BITE EQUILIBRATION CONSENT FORM

What is Occlusal Equilibration and its benefits?

Occlusion (or biting) is the result of all components used in bringing teeth together. These components include the TMJ joints, the biting muscles, the upper and lower jaws, gums, and teeth. The resulting bite or occlusion can become misaligned when any one of these components are outside of their normal limits. When this happens it results in pain, abnormal wear on teeth and restorations or broken teeth and restorations. Occlusal equilibration is the altering of the biting surfaces of teeth with the intent to place them back to a normal position. How they got out of position is usually due to the accumulation of several fillings, crowns, and bridges, having teeth extracted, orthodontics, developmental defects, trauma, and clenching or grinding habits.

What are the risks?

  1. The bite feels different: This is normal, and you will gradually accept this as your new bite
  2. Reduction in tooth or restoration surface: When adjusting the biting surfaces, it is necessary to grind off the offending areas of enamel or restorative material. This is minimal in most areas.
  3. Restorative care needed afterwards: If one or more teeth are severely out of alignment more aggressive adjusting will be necessary. This could result in the tooth needing a restoration in the form of a filling, on-lay or crown. Existing dental work may need to be replaced as well.
  4. Sensitive teeth: After adjustments the teeth may become sensitive. Topical application of a desensitizing gel can alleviate most symptoms. However, restorative care may be needed in the form of a filling, on-lay, crown or root canal.
  5. Occlusal guard may be needed: After equilibration it may become necessary to wear an occlusal guard (bite splint) to continue protecting the teeth and its bite.

What are my alternatives?

Considering the components used in creating a bite, altering other variables may be used. They include occlusal appliance therapy, orthodontics, reconstructive dentistry, and orthognathic surgery. After equilibration these other approaches may be necessary.

INFORMED CONSENT:

I can read and write English and have been given the opportunity to ask any questions regarding the nature and purpose of the proposed treatment and have received answers to my satisfaction. I do voluntarily assume any, and all possible risks, including the risk of substantial harm, which may be associated with any phase of this treatment in hopes of obtaining the desired result. The fees for these services have been explained to me and I accept them as satisfactory. By signing this form, I am freely giving my consent to authorize the doctors in rendering any services they deem necessary or advisable to treat my dental conditions, including the administration and/or prescribing of any anesthetic agents and/or medications.

Anesthetic:

The use of local anesthetic is used for pain control during dental procedures. There are inherent risks and side effects. They include, but not limited to swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction, and altered sensation that may lead to self-injury. Partial or complete numbness may linger after the dental appointment. In rare cases it can last for an extended time and potentially it can be permanent.

Guarantees:

The practice of dentistry is not an exact science, and no procedure is 100% successful. The doctors have made no guarantees of a successful outcome.

Notifications:

If a patient develops a problem, it is the patient’s responsibility to notify the doctors. Through this notification we will be able to act on the patient’s behalf. Attempts to correct a problem may occur at our office or a referral to another health care practitioner may be warranted. I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful. I authorize photos, slides, x-rays or any other viewings of my care and treatment during or after its completion to be used for educational purposes.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

  • Pre and post treatment instructions have been explained to me.
  • I had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
  • I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
  • Must notify the clinician if my medical history changes prior to subsequent treatments.
  • I consent to clinical photographs being taken of my treated areas for my personal health record only.
  • There are no refunds for services rendered and/or after a year from purchase and not used.
  • The treatments I receive here are voluntary and I release KAI LIFE Clinic, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
  • My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.



Patient Name :
Signature

Doctor Name
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date