Dental Treatment Consent Form

Dr. Ronald Ritsco and his team provide the following information to you related to your treatment

YOUR TREATMENT PLAN

Dr. Ronald Ritsco will perform a dental examination and advise you of the present condition of your teeth and gums. Based on this exam and discussions with you, Dr. Ritsco will recommend and present to you a custom-designed treatment plan (“Treatment Plan”), which has the goal of improving the function and/or appearance of your teeth and gums. Your Treatment Plan will involve one or a combination of the following (perhaps along with other recommended dental procedures): crowns, veneers, bonding, inlays, onlays, whitening, root canal therapy, gum or tooth contouring. Below are summary descriptions of some of these procedures. You may also be shown photographs of the recommended procedures for you, hear Dr. Ritsco’s explanations, and/or see multimedia presentations illustrating the primary procedures proposed for your Treatment Plan.

DESCRIPTIONS OF CERTAIN DENTAL PROCEDURES

Porcelain Veneers are shells of porcelain that are bonded to the teeth. They typically require some roughening or reduction of the outer tooth structure. Dr. Ritsco will endeavor to minimize the tooth reduction necessary under the circumstances to achieve the desired aesthetic and functional results. At a later visit, the veneers are bonded onto the prepared teeth. The veneers may be designed and fabricated in a variety of shapes and sizes to modify the appearance and function of teeth, including a V-shape that covers the front and backside of the teeth (for example, when opening a bite).

Crowns are life-like looking tooth restorations made out of porcelain or porcelain plus other materials. A crown covers the entire tooth structure. Typically, more tooth structure is removed to prepare for a crown placement than for a veneer. Crowns may be recommended for teeth requiring additional support due to a loss of healthy tooth structure.

Bonding is a term that is commonly used to refer to the placement of composite resins on teeth. Bonding can be used to make a tooth-colored filling for small cavities and repair broken or chipped tooth surfaces. It can also be used to close spaces between teeth.

Inlays or Onlays may be the recommended treatment when individual back teeth are broken down but retain enough healthy tooth structure to allow for the restoration of certain voids in the tooth structure. The tooth is prepared much like a normal filling or a short crown. The restoration material is custom fabricated out of composite resins, porcelain, or porcelain and gold and bonded into the void.

A Bridge is a replacement made for missing teeth. It is composed primarily out of porcelain, which is bonded to adjacent teeth. These abutment teeth may require some reduction or crowning in order to support the teeth being replaced.

Whitening is performed by applying a peroxide gel to the teeth. This can either be done in our office in an accelerated method or in a take-home system. The peroxide reacts with the tooth structure to safely whiten the teeth. Porcelain or composite restorations will not whiten with peroxide.

Root Canal Therapy consists of the removal of the infected or irritated nerve tissue that lies within the root of the tooth. This is a possible risk when tooth structure is removed from a tooth or the tooth receives trauma. Usually, in the same visit, the canal where the nerve is located will be reshaped and prepared to accept a special root canal filling material. The root canal is then sealed with sterile, plastic material.

Tooth Contouring is the reshaping of the existing tooth structure by removing small amounts. We give particular attention to the edges of the upper and lower front six teeth, which may be reshaped to create a more aesthetic result.

Gum Contouring is the reshaping of the gum tissue, which is many times done to give a more symmetrical appearance.

CUSTOM PREPARATION

Each person is unique and presents a different set of circumstances. Some of these circumstances are not revealed until during the procedure itself (for example, decay hidden under old crowns, etc.) or after. Therefore, the exact nature of the tooth and gum preparation for your Treatment Plan may vary somewhat from tooth to tooth and may vary from the general descriptions you have read above or seen elsewhere depending on the amount of decay (if any) present, the shape (e.g., gaps, chips, size) and position (e.g., the amount of rotation, spacing or flaring) of the teeth, and the desired look and function of the final restorations. As a result of these and other reasons, the exact nature and contours of the preparation of your teeth and the resulting restorations cannot be known until they are performed. During the course of treatment, unknown or unforeseen conditions may be revealed that necessitate a modification of the proposed Treatment Plan (e.g., a veneer preparation may become a crown prep). Dr. Ritsco will exercise his or her professional judgment to perform a conservative preparation of your teeth and to make other necessary decisions regarding the means, manner and method of any procedures as they deem appropriate to achieve the desired results of the Treatment Plan or as they otherwise deem advisable under the circumstances.

SPECIFIC RESULTS NOT GUARANTEED

The dental procedures described above have a high degree of success. Human tissues, however, react differently to dental treatment depending on a variety of factors. Each individual case is different and the exact result for each specific case is difficult if not impossible to guarantee. Thus, as with any branch of medicine or dentistry, the proposed Treatment Plan contains no guarantee of specific results. There are many variables that determine how long restorations or whitening can be expected to last, including general health, maintenance of good oral hygiene, regular dental checkups, diet, etc. Therefore, no guarantees can be made or assumed regarding the longevity of restorations or whitening. If you have been provided computer-generated imaging of your smile, you understand that this is an artificial mechanism to serve as a basis for a discussion of treatment, and in no way provides a warranty or representation of specific results. Natural teeth themselves are not “perfect” and contain certain embrasures, striations, and color variations. Dr. Ritsco will use his artistic skills to specify the shades, coloring, shape, and sculpting of the restorations to make what in their experience are very realistic replicas of teeth. As with any type of artistic endeavor, however, aesthetics is a highly subjective perception. You will be allowed to view and approve the lab fabricated porcelain restorations prior to bonding in. Once restorations are placed, and your approval is given, any redo's based on the shade, coloring, shape, sculpting, and/or other aesthetic issues will be at Dr. Ritsco’s sole discretion and at current rates. Therefore, you may want to bring a friend or loved one to attend the seat appointment to help approve the restorations.

ALTERNATIVE TREATMENTS

There are alternative treatments to Dr. Ritsco’s recommended Treatment Plan, which may include, but are not necessarily limited to one or more various combinations of veneers, crowns, bonding, Onlays, inlays, whitening, contouring of teeth or gums, bridges, dentures, extractions, root canal therapy, fillings, orthodontics, non-surgical therapy, surgical coverage or cleaning, tooth extractions, implant treatments, as well as other dental treatments. Please make sure you have had an opportunity to ask about these and had them explained to your satisfaction.

NON-TREATMENT OPTION

One option is to have no treatment performed. This alternative may entail a number of actual or potential risks, which are difficult or impossible to quantify or predict for specific cases. Some of the risks of non-treatment may include but are not necessarily limited to, exacerbation of any existing symptoms, deterioration of aesthetics or function of your teeth, improper biting, tooth, head and/or neck pain, the fracturing of teeth, discoloration or staining of your teeth, rotation or movement of teeth, TMJ complications, additional wear of your teeth to the point they are not candidates for reconstruction, loss of teeth, bite problems, poor chewing, loosening of teeth, need for dentures, gum recession, bad breath, inability to perform adequate oral hygiene, abscesses or infection, pain, tooth sensitivity, tooth movements, worsening periodontal condition, deeper pockets, and other oral health problems.

RISKS AND INCONVENIENCES

Inherent in Dr. Ritsco’s proposed Treatment Plan (as well as with many similar or other dental procedures) are certainly actual and potential risks and inconveniences, which vary based on individual circumstances and variations in teeth and gums. These risks and inconveniences may last for a short or indefinable length of time. They include, but are not necessarily limited to swelling, pain, tooth sensitivity, bleeding, bruising, discoloration, gum recession, abscesses, the need to repeat all or part of the procedure for known or unknown reasons, gagging, exposure of crown margins or edges, numbness, gum, bone or teeth inflammation, lisping, speech impediments or speaking difficulties, infections, transmission of bacteria or virus, changes in facial appearance, stretching of the mouth resulting in cracked corners, stiffness of facial muscles, changes in occlusion, tooth mobility, loss of teeth, oral surgery, food impaction, root staining, oral opening restrictions, tissue sloughing, continued periodontal disease, implant rejections, root canal therapy, numbness of lip, chin, and gums, dental neuropathy, temporary or permanent numbness or tingling in the lip, tongue, teeth, gums, chin, cheek or jaw area, nerve problems, parestesia, joint pain/disorder, need for a night guard, accidental nicks or cuts from dental instruments or needle sticks to the body, injuries to adjacent facial area and teeth, fillings in other teeth, other tissues, sutures, chipping, breaking or loosening of the temporary or permanent restorations, accidentally swallowing or aspirating restorations, materials or dental tools, referred pain to the ear, neck, jaw or head, temporomandibular joint (jaw joint) problems, nausea, allergic reaction, bone fracture, delayed healing, sinus complications, adverse reaction to drugs, medications, and/or anesthetic (including nitrous oxide), respiratory distress, heart failure, or death. You understand that your condition may be the same, better or worse after treatment. If previously placed dental restorations are in place on teeth, the Treatment Plan may entail additional alteration of tooth structure to properly prepare these teeth for new restorations, and/or other unknown or unspecified problems or risks, which Dr. Ritsco may or may not encounter, and which are difficult or impossible to predict or quantify.

MAINTENANCE OBLIGATIONS

For successful treatment results and to lessen the dangers of complication, you agree to comply with your individualized maintenance program and keep excellent oral hygiene. It is typical to need follow-up visits for occlusal or other adjustments. You agree to notify Dr. Ritsco at the soonest possible moment in the event that you experience pain or discomfort that you believe may be related to Dr. Ritsco’s treatment. You agree to keep your follow-up appointments and to follow recommended treatments for your Treatment Plan as well as follow other precautions and recommendations that may be provided as part of your pre-op or post-operative instructions.

YOUR CONSENT

I acknowledge that Dr. Ritsco and his team will have explained to me in general terms the diagnosis of my condition, the basis for his Treatment Plan recommendations, general descriptions of the proposed Treatment Plan, the alternatives (including non-treatment), and the risks and inconveniences. I will be given the opportunity to ask any questions and any such questions have been answered or explained to my satisfaction. By signing below, I acknowledge that I am above 18 years of age, have been given time to read, and have read the preceding information in this document and I agree to assume the risks and inconveniences of my treatment.

I consent to the making of records, including x-rays, photographs, prescriptions, and other information, which may include personal information before, during and after treatment (together, “Records”). Dr. Ritsco may disclose my Records for treatment, payment, or healthcare operations, including disclosure to laboratories, other dental offices or professionals involved in my care, and to my insurance providers.

I understand this form and I consent to performance of the Treatment Plan as described herein.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Authorized Representative
(If the patient is under 18 years of age or you are consenting to the care of another)