1033301 JOO Journal of OrthodonticsMeade and Dreyer

Scientific Section

Journal of Orthodontics

Orthodontic treatment consent forms: 1­–7

https://doi.org/10.1177/14653125211033301
DOI: 10.1177/14653125211033301
© The Author(s) 2021
A readability analysis Article reuse guidelines:
sagepub.com/journals-permissions
journals.sagepub.com/home/joo

Maurice J Meade and Craig W Dreyer

Abstract
Objective: To evaluate the readability of orthodontic treatment informed consent forms (ICFs).
Design: A cross-sectional observational investigation.
Methods: An online search strategy was adopted to identify ICFs for orthodontic treatment. The text of each form that
satisfied inclusion criteria was modified to a standardised protocol. The readability was evaluated using three validated
instruments. GraphPad Software (GraphPad Software Inc., La Jolla, CA, USA) was used for statistical analyses.
Results: A total of 59 ICFs were evaluated. The majority were available on the websites of orthodontists (66.1%) and
general dentists (27.1%). The scores recorded from the three instruments indicated that the content of 93.2%–98.3% of
ICFs was difficult to read. A strong correlation was observed between the Simple Measure of Gobbledegook (SMOG)
and the Flesch Kincaid Grade level (FKGL) instruments (r = 0.9782; P < 0.0001). The mean SMOG score for all assessed
forms was 11.19 (95% confidence interval [CI] 10.85−11.54). The ICFs authored by the manufacturers of orthodontic
appliances provided by clinicians recorded a mean Flesch Reading (FRE) score of 40.14 (95% CI 33.91−46.37) out of a
maximum 100. An analysis of the SMOG scores indicated that the content of ICFs authored by national orthodontic
societies was more difficult to read than those written by all other authors (P=0.01; 95% CI −1.6 to −0.2)
Conclusion: The readability of the ICFs was too difficult for a significant number of the population. Many patients
will be unable to validly consent to treatment based solely on reading of the content of the evaluated ICFs. A greater
effort is required to improve the readability of ICFs to help ensure patient autonomy regarding orthodontic treatment
decision-making and management.

Keywords
informed consent, orthodontic treatment, health literacy, readability

Date received: 13 April 2021; revised: 7 June 2021; accepted: 29 June 2021

Introduction Valid consent, however, is not a one-off event repre-

Valid consent is an integral component of modern health-
care and is essential for the enablement of patient autonomy
(Tyson, 2016). Three criteria must be satisfied to ensure
consent is valid: patient capacity; patient voluntariness; and
disclosure of information.
The judgement from a recent court case has signified a
more ‘patient-centred’ approach in what information should
be provided to patients and how this information is con-
veyed (Montgomery vs Lanarkshire, 2015). Although a
signed informed consent form (ICF) is not mandatory for
most dental procedures, an ICF is commonly obtained
before commencing orthodontic treatment (Tyson, 2016).
sented by a signature on a document. It is an ongoing pro-
cess that requires effective communication and engagement
between the clinician and the patient (Meade et al., 2019).
Nevertheless, a signed consent form can act as an outline of
Orthodontic Unit, The School of Dentistry, The University of Adelaide,
SA, Australia
Corresponding author:
Maurice J Meade, Orthodontic Unit, The School of Dentistry, The
University of Adelaide, Level 10 Adelaide Health and Medical Sciences
Building, Corner of North Terrace and George Street, Adelaide, SA
5000, Australia.
Email: maurice.meade@adelaide.edu.au
2 Journal of Orthodontics 
the material to include in the information disclosure process.
It can also act as a summary of the ‘conversation’ between
the clinician and the patient and a resource to which the
patient can refer during treatment (Prado and Waring, 2019).
The concept of health literacy refers to the ability to
acquire and understand health information combined with
the capacity to use this information to improve health
(Nielson-Bohlman et al., 2004). Health literacy has been
shown to be a predictor of general and oral health status in
addition to patient compliance with treatment (McCray,
2015). Reading ability or literacy is a key element of health
literacy (Pleasant, 2014).
Many factors require consideration in determining the
suitability of written information such as accuracy, presen-
tation and formatting (Harwood and Harrison, 2004). One
approach used to improve health literacy is to ensure that
written health information contained within an ICF, is
‘easy’ to read and therefore has a level of ‘readability’
(Meade et al., 2019).
Several reliable and valid formulae have been devised to
quantitatively determine the readability of written informa-
tion (Fitzsimmons et al., 2010). The formulae evaluate sen-
tences, words and syllables within a text to generate scores
that indicate the ease of readability or determine scores that
equate to the number of years of education that an individ-
ual must receive to read the text with ease.
In the UK, the average adult has a ‘reading age’ below
16 years with nearly one in seven adults having a ‘reading
age’ comparable with that of an 11-year old. Furthermore,
5% of adults in England have a reading level expected of a
child aged 5−years (Department for Business, Innovation
and Skills, 2011). Rates of literacy in the United States are
similar as research has indicated that 20% of adults read
below the level expected of a 5th grade (10-year-old) child
(Dobbs et al., 2017). The U.S. Department of Health and
Human Services (USDHHS, 2010) has advised that patient-
related health material should be written at, or below, a
‘6th-grade level’. This equates to a UK reading age of
11−12 years (Fitzsimmons et al., 2010). In the absence of
similar advice in the UK, the USDHSS guidance has been
adopted as a benchmark in many UK-based studies
(Fitzsimmons et al., 2010; Todhunter et al., 2010).
Current evidence, however, indicates that the readability
of a variety of written orthodontic information may be too
difficult for the individual with ‘average’ readability
(Harwood and Harrison, 2004; Meade and Dreyer, 2020a;
Patel and Cobourne, 2011) Although there is some evi-
dence related to the readability of ICFs in many medical
disciplines, there appears to be little research regarding the
readability of orthodontic treatment consent forms (Eltorai
et al., 2015; Graham et al., 2015; Perni et al., 2018;
Sivanadarajah et al., 2017).
The aim of this investigation, therefore, was to deter-
mine the readability of orthodontic treatment consent
forms.
Methods
Ethical approval was not required as this study only evalu-
ated forms available in the public domain.
The search term ‘orthodontic informed consent form’
was entered into three Internet search engines (Google™,
Yahoo™ and Bing™) on a desktop computer on 28
February 2021. The search engines’ geographical settings
were turned off and browsing history deleted before the
search. Inclusion criteria constituted ICFs contained within
the websites of orthodontic treatment providers and those
written in the English language. Also included were the
ICFs authored by the manufacturers of those orthodontic
appliances, such as Invisalign™, that are provided by
orthodontic treatment providers. Exclusion criteria involved
consent forms related to participants in clinical trials and
ICFs that contained identical text to ICFs already included
for analysis. ICFs, however, that contained variations of
text already included were evaluated. The unique resource
locator (URL) of each of the first 100 websites from the
three searches were recorded and each website was checked
for the presence of an ICF.
The website type (‘orthodontist’, ‘general dental practi-
tioner’ [GDP] and ‘other’) and the website’s country of ori-
gin that contained ICFs that satisfied inclusion and
exclusion criteria were recorded. The author of each
included ICF was also documented. If the author’s identity
was unclear, it was categorised as ‘unspecified’.
The written material within each form to be assessed was
‘copied and pasted’ as plain text in a Microsoft Word docu-
ment. The text of each form was modified to a standardised
protocol. All non-text, such as images and copyright sym-
bols, were removed. In addition, characters such as colons,
bullet points, abbreviations and typographical errors were
excluded from the text to be analysed (Dobbs et al., 2017;
Flesch, 1948; Meade and Dreyer, 2020b). Text up to the cal-
culator’s limit of 3000 words was then entered into an online
readability calculator (www.readabilityformulas.com).
Three readability tools were used to calculate readability
scores (Table 1).
The Simple Measure of Gobbledygook (SMOG) score is
based on the number of sentences and polysyllables within
the text (McLaughlin, 1969). The Flesch-Kincaid Grade-
Level (FKGL) and the Flesch Reading Ease (FRE) scores
are derived from the length of the average sentence and the
mean number of syllables per word, respectively. The
SMOG and FKGL provide scores that equate to the year
level in the US public school system that the text would
expect to be understood. The FRE score provides an ease of
readability metric where scores range are in the range of
0-100. Higher FRE scores indicate text that is easier to read.
Once scores are recorded, the ICF’s ‘readability’ can be
described as ‘easy’ (equivalent to grade 4−6), ‘average’
(equivalent to grade 7−9) and ‘difficult’ (equivalent to grade
10+) as per USDHHS criteria (Fitzsimmons et al., 2010).
Meade and Dreyer 3
Table 1.  Tools used to evaluate ICF readability scores.
Readability tool Formula
SMOG Index 1.043 × √ (C × (30/S)) + 3.1291
FKGL (0.39 × ASL) + (11.8 × ASW) − 15.59
FRE 206.835 − (1.015 × ASL) − (84.6 × ASW)
ASL, average sentence length; ASW, average number of syllables per
word; FKGL, Flesch-Kincaid Grade-Level; FRE, Flesch Reading Ease; ICF,
informed consent forms; SMOG, Simple Measure of Gobbledegook.
A reading age equivalent to 11 years (corresponding to
SMOG grade 6, FKGL grade 6 and FRE >70) was adopted
as the ‘gold standard’ (Todhunter et al., 2010).
Statistical analysis
Descriptive statistics are presented in text and graphic
form. The D’Agostino−Pearson omnibus normality test
was used to determine whether SMOG scores followed a
parametric distribution.
Unpaired t-tests with Welch’s correction were used to
compare subgroups with a parametric distribution of data
values. The Mann−Whitney test was applied to compare
SMOG scores between subgroups containing non-parametric
data.
Figure 1.  Website type and country of origin (n = 59). AUS, Australia; CAN, Canada; GDP, general dental practitioner; UK,
United Kingdom; US, United States.
A P value < 0.05 indicated statistical significance.
Statistical analyses were performed through GraphPad
Prism 9.0 (GraphPad Software Inc., La Jolla, CA, USA).
Results
A total of 59 websites out of 300 assessed websites con-
tained ICFs that satisfied inclusion and exclusion criteria.
Figure 1 shows that the majority of ICFs were obtained
from the websites of orthodontists (66.1%) and most web-
sites ‘originated’ from the USA (61%). Thirteen ICFs
(22%) were authored by orthodontic appliance manufactur-
ers (OAMs), 11 (18.6%) were authored by national ortho-
dontic societies (NOS) and 35 (59.4%) were unspecified.
No ICF was written at a level lower than grade 8 (Table 2).
A high correlation was observed between the SMOG and
the FKGL instruments (r = 0.9782; P < 0.0001). Figure 2
shows that 93.2%−98.3% of ICFs were categorised as dif-
ficult to read according to USDHSS criteria.
The D’Agostino–Pearson omnibus normality test showed
that SMOG data followed a parametric distribution apart from
data pertaining to the OAM and the NOS subgroups. Table 3
shows the readability scores of the ICFs according to the web-
site type in which they were located. There was no difference
in SMOG scores between the ICFs provided by orthodontist
and GDP websites (P = 0.35; 95% CI = −1.16 to 0.43). The
text was more difficult to read in the forms authored by NOSs
4 Journal of Orthodontics 

Table 2.  ICF readability scores by ICF author.

Readability test

ICF author SMOG FKGL FRE

Overall Mean ± SD 11.19 ± 1.32 12.06 ± 1.78 41.73 ± 7.96

  95% CI 10.85−11.54 11.6–12.52 39.65–43.8
  Range 8–15 8.5–17.9 23.7–60.1

NOS Mean ± SD 11.85 ± 0.59 12.78 ± 0.67 36.55 ± 4.44

  95% CI 11.45–12.24 12.31–13.32 33.56–39.53
  Range 10.2–12.4 12.33–13.23 32.3–49.3

OAM Mean ± SD 11.79 ± 1.655 13.08 ± 2.394 40.14 ± 10.31

  95% CI 10.79–12.79 11.64–14.53 33.91–46.37
  Range 9.7–15.1 9.6–17.9 23.7–60.1

UA Mean ± SD 10.76 ± 1.2 11.45 ± 1.5 43.94 ± 7.083

  95% CI 10.35–11.18 10.93–11.97 41.51–46.38
  Range 8.2–13.6 8.5–15.5 29.8–59

CI, confidence interval; FKGL, Flesch-Kincaid Grade Level; FRE, Flesch Reading Ease; ICF, informed consent form; NOS, National Orthodontic
Society; OAM, orthodontic appliance manufacturer; SD, standard deviation; SMOG, Simple Measure of Gobbledegook; UA, unspecified author.

Figure 2.  Reading difficulty as per USDHSS criteria (n = 59 per readability tool). FKGL, Flesch-Kincaid Grade Level; FRE, Flesch
Reading Ease; SMOG, Simple Measure of Gobbledegook.

compared with that written by all other authors (P = 0.01; The ICFs contained within US websites, however, were
95% CI −1.6 to −0.2). There was no difference in the ease of significantly more difficult to read compared with those
readability between those ICFs authored by NOSs and those located in UK websites (P = 0.0185; 95% CI = 0.1852
authored by OAMs (P = 0.69; 95% CI = –2.1 to 1.7). to 1.817).
Meade and Dreyer 5
Table 3.  ICF readability scores by ICF website type.
Readability test
Website type SMOG
Orthodontist Mean ± SD 11.37 ± 1.28
  95% CI 10.95−11.78
  Range 8.2–15.1
GDP Mean ± SD 11.0 ± 1.317
  95% CI 10.3–11.7
  Range 9.3–13.6
Other Mean ± SD 10.25 ± 1.59
  95% CI 7.71–12.79
  Range 8.2–12.1
CI, confidence interval; GDP, general dental practitioner; ICF, informed consent form; FKGL, Flesch-Kincaid Grade Level; FRE, Flesch Reading Ease;
SD, standard deviation; SMOG, Simple Measure of Gobbledegook.
Discussion
This appears to be the first study to investigate the readabil-
ity of orthodontic treatment consent forms. In addition,
apart from one investigation related to general dental pro-
cedures in a single university dental facility, this may be the
first published study evaluating ICF readability of any den-
tal procedure (Glick et al., 2010). The findings indicated
that the readability may be greater than the level understood
by a significant number of the general population. The rela-
tive difficulty of reading the information contained within
the ICFs means that many patients are not benefitting from
the content contained within and may even be harmed if
they misinterpret the information. Furthermore, reading
difficulty risks invalidating patient consent if the consent
process is overly reliant on the information within the
ICF—as patient comprehension of health information is
central to informed consent (Meade et al., 2019). This may
result in adverse legal and ethical consequences (Eltorai
et al., 2015).
The three most commonly used global search engines
were used in order to identify a wide range of ICFs written
in the English language (EbizMBA, 2021). A total of 59
consent forms were evaluated by this survey. This com-
pared favourably with 11−113 forms assessed in studies
investigating ICFs associated with a variety of dental and
medical interventions (Eltorai et al., 2015; Glick et al.,
2010; Perni et al., 2018; Sivanadarajah et al., 2017). The
majority of ICFs were sourced from websites in the USA.
This is consistent with that country’s position as the nation
with the greatest number of Internet users with English as
their first language (Meade and Dreyer, 2020a).
Readability is a core element of health literacy, which is
an essential component for the improvement of the health
FKGL FRE
12.24 ± 1.69 40.33 ± 7.4
11.69–12.79 37.93–42.73
8.5–17.9 23.7–59
11.8 ± 1.83 44.9 ± 8.935
10.82–12.78 39.73–49.25
9.3–15.5 29.6–60.1
11.35 ± 2.49 44.25 ± 7.69
7.38–15.32 32.02–56.48
8.7–14.7 34.3–52.4
of populations and individuals (Nielson-Bohlman et al.,
2004). Sub-optimal health literacy is associated with worse
general and dental health, higher rates of hospitalisation
and greater healthcare costs (McCray, 2015). It harms the
individual’s healthcare decision-making and management
capabilities and risks developing (and/or accentuating) cur-
rent health inequity. As a consequence of this association
between health literacy and health status, the USDHHS has
determined that patient-targeted health literature should be
written at or below a grade 6 level, which is equivalent to a
UK reading age of 11−12 years. Even if this target was
achieved, many would still be excluded from the benefits of
written health information as over 15% of UK adults have
a literacy level lower than that expected of a grade 6 pupil.
In addition, 20% of US adults have a literacy level below
that expected of a 10-year-old pupil (grade 5) (Dobbs et al.,
2017; Sivanadarajah et al., 2017).
The three readability tools used in the current survey
have been validated against the McCall Crabbs Standard
Test Lessons in Reading (Ley and Florio, 1996). All are
commonly used in assessing the readability of written
health materials and the application of all three increases
the reliability of this study’s results (Cheng and Dunn,
2015). Determining the scores is quick and easy via the use
of the many available online readability calculators.
The SMOG tool, in particular, is an accurate measure of
readability. It precisely determines the level for full text
comprehension and is considered the ‘gold standard’ read-
ability formula for health-related written material (Cheng
and Dunn, 2015; Fitzsimmons et al, 2010).
A disadvantage of the readability tools, however, is that
they do not recognise that some monosyllabic words may
be more difficult to read (for instance, ‘plinth’) than some
polysyllabic words (such as ‘pineapple’).
6 Journal of Orthodontics 
To provide context to the results determined by the pre-
sent survey, the mean FRE and FKGL readability scores of
articles in a range of British broadsheet newspapers article
were found to be 42.35 and 11.76, respectively, in a 2010
study (Williamson and Martin, 2010). In contrast, the same
investigation found that articles in a range of tabloid news-
papers were easier to read (mean FRE = 58; mean FKGL
= 9.9). In addition, the mean FRE, FKGL and SMOG
scores of the penultimate draft of the presented academic
article were 41.1, 9.7 and 8.5, respectively.
The mean overall FRE score of 41.73 is significantly
lower than the recommended minimum score of 70 recom-
mended for written health information (Perni et al., 2018).
This indicates the level of readability required by a student
attending university is required to understand most ICFs. It
compares with mean FRE scores of 29.1−68.9 observed in
‘general dental’, ‘invasive medical procedure’ and ‘ortho-
paedic procedure’ ICFs (Eltori et al., 2015; Glick et al.,
2010; Sivanadarajah et al., 2017).
The SMOG and FKGL scores were closely correlated in
the present survey. The mean SMOG score of 11.85 for
NOS ICFs exceeds the recommended grade 6 advocated by
USDHSS guidelines and ‘gold standards’ adopted in simi-
lar surveys. This equates to a UK school age of almost 17
years (Fitzsimmons et al., 2010). It compares with SMOG
scores of 14.1−14.5 for ICFs related to radiation therapy,
general dental and urological procedures (Glick et al.,
2010; Graham et al., 2015; Perni et al., 2018).
The British Orthodontic Society does not provide a ‘pro-
forma’ ICF. It, nevertheless, provides guidance regarding
the inclusion of content pertaining to treatment options,
treatment details, benefits and risks (British Orthodontic
Society, 2015). It also emphasises that valid consent com-
prises an ongoing communication process and is not just a
signed ICF. The judgement of a recent UK court case con-
cluded that valid consent must stress information that is of
particular relevance to the individual patient (Montgomery
vs Lanarkshire, 2015). This may mean that ICF templates
should be designed with ‘space’ to provide patient-specific
information. However, a well-designed ICF containing rel-
evant high-quality information is of little value if the infor-
mation is difficult to read.
The limitations of this investigation must be acknowl-
edged. The study did not assess the visual presentation and
graphic layouts of the ICFs which can further influence
readability (Glick et al., 2010). Visually impaired individu-
als, for example, prefer a less cluttered and larger typeface
(Harwood and Harrison, 2004). Similarly, the usefulness of
any images contained within the ICFs in aiding comprehen-
sion of the text were precluded from assessment. Research,
however, has shown that images presented with patient
‘education’ are not necessarily helpful in facilitating com-
prehension of the information (Shoemaker et al., 2014). In
addition, the present survey only assessed consent forms
that resulted from an online search. This may not correspond
to those used generally in orthodontic practice. Nevertheless,
it would be reasonable to expect that the ICFs provided by
the NOSs and OAMs to be used widely among orthodontic
treatment providers.
Improving patient comprehension and health literacy
through addressing the readability of ICFs will aid the ame-
lioration of patient outcomes. The orthodontic profession
needs to take the lead in providing ‘easier to read’ ortho-
dontic treatment ICFs as well as guiding clinicians and
manufacturers of orthodontic appliances on how best to
deliver more readable ICFs. Whether clinicians should be
using ICFs from OAMs, which risk providing biased infor-
mation, must be part of any conversation regarding patient
consent. Correspondingly, simpler terms, less technical
‘jargon’ and shorter sentences will improve readability
(Graham et al., 2015). In the future, quantitative and quali-
tative research will be required to enable the development
of consent forms that provide high-quality information that
is tailored for the patient, yet is easy to read.
Conclusion
Readability is a core element of health literacy and is essen-
tial to ensure that ICFs are understood as intended. The
readability of the ICFs evaluated in the present study was
determined to be too difficult to understand for a significant
number of the population. Many patients will be unable to
validly consent to treatment based solely on reading of the
content of the ICF. A greater effort is required to improve
the readability of ICFs to help ensure patient autonomy
regarding orthodontic treatment decision-making and
management.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Maurice J Meade https://orcid.org/0000-0001-5688-1079
References
British Orthodontic Society (2015) Risks of Orthodontic Treatment
Guidance on Informing Patients. London: BOS.
Cheng C and Dunn M (2015) Health literacy and the internet: A study on
the readability of Australian online health information. Australian and
New Zealand Journal of Public Health 39: 309–314.
Department for Business, Innovation and Skills (2011) Skills for Life
Survey: Headline Findings. London: BIS.
Dobbs T, Neal G, Hutchings HA, Whitaker IS and Milton J (2017) The
readability of online patient resources for skin cancer treatment.
Oncology and Therapy 5: 149–160.
Meade and Dreyer 7
EbizMBA. Top 15 most popular search engines. Available at: http://www.
ebizmba.com/articles/search-engines (accessed 5 April 2021).
Eltorai AEM, Naqvi SS, Ghanian S, Eberson CP, Weiss A-PC, Born
CT, et al. (2015) Readability of Invasive Procedure Consent Forms.
Clinical And Translational Science 8: 830–833.
Fitzsimmons P, Michael B, Hulley J and Scott G (2010) A readability
assessment of online Parkinson’s disease information. Journal of the
Royal College of Physicians Edinburgh. 4: 292–296.
Flesch R (1948) A new readability yardstick. Journal of Applied
Psychology 32: 221–233.
Glick A, Taylor D, Valenza JA and Walji MF (2010) Assessing the content,
presentation, and readability of dental informed consents. Journal of
Dental Education 74: 849–861.
Graham C, Reynard JM and Turney BW (2015) Consent information
leaflets – readable or unreadable? Journal of Clinical Urology 8:
177–182.
Harwood A and Harrison JE (2004) How readable are orthodontic patient
information leaflets? Journal of Orthodontics 31: 210–219.
Ley P and Florio T (1996) The use of readability formulas in health care.
Psychological Health Medicine 1: 7–28.
McCray A (2005) Promoting Health Literacy. Journal of the American
Medical Informatics Association 12: 152–163.
McLaughlin GH (1969) SMOG grading: a new readability formula.
Journal of Reading 12: 639–646.
Meade MJ and Dreyer CW (2020a) Orthodontic temporary anchorage
devices: A qualitative evaluation of Internet information available to
the general public. American Journal of Orthodontics and Dentofacial
Orthopedics 158: 612–620.
Meade MJ and Dreyer CW (2020b) Web-based information on orthodon-
tic clear aligners: a qualitative and readability assessment. Australian
Dental Journal 65: 225–232.
Meade MJ, Weston A and Dreyer CW (2019) Valid consent and orthodon-
tic treatment. Australasian Orthodontic Journal 35: 35–45.
Montgomery (Appellant) v Lanarkshire Health Board (Respondent)
(Scotland 11) [2015] UKSC 2013/0136. Available at: https://www.
supremecourt.uk/cases/uksc-2013-0136.html.
Nielson-Bohlman L, Panzer A and Kindig D (eds) (2004) Health Literacy:
A Prescription to End Confusion. Washington, DC: National
Academies Press
Patel U and Cobourne MT (2011) Orthodontic extractions and the
Internet: Quality of online information available to the public
American Journal of Orthodontics and Dentofacial Orthopedics
139: e103–e109.
Perni S, Einstein AJ, Horowitz DP, Rooney M, Golden DW, McCall
AR, et al. (2018) Readability of informed consent forms for cancer
patients undergoing radiation therapy: A nationwide survey. Journal
of Clinical Oncology 15: e22152.
Pleasant A (2014) Advancing health literacy measurement: a pathway
to better health and health system performance. Journal of Health
Communication 19: 1481–1496.
Prado N and Waring D (2019) Improving the orthodontic consent pro-
cess: Amending hospital policy and implementing change. Journal of
Orthodontics 46: 34–38.
Shoemaker SJ, Wolf MS and Brach C (2014) Development of the Patient
Education Materials Assessment Tool (PEMAT): a new measure of
understandability and actionability for print and audiovisual patient
information. Patient Education and Counselling 96: 395–403.
Sivanadarajah N, El-Daly I, Mamarelis G, Sohail MZ and Bates P (2017)
Informed consent and the readability of the written consent form.
Annals of the Royal College of Surgeons 99: 645–649.
Todhunter S, Clamp P, Gillett S and Pothier D (2010) Readability of
outpatient letters copied to patients: Can patients understand what
is written about them? Journal of Laryngology and Otology 124:
324–327.
Tyson J (2016) Obtaining consent in orthodontics: difficulties and consid-
erations. Primary Dental Journal 5: 73–75.
U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion (2010) National Action Plan to
Improve Health Literacy. Washington, DC: USDHHS.
Williamson J and Martin A (2010) Assessing the readability statistics of
national consent forms in the UK. International Journal of Clinical
Practice 64: 322–329.