Find-a-Dentist     www.idakerala.org.in

Dental Health

Home
/
Dental Health

Welcome

Teeth Whitening

INFORMED CONSENT

RISKS OF CONSENT FOR TREATMENT
I understand that almost all natural teeth can benefit from whitening treatments and significant whitening can be achieved in most cases.

I understand however that whitening treatment results may vary or regress due to a variety of circumstances.

I understand that whitening treatments are not intended to lighten artificial teeth,caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve betterresults than people with gray or bluish-gray teeth.

I understand that teeth with multiple colorations, bands, blotches or spots due to tetracycline use, orthodontics, or fluorosis do not whiten as well, may need multiple treatments or may not whiten at all.

I understand that teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternatives.

I understand that provisionals or temporaries made from acrylics may become discolored after exposure to whitening treatment.

I understand that whitening treatment is not recommended for pregnant or lactating women, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemo-therapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions.

I understand that the Whitening Lamp emits invisible blue light and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing the treatment.

I understand that the results of my Whitening Treatment cannot be guaranteed.

I understand that in-office whitening treatments are considered generally safe by most dental professionals.

I understand that although my dentist has been trained in the proper use of the whitening system, the treatment is not without risk.

I understand that some of the potential complications of this treatment include, but are not limited to:

Tooth Sensitivity/Pain –
During the first 24 hours after Whitening treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals.

Normally, tooth sensitivity or pain following a whitening treatment subsides within 24hours, but in rare cases can persist for longer periods of time in susceptible individuals.

People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after the whitening treatment.

Gum/Lip/Cheek Inflammation –
Whitening may cause inflammation of your gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel or the light.

The inflammation is usually temporary and will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or light.

Dry/Chapped Lips –
The whitening treatment involves three, or four 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor.

This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E cream.

Cavities or Leaking Fillings –
Most dental whitening is indicated for the outside of the teeth.If any open cavities or fillings that are leaking are present allowing gel to penetrate the tooth, it could result in significant pain.

I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the Whitening treatment.

Cervical Abrasion/Erosion –
These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth.

Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity.

I understand that if cervical abrasion/erosion exists on my teeth, I should get it filled if possible or have these areas covered with a dental dam prior to my whitening treatment.

Root Resorption –
This is a condition where the root of the tooth starts to dissolve either from the inside or outside.

Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures.

Relapse –
After the whitening treatment, it is natural for the teeth that underwent the treatment to regress somewhat in their shading after treatment.

This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents.

Treatment may involve wearing a take-home tray or repeating the whitening treatment.

I understand that the results of the whitening treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

I understand that my dentist has evaluated whether I am a proper candidate for an in-office whitening procedure.

The safety, efficacy, potential complications and risks of the whitening treatment has been explained to me by my dentist and I understand that more information on this will be provided to me upon my request.

Since it is impossible to state every complication that may occur as a result of whitening treatment, the list of complications in this form is incomplete.

The basic procedures of whitening treatment and the pros and cons, risks and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction.

In signing this informed consent I am stating I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by my dentist.

By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission for Whitening treatment to be performed on me.

Patient/ Guardian’s Signature & Date:
______________________________
Doctor’s Signature & Date:
______________________________

Root Canal Treatment

INFORMED CONSENT

I have been made aware of my condition requiring endodontic (root canal) therapy in the opinion of my dentists. I am aware that the practice of dentistry is not an exact science, and no guarantees have been made to me concerning the results of the procedure.

I understand that an alternative treatment might be (but not limited to) extraction of the involved tooth or teeth.

I understand that the consequences of doing nothing will lead to worsening of the condition, further infection, cystic formation, swelling, pain, loss of tooth, and/or other systemic disease and infection problems.

Some complications of root canal therapy may be, but are not limited to:

1. Failure of the procedure necessitating re-treatment, root surgery, or extraction.

2. Post-operative pain, swelling, bruising, and/or restricted jaw opening that may persist for several days or longer.

3. Breakage of an instrument inside the canal during treatment, which may be left as is, or may require surgery for removal.

4. Perforation of the canal with instruments, which may require additional surgical treatment or result in the loss of the tooth.

5. Sinus perforation and/or nerve disturbances.

I understand that during and after treatment, I may experience some pain or discomfort, swelling, bleeding and loosening of dental restorations. I may also need antibiotics and other medication to treat any associated infection and pain.

I understand that local anaesthetic will be given. Some discomfort following treatment may develop from the injection area and from opening my mouth for a long period of time during treatment. On rare occasions paresthesia of the nerve may occur.

Successful completion of the root canal procedure does not prevent future decay or fracture. An endodontically treated tooth will become more brittle and may discolor.

In most cases a full crown is recommended after treatment to lessen the chance of fracture.

If I fail to have the tooth restored with a dental crown, I risk the failure of the root canal treatment, decay, infection, tooth fracture and/or loss of tooth.

By providing my signature, I certify that I understand the recommended treatment, the risks of such treatment, any alternatives and the risks of these alternatives including the consequences of doing nothing. I also acknowledge that I have provided an accurate medical history. I have had a chance to have all of my questions answered.

Patient / Guardian Signature & Date
------------------------------------------------
Doctor’s Signature & Date
-----------------------------------------------

Orthodontic Treatment

INFORMED CONSENT

As a rule, excellent orthodontic results can be achieved with informed and co-operative patients. Thus, the following information is routinely supplied to anyoneconsidering orthodontic treatment in our practice.

While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has some inherent risks and limitations.These are seldom enough to contra-indicate treatment, but should be considered in making a decision to start orthodontics. Please feel free to ask any questions during the treatment.

The patient’s responsibility :

♦ It is the patient’s responsibility to follow the brushing and oral hygiene instructions that are given, so that no harm will come to the teeth and surrounding tissues.

♦ To come to all appointments on the proper day and time.

♦ To adhere to the list of food restrictions in order to keep from damaging the teeth and orthodontic appliance and retainers, if they are necessary, so that treatment time will be as short as possible and so we can achieve the best results.

♦ To visit the general dentist at least every six months for an examination and cleaning.

There will be additional orthodontic charges for replacement of appliances (such as retainers or braces) that are lost or damaged due to repeated patient neglect, or any excessive extension of treatment due to lack of patient co-operation.100% patient cooperation is very, very important.

Oral hygiene:

Decalcification (permanent markings), decay, or gum disease can occur if patients do not brush their teeth properly and thoroughly during the treatment period.

Excellent oral hygiene and plaque removal is a must. Sugars and between meal snacks should be reduced as much as possible.

A Non-Vital or Dead Tooth is a possibility:

A tooth that has been traumatized from a deep filling or even a minor blow can die over a long period of time with or without orthodontic treatment.

An undetected non-vital tooth may flare up during orthodontic movement, requiring endodontic (root canal) treatment to maintain it.

Root resorption:
In some cases, the root ends of the teeth are shortened during treatment. This is called root resorption.

Under healthy circumstances the shortened roots are no disadvantage. However, in the event of gum disease in later life the root resorption may reduce the longevity of the affected teeth.

It should be noted that not all root resorption arises from orthodontic treatment. Trauma, cuts, impaction, endocrine disorders, idiopathic reasons can also cause root resorption.

Growth issues:

Occasionally a person who has grown normally and in average proportions may not continue to do so. If growth becomes disproportionate, the jaw relation can be affected and original treatment objectives may have to be compromised. Skeletal growth disharmony is a biologic process beyond the orthodontist’s control.

Some orthodontic patients will require oral surgery to obtain a reasonable treatment result to complete their case. We can inform them ahead of time prior to starting any treatment that this is necessary.

Some patients with poor growth, poor response to treatment, or poor cooperation may also require oral surgery to complete their cases.

Gum tissues:

The bone-gum relationship around teeth is always dependent upon whether there is enough bone to support the gum tissue properly.

Many times when very crowded teeth are straightened there is a lack of bone and supporting gum tissues surrounding the teeth. Therefore, the gum tissue contour and support may not be adequate and require periodontal intervention.

Treatment time:

The total time for treatment can be delayed beyond our estimate.

Lack of cooperation, broken appliances and missed appointments are all important factors that could lengthen treatment time and affect the quality of the result.

TMJ:

There is a risk that problems may occur in the temporomandibular joints (TMJ). Although this is rare, it is a possibility.

Tooth alignment or bite correction sometimes can improve tooth related causes of TMJ pain, but this is not in all cases.

Tension appears to play a role in the frequency and severity of joint pains, and there are many other causes of TMJ dysfunction.

Very unusual occurrences:

Swallowed appliances, chipped teeth, dislodged restorations and allergies to latex or nickel rarely occur but are possible.

Termination of treatment:

It is understood that treatment can be terminated for failure to cooperate, missing appointments, not wearing appliances, excessive breakage, failure to keep financial commitments, relocation, personal conflicts or for any other reason the doctor feels necessary.

If termination is necessary, the patient will be given ample time to locate another orthodontist to continue treatment or the braces will be removed.

Expectations:

All orthodontic patients can expect improvement with their particular problem, but, in many cases, absolute perfection is impossible due to lack of muscle balance, tooth shapes and sizes and varying degrees of co-operation during treatment, along with hereditary aspects that affect everyone’s specific treatment results.

Relapse:

Teeth have a tendency to return to their original position after orthodontic treatment.This is called relapse.

Very severe problems have a higher tendency to relapse and the most common area for relapse is the lower front teeth.

After band removal, a positioner or retainers are placed to minimize relapse. Full co-operation in wearing these appliances is vital.

We will make our correction to the highest standards and in many cases over correct in order to accommodate the rebound tendencies. When retention is discontinued some relapse is still possible.

I consent to the taking of photographs, study models and x-rays before, during and after orthodontic treatment to assist in the planning and progression of treatment objectives.

If the case proves to be of special scientific interest, the dentist reserves the right to present the records in scientific papers or demonstrations to the profession.

I certify that I have read the contents of this form and do realize the risks and limitations involved, and consent to orthodontic treatment.

Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Oral Surgery and Dental Extractions

INFORMED CONSENT

Treatment

I understand that oral surgery and/or dental extractions include inherent risks such as, but not limited to the following:

1. Injury to the nerves::

This would include injuries causing numbness of the lips, thetongue, and any tissues of the mouth and/or cheeks or face.

The numbness which could occur may be of a temporary nature, lasting a few days,a few weeks, a few months, or could possibly be permanent, and could be the result of surgical procedures or anaesthetic.
administration.
2. Bleeding, bruising, and swelling.

Some moderate bleeding may last several hours. If profuse, you must contact us as soon as possible.

Some swelling is normal, but if severe, you should notify us. Swelling usually starts to subside after about 48 hours. Bruises may persist for a week or so.

3. Dry Socket:

. This occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process.

Dry sockets can be extremely painful if not treated. These usually develop 3-4 days after the surgery.

.4. Sinus involvement :

In some cases, the root tips of upper teeth lie in close proximity to sinuses. Occasionally during extraction or surgical procedures the sinus membrane may be perforated.
Should this occur, it may be necessary to have the sinus surgically closed.

Root tips may need to be retrieved from the Sinus.

5. Infection

No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile oral environment, for infections to occur postoperatively.

These may be of a serious nature.

Should severe swelling occur, particularly accompanied with fever or malaise, professional attention should be received as soon as possible.

6. Fractured jaw, roots, bone fragments, or instruments:

Although extreme care will be used, the jaw, teeth roots, bone spicules, orinstruments used in the extraction procedure may fracture or be fractured, requiring retrieval and possibly referral to a specialist.
A decision may be made to leave a small piece of root, bone fragment, or instrument in the jaw when removal may require additional extensive surgery, which could cause more harm and add to the risk of complications.
7. Injury to adjacent teeth or fillings:

. This could occur at times no matter how carefully surgical and/or extraction procedures are performed.

8. Bacterial Endocarditis:

. Because of the normal existence of bacteria in the oral cavity, the tissues of theheart, as a result of reasons known or unknown, may be susceptible to bacterial infection transmitted through blood vessels, and Bacterial Endocarditis (an infection of the heart) could occur.
It is my responsibility to inform the dentist of any heart problems known or suspected or of any artificial joints I may have.
9. Unusual reactions to medications given or prescribed:

. Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed.

All prescription drugs must be taken according to instructions.

Women using oral contraceptives must be aware that antibiotics can render these ontraceptives ineffective. Other methods of contraception must be utilized during the treatment period.

10. It is my responsibility to seek attention should any undue circumstances occur

postoperatively and I shall diligently follow any preoperative and post-operativeinstructions given to me.

As a patient, I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and have received answers to my satisfaction.

I do voluntarily assume any and all possible risks, including the risk of harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved.

No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me.

The fees for this service have been explained to me and are satisfactory.

By signing this form, I am freely giving my consent to allow and authorize Dr. ___________________ and his/her associates to render any treatments necessary or advisable to my dental conditions, including any and all anaesthetics and/or medications.

Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Inlays & Onlays

INFORMED CONSENT

Treatment

I understand that oral surgery and/or dental extractions include inherent risks such as, but not limited to the following:

1. Injury to the nerves::

This would include injuries causing numbness of the lips, thetongue, and any tissues of the mouth and/or cheeks or face.

The numbness which could occur may be of a temporary nature, lasting a few days,a few weeks, a few months, or could possibly be permanent, and could be the result of surgical procedures or anaesthetic.
administration.
2. Bleeding, bruising, and swelling.

Some moderate bleeding may last several hours. If profuse, you must contact us as soon as possible.

Some swelling is normal, but if severe, you should notify us. Swelling usually starts to subside after about 48 hours. Bruises may persist for a week or so.

3. Dry Socket:

. This occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process.

Dry sockets can be extremely painful if not treated. These usually develop 3-4 days after the surgery.

.4. Sinus involvement :

In some cases, the root tips of upper teeth lie in close proximity to sinuses. Occasionally during extraction or surgical procedures the sinus membrane may be perforated.
Should this occur, it may be necessary to have the sinus surgically closed.

Root tips may need to be retrieved from the Sinus.

5. Infection

No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile oral environment, for infections to occur postoperatively.

These may be of a serious nature.

Should severe swelling occur, particularly accompanied with fever or malaise, professional attention should be received as soon as possible.

6. Fractured jaw, roots, bone fragments, or instruments:

Although extreme care will be used, the jaw, teeth roots, bone spicules, orinstruments used in the extraction procedure may fracture or be fractured, requiring retrieval and possibly referral to a specialist.
A decision may be made to leave a small piece of root, bone fragment, or instrument in the jaw when removal may require additional extensive surgery, which could cause more harm and add to the risk of complications.
7. Injury to adjacent teeth or fillings:

. This could occur at times no matter how carefully surgical and/or extraction procedures are performed.

8. Bacterial Endocarditis:

. Because of the normal existence of bacteria in the oral cavity, the tissues of theheart, as a result of reasons known or unknown, may be susceptible to bacterial infection transmitted through blood vessels, and Bacterial Endocarditis (an infection of the heart) could occur.
It is my responsibility to inform the dentist of any heart problems known or suspected or of any artificial joints I may have.
9. Unusual reactions to medications given or prescribed:

. Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed.

All prescription drugs must be taken according to instructions.

Women using oral contraceptives must be aware that antibiotics can render these ontraceptives ineffective. Other methods of contraception must be utilized during the treatment period.

10. It is my responsibility to seek attention should any undue circumstances occur

postoperatively and I shall diligently follow any preoperative and post-operativeinstructions given to me.

As a patient, I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and have received answers to my satisfaction.

I do voluntarily assume any and all possible risks, including the risk of harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved.

No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me.

The fees for this service have been explained to me and are satisfactory.

By signing this form, I am freely giving my consent to allow and authorize Dr. ___________________ and his/her associates to render any treatments necessary or advisable to my dental conditions, including any and all anaesthetics and/or medications.

Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

GIC Filling

INFORMED CONSENT

★ I understand that a more extensive restoration than originally planned, or possibly root canal therapy, may be required due to additional conditions discovered during tooth preparation.

★ I understand that significant changes in response to temperature may occur after tooth restoration such as temporary sensitivity or pain.

★ I also understand that if my tooth does not respond to treatment with a filling, further treatment such as root canal therapy or crown may be necessary.

★ I realize that fillings are rarely “permanent” and usually require periodic replacement with additional fillings and/or crowns.

★ I understand I may need further treatment in this office or possibly by a specialist if complications arise during treatment, and any costs thus incurred are my responsibility.

★ Due to the unique differences in each patient’s oral cavity and oral hygiene abilities there is always a risk for relapse, recurrence, and/or failure of restorations.

I understand that it is impossible to predict if and how fast my condition would worsen if untreated, but it is the doctor’s opinion that therapy would be helpful and worsening of the condition(s) would occur sooner without the recommended treatment.

★ I understand that during the course of treatment it may be necessary to change or add procedures because of conditions discovered during treatment that were not evident during examination.

★ I authorize my doctor to use professional judgment to provide appropriate care and understand that the fee proposed is subject to change, depending upon those unforeseen or undiagnosed conditions that may only become apparent once treatment has begun.

★ I understand that I may require antibiotics, analgesics, anaesthetics and other medications that can cause allergic reactions, resulting in redness and swelling of tissues, itching, pain, nausea and vomiting or more severe allergic reactions which, although rare, can lead to death.

★ I have informed the doctor of any known allergies.

★ Certain medications may cause drowsiness and it is advisable not to drive or operate hazardous equipment when using such drugs.

★ I understand that pain, bruising and occasional temporary or sometimes-permanent numbness in lips, cheeks, tongue or associated facial structure can occur with local anaesthetics. About 90% of these cases resolve themselves in less than 8 weeks. Although very rarely needed, a referral to a specialist for evaluation and possibly treatment may be needed if thesymptoms do not resolve.

My signature below signifies that I understand the treatment and anesthesia that is proposed for me, together with the known risks and complications associated with that treatment. I hereby give my consent for the treatment I have chosen.


Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Dental Porcelain Veneers

INFORMED CONSENT

Veneers are custom made thin shells of tooth colored material. These shells arebonded to the front of the teeth and can be used to change their color, shape, size, or length.

Benefits of veneers also include providing protection to teeth that have been weakened by decay, prior restorations, or root canal treatment.

At the first visit, the dentist may contour the front side of the tooth to make room for the veneer to fit on the tooth. A temporary veneer may be worn while the veneer restoration is being made by the laboratory.

Alternatives: Depending on the diagnosis, there may or may not be alternatives to a veneer restoration. Possible alternatives may be a tooth colored filling, a crown, or no treatment.

Risks: I have been informed and understand that there are certain risks associated with dental veneers.

● I understand that my teeth may become sensitive.

● I understand that once any prior fillings or decay has been removed, it may reveal a more severe condition of my tooth, which may require root canal treatment or extraction.

● I understand that I may notice slight changes in my bite, and/or stiff or sore jaws following treatment.

● I understand that I will be given a local anesthetic and in rare cases patients have had an allergic or adverse reaction to the anesthetic, or temporary or permanent damage to nerves and/or blood vessels from the injection.

● I understand that veneers are not usually repairable should they chip or crack.

● I understand that veneers may become dislodged and fall off. To minimize the chance of this occurring, I should not bite my nails, chew on pencils, ice, or other hard objects, or otherwise put pressure on my teeth. It is oftenrecommended to wear a nightguard when sleeping to protect my veneers from clenching or grinding of my teeth.

● I understand there is a risk of aspirating (inhaling) or swallowing the veneer during treatment.

● I understand that proper brushing and flossing, a healthy diet, and regular professional cleanings are essential to help prevent decay (cavities) and gum irritation.

● I understand that every effort will be made to match and coordinate the form and shade of veneers so they are cosmetically pleasing to me. However, there are some instances which may make it impossible to have the shade and/or form PERFECTLY match my natural teeth.

Acknowledgment

● I understand that once a veneer restoration is started, I must return promptly to have it finished.

● I understand it is my responsibility to immediately inform the doctor and seek attention from her should any unexpected problems occur, or if I am dissatisfied.

● I understand that all instructions must be diligently followed including scheduling and attending all appointments.

● I acknowledge that no guarantees have been made to me concerning the results of treatment.

● I acknowledge that I have had an opportunity to ask all questions regarding veneer treatment and have had all my questions answered to my satisfaction.

Consent
● I freely give my consent to the proposed treatment as described above.


Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Dental Implant

INFORMED CONSENT

This form and your discussion with your doctor are intended to help you make informed decisions about your surgery.

As a member of the treatment team, you have been informed of your diagnosis, the planned procedure, the risks, benefits, and alternatives associated with the procedure, and any associated costs.

You should consider all of the above, including the option of declining treatment, before deciding whether to proceed with the planned procedure.

Your doctor will be happy to answer any questions you may have and provide additional information before you decide whether to sign this document and proceed with the procedure.

Diagnosis:

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________
Procedure:

___________________________________________________________________ _______________________________________________
Alternative options:

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________
If a crown, bridge, or denture is to be attached to the implant(s), this will be done by Dr. _____________________________________________

I have been informed of and understand the potential risks related to this surgical procedure include but are not limited to:

★ Pain, swelling, bleeding, infection, bruising, delayed healing, scarring, damage to other teeth and/or roots that may result in the need for tooth repair or loss, loose tooth/teeth, damage to dental appliances, cracking and/or stretching of the corners of the mouth, cuts inside the mouth or on the lips, jaw fracture, stress or damage to the jaw joints (TMJ), difficulty in opening the mouth or chewing, allergic and/or adverse reaction to medications and/or materials;

★ Nerve injury, which may occur from the surgical procedure and/or the delivery of local anaesthesia, resulting in altered or loss of sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste).

Such conditions may resolve over time, but in some cases may be permanent;

★ An opening may occur from the mouth into the nasal or sinus cavities;

★ Inability to place the implant due to the local anatomy; Implant failure;

★ Discoloration and appearance changes of the gum tissue; Unsatisfactory cosmetic result;

★ Jaw fracture;

★ Bone loss around the implant(s) and/or adjacent teeth; I understand that bone grafting may be necessary.

I have been informed of and understand the potential risks associated with anaesthesia include but are not limited to:

★ Allergic or adverse reactions to medications or materials;

★ Pain, swelling, redness, irritation, numbness and/or bruising in the area where the IV needle is placed. Usually the numbness or pain goes away, but in some cases, it may be permanent;

★ Nausea, vomiting, disorientation, confusion, lack of coordination, and occasionally prolonged drowsiness. Some patients may have an awareness of some or all events of the surgical procedure after it is over;

★ Heart and breathing complications that may lead to brain damage, stroke, heart attack (cardiac arrest) or death;

★ Sore throat or hoarseness if a breathing tube is used.

I have been informed of and understand that follow up visits or care, additional evaluation, treatment or surgery, and/or hospitalization may be needed.

Patient’s Responsibilities:

I understand that I am an important member of the treatment team.

In order to increase the chance of achieving optimal results, I have provided an accurate and complete medical history, including all past and present dental and medical conditions, prescription and non-prescription medications, any allergies, recreational drug use, and pregnancy (if applicable).
I understand the use of tobacco and alcohol is detrimental to the success of my treatment.

I agree to follow all instructions provided to me by this office before and after the procedure, take medication(s) as prescribed, practice proper oral hygiene, keep all appointments, make return appointments if complications arise, and complete care.

I will inform my doctor of any post-operative problems as they arise.

My failure to comply could result in complications, risks, or less than optimal results.

I understand and accept that the doctor cannot guarantee the results of the procedure or the length of time needed to complete my treatment.

I had sufficient time to read this document, understand the above statements, and have had a chance to have all my questions answered.

By signing this document, I acknowledge and accept the possible risks and complications of the procedure and agree to proceed.


Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Dental Crowns and Bridges

INFORMED CONSENT


I UNDERSTAND that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGEWORK includes certain risks and possible unsuccessful results, with even the possibility of failure.

By signing this informed consent, I agree to assume those risks, possible unsuccessful results and/or failure associated with, but not limited to, the following:

(Even though care and diligence is exercised in the treatment of conditions requiring crowns and bridgework and fabrication of the same, there are no promises or guarantees of anticipated results or the longevity of treatment.)

1. Reduction of tooth structure:

In order to place decayed or otherwise traumatized teeth it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as possible.

2. Sensitivity of teeth:

Often, after the preparation of teeth for the reception of either crowns or bridges, the teeth may exhibit sensitivity. It may be mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods.

If it is persistent, notifyour office.

3. Crowned or bridge abutment teeth may subsequently require root canal treatment:


There is the possibility that after being crowned, the teeth may develop a condition known as pulpits or pulpal degeneration. Usually, this cannot be predetermined. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes.

In this case, it is often necessary to do root canal treatments in these teeth.

Should teeth remain appreciably sensitive for a long period of time following crowning, it may be necessary to attempt root canal treatment for them.
Infrequently, the tooth (teeth) may abscess or otherwise not heal completely.

In this event, periapical surgery or extraction may be necessary.

4. Breakage::

Crowns and bridges are subject to the possibility of chipping or breakage.

There are many factors that may contribute to this possibility, including mastication of excessively hard materials, changes in the occlusal forces exerted, traumatic blows to the mouth, etc.

Many times unobservable cracks may develop in crowns from the aforementioned causes, but may actually break when chewing soft foods, or possibly for no evident reason.

Seldom does breakage or chipping occur due to defective construction or materials. If this may be the reason, the breakage should occur soon after placement.

5. Uncomfortable or strange feeling:

This may occur because of the differences between natural teeth and the artificial replacements.

Normally, a patient will become accustomed to this feeling over time.

6. Esthetics or appearance:

Patients will be given the opportunity to observe the appearance of crowns or bridges in their mouths prior to final cementation.

If satisfactory, this satisfaction will be acknowledged by an entry into the patient’s chart to be signed by the patient.

7. Longevity of crowns and bridges:

There are many variables that determine the longevity of crowns and bridges.

Among these are some of the factors mentioned in preceding paragraphs.

In addition, general health, maintenance of good oral hygiene, regular dental checkups, diet, and more can affect longevity. Because of this, no guarantees can be made or assumed.
8. Patient acknowledges:

It is a patient’s responsibility to seek attention should any undue or unexpected problems occur and also to diligently follow any instructions, including the scheduling and attending of all appointments.

★ I have been given the opportunity to ask any questions regarding the nature and purpose of crown and/or bridge treatment and have received answers to my satisfaction.

★ I have been given the option of seeking endodontic therapy with a specialist.

I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved.

★ No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me.

★ The fee(s) for this service have been explained to me and are satisfactory.

★ By signing this form, I am freely giving my consent to allow and authorize Dr.___________________________________

★ _______________________ to render any treatment necessary and/or advisable to my dental conditions, including any and all anesthetics and/or medications.


Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Composite Filling

INFORMED CONSENT


I understand that the treatment of my dentition involves the placement of composite resin fillings, which may be more aesthetic in appearance than some of the conventional materials that have been traditionally used, such as silver amalgam or gold, may entail certain risks.

There is the possibility of failure to achieve the desired or expected results.

I agree to assume those risks that may occur, even if care and diligence is exercised by my treating dentist in rendering this treatment

★ Composite Fillings are held to the teeth with bonding agents. The materials do not stand up to biting forces as well as metallic (silver or gold) fillings, and so are of limited value in the back of the mouth.

★ The shades may match closely but may not match perfectly.

★ Although it is not possible to predict success for individuals, the average lifespan for a tooth colored filling is 4 years, but failure may occur sooner.

★ A strong bite, large fillings or decay can short the longevity.

★ Smoking and drinking tea or coffee regularly will stain fillings.

★ Decay can occur around the filling if good plaque control is absent.

★ There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral or facial tissues from any dental treatment, particularly those involving the administration of local anaesthetics.

The resulting numbness that can occur is usually temporary, but in rare instances it could be permanent.

★ Often after preparation of teeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. The sensitivity can be mild or severe.
The sensitivity can last only for a short period of time or last for much longer periods of time.

If such sensitivity is persistent or lasts for an extended period of time, you should notify the dentist because this can be a sign of more serious problems.

★ When fillings are placed or replaced, the preparation of the teeth often requires the removal of adequate tooth structure to ensure that the diseased or otherwise compromised tooth structure is removed leaving sound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma to underlying pulp tissue.

Should the pulp not heal, which often is exhibited by extreme sensitivity or possible abscess, root canal treatment or extraction may be required.

★ If failure occurs you will be financially responsible for retreatment.

I understand that it is my responsibility to notify this office should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.
I have been given the opportunity to ask any questions regarding the nature and purpose of composite fillings and have received answers to my satisfaction.
I voluntarily accept any and all possible risks, including the risk of substantial harm, if any, that may be associated with any phase of this including the prescribing and administration of any medically necessary anaesthetic treatment in hopes of obtaining the desired outcome.

By signing this document, I authorize Dr. ___________________ and /or his/her associates to render any services deemed necessary or advisable in the treatment of my dental condition, agents and/or medications.


Patient/Parent/Guardian Signature & Date:
___________________________________
Doctor’s Signature & Date:
________________________________

Mouthlife

If you are worried about any longstanding symptoms mentioned below, in the head and neck region, a trained Dentist can help you to diagnose it.

Follow Us

Quick Links

Home IDAKSB Dental Health Resource Member Login

© 2023 mouthlife.org. All Rights Reserved.