Informed Consent for Dental Treatment

CROWNS - CAPS ROOT CANAL

BENEFITS: BENEFITS:
Make you look nicer (cosmetic) Eliminate decay
To repair a tooth which is badly broken down Relieve Pain
To prevent a tooth from fracturing Save the Tooth
To restore a tooth which has broken POSSIBLE COMPLICATIONS:
To eliminate a space where food is being trapped Undiagnosable root fracture means failure and extraction
To hold a false tooth in place as part of a bridge Undiagnosable auxiliary canal means failure and extraction
To make a solid structure to attach a partial denture CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING
To splint loose teeth together to strengthen them Extraction of tooth
The tooth no longer can be filled. ALTERNATIVES:
POSSIBLE COMPLICATIONS: Extraction
Porcelain portion of crown may fracture Bridgework
Crown may come off and need to be recommended Initials Date
Tooth may abscess and require further treatment (may not show up
until later) FILLINGS
Future decay may require a filling or new crown
CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING BENEFITS:
Tooth will probably fracture Eliminate decay
Tooth may need to be extracted Relieve pain
May need a root canal in addition to the crown Fill in a hole or space in a tooth
May need bridgework or denture Cover eroded area
ALTERNATIVES: Protect a sensitive surface
Extraction POSSIBLE COMPLICATIONS:
Temporary crown Tooth may abscess from the filing
Steel crown ______ May fracture the tooth
Initials Date Tooth will be sensitive to temperature change
Toxicity from silver fillings is alleged by some
BRIDGEWORK Filling may fall out CONSEQUENCES OF NOT HAVING
WORK DONE or POSTPONING
BENEFITS May loose the tooth
Make you look nicer Tooth may fracture
To replace missing teeth Decay will get worse
Missing teeth are not removable May result in need for a root canal
Some of same advantages as Crowns ALTERNATIVES:
Can improve chewing efficiency Temporary filling _____ _
POSSIBLE COMPLICATIONS: Initials Date
Same as Crowns
CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING GUM SURGERY (Gingivectomy)
Teeth will drift and lean over
May loose back teeth due to shifting BENEFITS:
Periodontal problems (Gum disease) Eliminate infection
Can reduce chewing efficiency Reduce food pockets around teeth
ALTERNATIVES: Eliminate foul odors
Partials Reduce overgrown tissue
Temporary partials Can eliminate Tartar effectively
No teeth in the spaces ______ ______ POSSIBLE COMPLICATIONS:
Initials Date May need to be repeated after a time
Some after- pain
Might loose teeth if they don't respond to treatment
PARTIALS (REMOVABLE BRIDGEWORK)
CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING
Will loose teeth sooner
BENEFITS:
May not get rid of infection
Cost POSSIBLE
ALTERNATIVES:
COMPLICATIONS:
More frequent appointments for scaling
Can wear on Teeth Initials
Can rock or stress teeth - may loosen own natural teeth Date
Metal clasps are sometimes visible
Decay can occur under clasps
Usually some amount of movement from the partial
CONSEQUENCES OF NOT HAVING WORK DONE orPOSTPONING
Same as under Bridgework
ALTERNATIVES:
Bridgework
Temporary partial
Keep spaces without teeth placement
Initials Date
 EXTRACTIONS BONDED FACINGS

BENEFITS: BENEFITS:
Last resort for non-salvageable tooth Esthetics - they look really nice
Eliminate pain Cover crooked teeth
Remove teeth that are out of position Close spaces and gaps
Eliminate infection Cover discolored teeth
POSSIBLE COMPLICATIONS: POSSIBLE COMPLICATIONS:
Fractured particles may remain Edges can stain after a time and need to be freshened up (additional fee)
Irritation to nerves may cause temporary or permanent numbness Breakage can occur, resulting in need for remake
Part or all of tooth may be lodged in sinus, requiring more surgery Difficult to remove
Bad infections may take long time to clear up CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING
Jaw may be stiff and difficult to open for a time None (other than appearance)
If Jawbone is very weak it may fracture ALTERNATIVES:
CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING Crowns
Spread of infection Initials Date
Swelling
Pain LOCAL ANESTHETICS
ALTERNATIVES:
None ______ _______ BENEFITS:
Initials Dale Avoid pain during treatments and procedures
POSSIBLE COMPLICATIONS:
CLEANING - SCALING Prolonged numbness may extend beyond normal
Nerve damage
BENEFITS: Bruising (hematoma)
Look nicer In rare instances, possible consequences may include all those applicable
Clean mouth General Anesthesia, including allergic reactions up to and including death
Eliminate odors CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING
Prevent odors Mild to severe pain during and after treatment
Prevents Gum Disease ALTERNATIVES:
Some portions may be performed by auxiliary personnel Willingness to accept pain during treatment
POSSIBLE COMPLICATIONS: Initials
Date
Sensitive teeth
Feeling of spaces between teeth
Filling may be loosened (Normal if filling was ready to fall out)
Sensitive gums
CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING
Stains on teeth
Odors
Gum disease
Will lose teeth sooner
ALTERNATIVES:
None ______ _______
Initials Date

X-RAYS

BENEFITS:
More complete diagnosis
Can find hidden problems
Can make a determination of treatment
X-Rays are taken by qualified personnel
POSSIBLE COMPLICATIONS:
Exposure to X-Ray radiation (minimal)
X-Ray pictures remain the property of this office
CONSEQUENCES OF NOT HAVING WORK DONE or POSTPONING
Can not perform dental services
ALTERNATIVES:
None ---------- — --------
Intuit Due

Name of Patient.
1 have read the above statements and have received a copy of them if requested, and recognize their importance in helping me nuke decisions. My initials indicate that I have read and
understand this consent document. 1 recognize that failures can occur for all kinds of reasons and that complications can occur in any procedure. 1 also understand that, where decay has
occurred, or a tooth has fractured or abscessed, that these same forces are still working on the tooth even after it has been restored: therefore, decay or fracture can still occur as the
restored tooth is no better than what nature has given in the first place. If for any reason a conflict or disagreement should arise 1 will first present such conflict or disagreement to my
attending dentist in order to resolve the problem. If we are unable to agree on a solution, then I agree to take the problem to a reconciliation / mediation board such as the dental society
and agree to accept their resolution in lieu of pursuing remedies by way of litigation. I also understand that this agreement is binding on my heirs and all other family members. I now
give my consent to the attending dentist to render to me the dental treatment that we have agreed is necessary (or myself. I also agree to reimburse the attending dentist for all services
rendered to me. and I am aware that the payment for these services is due at the time they are rendered.

Signature Signature