OSA Treatment Consent

OSA Treatment Consent

Background Information for Patients Considering

Oral Appliance Therapy with a Mandibular Advancement Splint (MAS):

Before treatment is commenced I would like you to read the following important information. If after reading this information you have any questions in relation to any aspect of your treatment please ask.


Snoring and Obstructive Sleep Apnoea (OSA) are breathing disorders, which occur during sleep, due to the narrowing or total closure of the airway.

Snoring is a noise created by the partial closure of the airway and is often no greater problem than the noise itself. However, consistent loud snoring with OSA symptoms had been linked to medical disorders such as hypertension (high blood pressure) and stroke.

OSA occurs where the airway totally closes many times during the night. It can significantly reduce oxygen levels in the body and disrupt sleep. To varying degrees, this can result in excessive daytime sleepiness, irregular heartbeat, hypertension, and occasionally heart attack and stroke. If you suspect that you have symptomatic snoring or OSA, you should consult your general medical practitioner.

Oral Appliance Therapy (OAT) using a mandibular advancement splint is effective in the treatment of snoring and OSA. It assists breathing by keeping the lower jaw and tongue forward during sleep, which opens the airway space in the throat. The mandibular advancement splint has substantially reduced snoring and OSA for many people, but there is no guarantee that the therapy will be successful for every individual.

Several factors contribute to snoring and OSA, including nasal obstruction, narrow airway space in the throat and excess weight. Other accepted treatments for snoring and OSA that should be considers by sufferers, include lifestyle changes (eg. weight loss), behavioural modification, continuous positive airway pressure (“CPAP”) and surgical procedures.

Possible Complications

The mandibular advancement splint is a two-piece, custom made, appliance that is only worn at night. Some patients may not be able to tolerate the mandibular advancement splint or any other device in their mouths.

Some patients may develop temporary side effects such as, sore jaw joints; excessive salivation; dry mouth; sore teeth; irritation of the soft tissues in the mouth and or slight change in their bite. In some cases, a permanent “bite” change may occur. If any unusual symptoms or side effects occur, you must contact your dentist immediately.

Length of Treatment

The mandibular advancement splint is a mechanical device to keep the airway open during sleep. It does not cure snoring or OSA. It must be worn each night during sleep to be effective.

Snoring may develop into OSA and it is possible that the appliance may not maintain its effectiveness over time and needs to be checked at least twice a year by your dentist to ensure proper fit and effectiveness.

Unusual Occurrences

As with any form of medical or dental treatment, unusual occurrences can and do occur. Broken or loosened teeth; dislodged dental restorations; sore mouth; gum disease; deterioration of tooth structure; non-vital teeth (dead teeth); muscle spasms and ear problems are examples of possible unusual occurrences.

These complications are unusual and infrequent.

Additional medical and dental risks that have been mentioned may occur, but are unlikely to. If any unusual symptoms occur, you should cease using the appliance immediately until you see your dentist or doctor.

Please call the surgery/practice if you have any questions or problems regarding the treatment.

Health Funds:
Any quotation includes the Australian Dental Associations scheduled item numbers and tooth identification if applicable. These numbers are recognised by the health funds. I answer to you for the services that I provide and the fees that I charge. That is your right and my responsibility. Your insurer answers to you for the rebates they give. That is your right and their responsibility.

Your insurer may insist on viewing the referral from the Sleep Physician before paying a rebate for the Mandibular Advancement Splint

It is neither my responsibility nor my right to be involved in that relationship.

Finally if you should have any further queries please do not hesitate to ask.


Consent for Treatment:

Oral Appliance Therapy with a Mandibular Advancement Splint (MAS)

This is my consent to provide the dental treatment as indicated in this form:

  • I have been assessed for snoring and/or OSA and understand that I should be examined by my medical GP and that I may also need to have a sleep study performed
  • I have read any provided ADA handout for this course of treatment.
  • I have received a written or verbal quotation and I am clear on the costs involved in this course of treatment.
  • I have given the practice a full, complete and up to date medical and medications history.
  • I am aware that a specialist referral is available for this procedure
  • I fully understand the entire document and the what the treatment entails including advantages, disadvantages, limitations, risks.
  • The treating dental practitioner has explained the known possible complications of and alternative treatments.
  • The treating dental practitioner has answered all of my questions to my full satisfaction.
  • I understand that the results of the treatment can not be guaranteed.
  • I give my permission and consent for the treatment to be performed.
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