Local Anesthesia
I realize that there are risks involved in receiving local anesthesia. Some of these risks include: partial face paralysis, inflamed tissue, trismus, adverse reactions to drugs causing cardiac arrest, stroke, hemorrhage, nerve damage and/or numbness.
Changes in treatment plan
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment outcome and have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.
Removal of teeth
Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment.
Restorations/Fillings
Fillings are procedures in which the dentist removes decayed tooth structure or a faulty restoration and replaces it with composite. I understand that these procedures could cause the teeth to be sensitive to hot and cold as well as chewing. The majority of the times, these sensitivities are temporary and they will go away within one or two weeks. However, there are times the depth of the decay in the tooth is greater than predicted by observation and dental radiographs and the tooth may need pulp treatment or root canal and/or crown. It is also possible that the pulp might already be infected by bacteria and become abscessed at some point after the filling procedure and require further treatment.
Crowns, Bridges
I understand that crowns and bridges are generally placed on teeth with extensive decay, large fillings, or fractures. These teeth have a greater chance of needing root canal therapy at a future date. If this future treatment is necessary, I understand that the fee is not included in the cost of the crown. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth.
Dentures (Complete or Partial)
I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee.
Endodontic Treatment
I understand that the purpose of a root canal or pulpotomy is due to deep decay into the pulp of the tooth. A root canal is performed in hopes of saving the tooth from extraction for the purpose of function. However, due to the fact that it is not possible to determine the extent of bacterial infection it is possible that even with best efforts, my tooth may become abscessed at some point after the pulp treatment and necessitate extraction. I realize there is no guarantee that root canal treatment will save my tooth, and complications can occur from the treatment.
I certify that I have read and fully understand the above consent to dental treatment and that the explanations therein
referred to were made. Anything I did not understand has been explained to me.
