300 S Center St. GOLDSBORO, NC 27530

Orthodontic New Start Paperwork

Office Policy & Rules

Welcome to our office! We are so glad you are becoming a part of the GPDO family! Our goal is to make this experience as enjoyable and rewarding as possible. We will be working by your side throughout this journey, so feel free to contact us with any questions or concerns you may have.

In order to ensure that treatment progresses in a timely fashion and oral health is maintained Goldsboro Pediatric Dentistry and Orthodontics has the following rules:

  • May not have constant broken brackets - Having broken brackets will cause major delay in treatment time and can also cause permanent damage to teeth. To prevent the occurrence of broken brackets, please do not eat foods that are not permitted and always wear a mouthguard when playing contact sports.
  • May not have repetitive missed/rescheduled appointments - Unsupervised orthodontic treatment can lead to permanent damage to the teeth and roots. The wires placed are very powerful and therefore must be supervised by a licensed orthodontist every 6-8 weeks.
  • Must maintain good oral health - This can be achieved by proper brushing and flossing and with regular visits to the general dentist for cleanings and check-ups. Poor oral health may result in decalcification, decay, bone loss, and premature loss of permanent teeth.

I understand that the rules of this practice must be abided by while in treatment, and if not, it will result in premature removal of all orthodontic appliances. I have reviewed the no-no list given and understand my child may not consume these items. I also understand that if the patient is not seen for a period of 12 consecutive weeks or more, orthodontic treatment will be discontinued at the following visit.

Once again, we are so glad that you are now a part of Goldsboro Pediatric Dentistry and Orthodontics, and we hope that this will be a wonderful experience!

Patient/Patient’s Responsible Party Signature:

INFORMED CONSENT for the Orthodontic Patient

Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; how- ever, all patients should seriously consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.

Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis, prevention, interception and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures.

An orthodontist is a dental specialist who has completed at least two additional years of graduate training in orthodontics at an accredited program after graduation from dental school.

Risks and Limitations of Orthodontic Treatment Below:
Results of Treatment

Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee that you will be completely satisfied with your results, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the orthodontist’s instructions carefully.

Length of Treatment

The length of treatment depends on a number of issues, including the severity of the problem, the patient’s growth and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if patient cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If treatment time is extended beyond the original estimate, additional fees may be assessed


The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction of orthodontic appliances. Non-prescription pain medication can be used during this adjustment period.


Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear your retainers as instructed or teeth may shift, in addi- tion to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situations may require non-removable retainers or other dental appliances made by your family dentist.


Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks associated with the removal of teeth, which you should discuss with your family dentist or oral surgeon prior to the procedure.

Orthognathic Surgery

Some patients have significant skeletal disharmonies, which require orthodontic treatment in conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery, which you should

discuss with your oral and/or maxillofacial surgeon prior to beginning orthodontic treatment. Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment!

Decalcification and Dental Caries

Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/ or decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient consumes sweetened beverages or foods.

Root Resorption

The roots of some patients’ teeth become shorter (re- sorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth throughout life with severe- ly shortened roots. If resorption is detected during or- thodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the appliances prior to the completion of orthodontic treatment.

Nerve Damage

A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the tooth. Also, the nerve of a tooth may die for no apparent reason, and this is known as “spontaneous pulpal necrosis.” Orthodontic tooth movement may, in some cases, aggravate these conditions and cause root canal treatment to be necessary. In severe cases, the tooth or teeth, may be lost.

Periodontal Disease

Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to the lack of adequate oral hygiene. You must have your general dentist, or if indicated, a periodontist monitor your periodontal health during orthodontic treatment every three to six months. If periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.

Injury From Orthodontic Appliances

Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliances can be inhaled or swallowed or could cause other damage to the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when ortho¬dontic appliances are removed. This problem may be more likely when esthetic (clear or tooth colored) appliances have been selected. If dam- age to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.


Orthodontic headgear can cause injury to the patient. Injuries can include damage to the face or eyes. In the event of injury or especially an eye injury, however minor, immediate medical help should be sought. Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.

Temporomandibular (Jaw) Joint Dysfunction

Problems may occur in the jaw joints, i.e., temporoman- dibular joints (TMJ), causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or face), arthritis,

hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without orthodontic treatment. Any jaw joint symptoms, including pain, jaw popping or diffi- culty opening or closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.

Impacted, Ankylosed, Unerupted Teeth

Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of these conditions depends on the particular circumstance and the overall importance of the involved tooth, and may require extraction, surgical exposure, surgical transplantation or prosthetic replacement.

Occlusal Adjustment

You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby “flattening” surfaces in order to reduce the possibility of a relapse.

Non-Ideal Results

Due to the wide variation in the size and shape of the teeth, missing teeth, etc., achievement of an ideal result (for example, complete closure of a space) may not be possible. Restorative dental treatment, such as esthetic bonding, crowns or bridges or periodontal therapy, may be indicated. You are encouraged to ask your orthodon- tist and family dentist about adjunctive care.

Third Molars

As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist should monitor them in order to determine when and if the third molars need to be removed.


Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan or discon- tinuance of treatment prior to completion. Although very uncommon, medical management of dental material allergies may be necessary.

Transmission of Disease

Although our orthodontic office is following the State and Federal regulations and recommended universal personal protection and disinfection protocols to prevent transmission of communicable disease, it is possible that that they will not always be successful in blocking the transmission of a highly infectious virus. It is not possible to render orthodontic treatment with social distancing between the patient, orthodontist, assisting staff and sometimes, other patients. Knowing that you could be exposed to communicable diseases anywhere, by presenting yourself or your child for orthodontic treatment, you assume and accept the risk that you may inadvertently be exposed to a communicable disease in the orthodontic office

General Health Problems

General health problems such as bone, blood or endocrine disorders, and many prescription and non-prescription drugs (including bisphosphonates) can affect your orthodontic treatment. It is imperative that you inform your orthodontist of any changes in your general health status.

Use of Tobacco Products

Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.

Temporary Anchorage Devices

Your treatment may include the use of a temporary an- chorage device(s) (i.e. metal screw or plate attached to the bone.) There are specific risks associated with them. It is possible that the screw(s) could become loose which would require its/their removal and possibly relocation or replacement with a larger screw. The screw and related material may be accidentally swallowed. If the device cannot be stabilized for an adequate length of time, an alternate treatment plan may be necessary.

It is possible that the tissue around the device could become inflamed or infected, or the soft tissue could grow over the device, which could also require its removal, surgical excision of the tissue and/or the use of antibiotics or antimicrobial rinses.

It is possible that the screws could break (i.e. upon insertion or removal.) If this occurs, the broken piece may be left in your mouth or may be surgically removed. This may require referral to another dental specialist.

When inserting the device(s), it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually these problems are not significant; however, additional dental or medical treatment may be necessary.

Local anesthetic may be used when these devices are inserted or removed, which also has risks. Please advise the doctor placing the device if you have had any difficulties with dental anesthetics in the past.

If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.


I hereby acknowledge that I have read and fully understand the treatment consider- ations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results.

I also acknowledge that I have discussed this form with the undersigned orthodon- tist(s) and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the orthodontist(s) indicat- ed below to provide the treatment. I also authorize the orthodontist(s) to provide my health care information to my other health care providers. I understand that my treat- ment fee covers only treatment provided by the orthodontist(s), and that treatment provided by other dental or medical pro- fessionals is not included in the fee for my orthodontic treatment.


I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment, and to the above doctor(s) and, where appropriate, staff providing orthodontic treatment prescribed by the above doctor(s) for the above individual. I fully understand all of the risks associ- ated with the treatment.


I hereby authorize the above doctor(s) to provide other health care providers with information regarding the above individu- al’s orthodontic care as deemed appro- priate. I understand that once released, the above doctor(s) and staff has(have) no responsibility for any further release by the individual receiving this information.


I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education, or publication in professional journals.

Patient/Patient’s Responsible Party Signature:

Illness Policy

In our office we have our patients, staff, and / or staff's children and families to think about when it comes to illness and health. We want our staff in the best health to accommodate our patients; for example you! We understand that deciding when to keep your child or yourself home from an appointment may be difficult. When a patient is sick we ask that you call and reschedule. If a medical provider makes a specific diagnosis (such as strep throat, conjunctivitis, or chicken pox), please let us know.

There are three reasons to keep a sick patient from an appointment:

  • The child does not feel well enough to participate comfortably in usual activities, such as with extreme signs of tiredness or fatigue, unexplained irritability or persistent crying.
  • The child requires more care than we may be able to provide with out effecting the health and safety of the other patients, patients families, and staff and family.
  • The illness is on the list of symptoms or illness for which exclusion is recommended.

We ask that you please call and reschedule if you or your child has any of the following illnesses:

  • Chicken pox - We ask that you reschedule for after child has fully healed from blisters and possible scabs.
  • Conjunctivitis - (pink or red eyes with thick mucous or pus draining from the eye) - Patient may be rescheduled 24 hours after treatment begins.
  • Coxsackie Virus - (hand, foot, and mouth disease) - We ask that the patient does not return symptoms are gone (for example: fever, malaise, rash, and small blisters that ulcerate. The most frequent locations for the blisters/ulcers are on the palms of the hand, soles of the feet, and in the mouth).
  • Diarrhea with illness - (vomiting, fever, and or rash) - Patient may be present if diarrhea is not illness related, I.E. caused by antibiotics or food sensitivity.
  • Fever with behavior changes or illness - When fever is elevated above 100 degrees and is accommodated by changes in behavior or other symptoms such as fatigue, rash, sore throat, vomiting, diarrhea, etc.
  • Head Lice - Patient may be seen once treatment and removal of all live lice and nits from hair has been completed.
  • Body rash with fever - Patient should seek medical advice. Any rash that spreads quickly, has open, weeping wounds and/or is not healing should be evaluated. Patient may be seen once medical provider determines that illness is no longer contagious.
  • Upper respiratory complications - Seek medical advice, patient may be seen once symptoms are improved. Examples: large amounts of thick nasal discharge, extreme sleepiness, ear pain, and fever above 100 degrees orally
  • Ring Worm - Patient may be seen after treatment has started and must be covered in office.
  • Strep Throat - We are able to see patient once patient has been on an antibiotic for 24 hours and no fever for 24 hours.
  • Vaccine Preventable Diseases - (Mumps, Measles, Whooping Cough, ETC.) - Patient may return after he or she is judged not infectious by a medical provider.
  • Vomiting - (Two or more episodes in the past 24 hours) - Until vomiting resolves or a health care provider determines that the cause is not communicable the patient should not be seen.

We appreciate your cooperation with our illness policy. By signing below means that you understand that we can not see the patient with any of the above illnesses listed. If we have any reason to believe that the patient has any of these illnesses please understand that we may respectfully ask you to reschedule the appointment. Thank you from the staff of Goldsboro Pediatric Dentistry and Orthodontics

Patient/Patient’s Responsible Party Signature: