Informed Consent for Restorative Procedures

I understand that the treatment of my dentition requiring fillings, veneers, gum procedures, crowns and/or bridgework includes certain risks and possible unsuccessful results, with even the possibility of failure. I agree to assume those risks, possible unsuccessful results and/or failure associated with, but not limited to the following:

Reduction of tooth structure: In order to replaced decayed or otherwise failing traumatized teeth it is necessary to modify the existing tooth or teeth so that the filling, veneer, crown (caps) and/or bridges may be placed upon them. Tooth preparations will be done as conservatively as possible.

Sensitivity of teeth: Often after the preparation of teeth for the placement of fillings, crowns or bridges, the teeth, after being restored may exhibit sensitivity. It may be mild to severe. This sensitivity may only last for a short period of time or may last for much longer periods. In severe, or even moderate cases, root canal therapy may be necessary. If it is persistent, notify us.

Crowned or bridged abutment teeth may require root canal treatment subsequently: There is the possibility that the teeth after being filled or crowned may develop a condition known as pulpitis or pulpal degeneration. Usually, this cannot be predetermined. The tooth or teeth may have been traumatized from accident, deep decay, extensive preparation, or other causes. In this case, it is often necessary to do root canal treatment in these teeth. Should teeth remain appreciably sensitive for a long period of time following filling, veneering, or crowning, it may be necessary to attempt root canal treatment to them. Infrequently, the tooth (teeth) may abscess or otherwise not heal completely. In this event, periapical surgery or even extraction may be necessitated.

Breakage: Fillings, veneers, crowns and bridges are subject to the possibility of chipping or breakage. There are many factors that may contribute to this possibility including biting, chewing and mastication of excessively hard material, changes in the occlusal (biting) 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 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 the placement.

Uncomfortable or strange feeling: This may occur because of the difference between natural teeth and the artificial replacements. Normally, a patient will become accustomed to this feeling in time.

Esthetics and appearance: Every attempt possible will be made to match and coordinate both the form and shade of veneers which will be placed to be cosmetically pleasing to the patient. However, there are some differences which may exist between that which is natural and that which is artificial, making it impossible to have the shade and/or form perfectly match your dentition.

Longevity of crowns and or bridges: There are many variables that determine “how long” fillings, veneers, crowns and bridges can be expected to last. Among these are some of the factors mentioned in the preceding paragraphs. In addition, general health, maintenance of good oral hygiene, regular dental checkups, diet, etc. can affect longevity. Because of this, no guarantees can be made or assumed.

Injury to nerves: Surgical procedures or local anesthesia may possibly result in injury to the nerves of the lips, tongue, or other oral tissues. Numbness could occur which may either by temporary or permanent.

Patient responsibility: It is the 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.

Informed consent: 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 voluntarily assume any and all possible risk of substantial harm, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may not be achieved. No guarantees or promises have been made to me concerning the results. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consents top allow and authorize Dr. Sian and/or her associates to render any treatment deemed necessary, desirable and/or advisable to my dental conditions.

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.