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Informed Consent for Sleep Orthotic Appliance

Informed Consent for Sleep Orthotic Appliance

The Sleep Orthotic Appliance is a mechanical device to keep the airway open during sleep. It does not cure snoring or OSA. It must be worn each night to be effective. It is possible that the appliance may not maintain its effectiveness over time and needs to be checked at least twice a year by your dentist to ensure proper fit and effectiveness. Some patients may not be able to tolerate a Sleep Orthotic Appliance or any other device in their mouths.

Potential Complications
Some patients may develop temporary side effects such as:
• sore jaw joints;
• excessive salivation;
• dry mouth;
• sore teeth;
• irritation of the soft tissues in the mouth;
• slight change in the bite. In some cases, a permanent “bite” change may occur.
If any unusual symptoms or side effects occur, you must contact your dentist immediately.

As with any form of medical or dental treatment, unusual occurrences can and do occur:
• broken or loosened teeth;
• dislodged dental restorations;
• sore mouths;
• gum disease;
• deterioration of tooth structure;
• non-vital teeth (dead teeth);
• muscle spasms;
• ear problems;
These are examples of possible unusual occurrences and are unusual and infrequent.

Additional medical and dental risks that have been mentioned may occur, but are unlikely to. If any unusual symptoms occur, you should cease using the appliance immediately until you see your dentist or doctor. Please call the surgery/practice if you have any questions or problems regarding the treatment.

Alternative Treatment Options
Several factors contribute to snoring and OSA, including nasal obstruction, narrow airway space in the throat and excess weight. Other accepted treatments for snoring and OSA that should be considered by sufferers, include:
• lifestyle changes (e.g. weight loss);
• behavioural modification;
• Continuous Positive Airway Pressure (“CPAP”);
• and surgical procedures.

The cost of treatment with a Sleep Orthotic Appliance is as outlined in the attached treatment plan. Full payment is required on insertion of the device, regardless of whether treatment is discontinued for any reason. This may include the patient being unable to tolerate wearing the Sleep Orthotic Appliance.

The above fee includes the construction of the Sleep Orthotic Appliance, as well as the standard follow-up visits associated with adjusting the device, which are the 1-week, 2-week, 1-month, 3-month, 6-month and 1 year adjustment and review visits. Any additional visits regarding the device may incur additional costs

• I have been assessed for snoring and/or OSA through a sleep study.
• I have read and understand the conditions and information in this Consent Form.
• I have discussed the information contained in the Consent Form concerning the Sleep Orthotic Appliance with my dentist.
• I have had explained to me the cost of the treatment and I accept responsibility for that cost.
• I authorise my dentist to provide me with treatment using a Sleep Orthotic Appliance.