WP E-Signature by Approve Me - Sign Documents Using WordPress -

For the Orthodontic Patient

Risks and Limitations of Orthodontic Treatment

Patient Name:

Parent/Guardian Name:

The purpose of this document is to inform you of the general risks associated with orthodontic treatment of patients who are now taking, or have taken in the past, medications known as "bisphosphonates”, or other antiresorptive drugs for treating osteopenia or osteoporosis.

Bisphosphonate medications you may be taking, or have taken, include: Fosamax® (alendronate), Actonel® (risedronate), Boniva® (ibandronate), Skelid® (tiludronate), Didronel® (etidronate), Aredia® (pamidronate), or Zometa® (zoledronic acid). There may be other brand names in addition to those listed above. Other antiresorptive drugs you may be taking, or have taken, include: Prolia®, Forteo®, Xgeva® (denosumab).

These types of medications are prescribed by your physician as part of a treatment regimen to minimize bone loss throughout your body. However, for the bone surrounding the teeth, these medications may have a negative effect on normal orthodontic tooth movement. Because these drugs inhibit bone resorption, it is likely they will inhibit tooth movement during

orthodontic treatment. This inhibitory effect on tooth movement may lengthen your orthodontic treatment time. The effects of these medications may be severe enough to stop tooth movement, which may require cessation of your treatment (removal of braces), resulting in tooth positions that are unfavorable. No orthodontist can predict the effect bisphosphonates, or other antiresorptive drugs, on an individual’s orthodontic tooth movement.

Long-term use of bisphosphonates has been observed to decrease bone healing. This effect may impact surgical procedures performed within the jaws or bone surrounding the teeth and may result in compromised healing, and, in some cases, no bone healing.

The risk for developing osteonecrosis is higher for cancer patients on I.V. bisphosphonate therapy. There is also a higher risk of osteonecrosis of the lower jaw for patients taking Prolia® (denosumab, an Anti-RANKL agent).

I have reviewed this notice, and I understand the issues it describes. I have discussed any questions I have with my doctor. I acknowledge I assume these risks and choose to continue with treatment.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

March 11, 2020 1:48 pm MST

Orthodontic Informed Consent for the Use of Bisphosphonates or Other Antiresorptive Drugs for Treating Osteopenia or Osteoporosis Uploaded by Won-Woo Park - forms@ooliortho.com IP 70.163.243.141

April 2, 2023 5:46 pm MST

WW Jonathan Park - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

April 2, 2023 5:46 pm MST

MJ Cindy Kim - cindy@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141