Consent
for Dental Impression and Molding: Benefits and Risks
BENEFITS
The goal of pre-surgical nasal alveolar molding is to reposition the
infant’s tissue for proper alignment and symmetry of the affected
nostrils, columella, pro labia, lip and alveolar ridge (the gum where
the teeth come in).
Molding significantly
improves the surgical outcome of the lip and nose by reducing the size
of the gap and lifting the nostril before the first surgery.
Molding cancan reduce
the numbers of surgical procedures that your child may need. It also minimizes
scarring. Molding will not completely correct the defect caused by the
cleft but should markedly improve the surgical outcomes following molding.
RISKS
Risks associated with taking the impression
1. If anesthesia is needed, the risks include: respiratory problems, drug
reactions, paralysis, brain damage or even death. .
2. Aspiration of the impression material is unlikely but may result in
surgical intervention
3. Injury to the soft/hard tissues associated with the peri-oral region.
Risks associated with
use of the appliance:
1. Sore spots, irritation, discomfort
2. Candida or other types of infection if proper hygiene is not maintained
3. Possible damage or perforation of the involved tissue if appliance
is not properly positioned or improperly used.
Risks of Taping (use
of tape and adhesive and adhesive remover) include but are not limited
to:
1. Irritation, scabbing, discomfort
2. Pain, infection
3. Injury to eyes or adjacent tissue if liquid adhesive is misused
I have read and discussed
the “Pre Surgical Nasal Alveolar Molding (PNAM) Benefits and Risks”
as written above. I have had the opportunity to ask questions about the
process.
I understand that
the information provided in the Benefits and Risks is not meant to scare
or alarm me; it is provided in an effort to make me better informed so
that I can decide whether to choose to have dental impressions taken for
my child and actively participate in the pre surgical nasal alveolar molding.
I understand
that there are risks involved in taking the impression, inserting the
appliance and taping. I also understand that I have a right to chose not
to participate in pre-surgical nasal alveolar molding. I understand that
pre surgical molding generally results in significantly better surgical
outcomes than surgery without pre surgical molding. I also understand
that molding does not preclude the need for future surgery(s) or orthodontic
work.
___________________________________________________________________________________________________________
I Do ⌊ Do Not
⌊ Consent to proceed with dental impressions and pre-surgical nasal
alveolar molding of my child
________________________________
_____/____/_____
First Name - Initial - Last name
Date of birth: month/ day / year
_______________________________
___________________________________
Signature of Parent/Legal Guardian
Date/Time Witness Signature:
____________________________________
___________________________________
Printed Name of parent/guardian
Printed Name of Witness
U.T. Dental Branch/Pediatric Dentistry
6655 Travis, #460, Houston, TX 77030
Translated into: __________________________By:_________________________
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