I UNDERSTAND that the treatment of dental conditions pertaining to ORTHODONTIC TREATMENT (straightening or repositioning of teeth) includes certain risks and potential unsuccessful results. Even though great care and diligence will be used in treatment, no promises or guarantees for desired results can be made nor expected. Please Note: for the safety and security of our patients and staff, there is CCTV on the premises.
1. Complete cooperation of the patient is essential. Once treatment has begun, each appointment must be attended as schedule. Each delayed or missed appointment will prolong the time necessary to complete treatment (which can never be precisely determined) and may create problems making it impossible to achieve the desired results. If 3 or more appointments are failed to attend without prior notice or you do not attend for a long period of time, your treatment will be discontinued.
2. Instructions must be diligently followed. There will be instructions given concerning special oral hygiene measures which must be followed. Also, as treatment progresses, certain adjunctive appliances may be necessary. Instruction will be given as to their care and use which must also be followed exactly. Informational and instructional literature will be given. It is the responsibility of the patient to thoroughly study and understand this material.
3. Decalcification (permanent markings on the teeth), decay, and/or gum disease can occur if the teeth are not brushed properly and thoroughly during the treatment period. Sweets, fizzy drinks and between meal, snacks must be eliminated, if desired results are to be achieved, this is necessary. Continuing check-ups and dental care from the patient’s general dentist during treat during hygienist visits during your orthodontic treatment.
4. Teeth may become non-vital. This is always a possibility, with or without orthodontic treatment. Trauma from a blow, deep fillings, etc. may cause the nerve tissue in a tooth to die. This can happen over a long period of time. Even though this problem may exist, it may be undetectable at the beginning of orthodontic treatment, but through tooth movement it may exhibit itself. Root canal treatment may then become necessary in order to preserve the tooth or teeth.
5. Root resorption is a condition where roots may become shortened during the treatment. Under healthy conditions, this is no serious disadvantage. However, if gum disease occurs in later life, the longevity of the teeth could be compromised. Other conditions can cause root resorption such as: trauma, cuts, impaction, endocrine disorders, or idiopathic (unknown) reasons.
6. Temporomandibular Joint (TMJ) dysfunction can occur before, during or after orthodontic treatment. Many times, the TMJ, even though the damage had begun long before the orthodontic treatment because of the subtle changes in the bite through treatment, symptoms of this damage such as clicking, popping, crackling, pain, headaches, etc., may then become evident. Even though there were no apparent symptoms previously, these may begin to exhibit themselves during treatment. Should such symptoms occur, it may be necessary for the patient to be referred to a TMJ specialist.
7. Shifting of teeth occurs after braces are removed. For this reason, retainers are constructed which must be diligently worn for a period which will vary between patients. Retainers are made of materials that are subject to breakage no matter how well constructed. Retainers must be handled and used carefully. Replacement charges may be made if the appliance is lost or broken beyond repair. Instructions will be given concerning these appliances.
8. I recognize that it is my responsibility to follow instructions completely and seek attention in a timely manner should any unexpected problems occur by informing the practice immediately. I must explicitly follow any instructions, either written or oral, which have been given to me relating to this orthodontic treatment.
9. I understand that if any of my booked appointments are cancelled by the practice, the practice will endeavour to re appoint and inform me at the soonest opportunity. This will be done either verbally, in writing or via text message.
INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of orthodontic treatment and have received answers to my satisfaction. I have been given the alternative of seeking care with an orthodontic specialist. I do voluntary assume any and all possible risks, including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired potential results, which may or may not be achieved. No guarantees or promises have been made to me concerning any results from treatment. The fee(s) for these services have been explained to me and I accept them as satisfactory. By signing this term, I accept all terms and conditions expressed within it and freely give my consent to authorize Dr SAMIR MOGHANCHI and any and all associates including orthodontic therapist necessary in rendering services that he/she deems necessary or advisable for this subject orthodontic treatment.
