General Dental Informed Consent Form
Crabtree Valley Dental would like to inform all patients of the risks and benefits of various dental procedures. Please review the following procedures and feel free to ask any questions. A treatment plan for all restorative needs, which includes estimated fees and treatment specific authorization will be presented to you for your review and your signature at the time the treatment plan is diagnosed.
1. Drugs and Medication:
Antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). Risk of local anesthesia may include temporary or permanent numbness, swelling, pain and bruising at the injection site. It is my obligation to let the dentist know all of my medical conditions, medications and allergies to help avoid any adverse reactions.
2. Changes in treatment:
during treatment, it may be necessary to change, omit, or add procedures because of conditions discovered while working on the teeth that were not evident during the examination. For example, root canal therapy following routine restorative procedures. I give my permission to the doctor to make any changes or additions as necessary.
3. Removal of teeth:
alternatives will be explained to me (root canal therapy, crowns and periodontal surgery...etc.). The removal of teeth does not always remove all of the infection, if present, and it may be necessary to have further treatment. Some risks are pain, swelling, spread of infection, jaw fracture, dry socket, loss of feeling in teeth, lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time. I understand that I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.
4. Crowns and bridges:
sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I may wear temporary crowns, which may come off easily. If a temporary crown dislodges, I understand the need to contact my doctor. It can be aspirated or ingested requiring immediate medical attention. If my temporary dislodges, I will contact my dentist so that it can be replaced. I will need to be careful to ensure that they are kept on until the permanent crown is delivered. I realize the final opportunity to make changes in my new crown/bridge (including shape, fit, size and color) will be before cementation. It is also my responsibility to return for cementation within 30 days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown/bridge. I understand there will be additional charges for remakes due to my delaying cementation.
5. Partials:
They are artificial, constructed of acrylic, metal and/or porcelain and are not anchored to bone like natural teeth. The potential consequences of wearing these appliances include loosening of abutment teeth, soreness, tooth loss and possible fracture of the appliance. Most partials require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial fee. I also understand that if I do not wear my partials at least 6 hours/day, my teeth will shift and the partial will no longer fit, necessitating a new partial.
6. Endodontic Treatment (Root Canal):
there is no guarantee that root canal treatment will save a tooth. Complications may occur during treatment which include file separation and perforation of the tooth which may compromise the prognosis of the tooth. Additional surgical procedures may be necessary following root canal treatment (apicoectomy) to help save the tooth but occasionally, the tooth will need to be extracted despite all efforts to save it.
7. Periodontal Disease:
This is an active infection of the gums and supporting bone that leads to many unhealthy conditions including but not limited to tooth loss, pain, acute infection, swelling and systemic infection. Treatment will be recommended by the dentist explained. Depending on the severity of the disease, a referral to a specialist may be required.
8. Implants:
They are an alternative to bridges, partials or dentures. This process may involve the participation of an oral surgeon or periodontist. Fees for his/her services are separate from those of Crabtree Valley Dental. This process involves several steps and could require up to one year to complete. As with crowns, color may not match perfectly with natural teeth.
9. Sealants:
Although they form a hard shield that helps keep food and bacteria from getting into tiny grooves and causing decay along the chewing surfaces of the teeth, there is no guarantee that a sealant will prevent cavities. Occasionally sealants need to be replaced because they do not last a lifetime. We do, however, warranty our sealants for 18 months, granted that the patient is seen twice/year for prophylaxis visits. Sealants can be done at any age as long as the teeth are free of decay and fillings. The doctor will determine the best time to have them done.
10. Sedative fillings:
Sedative fillings are temporary. They are placed if inadequate anesthesia is obtained or the dentist wants to monitor the tooth after the decay has been removed prior to placing permanent restoration or a pulpal exposure has occurred necessitating a root canal or extraction. If a sedative filling dislodges, I understand the need to contact my doctor. It can be aspirated or ingested requiring immediate medical attention. If a sedative dislodges, I will contact my dentist so that it can be replaced.
11. Restorative:
I understand that any time a restoration is performed, there is a possibility of trauma to the nerve of the tooth, which could result in varying degrees of sensitivity and complications including but not limited to the following: cold sensitivity, hot sensitivity, sensitivity when flossing, biting sensitivity, abscess formation, pulp necrosis (when the nerve dies in the tooth) and pain. Most of the symptoms usually resolve as the nerve heals. I will contact Crabtree Valley Dental if any signs or symptoms present. Complications may arise resulting in the need for additional treatment, including one or more bite adjustments, replacement of the restoration due to open margins discovered after final cementation, root canal treatment or tooth removal.
12. Dentures:
I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placement of denture immediately after extractions) may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline will be needed. A new set of dentures are often needed after the healing phase of 2 months. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delay of more than 30 days, there will be an additional charge.
I have carefully read the above informed consent and fully understand all risks as it relates to my case.
