You have been diagnosed by your physician as requiring treatment for sleep disordered breathing (snoring and/or obstructive sleep apnea). This condition may pose serious health risks since it disrupts normal sleep patterns,  can reduce normal blood oxygen levels and may result in excessive daytime sleepiness, irregular heart beat, high blood pressure, heart attack or stroke. If you are medically diagnosed as having sleep apnea, a follow-up sleep study to objectively assure effective treatment has been or is to be obtained from your physician.

Published studies show that short term side effects of oral appliance use may include excessive salivation, difficulty swallowing with the appliance in place, sore jaws, sore teeth, jaw joint pain, dry mouth, gum pain, loosening of teeth and/or bite changes. There are also occasional reports of the dislodgment of ill-fitting dental restorations. Most of these side effects are minor and resolve quickly on their own or with minor adjustment of the appliance. Long term complications may include bite changes that may be permanent that result from tooth movement and/or jaw joint repositioning. These complications may or may not be fully reversible once appliance therapy is discontinued. If not, additional dental intervention may be suggested in certain cases for which you will be financially responsible.  However, tooth movement may continue for as long as the oral appliance is worn.  As the severity of the disease may increase over time, additional advancements and/or new appliances may be required in the future.  Follow-up visits with the provider of your oral appliance are mandatory to ensure proper fit and to allow an examination of your mouth to assure a healthy condition.

Today, specific side effects of long term oral appliance wear were identified and discussed:

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Other accepted treatments for sleep disordered breathing include behavioral modifications, positive airway pressure and various surgeries. It is your decision to continue to treat your sleep disordered breathing with an oral appliance and you are aware that it may not be completely effective for you. It is your responsibility to report the occurrence of side effects and to address any questions to this provider's office. Failure to treat sleep disordered breathing may increase the likelihood of significant medical complications.  If you elect to stop wearing your oral appliance now or at any time in the future, it is your responsibility to contact your sleep specialist and/or family physician as soon as possible to discuss alternative forms of therapy for your specific sleep problem.

I have had the opportunity to discuss the foregoing conditions and the information concerning the long term wear of my oral appliance. Furthermore, I give my permission for my diagnostic and treatment records to be used for the purposes of research, education or publication in professional journals. I also accept financial responsibility for this therapy. With all of the foregoing in mind, I authorize continued treatment with an oral appliance and confirm that I have received a copy of this long term consent form

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