Patient's Informed Consent and Agreement Regarding Orthodontic Treatment

The following information is routinely supplied to anyone considering orthodontic treatment. Although orthodontic treatment can provide the benefits of healthy teeth and an attractive smile, you should also be aware that orthodontic treatment has limitations and potential risks that should be considered before undergoing treatment.

Risks and Inconveniences

Many of the problems discussed below can occur without orthodontic treatment, but the risk is greater to an individual wearing an orthodontic appliance. The risks associated with orthodontic treatment may include the following:

Dental tenderness experienced from time to time should be expected. The period of tenderness varies with each patient and the procedure performed. With braces, the soreness in the teeth is usually at its peak one day after the initial placement of the braces and the first wires. It typically lasts a few days to a week, and may require medication. The gums cheeks and lips may be scratched or irritated. Orthodontic appliances may be accidentally swallowed or aspirated. Tooth decay, periodontal disease or permanent markings (decalcification) on teeth can occur if orthodontic patients eat foods with sugar and/or do not brush their teeth properly. This is totally preventable with good oral hygiene, and limiting the foods high in sugar.

Poor cooperation, lost or broken appliances, missed appointments and atypically shaped teeth can lengthen the treatment time and affect the quality of the end results or the ability to achieve the desired results.

Teeth may shift their position after treatment. Faithful wearing of retainers at the end of orthodontic treatment should reduce this tendency. Throughout life, the bite can change adversely from various causes, including growth changes, playing of musical instruments and other oral habits. All of these causes may be out of the control of the doctor. In rare instances, problems may also occur in the temporomandibular joint (jaw joint), causing joint pain, headaches and/or ear problems. Although orthodontic treatment does not cause anorexia, it may be one of the factors which may trigger the onset of anorexia.

For some patients, orthodontic treatment temporarily affects their speech and they may experience a lisp, although any speech impediment caused by orthodontic appliances usually disappears within one or two weeks.

The health of the bone and gums which support the teeth, may be affected by orthodontic treatment, particularly if a condition already exists and in some cases where a condition does not appear to exist. Inflammation of the gums and loss of supporting bone can occur if plaque is not removed with daily brushing and flossing.

Oral surgery (eg. tooth extraction) may be necessary in conjunction with orthodontic treatment, especially to correct crowding or severe jaw imbalances. If such surgeries are necessary, risks associated with treatment and anesthesia should be discussed with the oral surgeon.

A tooth that has been previously traumatized or significantly restored may be aggravated by orthodontics. In rare instances this may require additional dental treatment such as endodontic and/or additional restorative work. There is also the possibility that existing dental restorations (eg. crowns) may become dislodged and require re-cementation or in some instances, replacement. Occasionally, a tooth may be ankylosed, or fused to the bone of the jaw. An ankylosed tooth is impossible to move orthodontically, in which case it may require extraction or to be left in a non-ideal position.

In some patients, the length of the roots of the teeth may be shortened during orthodontic treatment. Usually this does not have significant consequences, but on occasion it may become a threat to the longevity of the teeth. Some patients are more prone to this process (called root resorption) than others. In severe cases this may result in tooth loss.

In patients who have impacted teeth, orthodontic treatment is often aimed at bringing these teeth into their correct position within the dental arch. Impacted teeth may require a surgical procedure to expose them so that an orthodontic attachment could be bonded to them. Such impacted teeth may cause damage to adjacent teeth either by themselves without any treatment or in the process of surgical or orthodontic treatment. Some impacted teeth may also suffer damage to their roots or the gum tissues and bone supporting these teeth during the course of orthodontic or surgical treatment. In rare cases, this can result in loss of either the impacted tooth or other teeth in the vicinity of the impaction. Also rarely, impacted teeth may not respond to orthodontic treatment and may need to be extracted.

In cases where overbite/underbite is present, chipping or uneven wear may occur on the edges of opposing teeth due to biting on the brackets. Teeth may require small restorations or edges trimmed by a doctor at treatment end. Any risks associated with this procedure should be discussed with your dentist.

In cases where teeth are overlapping significantly before treatment, triangular spaces may develop at the level of the gum tissues as these teeth are straightened. This is because gum tissues that are normally present between teeth were never developed properly due to the dental irregularities. Such spaces may be reduced by filing teeth in the areas where they contact each other. In some instances, teeth may also require filling in order to create space to allow tooth movement to occur. Any risks associated with this procedure should be discussed with your doctor.

No Assurances/Guarantees

No assurance or guarantees can, has or will be made to you regarding the outcome of the treatment. Orthodontics is not an exact science, and therefore no orthodontist can guarantee any specific outcome.

Alternative Treatments

For most patients, orthodontic treatment is an elective procedure. There are alternatives to orthodontic prosthetic solutions such as bonding, veneers, crowns or no treatment at all. You could choose to live without orthodontic correction or improvement. The specific alternative to the orthodontic treatment of any particular patient depends on the nature of the patient’s teeth and supporting structures.

Orthodontic Microimplants

This is a relatively new technology, originally developed in Europe and Korea, and now widely accepted in North America. Orthodontic microimplants are essentially miniature screws made of surgical grade titanium. These microimplants are inserted through the gum in certain strategic locations in the mouth, with local anaesthesia. The microimplants give an orthodontist an opportunity to treat problems previously considered either very difficult or impossible. To the patient this often means having difficult overbite, underbite, open bite and crowding problems corrected with braces and microimplants without more risky and aggressive treatments such as jaw surgery or extraction of teeth. Microimplants allow significant overbites to be corrected without the less desirable Headgear, or other more bulky and less comfortable orthodontic appliances.

At our office, we have successfully placed hundreds of microimplants often with remarkable and inspiring results.

The procedure of placing microimplants typically is surprisingly painless and innocuous, with only mild discomfort that lasts a day or so. Microimplants are without question the most noteworthy development in orthodontics in recent years, opening remarkable opportunities for our patients.

Potential risks associated with microimplants include implants getting loose and needing replacement (less than 5% chance), breakage of implants (less than 1%), soft tissue irritation (depending on site), infections (less than 1 %), or damage to roots (extremely unlikely).

Orthodontic Treatment Consent

I have been given time to read and have read the preceding information describing orthodontic treatment. I understand the benefits and the risks and inconveniences associated with this treatment as outlined in the previous pages. I acknowledge that no assurances or guarantees have been made to me by any other person or any company concerning any specific outcome of my treatment. I have been sufficiently informed about this treatment and have had the opportunity to ask questions and discuss concerns. With my signature below, I consent to such treatment in conjunction with Dr. Eugene Kholov or another doctor who may be an associate or a partner of Dr. Kholov.

Patient PIPEDA Consent

I have reviewed the Personal Information Protection and Electronic Documents Act information that explains how your office will use my personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Dr. Eugene Kholov, or any other doctor who may be associated with or a partner of Dr.Kholov, can collect, use and disclose personal information about the patient as set out in the information about the office’s privacy policies.

Patient First Name:
Last Name:

I agree, that my personal information is stored in the cloud with Dr. Eugene Kholov’s software provider in the US.

Patient/Representative E-Signature:
Relationship to Patient: