BrightSmile Avenue Makati Consent Forms

Medical Clearance for Patients with Underlying Medical Conditions

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General Consent Form

Please read below carefully and ask for help if you need clarification or further information.

 

I, the undersigned, do hereby state and confirm as follows:

• I have been explained the following in terms and language that I understand. I have been explained the following in a language that is spoken and understood by me.
  
  
• I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above.
  
  
• I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
  
  
• I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
  
  

• In the removal of plaque, calculus, and stains, the dental professional may using specialized instruments that will carefully remove soft plaque build-up, harder calculus deposits, and surface stains from the surfaces of your teeth, both above and below the gum line. Please note that while stain removal is typically part of the cleaning (prophylaxis) procedure, the complete removal of all stains cannot be guaranteed. The extent of stain removal may vary depending on the type and severity of the stains.Additionally, it is important to be aware of your insurance coverage. I understand that my HMO insurance may not cover treatments for moderate to severe calculus deposits or stain removal, and I am responsible for any associated costs.

  Please remember to consult with your dental professional and insurance provider to obtain accurate information regarding your specific insurance coverage and potential out-of-pocket expenses.

• Additionally, it is important to be aware that anterior restorations, such as diastema closure, class 3, 4 and 5 restorations, composite veneers, are considered esthetic restorations and may not be covered by my dental HMO insurance. I understand that I am responsible for any associated costs for such treatments
• I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment.

• I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
  
  
• I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
  I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
  
  
• I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
  
  
• I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.

Medical Photography Consent

• I consent to photographs being taken for my medical records.
  
  
• I consent to the photographs being made available to other clinicians involved in my treatment.
  
  
• I consent to my photographs being used for teaching purposes provided these are anonymized.
  
  
• I consent to my photographs being used for the website provided these are anonymized.

Informed Consent for Biopsy with Local Anesthesia

Please read below carefully and ask for help if you need clarification or further information.

 

I understand that due to the type of lesion I have, my dentist has recommended that I undergo a biopsy, which is a procedure in which a portion of the lesion will be removed.  The expected result of this procedure is to adequately diagnose the lesion type. 

I understand that there are risks and complications associated with this procedure, which include but are not limited to infection, need for another biopsy to be performed, and scarring. 

Understanding all of the above, I request that and hereby provide my informed consent to the treating doctor and his/her assistants to perform a biopsy.  I understand that in the course of the biopsy it may become necessary to perform additional procedures which are not known to be needed at this time.  I request that and hereby provide my informed consent to the treating doctor to perform such procedures at his/her discretion if needed during my biopsy. 

I consent to having local anesthesia.  I understand the performance of diagnostic studies relating to my biopsy will be performed by other medical/dental professionals. 

I confirm with my signature that: 

• My dentist has discussed the above information with me. 

• I have had the chance to ask questions. 

• All of my questions have been answered to my satisfaction. 

• I do hereby consent to the treatment described in this form. 

I confirm with my signature that I have discussed with the above-named patient the risks, potential complications, and intended benefits of the biopsy, as well as alternatives.  The patient has had the opportunity to ask questions, all questions have been answered, and the patient has expressed understanding.  Thus informed, the patient has requested that I perform a biopsy upon him/her.

Consent Form for Chairside Whitening Treatments

Please read below carefully and ask for help if you need clarification or further information.

 

This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching") of my teeth. 

Risks of Consent for Treatment 

I understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all-natural teeth structure can benefit from whitening treatments and significant whitening can be achieved in most cases. I understand that whitening is not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently receive better results than people with gray/bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches, or spots due to tetracycline use/fluorosis do not whiten as well, may need multiple treatments/may not whiten at all. I understand that Provisionals/temporaries made from acrylics may become discolored after exposure to whitening treatments. 

I understand that whitening is not recommended for pregnant/lactating women, light sensitive individuals, patients receiving PUVA (psoralen + UVA radiation) or other photo chemo-therapeutic drugs/treatment, as well as patients with melanoma, diabetes, or heart conditions. I understand that the ZOOM/Laser light emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing any whitening treatment 

I understand that the results of my Whitening treatment cannot be guaranteed. 

I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the whitening systems, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to: 

• Tooth sensitivity/Pain: During the first 24 hours after whitening treatment, some patients can experience some tooth sensitivity/pain. the is normal and is usually mild, but it can be worse in susceptible Individuals. Normally sensitivity/pain subsides within 24 hours, but in rare cases can persist for longer periods of time. People with existing sensitivity, recession, exposed dentin, exposed tooth surfaces, recently cracked teeth, open cavities, leaking fillings, or other dental conditions that cause sensitivity/allow penetration of the gel into the tooth may find that those conditions increase/prolong sensitivity/pain after whitening treatment. 
• Gum/Lip/Cheek Inflammation: Whitening may cause inflammation of your gums, lips, or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel/the ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain/discomfort, depending on the degree to which the soft tissues were exposed to the gel/ultraviolet light 
• Dry/Chapped Lips: The whitening treatment involves three/four 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness/chapping of the lips/cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E cream. 
• Cavities/Leaking Fillings: Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone root canal treatment. If any open cavities/fillings that are leaking and allowing gel to penetrate to the present tooth, significant pain can result. I understand that if my teeth have these conditions, I should have my cavities filled/my fillings redone before undergoing the whitening treatment. 
• Cervical Abrasion/Erosion: these are conditions, which affect the roots of the teeth when the gums recede/they are characterized by grooves, notches/depressions, that appear darker that the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they call allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with the dental dam prior to my whitening treatment. 
• Root Resorption: This is a condition where the root of the tooth starts to dissolve wither from the inside/outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures. 
• Relapse: After the whitening treatment, it is natural for the teeth that underwent whitening to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment may involve wearing a take-home whitening tray or repeating the whitening treatment. I understand that the results of the whitening treatment are not intended to be permanent and secondary, or repeat/take-home treatments may be needed to maintain the shade I desire for my teeth. 

I understand that my dentist has evaluated whether I am a proper candidate for an in­ house whitening procedure. The dentist can explain the safety, efficiency, potential complications, and risks of whitening to me, and I understand that more information on this will be available upon my request. Since it is impossible to state every complication that may occur because of whitening, the list of complication on this form is incomplete. 

In signing this consent form, I am stating I have read this informed consent (or it has been read to me) and I fully understand it and possible complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by the dentist. 

Conscious Sedation Consent Form

Please read below carefully and ask for help if you need clarification or further information.

1.     For the dental procedure you are to undergo, sedation and analgesic medications may be used. The benefit of sedative and analgesic medication is to allow the safe, comfortable completion of your dental treatment.  I understand that the anesthetics/ sedative drugs and physical restraints are necessary to assist the dentist in performing the dental treatment with increased patient comfort and cooperation.

2.     I have been informed and understand that there are associated risks with the use of local anesthetic agents and sedative drugs used to increase the patient comfort and to control patient veins used for administering the drugs; discoloration of the tissue surrounding the injection site, swelling, infection, bleeding, nausea, vomiting, and allergic reaction. The primary risk of these medications is respiratory depression (decreased breathing effort), which can be serious or even fatal if not treated. This risk is minimized by careful administration of these medications and by the vigilant monitoring of my blood pressure, heart rate and breathing.

3.     Infrequently, allergic reactions to medications can occur. I have been informed to advise the dentist of any known allergies to any medications or have any concerns about receiving sedation/analgesia.

4.     I have been informed and understand that in rare instances, the risk of a sedative drugs include but are not limited: breathing difficulties; brain damage; stroke; heart attack; or loss of function of any limb or body organ. I understand that severe complication may require hospitalization and may even result in death.

5.     The purpose and possible complications to the used sedative drugs have been explained to me as well as possible alternative methods and their advantages and disadvantages. I understand the purpose, possible risks, and probable effectiveness of each method approach to treatment as well as the probable result if no treatment is provided.

6.     I have been advised that good results are expected and that the possibility and exact nature of complications cannot be accurately predicted. I acknowledge that no implied or expressed guarantees as to the result of the treatment or use of anesthetic or sedative drugs have been given to me.

7.     I acknowledge that I have received written preoperative and postoperative instructions regarding the use of sedative drug that these instructions have been explained to me, and that understand this information.

8.     I am aware that I may decline the administration of sedatives and analgesics or wish to discuss other alternatives, which include local anesthesia, and general anesthesia.

9.     I have had the opportunity to ask of my questions and all my questions have been answered to my satisfaction. I believe I have been given adequate information upon which to base and informed consent.

I have read this consent and understand, to my satisfaction, the procedures to be performed and accept the possible risks. I consent to allow BrightSmile Avenue and its associates to administer, as appropriate the medications(s) required to complete this dental procedure.

Consent Form for Dental Crowns and Bridges

Please read below carefully and ask for help if you need clarification or further information.

I voluntarily consent to dental crowns and bridges (the differences which have been explained to me) and bonding. I further authorize you to use methods of treatment you may find necessary during the procedure which may have not been known to me before the procedure began. I have chosen veneers and bonding over the alternatives that have been explained to me.

The preparation has been fully explained to me, including the risks involved. I have been informed that complications might include, but are not limited to: 

• Some of the enamel from my teeth will be removed
• I give my consent to use local anesthetic and take x-rays as needed
• I will have temporaries on my teeth until such time the veneers are delivered, which may break and be dislodged and require replacement at my expense
• Some of my opposing teeth may be altered and my occlusion(bite) may be altered
• I might be required to wear a mouth guard to bed each night
• Some of my teeth may remain sensitive and root canals may be required if necessary.
• Should teeth fracture during preparation, posts  may be required
• There may be chipping, fracture, and discoloration as time progresses, which might not be reparable. Replacement, at my expense, may be required
• There is no guarantee as to how long the crowns or bridges and bondings will last, and I have been instructed in hygiene and parafunctional habits
• Once I have approved of the shade(color) of the veneers and they are delivered, if I wish a change, it will be at my expense.
• I am responsible for regularly visiting the dentist for check up and maintain good oral health/habits in order to prolong the stability of my crowns and bridges.

In addition, the consequences of non-treatment have been explained to me. I have had an opportunity to ask questions and am fully satisfied with the answers I have received. I have also been given instructions in care and maintenance regarding this procedure and agree to follow the instructions carefully.

Consent Form for Extraction/ Oral Surgery Treatments

Please read below carefully and ask for help if you need clarification or further information.

 

I understand that oral surgery and/or dental extractions include inherent risks such as, but not limited to the following:

• Injury to the nerves: This would include injuries causing numbness of the lips, the tongue, and any tissues of the mouth and/or cheeks or face. The numbness which could occur may be of a temporary nature, lasting a few days, a few weeks, a few months, or could possibly be permanent, and could be the result of surgical procedures or anesthetic administration.
• Bleeding, bruising, and swelling: Some moderate bleeding may last several hours. If profuse, you must contact us as soon as possible. Some swelling is normal, but if severe, you should notify us. Swelling usually starts to subside after about 48 hours. Bruises may persist for a week or so.
• Dry Socket: This occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process. Dry sockets can be extremely painful if not treated. These usually develop 3-4 days after the surgery.
• Sinus involvement: In some cases, the root tips of upper teeth lie in close proximity to sinuses. Occasionally during extraction or surgical procedures the sinus membrane may be perforated. Should this occur, it may be necessary to have the sinus surgically closed. Root tips may need to be retrieved from the Sinus.
• Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile oral environment, for infections to occur post-operatively. These may be of a serious nature. Should severe swelling occur, particularly accompanied with fever or malaise, professional attention should be received as soon as possible.
• Fractured jaw, roots, bone fragments, or instruments: Although extreme care will be used, the jaw, teeth toots, bone spicules, or instruments used in the extraction procedure may fracture or be fractured requiring retrieval and possibly referral to a specialist. A decision may be made to leave a small piece of root, bone fragment, or instrument in the jaw when removal may require additional extensive surgery, which could cause more harm and add to the risk of complications.
• Injury to adjacent teeth or fillings: This could occur at times no matter how carefully surgical and/or extraction procedures are performed.
• Bacterial Endocarditis: Because of normal existence of bacteria in the oral cavity, the tissues of the heart, as a result of reasons known or unknown, may be susceptible to bacterial infection transmitted through blood vessels, and Bacterial Endocarditis (an infection of the heart) could occur. It is my responsibility to inform the dentist of any heart problems known or suspected or of any artificial joints I may have.
• Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed. All prescription drugs must be taken according to instructions. Women using oral contraceptives must be aware that antibiotics can render these contraceptives ineffective. Other methods of contraception must be utilized during the treatment period.

It is my responsibility to seek attention should any undue circumstances occur post-operatively and I shall diligently follow any pre-operative and post-operative instructions given to me.

Patient Consent

I, the undersigned, do hereby state and confirm as follows:

• I have been explained the following in terms and language that I understand. I have been explained the following in terms and language that is spoken and understood by me.
• I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above-named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above
• I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
• I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
• I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment.
• I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
• I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
• I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
• I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
• I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.

Consent Form for High Risk Treatments

Please read below carefully and ask for help if you need clarification or further information.

 

I, the undersigned, do hereby state and confirm as follows:

• I have been explained and have understood that the proposed treatment is uncommon/ complicated/ risky.
• I have been explained and have understood that the proposed treatment is based on technique/ procedure/ drug/ protocol that is relatively new.
• I have been explained and have understood that the proposed treatment has high rate of failure.
• I have been explained and have understood that the proposed treatment has high rate of relapse and recurrence.
• I have been explained and have understood that the proposed treatment generally require multiple sessions / sittings and I give my consent for the same.
• I have been explained and have understood that the proposed procedure generally require second intervention and I give my consent for the same.
• I have been explained and have understood that the proposed procedure generally requires further corrective surgery / procedure to deal with known post-procedure / surgery complication/s and I give my consent for the same.
• I have been explained and have understood that the proposed procedure generally requires ‘re-exploration’ and I give my consent for the same.
• Multi-stage treatments have been explained and have understood that the proposed treatment is a multi-stage treatment / procedure / surgery and I do hereby consent for each and every stage of the same.
• I have been explained and have understood that I may need long-term treatment.
• I have been explained and have understood that I may need long-term follow-up care.
• I have been explained and have understood that I may need longer period for recovery.

Consent Form for All-on-4 Implants

Please read below carefully and ask for help if you need clarification or further information.

All-on-4 is a type of dental implant that may be right for you if you’ve been told that traditional implants are not possible. Many men and women need this type of implant because they are missing all or most of the teeth in the lower or upper jaw. Some people may not be a candidate for traditional implants because of the condition of their oral health. With All-on-4, you may be able to have the long-lasting, beautiful tooth replacement you desire.

A key concern for many people is a loss of bone. If you have a significantly lower bone density in your jaw, you may not be able to support the style and function of traditional dental implants. However, All-on-4 may offer another option for you.

All-on-4 provides an important difference. It is faster to implant than traditional implants. It is best for those who have lost all of their teeth. Additionally, this method is less invasive and requires fewer prep procedures before putting it into place. For total tooth loss, this method also tends to be more affordable than other options.

When considering it, realize there are three main tooth materials to choose from with All-on-4:

Acrylic
With acrylic implants, a bar (usually made from titanium) connects the implants. This is considered the traditional option and was the first product available. This method is best for people that do not clench or grind their teeth. It is the least expensive option and the easiest to fix if necessary. It is available in various sizes and shapes. And, it has a softer bite than other products, which creates a natural feel. However, it does not have the aesthetics of other products. They tend not to last as long either. They can wear down and require a bit of maintenance over their lifetime.

Porcelain
Porcelain is another option in these implants. They are implants, but they are designed much like the traditional crown and bridge style. As a result, they last a long time and continue to look good for a longer period of time than other products. Another key benefit is that they can be customized to fit just about any style. There are a few drawbacks. For example, they can be expensive and require a skilled and experienced provider to ensure the best results. If there is damage and a break occurs, it can be difficult to repair. Still, they look good compared to other products.

Zirconia
A third option in these implants is zirconia. This is a newer material to the line up, but it offers some key benefits. For example, it is a very strong and durable option that is less likely to become damaged. They can look beautiful, but this depends on the overall skill of the dental provider. It takes a significant amount of experience to create a beautiful look. They can be customized as well. A drawback to this particular option is that they are expensive and hard to repair if they do break. Some people do not like the sound that occurs when biting down.

The Best Material Is One that Works Best You
When choosing the best material, it comes down to what works best for your individual needs and goals. A few aspects to consider include:

Your Opposing Teeth – What are the teeth opposing the dental implants like? Are they dentures, acrylic hybrids, natural teeth, or zirconia? It’s important to choose products that complement each other, not just in looks but also in function.

Grinders – For those who grind their teeth, some materials, such as acrylic, are simply not going to work well. They become damaged too quickly, limiting their effectiveness.

Your Budget – There is no doubt some products are more expensive, especially porcelain and zirconia. Acrylic is more affordable and can work well in the hands of the right dentist.

Your Age – Zirconia lasts longer, which means that if you are younger, buying these could mean the dental implants do not need to be replaced so soon.

Your Oral Health – Your dentist also needs to consider whether or not the implants are being placed into regenerated bone as well as the spread of your implants.

Reason for Tooth Loss – If you have oral health concerns, such as cavities and gum disease that brought you to this point, they must be taken into consideration.

Speech issues -  Speech issues are a major concern for patients. What may seem to us to be a minor speech flaw can become an overwhelming concern for the All-on-4 patient. Implant-supported bridges require both vertical and horizontal bulk for strength. Vertical needs vary with different restorative materials, but most bridges require 15 mm or more of height. As a result, clinicians are forced to replace more than just the volume of the missing teeth in order to achieve these measurements. We must often replace bone and soft-tissue volume, even if it is healthy. The result is that the portion of the bridge adjacent to the soft tissue will be bulkier than the original bone and soft-tissue volume that it replaced (figure 2). Consequently, this can have an impact on speech sounds such as "D," "T," and "N," as the tongue contacts the hard palate lingual to the central incisors to form the sound.

Difficulty adapting to bridge bulk -  It can be very difficult for patients to adapt psychologically to the different feel of an All-on-4 bridge. They are used to feeling the transition from their soft tissue to their teeth. With the All-on-4 bridge, patients feel real soft tissue and then fake soft tissue (the tissue portion of the bridge) prior to transitioning to the teeth. This can be a big problem for some patients, and sadly they often figure out that it's a problem after surgery when the ridge has been reduced. At that point, nothing can be done to get them back to that natural-feeling transition.

Proprioception - Periodontal mechanoreceptors (PMRs), which are present in the periodontal ligament, make teeth sensitive to low forces (<1 to 4 N).3-4 A dental implant does not have a periodontal ligament, and it takes approximately 10 times more force to register the same proprioception as a tooth.5 The proprioception associated with a dental implant is similar to that of a tooth affected by local anesthesia.6 As a result, patients will have difficulty recognizing premature or excessive occlusal contacts.

Because so many variables exist, many dentists choose hybrid materials. In some situations, it may be best to mix materials depending on what is being done. In a case where both the upper and lowers will be installed, it may be beneficial to install zirconia along the top and acrylic along the bottom. The key here is to work with a dentist that knows and understands all of these factors and can offer the right recommendation for your needs.

Given the information above, I, the undersigned, do hereby state and confirm as follows:

• I have been explained the following in terms and language that I understand. I have been explained the following in terms and language that is spoken and understood by me.
• I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above-named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above
• I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
• I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
• I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment.
• I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
• I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
• I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
• I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
• I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.

Consent Form and Information for Orthodontic Treatments

Please read below carefully and ask for help if you need any clarifications or further information.

We appreciate your confidence in selecting our office for your orthodontic treatment. We want you to be fully informed and invite you to inquire about your treatment at any time.

As a rule, excellent orthodontic results can be achieved with informed and cooperative patients. Thus, the following information is supplied to anyone considering orthodontic treatment in the office. While recognizing the benefits of a pleasing smile and healthy teeth, you should also aware of the orthodontic treatment has some risk and limitations.

1. Oral hygiene is a must orthodontic treatment. Failure to brush and floss thoroughly everyday may result in decalcification (permanent white marking on teeth), decay or gum disease. Food containing sugars and between meal snacks should be eliminated.
2. A non-vital ("dead") tooth is possibility or rare occasions. An undetected non-vital tooth may flare up during orthodontic treatment necessitating root canal therapy. In some cases canker sores or allergic reactions are also a possibility.
3. Root resorption can occur in some cases. This a shortening of the ends of the roots of teeth. Normally the shortened roots are not a disadvantage. However, should this patient experience gum disease in later years, severely shortened may reduce the longevity of the affected teeth. It should be noted that there are other cause of the root resorption as well. It can be resulted of a trauma, cuts, impactions, endocrine disorders or unknown causes.
4. Problems with accompanying pain in the Temporo-mandibular joint (TMJ), also called the "jaw joint", are also a possibility. Many times orthodontic treatment can improve already existing TMJ pain, but not in all cases. Stress and tension are also factors in some TMJ problems.
5. Teeth have a tendency to relapse toward their original position following active orthodontic treatment. Full cooperation in wearing retainers is necessary to reduce this tendency. When retainer use is discontinued some relapse is still possible.
6. The total time of treatment may be extended beyond our original estimate. lack of facial growth, poor patient compliance, broken appliance, and missed appointments are all factors which will lengthen the time of treatment.
7. Accidental or Intentional loss or damage of bracket is charged an appropriate fee. Two consecutive bonding of loose bracket, buccal tube or molar bond will also be charged.
8. Regular cleaning and check- ups at three-month intervals, or more frequently if needed, will still be necessary to maintain the teeth in good health.
9. Retainer fee, other orthodontic appliance, and other treatment done during and after orthodontic procedure will be charged an additional fee.

I have read and understand this letter of information and hereby give consent to the orthodontic treatment recommended by my dentist.

Consent Form for Graphy Aligners

Please read below carefully and ask for help if you need clarification or further information.

You are considering receiving direct printed orthodontic aligners as part of your orthodontic treatment. These aligners are custom-made and involve the use of special resin materials. It is essential for you to understand the potential risks and benefits associated with this treatment. This document aims to provide you with the necessary information to make an informed decision.

Purpose of Orthodontic Aligners:

Orthodontic aligners are designed to gradually straighten your teeth, improve your bite, and enhance your overall oral health.

Treatment Process:

1. Wearing Schedule:  You will be provided with a series of aligners to be worn for a specified duration, typically 20-22 hours a day. You will progress to the next set of aligners as instructed by your dentist/orthodontist.
2. Resin Material: The aligners are made from a special resin, having necessary certificates and approvals to be used for this specific treatment. This resin contains various materials, including polymers and additives, to achieve the desired properties and advantages demonstrated to you.

Potential Risks and Dangers:

1. Allergic Reactions: Although rare, some individuals may develop allergies or sensitivities to the materials used in the aligners. This can result in symptoms such as irritation, itching, or swelling of the gums, tongue, or lips. If you experience any unusual or severe reactions, it is advised to discontinue wear of aligners immediately, take anti-allergy medications which will be prescribed to you on your first appointment and contact your physician immediately for further control and treatment of allergic reactions. Keep your orthodontist informed about the allergic reaction and discontinuation of aligners.
2. Discomfort:  You may experience some discomfort or soreness when wearing aligners, especially during the initial days of each new set. This discomfort is usually temporary and can be managed with over-the-counter pain relief medication.
3. Oral Hygiene: Maintaining proper oral hygiene is essential during orthodontic treatment. Failure to do so can lead to issues such as tooth decay and gum disease.
4. Treatment Outcomes: The success of your orthodontic treatment depends on factors such as compliance with wearing instructions and attending regular follow-up appointments. Results may vary from patient to patient.
5. Temporo-mandibular joint disorder (TMD): People with TMD before starting orthodontic treatment, might end up with more dysfunction of the jaw joint.
6. Ankylosis: A tooth can lose the ligament that attaches the root of the tooth to the bone, this is called ankylosis. When this occurs, the tooth cannot be moved. This ankylosis can even occur during tooth movement, and is not caused by your orthodontic treatment. Any ankylosed tooth must remain in position or be extracted as part of the treatment.
7. Inter Proximal Reduction (IPR): Space must be present for the aligners to correctly position each tooth. This space may be obtained by reducing a small amount of tooth structure, known as IPR (Inter Proximal Reduction), on various teeth. This space may also be obtained by “expanding” the size of the dental arches. Sometimes it is best to extract teeth to create this space. Your dentist will explain the treatment options available to you.
8. Relapse: Teeth can move and your bite can change following orthodontic treatment. You must follow your dentist’s instructions for retention to prevent this unwanted dental relapse.
9. Black triangles: You might end up with small gaps (“black triangles”) between the teeth near the gum line as a result of the teeth straightening. This can be improved if wanted by means of composite bonding after completed treatment, at an additional cost.

Benefits:

• Improved alignment and aesthetics of your teeth.
• Enhanced oral function and comfort.
• Reduced risk of dental issues related to misalignment.

Alternatives:

• The dentist/orthodontist has discussed alternative treatment options, such as traditional braces and thermoformed aligners. The dentist/orthodontist, the patient and patient´s guardians (for minor patients) have agreed and consented on the use of direct printed aligners for the treatment.

 

Given the information above, I, the undersigned, do hereby state and confirm as follows:

• I have read and understood the information provided in this document regarding the potential risks and benefits of direct printed orthodontic aligners. I have had the opportunity to ask questions and have received satisfactory answers to my inquiries. I hereby consent to undergo orthodontic treatment with direct printed aligners, understanding that no guarantees have been made regarding the outcome of treatment.
• I acknowledge that you have been informed about the potential risks and benefits of orthodontic aligner treatment, including the rare possibility of allergic reactions and discomfort associated with the materials used. I agree to comply with the treatment plan and follow my dentist/orthodontist's instructions for the best possible outcome.
• I have been explained the following in terms and language that I understand. I have been explained the following in terms and language that is spoken and understood by me.
• I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above-named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above.
• I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
• I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
• I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment.
• I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
• I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
• I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
• I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
• I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.

Consent/ Request for Early Removal of Ortho Appliance

I request that my orthodontic appliances/brackets be removed on this date. I understand that I will not have the best achievable orthodontic result and accept the consequences of having my orthodontic appliances/ brackets be removed. I realized that leaving teeth in their current position may be a periodontal compromise or affect my temporo-mandibular joint. I understand that for teeth to remain in their current position, use of removal retainers is required. I also understand that I, upon the removal of the orthodontic appliance/ brackets, release the orthodontist, BrightSmile Avenue and its affiliates of any liability and responsibility. If I decide to continue orthodontic treatment later, then the decision as to whether to treat my case will be entirely up to the orthodontist. If considered, a full case fee will be charged. 

Consent for Braces Removal and Instructions for Retainer

Congratulations! Today is the day that your braces are coming off to unveil your beautiful smile! You are now entering an important phase of your treatment—the Retention Phase.

Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Teeth have a memory and often try to move back to their original positions. Retainers are required to keep your teeth in their new positions. Regular retainer wear is necessary for lifetime as your body is continually undergoing growth and maturation. Minor irregularities, particularly in the lower front teeth may occur. In summary, you need your retainers to keep your teeth as straight as possible. But even with good retainer wear, your teeth may move slightly.

 

Retainer Instructions and Responsibilities

I understand that I have the following responsibilities:

1. Wear my removable retainers 22 hours a day (including sleeping) for the first year followed by “night-time for life-time” wear.

2. Do not wear my removable retainers during eating to prevent damage.

3. Keep my removable retainers in the proper case when not wearing them.

4. Maintain my scheduled retention appointments as prescribed by my orthodontist.

5. Bring all removable retainers to my retention appointments.

6. Clean around my bonded retainer.

7. Have my General Dentist evaluate the readiness for wisdom tooth extraction.

8. Call the office immediately if my retainer breaks or is not fitting properly.

 

Lost or Broken Retainers

Your retainers are made using only the best possible material. If a retainer is lost or damaged, call our office immediately to schedule an appointment. There will be a laboratory charge per replacement retainer.

If further treatment is required due to unexpected growth or noncompliant retainer wear, additional charges will be applied.

I understand the above information. I have had an opportunity to ask any questions and I have had those questions adequately answered.

Consent Form and Information for Periodontal Treatment

Diagnosis

Your Periodontist has made a diagnosis that you have periodontal disease and has made a recommendation that you require periodontal treatment. This document is designed to outline this treatment, its risks, expected outcomes, alternatives and your responsibilities.

Treatment

Periodontal therapy includes conservative treatment, surgical treatment and periodontal maintenance. The treatment plan recommended to an individual patient may involve some or all of these types of periodontal treatment.

Conservative treatment involves comprehensive instruction in oral hygiene techniques, periodontal charting involving measurement of pocket depths and other clinical features and the use of hand and sonic instruments that are placed between the gum and tooth surfaces. These special instruments are used to remove bacterial bio film and infected gum tissue that accumulates over time on the root surfaces of teeth and in periodontal pockets. This treatment is also referred to as scaling and sub gingival debridement and may be carried out over several visits by your Periodontist, a Hygienist or both. In addition, administering local anaesthetic, antibiotics or antiseptics may form part of this treatment.

Surgical treatment involves administering local anaesthetic prior to cutting and opening up the gum to permit better access to the roots and to the eroded bone. Inflamed and infected gum tissue will be removed, and the root surfaces will be thoroughly cleaned. Bone irregularities may be reshaped and bone regenerative material may be placed around teeth. The gum will then be sutured back into position, and a periodontal bandage or dressing may be placed. The administering of antibiotics and antiseptics may form part of this treatment. Unforeseen conditions may call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, (1) extraction of hopeless teeth to enhance healing of adjacent teeth, (2) the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, or (3) termination of the procedure prior to the completion of all of the surgery originally outlined.

Periodontal surgical treatment also involves the patient returning for follow up visits to check on healing. Smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of surgery. It is important that patients abide by the specific prescriptions and instructions given by the Periodontist or his/her staff after surgery.

The Expected Benefits of Treatment

It is expected that periodontal treatment will control periodontal disease to prevent potential loss of teeth in the future. It should also reduce or eliminate symptoms of the disease such as bad breath and bleeding of the gums when brushing and flossing. In addition, treatment may make oral hygiene techniques more effective and enable professionals to better clean the patient’s teeth.

The Principal Risks and Potential Complications

A small number of patients do not respond successfully to periodontal treatment. Due to individual patient differences there remains some risk of treatment failure, relapse, additional treatment, or even worsening of the present condition, including oss of certain teeth, despite the best of care.

There is no method that will accurately predict or evaluate how an individual’s gum and bone will heal. There may be a need for a second procedure if the initial results are not satisfactory. In addition, the success of periodontal procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and medications. It is the patient’s responsibility to disclose prior drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any way relate to periodontal treatment.

If you elect not to have local anaesthetic during conservative periodontal treatment some discomfort (mild to moderate depending on your individual pain threshold) may be experienced. If local anaesthetic is used no discomfort should be experienced. However, care will be required for up to 4 hours following the procedure not to inadvertently cause damage to the numb area (either hot/cold or biting the lip). Some discomfort of the gum tissues is common following treatment. This is usually of very short term and controlled at worst with normal over-the-counter pain relievers. Increased sensitivity of the root surfaces to hot and cold is also common (this will resolve in most cases if the oral hygiene instruction you will be given is followed carefully). Rarely, an abscess may occur in the gum following treatment and our practice will treat this if it occurs promptly.

Complications may also result from periodontal surgery, drugs, or anaesthetics. The exact duration of any complications cannot be determined, and they may be irreversible. These complications include, but are not limited to:

• post-surgical infection
• bleeding, swelling and pain
• facial discoloration
• transient but on occasion permanent numbness of the jaw, lip, tongue, teeth chin or gum, jaw joint injuries or associated muscle spasm
• transient but on occasion permanent increased tooth looseness
• tooth sensitivity to hot, cold, sweet or acidic foods
• shrinkage of the gum upon healing resulting in elongation of some teeth and greater spaces between some teeth
• cracking or bruising of the corners of the mouth
• restricted ability to open the mouth for several days or weeks
• impact on speech
• allergic reactions, and
• accidental swallowing of foreign matter

Possible Alternatives to our Recommended Treatment

Similar treatment may be available within your general dentists practice. Our practice is a specialist practice and outcome centred. Research and experience suggests that treatment within a specialist practice will be much more likely to achieve a positive result and that this result is also likely to be longer lasting.

Periodontal maintenance and self care

The outcome of periodontal treatment is highly dependent on the levels of your home oral hygiene program and on long term professional periodontal maintenance. Natural teeth and their artificial replacements should be maintained daily in a clean, hygienic manner. You will need to brush your teeth as instructed and also be required to clean between your teeth (floss and inter dental brushes are most commonly used) daily.

You could elect not to seek treatment for your periodontal problems. This may result in ongoing bad breath, bleeding of the gums, loosening of teeth and potential loss of teeth due to periodontal disease in the future. It is essential to your long term stability that recommended periods for maintenance are undertaken.

Periodontal maintenance involves examination and assessment of the teeth and periodontal tissues, reinstruction in oral hygiene techniques and removal of plaque and calculus from teeth. Maintenance also may include adjustment of prosthetic appliances. Further treatment (in addition to ongoing periodontal maintenance) may be recommended at these visits if required. Periodontal maintenance may be carried out by a Periodontist, a Hygienist, a Dentist or a combination of these.

It is also important to continue to see a Dentist. Existing restorative dentistry can be an important factor in the success of failure of periodontal therapy. From time to time, the Periodontist may make recommendations for the placement of restorations, the replacement or modification of existing restorations, the joining together of two or more of my teeth, the extraction of one or more teeth, the performance of root canal therapy, or the movement of one, several, or all of my teeth. Failure to follow such recommendations could lead to ill effects, which would become the patient’s sole responsibility.

No Warranty or Guarantee

We give no guarantee, warranty or assurance that the proposed treatment will be successful. In most cases, the treatment should provide benefit in reducing the cause of periodontal disease and should produce healing which will help the patient keep teeth. Due to individual patient differences, however, a Periodontist cannot predict certainty of success. There is a risk of failure, relapse, additional treatment, or even worsening of the present condition, including the possible loss of certain teeth, despite the best of care.

Patient Consent

I have been fully informed of the nature of periodontal therapy, the procedure/procedures to be utilized, the risks and benefits of periodontal therapy, the alternative treatments available, and the necessity for followup and self-care. I have had an opportunity to ask any questions I may have in connection with the treatment.

After thorough deliberation, I hereby consent to the performance of periodontal therapy as presented to me during consultation and in the treatment plan presentation as described in this document. I also to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my Periodontist.

I certify that I have read and fully understand this document. 

Consent for Porcelain, Zirconia or Resin Veneers and Bonding

Please read below carefully and ask for help if you need clarification or further information.

 

You have been informed that you require, or would benefit from, veneers on the following teeth:

UPPER RIGHT 8 7 6 5 4 3 2 1    |   1 2 3 4 5 6 7 8  UPPER LEFT
LOWER RIGHT 8 7 6 5 4 3 2 1  |  1 2 3 4 5 6 7 8 LOWER LEFT

PURPOSE OF THE TREATMENT:

This procedure is deemed necessary because the teeth are:

□   Heavily Restored

□   Chipped

□   Stained

□   Poorly Spaced or Misaligned

□   Worn Down

□   Discolored

□   For Aesthetic Purposes

□   Others

A PORCELAIN VENEER PROCEDURE REQUIRES TWO TO THREE (2-3) APPOINTMENTS:

The first appointment will require 30-45 minutes of your time per veneer.

It consists of:

Anesthesia Tooth Reduction/Preparation

Tooth Isolation Impression(s) Taken

Shade Selection for Veneers

Fabrication of Temporary Veneers (if needed)

 

The second appointment will require 45-60 minutes of your time per veneer, approximately one week after the first appointment.

It consists of:

Anesthesia

Removal of Temporary Veneers (if placed) Try-in of veneers

Preparation of veneers Preparation of Teeth Bonding of Veneers Bite Adjustment

Final Contouring and Polishing

 

If a third appointment is needed it will require 30-45 minutes of your time per veneer, approximately 3-5 days after the first appointment.

It consists of:

Anesthesia

Removal of Temporary Veneers (if placed) Try-in of veneers

Preparation of veneers Preparation of Teeth Bonding of Veneers Bite Adjustment

Final Contouring and Polishing

 

A RESIN VENEER PROCEDURE REQUIRES ONE (1) APPOINTMENTS

BENEFITS OF THE TREATMENT:
The appearance of a previously unattractive tooth is corrected. Restorations replace diseased, missing, or defective tooth structure, and support or strengthen that which is remaining. They can improve chewing, allow proper speech, assist in the maintenance of healthy supporting tissue, and enhance appearance.

RISKS OF THE TREATMENT:
Veneer preparation involves cutting away diseased and/or healthy tooth structure. In rare cases, removal of tooth structure may irritate the pulp of individual teeth. The appropriate treatment at this point is a root canal treatment. Although infrequent, this treatment may be required before, during or after the veneer procedure to alleviate discomfort or infection.

When impressions of a patient's mouth are being taken for dental lab specifications, the gum tissues which cover the edges of the tooth may have to be pushed back or trimmed away. Receding gums, a common aging process, may on occasion be accelerated by these steps. If gum recession occurs, the veneer margins may become visible, or the roots may be exposed. These areas require the application of desensitizing agents.

Sometimes it is necessary to adjust the shape of teeth other than those being restored. Joints, muscles, and ligaments of the jaws on occasion react adversely to even minor changes to the biting surfaces of the teeth. Minor reshaping may be required to ensure that any discomfort or pain is avoided.

A veneer may become loose or require replacement if decay has developed at the margins, or if heavy biting forces (grinding, clenching, biting habits) break down the bonding materials. Patients must be diligent with home oral hygiene in addition to being careful with biting and chewing.

Gums or tissues involved in the anesthetic injection may be sore for several days following           treatment. Swelling of the tissues around the injection site is possible and can be treated by applying pressure and cold (i.e., ice packs) the day of treatment to the area of swelling for a minimum of 1-2 minutes. In addition, if freezing involves the lower jaws, there may be difficulty opening the jaw for the first few days. The soreness and stiffness will dissipate with time but warm saltwater rinses or moist heat on the side of treatment will facilitate healing. Transient facial paralysis is a rare possibility upon anesthetic injection, but it will almost always resolve itself without any future consequences.

ALTERNATIVES TO THE TREATMENT:
Veneers are an option if less intrusive treatments ex. bleaching is not sufficient to adequately correct the problem. Crowning (capping) the tooth is also an alternative to treatment however, there are no alternatives that are less intrusive than veneers that yield the same quality results.

• I hereby authorize BrightSmile Avenue to perform the procedure(s) necessary to my dental treatment, and any additional treatment procedures as are considered immediately necessary based on findings during the above-mentioned treatment.
• I have had the purpose, benefits, reasonable risks, and alternatives, if any, to the procedure(s) explained to me. I have carefully read and understood all available explanatory material. I have been given the opportunity to ask questions.
• Soreness of the gums or tissues involved in the anesthetic injection may be sore for several days following treatment. In addition, if freezing involves the lower jaws, there may be difficulty opening the jaw. The soreness and stiffness will dissipate with time.
• I consent to the administration of such local anesthesia and/or medication as is required for the dental treatment.
• I consent to the taking of photographs throughout the entire treatment procedure. Should these photographs be deemed by BrightSmile Avenue to benefit dental research, science, or education, I consent to their publication and republication, either separately or together, in professional journals or dental books or used for any other purpose which BrightSmile Avenue may deem proper in the interest of dental education, knowledge or research.

Informed Consent for Root Canal Treatment

Please read below carefully and ask for help if you need clarification or further information.

1. Success Rate. Root Canal Treatment (endodontic therapy) is about 80% successful. Many factors affect the success of the treatment: your general health, condition of the nerve and the root canal(s), bone support around the tooth, strength of the tooth (fracture lines), etc. 
2. Completion of Treatment. Root Canals are sometimes completed in a single appointment or may take several appointments, if the treatment spans several appointments, you will have a temporary filling placed on the tooth to protect the canal. If the filling should come out, please call the office so we can replace it. Once treatment is begun, it is absolutely necessary that the treatment be completed, and the patient must diligently follow any and all instructions. 
3. Sensitivity. Just like with fillings, a root canal tooth can be sensitive both during and after final treatment. Usually this sensitivity disappears in several weeks. If it does not or appears to worsen, please call the office to let us know. 
4. Crown Needed. A crown is usually recommended for any tooth that has a root canal. This is because root canal teeth no longer have a blood supply to them and become more brittle than your other teeth. This is especially true of your back chewing teeth—the molars and bicuspids. A crown goes over the root canal tooth to strengthen it and protect it from breakage. 
5. Causes of Fracture. One of the main reasons root canals fail is because of breakage or fracture of the tooth. A fractured tooth (especially a vertical fracture) can require extraction of the tooth. One of the best ways to prevent fracture of a root canal tooth is to have a crown put over the tooth to strengthen it. Other causes of fracture include grinding of teeth, improper bite, trauma, etc. These fractures can occur either before or after the root canal and often are invisible and/or hard to detect. 
6. Proper Care. Root canal teeth have no nerve, but they can still decay. It is important to take care of root canal teeth just as you would any other tooth: good home care, proper diet, and regular dental checkups. 
7. Additional Treatment. Additional treatment may be necessary. Occasionally, root canal treatment alone does not complete the treatment. The canals of the tooth can be very narrow or curved or calcified. There may be infection around the roots of the tooth. Instruments used to treat the tooth may become separated in the canal. The tooth may remain or become sensitive. A surgical procedure or possibly extraction may be necessary to try to resolve the problem. 

The nature and purpose of root canal treatment has been explained to me, and I have had an opportunity to have my questions answered. I understand that dentistry is not an exact science and success with root canals cannot be guaranteed. In view of the above information, I authorize the doctor and/or such associates and assistants as necessary to render any treatment necessary and/or advisable to my dental condition including any and all anesthetics and/or medications.

Consent to the Use of Papoose Board and Behavior Therapy for Pediatric Patients

Please read below carefully and ask for help if you need clarification or further information.

 

Because your child is a minor, it is necessary that signed permission be obtained from a parent or guardian before any/or all necessary dental treatment is performed. Diagnosis of services needed and financial obligations will be discussed with you by the doctor and/or staff before treatment is rendered.

Your signature authorized BrightSmile Avenue and/or its Pediatric Dentist Associate to render necessary dental treatment, to administer anesthetics, to administer medication, to take radiographs (X-rays), clinical photographs, study models and other records necessary for an accurate diagnosis, to utilize behavior management therapy as needed to provide safe dental care for your child and employ such assistance as is appropriate.

Providing quality dental care for children requires expertise in directing child behavior. Our goal is to instill in the child, a positive attitude towards dentistry. Maintaining proper behavior of children while in the dental office demands skill of verbal guidance, prevention of inappropriate actions, and reinforcement of appropriate behavior. These techniques are used only for behavioral modification and not to reprimand or punish a child.

The following are various behavior management techniques used in this office.

• Positive Reinforcement: Social reinforcers such as verbal praise and non-social reinforcers such as rewards (toys, stickers).
• Tell-Show-Do: Explain procedures and instruments to the child with the use of modified terms such as “sleepy juice,” “water whistle,” and “wiggle tooth” rather than “shot,” “drill,” and “pull tooth.”
• Distraction: Use of distraction to divert the patients' attention from what he/she may perceive as unpleasantness.
• Voice Modification: Change of voice volume or tone to gain a child's attention and direct his/her behavior.
• Nitrous Oxide/Oxygen Sedation: This is a very safe and effective conscious sedation method which is easily monitored. The onset of this sedation is quick and recovery is fast and complete before the child leaves the office.
• Pediwrap or Papoose: Partial or complete immobilization with the use of a blanket type wrap, is sometimes necessary to protect the child from injury while using dental instruments. This technique is only used in cases when it has been determined that all other forms of behavior management have not or will not be effective.

It is our office policy to minimize the use of more extreme forms of behavior management techniques and to implement them only when necessary.