ADVICE SHEET 4 BRITISH ORTHODONTIC SOCIETY

CONSENT IN ORTHODONTICS
In 1998 the BMA Representative Board recognised that "…the current practice of obtaining
informed consent fails to serve patients or doctors" and set up a working party to produce
guidelines to assist clinicians (BMA 2001). Their aim and that of other recent reports is to
achieve the highest standards of ethical practice, rather than just the legal minimum.
Consent to treatment is essentially a process, not a signature. This process is the
communication of key information to the patient about the proposed treatment and the
patient's response in terms of an informed decision whether or not to proceed. Any
subsequent signature is merely a written record that such a process has occurred.

The main issues in consent are summarised in the Department of Health document "12
Key Points on Consent: the Law in England". The Toolkit of Consent Cards produced by
the Consent Working Party of the BMA are also a concise source of guidance. More
detailed information is to be found in the other publications referred to below.

In an orthodontic context the following observations may be added.

1. Consent to examination. Orthodontic examinations are commonly carried out on the
basis of implied consent, whereby the patient sits in the chair and tacitly agrees to the
examination. Implied consent depends on the patient being aware of what is proposed
and care should be taken not to go beyond what the patient has been led to expect,
without giving further explanation.
2. Consent to treatment. Consent to orthodontic treatment should normally be sought
by the senior clinician responsible for the patient's treatment. Time needs to be taken
to explore the patient's needs and wishes in order to tailor the process accordingly.
The Senate of Surgery advises that information "should be provided in the detail
required by a reasonable person in the circumstances of the patient to make a relevant
and informed judgement" (Senate of Surgery, 1997). In seeking consent in orthodontics
the following factors need to be addressed:
2.1 Patient commitment A course of orthodontic treatment involves a prolonged
commitment on the part of the patient in order to achieve success. It is essential
that patients (and parents as appropriate) understand at the outset, the implications
of treatment in terms of regular attendances and the time out from school or
employment, oral hygiene requirements, dietary restrictions, discomfort, extractions,
appliances and post-treatment retention. The need to continue regular visits to the
family dentist and the likely duration of treatment should be made clear.
2.2 Benefits of treatment The likely benefits (or otherwise) in terms of appearance,
occlusal function, the TMJ or other areas (as appropriate to the case) should be
explained; care should be taken not to make claims which go beyond the evidence
and it should be made clear where uncertainty exists about outcomes. The possible
consequences of not undertaking treatment should also be covered
2.3 Limitations of treatment Patients should be clear about what the treatment will and
will not achieve, particularly if the treatment objectives are limited.
2.4 Risks of treatment Significant risks for the case in question should be covered,
including the possibility of relapse. It is not possible to be specific here about the
risks which should be mentioned in any particular case, but from a knowledge of the
case the clinician has to make a careful judgement of the material risks about which
the patient could reasonably wish to be informed before reaching a decision.
Mentions of any special factors applying to the case should be recorded in the
notes.
 2.5 Multidisciplinary treatments Cases involving both orthodontics and a procedure in
an associated discipline need particular care. The patient must be given sufficient
information at the outset to be able to consent to both the orthodontic treatment and
the associated procedure, before either treatment is started. For major surgical
procedures a pre-treatment consultation with the surgeon is important. Where
extensive restorative procedures are planned, the patient must be fully aware of the
long-term implications (including the possibility of costs) and a consultation with the
clinician who will be undertaking the restorative procedures is advisable.
2.6 Treatment options In some orthodontic cases there is only one approach which the
clinician would be happy to recommend, and there is little scope for considering
other possibilities. However in other cases alternative approaches to treatment are
possible, sometimes with very different outcomes. In such cases, the options
should be explored with the patient in order to reach a decision which reflects the
patient's priorities. Questions should be answered as factually as possible and
without bias. Patients wishing to seek a second opinion should feel free to do so.
2.7 Weighing up The need to balance benefits against risks and drawbacks should be
emphasised, particularly in the treatment of milder malocclusions. Patients
commonly find some difficulty in reaching a firm decision in the unfamiliar
surroundings of a surgery. In such cases it is advisable to let them consider at
leisure, with clear arrangements about what they should do once a decision has
been reached. Written material may be helpful in supporting the process of
reaching a decision. Some clinicians in fact adopt this arrangement with all their
patients and there is value in routinely giving time for a decision to mature.
Sometimes a further discussion will be required before a final decision can be
reached.
3. Reaffirming consent. Where there has been a lengthy delay between the initial
consultation and the start of treatment (as for example when a patient has been on a
treatment waiting list), the patient's views or circumstances may have changed, or
treatment techniques may have evolved. Reaffirmation of consent is therefore needed.
4. Consent to continuation of treatment. Once explicit consent to an entire course of
treatment has been given, the fact that a patient continues to attend for treatment in the
normal way can be regarded as implied consent for its continuation unless the patient
states otherwise. When giving implied consent by attending for subsequent treatment
visits, the patient should be aware, at least in general terms, of what procedure is about
to be undertaken at that visit.
5. Change of plan. If a change of plan is needed during treatment (e.g. additional
extractions or a different type of appliance) the patient should be fully informed of the
circumstances and continuation of consent confirmed. Consent for one procedure
cannot be assumed to extend any other procedure. If during treatment it becomes
apparent that the treatment will take longer than anticipated, the patient and parent
should be informed so that they can plan accordingly.
6. Withdrawal of consent. Consent to treatment can be withdrawn at any time, even in
the middle of a course of orthodontic treatment. If a patient indicates a wish to
terminate treatment, advice should be given to the patient on any likely adverse
consequences of a premature termination. If the patient continues to request
termination, the operator is obliged to comply and must remove any fixed appliances.
Although the operator would not normally be responsible for the adverse
consequences of premature termination in these circumstances, there is a continuing
responsibility for the patient's welfare and measures which may help to improve the
outcome (e.g. retention appliances) should still be offered if the operator judges that
they are likely to be beneficial.
7. Who can give consent? Patients can only give consent if they are competent to
make the decision.
7.1 Adults and young people aged 16 or 17 are presumed to be competent to give
consent for themselves unless there is evidence to the contrary.
 7.2 Patients under 16 who understand fully what is involved in the proposed procedure
can also give consent. It is important that a child should not feel under duress to
accept treatment. Legally a person with parental responsibility can give consent if
the child refuses, but this would generally be unwise in an orthodontic context as
the success of treatment is very dependent on the co-operation of the child, and in
any case it is debatable whether the benefit to the child would be sufficient to justify
violating the child's wishes. Equally, a competent child can in principle consent
without the agreement of the parents, but as parental support is also a key factor in
the success of treatment, every effort should be made to reach consensus.
Although an unaccompanied child may be competent to give consent, it is wise to
encourage the child to involve the parents if at all possible, and to give the parents
an opportunity to discuss the treatment with the clinician.
7.3 For a child under 16 who does not have sufficient understanding to give informed
consent, consent is required from a person with parental responsibility.
7.4 In the case of patients with mental incapacity, the parents can consent for a minor,
but not for adults. In the latter instance the clinician has to make a judgement as to
whether the treatment is in the patient’s best interests; the views of relatives should
be taken into account but they cannot give consent. It is important not to
underestimate the competence of patients with a degree of mental incapacity to
give valid consent; carers can often advise on the degree of understanding which
an individual can achieve.
8. Communication. The information needs to be communicated in terms which are
comprehensible to the patient and parents. Account has to be taken of cultural and
linguistic backgrounds. Interpretation may need to be arranged. Particular care is
needed in communicating with patients who have impaired hearing, sight or speech.
9. Clinicians in training. The clinician responsible for a case may delegate all or part of
the treatment to other members of the team including those in training. The delegating
clinician is responsible for ensuring that the person to whom a procedure is delegated
is competent to undertake the procedure. When consenting to treatment, patients
should be aware if clinicians in training or dental students might be involved in their
treatment. An explanation of the need for practical experience during training may well
be helpful. Where an additional procedure is undertaken primarily as a teaching
exercise rather than as part of a patient's treatment, specific patient consent must be
obtained.
10. Student teaching. If students or others are to observe patient consultations or
treatment, an explanation should if possible be given to the patient in advance. The
patient should feel free to refuse consent to the presence of the observers without
detriment to the treatment. Local protocols should be followed regarding the active
participation of students in treatment and specific consent sought.
11. Written or Verbal Consent? There is no legal requirement for consent to be written.
Written confirmation of consent may be thought to offer a more satisfactory defence in
the case of subsequent litigation, but the fact that it is in writing does not necessarily
demonstrate that it was valid and much will hinge on the degree to which it could be
considered to be informed. Verbal consent obtained through the medium of good
practice may be more robust than a poorly obtained written consent. Procedures to be
undertaken under general anaesthetic normally require written consent. The GMC
recommends that written consent is obtained in cases where:
x The treatment or procedure is complex, or involves significant risks and/or side-
effects
x Providing clinical care is not the primary purpose of the investigation or examination
x There may be significant consequences for the patient's employment, social or
personal life
x The treatment is part of a research programme


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AdministrativeOffice:
Administrative Office:291 12 Gray’s
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1073464



 <Clinic or practice address>

Patient agreement to orthodontic treatment

Patient details (or pre-printed label)

Patient’s surname …………………………………………….

Other names ………………………………………………….

Date of birth ………………………………………………….

Clinician ………………………………………….

NHS number (or other identifier)……………………………..

M/F

Based on the Department of Health draft consent form August 2001

1
To be completed in advance by a clinician or clinicians with appropriate
knowledge of the proposed procedure [this page in duplicate]

Orthodontic treatment
Describe below what is proposed in everyday language, including as appropriate: -
(a) the aim of the treatment
(b) any extractions or surgery which may be required
(c) the type of appliance to be used
(d) the likely duration of the treatment
(e) any limitations to the expected outcome of the treatment
(f) serious or frequently occurring risks
(g) any common side effects or problems.
(h) possible alternative options for treatment

This may well be done over more than one visit. It is helpful to supply pre-printed
information, such as the patient information leaflets provided by the BOS. Make a note of
any such leaflets provided in order to reinforce and clarify the consent process.

Treatment:

Extractions………………………………..
Upper removable appliance……………….
Lower removable appliance……………….
Upper fixed appliance……………………...
Lower fixed appliance……………………..
Extra-oral appliance (headgear)………….
Functional appliance……………………….
Retainers at completion of treatment…….

Anticipated treatment length:

Limitations, serious risks, side effects:

Alternative treatment options:

Leaflet provided… Details: Tape given…

(e.g. name of BOS leaflet or locally produced leaflet)

Contact phone number if patient wishes to discuss options later:

Additional procedures which might be necessary (e.g. surgery)

TOP COPY TO BE GIVEN TO PATIENT

2
To be filled in by the clinician(s) providing information to the patient:
I confirm that I have explained the treatment to the patient, along with the significant risks
and the possible alternatives. I also confirm that I have the necessary competence to
provide this information.
Name (PRINT) Date
Signature Position

(If a second clinician is involved in providing information)

Name (PRINT) Signature Date

If interpreter present: I have interpreted the information on page 2 to the patient to the
best of my ability and in terms which I believe he/she can understand.

Name (PRINT) Signature Date

To be filled in by the patient or (in the case of children unable to consent for
themselves) by a person with parental responsibility:
Please read this form carefully. If your treatment has been planned in advance, you should
already have been given your own copy of page 2, which describes the proposed
treatment. If you have any further questions do ask the person who is asking you to sign
this form. You have the right to change your mind at any time, including after you have
signed this form.

I agree to what has been explained to me by the person(s) named on this

form;

I understand that the procedure may not be done by the person who has been
treating me or my child so far;

I have been advisedof additional procedures which may become necessary. I have listed
below those which I do not wish to be carried out without further
consultation and consent.

To be completed by the patient (children who are unable to give a valid consent may
still be invited to sign here to show they agree with their parent’s decision):

Name (PRINT) Signature Date

To be completed by person with parental responsibility if the patient is a child

unable to give a valid consent (or if a competent child wishes their parent to sign as
well):

Name (PRINT) Relationship to child

Signature Date

To be completed by clinician confirming patient’s consent:

On behalf of the team treating the patient, I have confirmed with the patient that s/he wants
the procedure to go ahead. I have also checked that any further questions that the patient
has have been answered.

Name (PRINT) Signature Date

3
Information for patients about consent
[separate sheet to be given at an early stage ]

Signing a consent form

Before health care professionals can go ahead with any kind of investigation or treatment, they
need your ‘consent’ or agreement. Sometimes you may just say ‘yes’ or ‘no’ to show that you
agree or don’t agree. Sometimes, however, if you agree to treatment you will be asked to sign a
consent form so that there is a record of your decision. The consent form will also contain
information about the treatment, and you will be given a copy of this information to keep. If you
decide later that you don’t want to go ahead with treatment, you are always entitled to say so (even
if you have already signed the form).

Information and questions

Before you can decide what treatment you want to agree to, you need enough information to make
the decision. The health care professionals caring for you will talk to you about the options. They
may well recommend a particular option, but you don’t have to take their advice — sometimes you
may feel that one of the other options would suit you better. People have different opinions on
things like risk, or the level of pain they are willing to put up with.
Always ask any questions you want (there is space over the page to write down questions in
advance so you won’t forget to ask them). If the person you are asking doesn’t know the answer,
they should find out for you or find someone else for you to talk to. You may like to take a friend or
relative with you to support you and to remind you if you forget to ask something. Ask if you would
like an independent advocate to help you, or if you need an interpreter.

More information about consent

The Department of Health has produced a series of leaflets about consent, called Consent — what
you have a right to expect, for adults, children, parents and carers/relatives. If you would like to
know more about consent, ask for a copy from your health care professional or hospital, or look at
the leaflets on the internet at www.doh.gov.uk/consent.

Who is treating you

Many orthodontic procedures in the NHS are carried out by ‘dentists in training’. This term covers a
very wide range of dentists — from those who have just qualified to those who are almost ready to
become specialists. If your procedure is being performed by a dentist in training, he or she will be
appropriately supervised. This may mean that the supervisor is standing next to the dentist in
training during the whole procedure (where the dentist in training is relatively inexperienced), or it
may mean that they are available for advice if necessary (if the dentist in training is experienced in
carrying out procedures of this sort).

What if things go wrong?

Things do sometimes go wrong. Often you, the patient, will be the first to notice because it affects
you most. If you think something might be wrong (for example, if pain after fitting a brace seems to
go on much longer than you were told to expect) contact the clinic straight away. The phone
number of the clinic where you were treated should be on your appointment card, your
appointment letter or on your copy of the consent form.

Questions to ask the clinician

You might find it helpful to note down here questions which you want to ask your orthodontist or
other dental health professional, when you next see them. Possible questions might include:
- what are the main treatment options available?
- what are the benefits of each of the options?
- what are the risks of each of the options?
- what are the risks if I decide to do nothing for the time being?
- where can I find out more information?
- how will I feel after a brace is fitted?
If there is something that particularly matters to you that might be relevant, note it down here so
you remember to tell the health professional - for example, if you have strong views about certain
states of health, or if certain activities in your life are very important to you. In some cases, things
like these might affect the decision you take about your treatment.

4
Guidance to clinicians
What a consent form is for
This form documents the patient’s agreement to go ahead with the orthodontic treatment
you have proposed. It is not a legal waiver — if patients, for example, do not receive
enough information on which to base their decision, then the consent may not be valid
even though the form has been signed. Patients also have every right to change their mind
after signing the form. The form should act as an aide-memoire to clinicians and patients,
by providing a check-list of the kind of information patients should be offered, and by
enabling the patient to have a written record of the main points discussed. However, the
written information provided should not be regarded as a substitute for face-to-face
discussions with the patient.
This orthodontic consent form derives from the DOH draft consent form and should only be
used in connection with orthodontic treatment. Where the proposed treatment also
includes surgery and general anaesthesia the standard DOH form should be used instead.
(www.doh.gov.uk/consent) For orthodontic treatment performed in either the hospital
dental service or the community dental service the standard NHS DOH consent form
should be used (www.doh.gov.uk/consent/consentform1.doc or
www.doh.gov.uk/consent/consentform3.doc) or a Trust agreed version.

The law on consent

See the Department of Health’s Reference guide to consent for examination or treatment
for a comprehensive summary of the law on consent (also available at
www.doh.gov.uk/consent). Further advice on consent in orthodontics is available in the
BOS leaflet on Consent in Orthodontics.

Who can give consent

Anyone aged 16 or more is presumed to be competent to give consent for himself or
herself, unless the opposite is demonstrated (see below).

If a child under the age of 16 has “sufficient understanding and intelligence to enable him
or her to understand fully what is proposed”, then he or she will be competent to give
consent for himself or herself. If the child is not competent to give consent to the particular
intervention, consent should be sought from someone with “parental responsibility”. This
will usually be the birth parents, but may also be a legally appointed guardian, the local
authority where the child is on a care order, or a person named in a residence order in
respect of the child. Fathers who have never been married to the child’s mother will only
have parental responsibility if they have acquired it through a court order or a parental
responsibility agreement (although this may change in future). See the Reference guide to
consent for examination or treatment for further detail. Even where someone with parental
responsibility is giving consent, you should involve the child himself or herself as much as
possible in the decision-making process.

While legally you may treat a child under the age of 18 on the basis of their parent’s
consent, it is good practice always to seek the child’s own consent where they are
competent to give it. Some children/young people may be competent to give consent for
themselves, but still wish a parent to sign their form as well.

If a patient is mentally competent to give consent but is physically unable to sign a form,
you should complete this form as usual, and note on it that the patient has given their
consent orally or in another way.

5
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Recommendations may change
in the light of new evidence.


Administrative Office: 291 Gray’s Inn Road, London, WC1X 8QJ. Email: ann.wright@bos.org.uk Telephone: 020 7837 2193
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