If bacterial plaque is not controlled with brushing and
flossing, enamel white spots (early enamel
damage) and enamel destruction (decay) can result.
This destruction is worsened considerably by the
regular consumption of acidic drinks - soft
drinks, sports drinks, fruit juices, tea, lemonade.
________
Continued adverse growth
Nothing lasts forever. This includes orthodontic results
that are achieved. Appliance therapy is undertaken to
improve overall oral health and to make your child’s bite
as normal as possible given the clinical circumstances.
However, throughout growth, bone and tooth positions
are constantly changing. Post-orthodontic patients are
subject to these same changes that occur in nonorthodontic patients. These are factors that treatment
cannot control:

The direction and amount of growth remaining in the
jaws

The size and/or relationship of jaws to each other
and to the rest of the face

The soft tissue and bony support for the teeth

The size and shape of teeth and fillings in teeth

Any oral habits including tongue position

Patient cooperation during treatment and during
retention
All of these factors have the potential to affect the
stability of the finished result. Know that all tissues in the
body change with the aging process, including the
position of your child’s teeth and jaws.
Treatment time estimate


Occasionally a person who has grown normally and
in average proportion may not continue to do so, or
original growth problems may become exaggerated.
If growth becomes disproportionate or if your child’s
lower jaw re-positions itself in an unfavorable
manner, the original treatment objectives may have
to be altered or compromised. Total treatment time
can be extended beyond the estimate by slow or
undesirable facial growth. Skeletal growth
disharmony is a biological process, beyond
treatment control. Also, a combination orthodonticsurgical approach may be required to properly solve
the problem.
Treatment time can also be extended by inadequate
cooperation in the wearing of removable appliances
such as chin slings. Also, broken appliances and
missed appointments delay treatment time; these
important factors will affect the quality of the
treatment result as well. Lack of cooperation may
necessitate premature appliance removal, short of
the desired end result.
Parent’s initials

In healthcare treatment there is no certainty of
particular results. The anticipated benefits are based
on results from treating similar conditions and may
vary depending on individual human differences,
child to child.
Summary
The information noted above is solely so you, an
informed consumer, can better understand your child’s
dental treatment plan, and can appreciate that all
medical treatment, including dental care, carries some
risks. Fortunately dental treatment provides tremendous
benefits. Please allow us to make every effort to do it
right. This takes work, input and cooperation from
everyone - Dr. Chris, the staff, and you as a parent.
Dr. Chris is a specialist in pediatric dentistry, and
provides orthodontic treatment as part of your child’s
comprehensive pediatric care. I am aware that Dr. Chris
is a pediatric dentist licensed to provide orthodontics and
all specialty areas of pediatric dentistry. I am aware Dr.
Chris has extensive training in orthodontics, teaches
comprehensive orthodontics nationally, and has been
providing orthodontic treatment services since 1985. I
am aware that Dr. Chris is not an orthodontic specialist.
My child’s treatment plan has been reviewed with me and
my questions have been answered.
I understand that due to the above stated limitations and
other unknowns, which are inherent in working with the
human body and mind, there can be no specific
guarantee as to result or cure.
I consent to my child’s treatment.
_________________________________________
signature of patient, parent/guardian
____________________
date
_________________________________________
staff member
Other potential
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risks ky 40503  (859) 272-3773  fax (859) 245-4188  www.doyleandbaker.com
2387 professional
heights
dr #180.and
lexington,

When sharp instruments are used or placed in the