The following is provided to allow you to make informed personal decisions concerning your child's dental treatment after considering the risks, benefits and alternatives. Please read this form carefully and ask about anything that you do not understand.
It is very important that you appreciate that I adhere to what I call the Vanessa, Natalie and Emily Principle. Briefly stated, Vanessa, Natalie and Emily are my own children and all treatment decisions in this office are based on the philosophy that I treat my patients in the same manner that I would want my own children treated. For over twenty years of providing dental services for children, I have found this to be an invaluable golden rule.
It is my intent that all professional care delivered in this office shall be of the best possible quality I can provide for your child. Providing high quality care can sometimes be made very difficult, or even impossible, because of lack of cooperation of some child patients. Among the behaviors that can interfere with the proper provision of quality care are hyperactivity, resistive movements, refusing to open the mouth or keep it open long enough to perform necessary dental treatment, and even aggressive or physical resistance to treatment, such as kicking, screaming and grabbing the dentist's hands or sharp instruments.
My goal is to help my child patients master the dental experience. Some children may cry as part of this learning process. Childhood emotions are intense and crying is a natural release of anxiety and/or an avoidance scheme. All efforts will be made to obtain the cooperation of our patients by the use of warmth, friendliness, persuasion, humor, charm, gentleness, kindness and understanding.
There are several recognized management techniques that are used by pediatric dentists to gain cooperation of child patients, to eliminate disruptive behavior or prevent patients from causing injury to themselves due to uncontrollable movements. We combine the following recognized techniques individually, as appropriate for each child.
TELL-SHOW-DO: The child is told what is to be done using simple words and then shown on a model or finger. The procedure is done exactly as told. Praise is given to reinforce positive behavior. Children have less anxiety when they know what to expect.
POSITIVE REINFORCEMENT: This technique rewards the child who displays any desirable behavior. Rewards include praise, compliments, a pat on the back, gentle hug or a prize, etc.
VOICE CONTROL: The attention of a child exhibiting disruptive behavior is gained by changing the tone or volume of the dentist's voice. Content of the conversation is less important than the abrupt or sudden nature of the voice change.
MOUTH PROP: A device placed in the child's mouth to prevent accidental closing and/or injury and to allow jaw muscles to relax for ease of swallowing.
PLEASE NOTE: The following technique is sometimes utilized to help small children cooperate. If your child is of school age and is not a special needs patient, the chance of your child requiring such management is remote.
PHYSICAL RESTRAINT BY DENTIST/ASSISTANTS: The restraining of a child from undesirable movements by holding down the child's hands or upper body, stabilizing the child's head and/or controlling leg movements with the intention of preventing possible injury. A pedi-wrap may be utilized for this purpose.
CONSCIOUS SEDATION: Sometimes sedative drugs are used to relax a child so that he/she can more readily accept dental treatment. These drugs may be administered orally, by injection, or as a gas (nitrous oxide and oxygen). The child does not become unconscious. Your child will not be sedated without your knowledge and consent.
GENERAL ANESTHESIA: For some children with medical complications or in instances where conscious sedation is ineffective, a child's dental treatment can be accomplished under general anesthesia. Additional information will be provided to parents if this is recommended for your child.
I hereby authorize and direct Dr. Brandt and his staff to utilize the behavior management techniques listed above on this form to assist in the provision of the necessary dental treatment with the exception of: (If none, so state)
I hereby acknowledge that I have read and understand this consent form, and that all questions about the behavior management techniques described here have been answered in a satisfactory manner, and I further understand that I have the right to be provided with answers to questions which may arise during my child's treatment. I further understand that I am free to withdraw my consent to treatment at any time and that this consent shall remain in effect until I choose to terminate it.