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PATIENT CONSENT FORM TO BEGIN ORTHODONTIC TREATMENT
As a general rule, orthodontic treatment is an elective procedure and excellent results can be achieved with informed and cooperative patients.
While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of
the body, has some inherent risks and limitations.
General Patient Cooperation: Patient responsibilities are: brushing and flossing on a daily basis, being on time for all appointments, adhering to the
food list restrictions, wearing removable appliances as required, and visiting your general dentist for your regular six month cleanings. When
patients follow the instructions that are given, this will prevent damage to the teeth and surrounding tissues. These instructions will also help keep
initial treatment time accurate.
Oral hygiene: Tooth decay, gum disease, or enamel decalcification (permanent white stains on teeth caused by early stages of decay process) can
occur if patients do not brush their teeth properly during treatment period. Excellent oral hygiene and plaque removal is very important. Sugar
snacks and sugary drinks between meals should be reduced as much as possible.
Treatment time: Your initial estimation of orthodontic treatment time is based on average treatment times of very large patient populations. Each
patient is unique and their response to treatment may pose slightly different results that will change the original length of care. The total time for
treatment can be altered or delayed beyond your original estimate. The lack of facial growth or poorly directed facial growth; poor elastic wear;
repeated broken appliances and missed appointments are all examples of important factors that could lengthen treatment time and affect the
quality of the final result.
Growth patterns: Occasionally a person who has shown normal growth in average proportions may not always continue to do so. If facial growth
becomes disproportionate during treatment, the jaw relationship can be affected and original treatment objectives may have to be compromised
or altered. Skeletal growth disharmony is a biological process beyond the orthodontist’s control. Some orthodontic patients will require oral
surgery to obtain a reasonable treatment result if skeletal disharmony exists.
TMJ: There is a risk that problems may occur in the tempromandibular joint (TMJ). Although this is rare, it is a possibility during treatment. Tooth
alignment or bite corrections can sometime improve tooth related causes of TMJ pain, but this is not true in all cases because there are many other
causes of TMJ dysfunction. Please inform us if you have a history of TMJ pain, are currently experiencing TMJ pain or develop symptoms during
treatment.
Unusual occurrences: Swallowed appliances, chipped teeth, dislodged restorations and allergies to latex or nickel rarely occur but are possible
during orthodontic treatment. Please inform us if anything unusual occurs or develops during your treatment.
Root Resorption: In some cases, the ends of the roots of teeth are shortened during treatment. Under healthy circumstances the shortened roots
are no disadvantage. However, in the event of gum disease later in life, the root resorption may reduce the longevity of the affected teeth. It
should be noted that not all root resorption arises from orthodontic treatment. Trauma, impaction, genetics, endocrine disorders, and unknown
reasons can also cause root resorption.
Impacted teeth: Some teeth do not erupt normally on their own and are referred to as being impacted. In attempting to move these impacted
teeth orthodontically, various problems are sometimes encountered which may lead to periodontal problems, relapse, or potential tooth loss.
Some impacted teeth may be fused to the jaw bone (ankylosed) and are unable to be moved.
Post treatment tooth movement (Relapse): Teeth always have a tendency to return to their original position after orthodontic treatment. Severely
rotated teeth have a higher tendency to relapse and this is most commonly seen in the lower front teeth. Retainers are placed or provided to
minimize this relapse from occurring. Your full cooperation in wearing these appliances is vital to long term success. To prevent relapse of your
teeth you should always remember to wear retainers “night time for lifetime!”
Special Needs Cases: Appointments must be in the morning and parent/patient is responsible for those accommodations.
I consent to the taking of photographs, study models, and x-rays needed for orthodontic records before, during, and after orthodontic treatment to
assist in the treatment planning and progress treatment objectives. If the orthodontic case proves to be of special scientific interest, the doctor
reserves the right to present or publish the records in scientific papers or presentations to the profession for educational purposes. I certify that I
have read or had read to me the contents of this form and do realize the risks and limitations involved, and I do consent to orthodontic treatment.
I also consent to the pictures that are being taken to be used on the orthodontic website and Facebook. Yes___ No___
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PATIENT CONSENT FORM TO BEGIN ORTHODONTIC TREATMENT

Patient / Parent / Guardian Signature Witness Signature Date

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