Grandville Pediatric Dentists West Michigan

Informed Consent Form

  • Pediatric Dentistry Informed Consent Form

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  • Pediatric Dental procedures include but are not limited to teeth cleaning, fluoride application, dental radiographs, fillings, nerve treatment, crowns, extractions, tooth repositioning, and space maintenance.

    It is your right, as a parent, to understand the risks, benefits, and alternatives of your child’s dental treatment before giving consent for specific dental treatment.

    Patient Management Techniques

    We make every effort to maintain the cooperation of young patients using warmth, humor, friendliness, persuasion, gentleness and positive reinforcement. We invite you to stay with your child during the first visit and the initial examination so you will be familiar with our office and the staff providing care for your child. At future visits where your child may need restorative care, we know that many children tend to get anxious. This is why we ask that you allow your child to come into their appointment without you. We find that this allows to gain rapport and trust with your child. There are occasions where additional behavior management may be required to gain cooperation and prevent children from injuring themselves or dental staff. The following is a list of behavior management techniques that are recommended by the American Academy of Pediatric Dentistry.

    Tell-show-do: The dentist or assistant explains to the child what is to be done using simple terminology and shows the child what is to be done by demonstrating with instruments. The procedure is then performed in the child’s mouth as described. Praise is used to reinforce cooperative behavior.

    Positive Reinforcement: This technique rewards the child who displays any behavior that is desirable. Examples of rewards include compliments, encouragement, praises, or prizes.

    Voice Control: The attention of a disruptive child is gained through lowering or raising the tone and volume of the dentist’s voice. Care is taken not to make the child feel threatened. Content of the conversation is less important than the manner in which it is communicated.

    Nitrous Oxide “laughing gas”: It is not intended to put children to sleep, but only to relax them and minimize their anxiety.

    Mouth Props “tooth pillow”: A soft, rubber device used to assist the child in keeping their mouth open during a procedure. A MOLT might also be used. It is an external mouth opening device used in children with a strong gag reflex.

    Protective stabilization by the dental assistant: The assistant gently protects the child from movement by holding the child’s hands, stabilizing the child’s head or positioning the child safely in the dental chair. This is only used if absolutely necessary.

    Pedi-wrap: rarely used. This is a restraining device to limit a patient’s uncontrollable movements and to prevent injury. It is used as a last resort when treatment cannot be accomplished any other way and only upon consent by parent.

    Possible Risks Associated With Dental Procedure

    Although good results are expected, some risks are known to be associated with dental procedures. The risks include but are not limited to: pain, bleeding and swelling, tooth discoloration, nausea, vomiting, hyperventilation, fainting, temporary or permanent numbness, and allergic reactions. The listed pediatric dentistry behavior management techniques have been explained to me. I understand their use, and the risks/benefits/alternatives available. I have had all my questions answered and I realize I can always seek further information or revoke permission for the use of these techniques.

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