Jaw wiring Informed Consent

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Ted Rothstein DDS, PhD
Specialist in Orthodontics for Adults and Children and founder of the DPOJW****
35 Remsen, Brooklyn NY  11201
718 852 1551  Fx 718 852 1894   drted35@aol.com
 Orthodontic Jaw Wiring for Weight Loss (OJW®) Informed Consent

DIRECTIONS:

Carefully read the Informed Consent then fill in the data requested (* information requested is mandatory). Place your initials/name in all places requested and email the Informed Consent to drted35@aol.com. Then just below see hyperlinks to the "Adult Acquaintance" and  "Adult Medical History" forms. Download and complete BOTH  forms and mail or fax them  to the office (fax 718 852 1894 evening best).  When I have received ALL THREE FORMS  I will call you without further delay. With care, Dr. Ted Rothstein.

* Date:    /    / 2013       * Name:                         * Age:     Date of birth:     * Height:          
* Present Weight:                               * Goal Weight: 
         (click on link)--->*Present Body Mass Index (BMI):  
* Activity Level  (Life style): (Circle one) inactive, mildly a., moderately a., very active 
 
*Number of months you are initially willing to dedicate passionately to the jaw wiring (OJW) approach to weight loss:
  2 3 4 5 6 (3 months/ 21 pounds, assuming 5 pounds first week then 1.5 pounds each week thereafter)
*Address:                        *City:              *State:       * Zip:
*Occupation:
*Home Telephone:                 *and Work Telephone (Other):                 * and Cell/ Mobile Telephone:
 *Email Address: Dr. Ted will not contact you if you do not provide this item. 
* Your dentist's name:
   Address:
  * Telephone number:
   I give Dr. Ted my permission to call my dentist by placing my initials here_______.
*You physician's name:
   Address:
   *Telephone number:
 * I give Dr. Ted my permission to call my physician by placing my initials here_______.
* OJW preferred appointment date:________ ** Alternative OJW appointment date:__________  or "Date undecided"
Please complete both forms indicated below and FAX to my office: 718 852 1894.  After I review the data from ALL THREE FORMS I will call you to discuss your goals and help you arrange an appointment. 

I, _________________________, authorize Dr. Rothstein to wire my jaws into the OJW position of physiologic rest ††. realize that I will need to be on a low calorie liquid diet to achieve my weight loss goal. I know I can have the  orthodontic jaw wiring (brackets and wire) removed at any time I request. I have read and I understand all the material on Dr. Rothstein’s web site related to the orthodontic jaw wiring procedure. I also recognize that even if I achieve my weight loss goal, I may well regain the weight. I have been advised that the best way to maintain the weight loss is be means of life style changes, which include a low calorie, balanced diet matched to an appropriate exercise regime for my life style.

I understand that Dr. Rothstein requires a note from a physician indicating: "You may begin a long-term, low-calorie liquid diet.". The purpose of such a note is to rule out for your own safety and my assurance that such a diet would not be harmful to you. Such a release is taken  to mean that you have no gastro-intestinal issues or other medical problems that would harm you by beginning such a diet. Lacking this medical release note the OJW service can not be provided.

I understand that  OJW requires that braces (brackets) be bonded to my teeth; that braces may sometimes become detached and need to be rebonded. Moreover, I realize that if I come from out-of-state and a bracket detaches, I will need to see a local orthodontist to have the bracket(s) rebonded at an additional cost to me ($50-$85/bracket). Finally, that at present there are few if any orthodontists who will rewire me and for that reason I have elected  to rewire myself (or have my significant other do the rewiring for me following the method Dr. Rothstein taught me when the OJW was placed.

Since I may come from out-of-state and may not be able to return to Dr. Rothstein's office to have my OJW brackets removed, I will need to locate a local orthodontist whose fee may range from $300- $400+  to remove the OJW brackets and adhesive.

I am at liberty to review the results of the survey Dr. Rothstein completed in January of 2009 to see how other OJW patients fared.  View the benefits and problems of OJW (as an Excel spread sheet) and to read  his manuscript on the nature of the OJW service as provided by dental professionals: Orthodontic Jaw Wiring: The Dental Professional's Role in Weight Control for Compulsive Overeating Leading to Obesity  

Dr. Rothstein’s work shall be largely limited to placement and removal of the orthodontic jaw wiring appliance as a whole, periodic rewiring and tooth cleaning of the inside of my teeth, replacement of any accidentally detached brackets and finally, warning me if he thinks that continued use of the orthodontic jaw wiring is causing/may cause harm to my gums, teeth and jaw joints.

The OJW appointment will include an oral examination in conjunction with a panoramic X-ray, and detailed instructions how to place and remove the OJW wiring. I understand that I must remove the wires at the end of five weeks and return to the office (not applicable to out-of-town patients) to have Dr. Rothstein re-examine me to ascertain that my teeth, gums and jaw joints (TMJ) are in healthy condition. Above all, I understand that he will not rewire me if I cannot pass  the three-finger mouth opening test  without difficulty or discomfort. Finally, that Dr. Rothstein will provide me with the prerequisite instruments needed to place and remove the wiring.

I am fully aware that other methods of weight loss are available to me including: weight loss medicines such as Alli, Meridia  Xenical, "Qysymia" formerly Qnexa, Belviq, Weight Watcher's and Jenny Craig programs and a variety of bariatric surgical techniques. I am also aware of such organizations as
Overeaters anonymous and Greysheeters anonymous (GSA) for compulsive overeaters.

I understand I am required to make a new appointment for between 4 and 6 weeks after each time Dr. Rothstein rewires my jaws and I realize that I must release the wire {See Release methods]  4-6 days prior to that to permit me to exercise my jaw muscles.  [See jaw joint exercises] I realize that if I do not eat a soft diet during those times that my jaw is unwired I may cause brackets to become detached.

I have been advised that if I have any conditions which are medically compromising and that demand special medical attention to dietary details such as, to mention just a few: diabetes, gastric reflux, Crohn’s disease, irritable bowel syndrome and malabsorption syndrome, I should not have this procedure done. I have had a medical exam in the recent past and I am in good health and I have no medical problems that may interfere with or be at odds with this procedure. My physician has not advised me to forego this procedure. 

I have read all the  FAQ's related to OJW and I have especially read the question ,  "Who is NOT a good candidate for the OJW procedure."   I realize  the list of reasons for not being a good candidate does not cover every possible condition of ill health.  I am confirming that I am a good candidate and I am providing  my initials as acknowledgment in this space _________. There is also the possibility that I might be allergic to metal components in the brackets/wire such as Nickel
 (Get Information about Nickel allergy)  or even the adhesive used to bond the brackets to the teeth any of which might require having to have the OJW removed.

I have been advised that prior to orthodontic jaw wiring I should have a complete physical exam including a complete blood study, and an analysis of my present caloric intake by a registered dietitian [Find a registered dietician in the American Dietician's Association]  so that a liquid diet can be designed for my  body type and activity level that is compatible with my weight loss goals.** I realize that while Dr. Rothstein may try to help me with the liquid diet suggestions that it will be my total responsibility to create a liquid diet compatible with my goals. I agree to keep an accurate daily log of my liquid diet showing the calories in each meal and the total of my daily and weekly intake. I agree to show Dr. Rothstein this log at each office appointment. I realize that I may not reach my weight loss goal, but I do not hold Dr. Rothstein responsible since he has not made any guarantee regarding the success of attaining my goal. I realize that exercise is a very important factor in losing weight and that Dr. Rothstein will/has apprise(d) me of the relationship between weight loss and gain and the number of calories and activities I do. [See Dr. Ted's exercise]

I realize that extensive vomiting could result in vomitus being taken into my airway, which could be a very serious medical problem requiring immediate medical attention. Consequently, I realize I should immediately remove the wires that hold my teeth together under conditions of suspected or impending nausea.[Read special note from highly respected teacher, educator and practitioner] Dr. Rothstein will/has also show(n) me how to remove the wiring with a Nippy wire cutter and even a fork. I have been advised to carry at all times the Nippy wire cutter that Dr. Rothstein gave me.  Dr. Rothstein has told/shown me how to remove the wire in an emergency with a simple fork and shown me that it can be easily accomplished in less than 10 seconds. [SEE INSTRUMENTS AND METHODS OF REMOVING THE WIRE.]  Dr. Rothstein has/will give(n) me his home phone with special instructions to call him if I ever have any problems related to this procedure outside of regular office hours. I acknowledge by my  signature here _________ that I understand the above.

I have been told that my speech may be somewhat impaired, that Listerine rinses will be the only way to keep the insides of my teeth and mouth clean. I have been told to avoid and/or report any gnashing/bruxing or sideways grinding of my teeth or any jaw muscle aches since they can cause problems to my teeth and jaw joints.

Dr. Rothstein has prepared me for the uncommon possibility of "panic attack" upon being wired and  that I may have to release/remove  the wiring immediately or within a few days from the OJW appointment  because I find that I am unable to adapt to/tolerate my jaws wired in the "OJW position of physiologic rest Or, or I may find the orthodontic brackets and wiring themselves are feeling "foreign"/uncomfortable to me.†† Consequently, I understand there will  be an initial trial period when the OJW is first placed when I will have to adapt to novel situation that I have never experienced before. I understand that Dr. Rothstein will remove the OJW Immediately if requested, or rewire me when I am ready for it (at no additional charge as long as the brackets are still in place. [Read D.V.'s experience.]

I understand that if I pay the fee prior to the OJW appointment and then decide that I do not want to proceed with the OJW that Dr. Rothstein will refund all of the fee I paid except a service fee of $175.

I understand that the OJW placement  is non-refundable following insertion/placement of the OJW and that the removal of the wiring and all braces and final cleaning at the last visit is included in the fee. However, for those OJW patients from out-of-state who can not return to my office to have their  OJW brackets removed, Dr. Rothstein will assist you in locating an orthodontist as close as possible to your home who will remove the 12 brackets (one minute or less)  and the adhesive (about 5 minutes).  The fee may vary from $75 -175 so do confirm the fee before having the local orthodontist perform the OJW removal.

Finally, I permit Dr. Rothstein, if he chooses, to show the chart entries of my case on his website in the "orthodontic jaw wiring for weight loss section." I realize he will respect my right to anonymity. And, I authorize Dr. Rothstein to share my records with other dental, medical and related healthcare professionals concerned with helping the overweight control their problem as part his goal to further the gathering of knowledge about OJW (which is still an experimental method for weight control in obesity) into a national database.

OJW has not as yet been submitted to the FDA for its approval.  Dr. Rothstein has provided OJW to 150+ patients. A utility patent application was submitted to the USPTO and an application to was submitted to the USPTO to register the mark "OJW" and OJW was approved as a registered trade mark for Orthodontic Jaw Wiring for weight control/loss

Readers are urged to read Dr. Rothstein's paper on OJW as a Treatment Modality for Binge Eaters [Click here].

I have read the Informed Consent above including the hyperlinks directing me to supporting educational material. I fully understand the OJW service that Dr. Rothstein is going to provide me with. My signature acknowledges my consent for Dr. Rothstein to provide me with the OJW appliance:
PATIENT'S SIGNATURE:_______________________________________  DATE:____________

Latest Revision 071313

* orthodontic jaw wiring (Links to sites with information on losing weight and liquid diets, sustaining 
    nutrition and, hazards in dieting)
  
*(See a liquid diet that was created by a person who was considering weight control by orthodontic jaw wiring)

** Dr. Rothstein can refer you to local hospitals that provide the services of a registered dietitian. At least 2 visits are needed: The first, for a physical exam and blood samples, at which time you must present an accurate record of your food intake for at least one week. The second, to report to you the results of your blood study, and to provide you with a low calorie liquid diet specifically tailored to your needs and goals. The total cost of those services is about $200.
*** The present fee for OJW is $2685. This fee includes all OJW appointments including removal of the OJW appliance.
††THE OJW POSITION OF PHYSIOLOGIC REST is a parted resting position of the mandible at which the muscles of mastication are in a minimally contracted position thereby allowing the lower jaw to be suspended from the maxillary teeth in a condition of "weightlessness". Inter-occlusal wiring permits the mandible to move  2.0 mm - 4.0 mm laterally, vertically and antero-posteriorly  thereby minimally impeding speech and minimizing the possibility of TMJ stiffening. This position is often congruent with an observable inter-occlusal space of 2.0 mm - 4.0 mm and closely approximates the position we know as the "physiologic jaw resting" position, the initial position  from which all jaw excursions begin. It is this condition of  jaw "weightlessness" that precludes the possibility that the upper/lower teeth are extruded during the time the OJW device is in place.

 

Understanding the OJW Position of Physiologic Rest

OJW Side View: Note teeth are apart

OJW: Front View

 

(DOWNLOAD ADULT ACQUAINTANCE FORM)


(DOWNLOAD THE ADULT MEDICAL HISTORY FORM)