Informed Consent for Braces

Abstract

The influence of law on the orthodontic profession has greatly increased in the last few decades. Dental law has emerged today as a full-fedged specialty dealing with a variety of areas, like professional negligence, doctor-patient contracts, consumer protection laws, ethics, general and special health legislations and practice regulatory mechanisms. This article highlights the concept of informed consent which is based on the premise that each individual has a right to make decisions concerning his health, disease and treatment.
How to cite this article: Jharwal V, Trehan M, Rathore N, Rathee P, Agarwal D, Mathur N. Informed Consent for Braces. Int J Clin Pediatr Dent 2014;7(2):105-108.

Full text

International Journal of Clinical Pediatric Dentistry, May-August 2014;7(2):105-108
105
IJCPD
Informed Consent for Braces
Informed Consent for Braces
1
Vikas Jharwal,
2
Mridula Trehan,
3
Nidhi Rathore,
4
Pooja Rathee,
5
Deepesh Agarwal,
6
Nikunj Mathur
IJCPD
REVIEW ARTICLE
1,3
Senior Lecturer,
2
Professor and Head
4,6
Assistant Professor,
5
Reader
1-3
Department of Orthodontics and Dentofacial Orthopedics
Mahatma Gandhi Dental College and Hospital, Jaipur
Rajasthan, India
4
Department of Orthodontics and Dentofacial Orthopedics
Government Dental College, Jaipur, Rajasthan, India
5
Department of Orthodontics and Dentofacial Orthopedics
Jaipur Dental College, Jaipur, Rajasthan, India
6
Department of Oral Medicine and Radiology, Government
Dental College, Jaipur, Rajasthan, India
Corresponding Author: Vikas Jharwal, E-117/118, Siddharth
Apartment, Sect-14, Malviya Nagar, Jaipur, Rajasthan-302017
India, Phone: 91-9982000019, e-mail: vikasjharwal19@
gmail.com
10.5005/jp-journals-10005-1246
ABSTRACT
The inuence of law on the orthodontic profession has greatly
increased in the last few decades. Dental law has emerged
today as a full-edged specialty dealing with a variety of areas,
like professional negligence, doctor-patient contracts, consumer
protection laws, ethics, general and special health legislations
and practice regulatory mechanisms. This article highlights the
concept of informed consent which is based on the premise
that each individual has a right to make decisions concerning
his health, disease and treatment.
Keywords: Consent, Informed consent, Ethics, Medicolegal
perspective.
How to cite this article: Jharwal V, Trehan M, Rathore N,
Rathee P, Agarwal D, Mathur N. Informed Consent for Braces.
Int J Clin Pediatr Dent 2014;7(2):105-108.
Source of support: Nil
Conict of interest: None declared
INTRODUCTION
The Webster’s dictionary defines consent as ‘to give assent
or approval’. The over simplification of Webster’s defini-
tion however does not and should not apply to the field of
dentistry.
1
The British Dental Association (BDA) ‘Ethics
in Dentistry’ advice sheet is a case in point. The concept of
medical informed consent is evident already in the Hippo-
cratic Oath, which clearly illustrates the notion that respect
is an integral part of the relationship between patients and
healthcare professionals in the pledge, ‘first, do no harm’.
2
CONSENT TO DENTISTRY
Informed consent is not a signature on a consent form. It is
not a single event, it is a process of dialog between the den-
tist and the patient. The British Dental Association ‘Ethics
in Dentistry’ advice sheet defines the process of expressing
consent as ‘a patient gives express consent when he or she
indicates orally or in writing consent to undergo examination
or treatment or for personal information to be processed’.
2,3
TYPES OF CONSENT
The BDA Ethics in Dentistry further lays down the follow-
ing definitions:
2,3
• Impliedconsent: Where the patient indicates agreement
to examine by lying in the dental chair and opening the
mouth.
• Validconsent: For consent to be valid, it must be specific,
informed and normally be given by a patient, or a parent
or a guardian.
• Writtenconsent: It is to be taken for major procedures,
examples being in orthodontics, therapeutic extraction,
orthognathic surgery, orthodontic mini-implant place-
ment, sedation, etc. Written consent is all the above with
a signature of the patient. Written consent is important
but cannot be considered a substitute for obtaining valid
consent. This brings us to the obvious question of the
right age of patient for giving consent.
• Informed consent: Requires a full explanation of the
nature, purpose and material risks of the proposed
procedures in a language that the patient understands.
The patient should have the opportunity to consider the
information and ask questions in order to arrive at a
balanced judgment of whether to proceed with the
proposed treatment.
The following information is provided to patients who
will be starting orthodontic treatment in dental office:
While recognizing the benefits of teeth that function well
and have a pleasing appearance, a patient should be aware
that orthodontic treatment, like any other treatment of the
human body, has inherent risks and limitations. If a patient
decides not to proceed with treatment, then the state of the
dentition (teeth) can be expected to continue on its present
path. But, the rate of these changes is very unpredictable.
A patient must balance the risks of nontreatment against
the risks of treatment. In our opinion, the risks of treatment

106
Vikas Jharwal et al
are not enough to rule against proceeding; nevertheless, a
patient should consider them carefully before they make a
final decision.
4,6
PATIENT’S RESPONSIBILITIES
Orthodontic treatment will not be completely successful
unless a patient complies with the directions given by us.
Many treatment forces are applied by our patient outside
of the office. A patient needs to fulfill their responsibilities
because the patient’s effort is equal to their treatment result.
It is just that simple! Typically, these responsibilities will
include the following:
• Correct use of the appliance: Orthodontic appliances
are designed to deliver forces in a very specific manner.
If the appliance is not worn as requested, the treatment
will not proceed as planned.
• Meticulousoralhygiene: A thorough brushing several
times each day, complete ossing once each day and
daily application of a uoride mouth rinse are important.
• Careoftheappliance: Lost, broken or bent appliances
disrupt the treatment plan. Unwanted tooth movement
may occur, if the appliance is not working as designed.
• Regularlyscheduledappointments: Appliances must be
adjusted periodically and treatment progress must be
monitored carefully. Missed or rescheduled appointments
prolong treatment inevitably. Some appointments will be
during work or school hours.
• Routinedentalvisits: An orthodontic patient should conti-
nue to consult his/her family dentist for regular cavity
check-ups, teeth cleaning, sealants and uoride varnish
applications and periodontal evaluations based on their
risk assessment.
4,6,9
TOOTH DECAY/STAINS/DECALCIFICATION
The bacteria present in plaque (the white, sticky material that
is constantly forming on tooth surfaces) release acids that
draws the calcium and phosphorous out of the outer surface
of the tooth. This will damage patient’s tooth surfaces if the
plaque is not removed several times each day by thorough
brushing, ossing and rinsing. This damage includes tooth
decay and permanent white decalcification markings. The
bacteria that live in plaque thrive on refined carbohydrates
(sugar!). While a patient is undergoing orthodontic treat-
ment, they should minimize the amount and frequency of
sugar in their diet. These same problems can occur without
orthodontic treatment, but the risk is greater to an individual
wearing braces.
4,6,9
INFLAMMATION OF THE SOFT TISSUES
The wires, brackets or band attachments can sometimes
irritate the lips, cheeks or gum tissue. These soft tissue
irritations usually heal quickly. The wax that we give our
patients can help cushion these irritations while they are
healing. If the irritation is persistent, a patient should contact
us immediately so that we can solve the problem. Poor oral
hygiene during orthodontic tooth movement can accelerate
deterioration of the periodontal tissues (gums and under-
lying bone). Severe tissue reactions may require us to refer
a patient to a periodontal (gum) specialist or discontinue
orthodontic treatment.
4,6,9
TREATMENT GOALS AND
TREATMENT COMPLETION
We have tried to establish realistic and achievable goals
for treatment. We know that patients share our desire to
produce the best result that is possible. As we begin treat-
ment, we believe that we will be able to achieve those goals.
Nevertheless, unforeseen factors, such as atypical tooth
formation and disproportionate jaw growth may interfere
with our intentions. These biological processes are beyond
the orthodontist’s control. As treatment proceeds, we will
keep a patient fully informed as to treatment progress. If
our original goals become unreachable, we will discuss the
alternatives with the patient.
4,6,9
TREATMENT DURATION
Although we give an estimate to a patient of his/her treatment
time, we do not know exactly how long his/her treatment
will take. Individuals vary considerably in their response to
orthodontic forces, so treatment time may be more or less
than our estimate. It is our general intention to have the
treatment move along in a fashion that is consistent with
tissue health, minimal discomfort and long-term stability.
6,10
PAIN OR DISCOMFORT IN
THE JOINT OF THE JAW
Pain, discomfort, clicking or popping noises may occur in
or near the joint of the jaw at any time, including during
orthodontic treatment. Just as with any joint discomfort,
the possible causes vary widely. Orthodontic treatment did
not provide risk to the development of signs and symptoms
of TMD, regardless of the technique used for treatment,
the extraction or nonextraction of premolars and the type
of malocclusion previously presented by the patient. It is
important that we be told about jaw joint problems so that
we can deal with them promptly.
6,9,10
LOSS OF TOOTH VITALITY
It is possible for the nerve of a tooth to die during orthodontic
treatment, especially if a tooth was previously injured,
bumped or impacted. It is helpful in our monitoring the

International Journal of Clinical Pediatric Dentistry, May-August 2014;7(2):105-108
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IJCPD
Informed Consent for Braces
health of each tooth for a patient to tell us about any pre-
vious injury or stress to the tooth. Sometimes seemingly
minor bumps can result in nerve damage that is unknown
to a patient. Such previous injuries cannot always be detec-
ted during the orthodontic diagnostic process. Root canal
treatment may be recommended if such a problem occurs.
Extraction is necessary occasionally, though not usually.
6,10
INJURY FROM APPLIANCES
Appliances are designed to have a maximum amount of
strength and a minimum amount of injury potential. Never-
theless, accidents can occur and a patient can be injured
by sharp parts of the appliances. A patient could also be
injured during a routine appointment by one of our sharp
instruments. It is also possible for a patient to swallow or
inhale small parts of the appliance that fall into the back of
the throat at any time, including routine office visits. Every-
one working with a patient in the office will be attentive
particularly to preventing accidents. Headgear instructions
must be followed carefully. Improperly handled headgear
may cause injury to the face or eyes, even blindness. Patients
are warned not to wear the headgear during times of horse-
play or competitive activity. Always release the elastic force
before removing the headgear from the teeth. Although our
headgear is equipped with a safety system, we urge caution
at all times. Tender teeth should be expected after in office
adjustments. The period of tenderness or sensitivity varies
with each patient and the procedure performed. Typically,
post adjustment tenderness may last 24 to 48 hours. Abnor-
mal wear of tooth structures is also possible if a patient grinds
his/her teeth excessively.
5,6,10
UNEXPECTED GROWTH CHANGES
Growth of the facial structures and the teeth can sometimes
take unexpected turns. A child who has grown in average
proportions may not continue to do so. If growth becomes
disproportionate, the jaw relationships can be affected. If
this occurs, original treatment objectives may not be met.
6,10
UNEXPECTED TOOTH ERUPTION PROBLEMS
Sometimes when a tooth is erupting (growing in), it does
not follow the usual and expected direction of eruption.
The tooth may not be able to reach its normal position and
will become impacted or stuck under the bone. Usually, it
is possible to solve these impactions, but not always. If the
impaction is extreme and the tooth becomes tightly bound
to its surrounding bone, it may not be possible to move
that tooth at all. We will be monitoring the teeth carefully
as they grow into catch such a problem. If a tooth does
become impacted, a change in the plan of treatment may
be necessary.
6,10
ENAMEL FRACTURES
Tooth enamel is a crystalline structure and like other crystals,
it can have undetected defects and fracture lines within it.
As a result, even when extreme care is taken, enamel can
fracture during placement or removal of the appliances. Such
fractures may also occur if a band or bracket is bitten on at
just the wrong angle or if the enamel has been weakened
by decay or dental restorations (fillings). The enamel may
also be damaged by rubbing against a part of the appliance.
Tooth colored ceramic brackets are abrasive to enamel. A
patient must be sure to report if any tooth is bearing against
a ceramic bracket.
6,10
ORAL SURGERY
Sometimes tooth removal or orthognathic (jaw) surgery is
necessary in conjunction with orthodontic treatment, espe-
cially to correct crowding or severe jaw imbalances. We
will recommend these procedures only if it improves the
prospects for successful treatment. Risks involved with treat-
ment and anesthesia should be discussed with the patient’s
general dentist or oral surgeon before making a decision to
proceed with this procedure.
6,10
SUCCESS OF THE TREATMENT
We intend to do everything possible to provide the very
best treatment result. However, we cannot guarantee that
the proposed treatment will be successful to a patient’s
complete satisfaction. Individual patient differences create
the possibility of incomplete or unstable results. Selec-
tive retreatment may be necessary despite the very best of
care.
6,10
Emphasis must be placed on early, timely inter-
vention, parental involvement, effective communication,
cultural competence, and the ‘medical/dental home’ concept
as methods to reduce negative dental attitudes and behaviors
of children.
11
Although some patients were happy with the
way, their consent was obtained examples were also given
of lack of information, confusion and even of deceit.
12
ADDITIONAL TREATMENT
Unforeseen circumstances, such as growth changes or gum
disease, may cause us to recommend a form of treatment not
previously discussed. These changes in treatment plan may
require additional treatment in our office or with another
specialist. Additional treatment with associated fees will be
discussed with the patient.
7,6,10
ROOT RESORPTION
Orthodontic forces initiate a cellular response in the sup-
porting tissues surrounding the roots of the teeth. It is this
cellular response that allows the teeth to move. Sometimes,

108
Vikas Jharwal et al
this response becomes confused resulting in damage to the
ends of the roots of the teeth. Usually, this effect is mild and
does not compromise the teeth. However, sometimes this
root resorption can be extensive and may then endanger the
teeth, if periodontal (bone and gum) support is lost at some
future time. Some patients are prone to this happening, some
are not. Because it is not possible to predict which teeth
might be affected, we may want to take progress X-rays of
a patient’s teeth during the treatment process to evaluate
whether root resorption is occurring.
6,10
STABILITY OF THE FINAL RESULT
The tooth positions achieved at the end of treatment may
not be perfectly stable. The retainers that, a patient wears,
will enhance the stability of the final result, but even diligent
wear of the retainers may not keep a patient’s teeth exactly
as they were at treatment’s end. The teeth and jaw structures
are dynamic system that constantly changes throughout one’s
lifetime. Orthodontic treatment does not make a patient
immune to this process. Maturational changes that occur
after active orthodontic treatment may alter the quality of
the end result. Ongoing wear of the retainers will minimize
changes. If a patient decides to stop wearing, his/her retai-
ners at some point, his/her teeth may change. Some of the
original problem may re-emerge.
6,8,10
CONCLUSION
Clearly, there are a number of sources of potential iatrogenic
damage to the patient during orthodontic treatment. However,
severe damage is rare. Severe malocclusions have more to
benefit from treatment than less severe malocclusions, and
motivation between such groups may vary. Individuals
should be assessed for risk factors for all aspects of care
content and recommendations are analyzed and discussed
from a medicolegal perspective. It is important that such
guidelines are updated in the light of research findings and
clinical audit. Clinicians should be aware of such guidelines
and the legal implications of failing to at least consider when
providing advice and/or treatment for patients.
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