Obstructive Sleep Apnea/Sleep Disordered Breathing

Informed Consent for treatment of Obstructive Sleep Apnea/Sleep Disordered Breathing

Obstructive sleep apnea (OSA) & Sleep Disordered Breathing (SDB) are medical conditions with a dental treatment. Dr.Cichon will work in collaboration with your physician to achieve the best results possible for the treatment of sleep apnea.

SUCCESSFUL TREATMENT: Oral appliance therapy is a very effective treatment. However, no therapy works 100% of the time. The mandibular advancement device (MAD) works by moving the jaw and tongue forward at night which acts to keep the airway open. As with any medical therapy, successful treatment of OSA using dental appliances cannot be guaranteed. Success depends on many things. The most important component of success is patient compliance. By signing this document, you hereby agree to follow Dr.Cichon's instructions in detail. Failure to do may well result in a poor clinical outcome.

COMPLICATIONS OF TREATMENT: OSA has been associated with many other medical conditions. As a result of OSA, or as a complication of OSA treatment, patients may develop these or other temporary or permanent co-morbid diseases: coronary artery disease, high blood pressure, diabetes, cerebrovascular disease, stroke, heart problems, heart attack, arterial fibrillation, depression, mood disorders, sexual dysfunction, weight gain, obesity, excessive daytime sleepiness, increased work-related and traffic-related accidents, and death.

DENTAL ISSUES: A number of temporary or permanent dental issues can develop as a result of long term treatment of OSA with a mandibular advancement device (MAD), including but not limited to: jaw joint pain, TMH dysfunction, morning headaches, popping and noise in the jaw, sore teeth, dental decay, gum (periodontal) disease, gingivitis, worsening of periodontal pockets, tooth loss, loosening of teeth, dry mouth or excess saliva, fracturing or loosening of dental fillings, crowns or bridges, short term or long term bite changes, spacing or shifting of teeth, tilting of teeth profile changes, lessening of overbite or overjet, dental infection, infections of the gums, difficulty chewing, oral cysts, oral tumors, oral cancer, and death.

FINAL SLEEP STUDY AND EVALUATION: After your appliance is delivered, you will be adjusting it to achieve the best improvements in symptoms such as snoring and daytime sleepiness possible. When your apnea symptoms have improved and you and Dr.Cichon are satisfied with the results of the adjustments, you will be referred back to your physician for post-treatment evaluation. This evaluation is to assess the effectiveness of MAD in maintaining an open airway during sleep and often includes a repeat sleep study.

FOLLOW UP APPOINTMENTS: are required with Dr.Cichon on a 6 month or yearly basis to check the effectiveness of your appliance and monitor appliance condition and evaluate any dental complications that may occur. Failure to maintain these follow-up appointments will constitute a lack of compliance with Dr.Cichon’s treatment plan. Any decision on your part to forego follow-up appointments places your health at risk and increases the probability of complications and treatment failure.

Additionally, recall appointments should be kept with your general dentist on a three month schedule for the first year that you wear a MAD to evaluate your dental hygiene, gums and check for decay. By signing this agreement you agree that you have heard this recommendation; avoiding this preventive oversight might result in excessive dental disease.

ALTERNATIVE TREATMENTS: By signing this consent form you acknowledge that you have been made aware of reasonable alternatives to MAD therapy for obstructive sleep apnea including, but not limited to: Positive Air Pressure therapy (CPAP or other variants), oral or pharyngeal surgery, positional sleep therapy, weight loss, and exercise. Additionally, you are aware that more than one treatment may be necessary for the best results.

WHEREFORE: | give my consent for the treatment of my OSA/SDB using a mandibular advancement device (MAD). | agree and consent to allow Dr.Cichon and his staff to examine my mouth, teeth, jaws, gums, and associated structures. | give consent for the taking of x-rays, photos, impressions and any other procedures necessary for the treatment of my OSA/SDB. |give consent for a home sleep study, if necessary, for the adjustment of my appliance. | consent for the contents of my record to be shared with my medical providers whose names | have provided and insurance company(s) for the purpose of obtaining medical coverage.

| affirm that | have read this document and have been given adequate information regarding the treatment of my condition to give my informed consent. | understand the proposed treatment of my OSA using MAD therapy and | have been given the opportunity to ask questions. All of my questions have been answered and | am ready to proceed with treatment.

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