I understand that the long-term success of treatment and status of my oral condition depends heavily on my own effort at proper oral hygiene and maintaining regular recall dental visits (at least every 6 months).
Occasionally, treated teeth may require extractions.
DENTAL PROPHYLAXIS, EXAMS, AND RADIOGRAPHS - I understand that dental prophylaxis (cleaning) involves the removal of plaque and calculus above the gum and is not intended to treat gum infections below the gum line called periodontal disease. I understand bleeding may occur and gums may be sore for a few days after. It is important to remove plaque and calculus on a regular basis in healthy individuals to prevent gum diseases. I understand fluoride may be recommended. Studies have shown fluoride to be safe and effective in preventing dental decay in children and adults. I understand that radiographs are required at times to complete the examination, diagnosis, and treatment plan. This dental office uses digital imaging which uses less radiation, making dental radiographs extremely safe.
SCALING AND ROOT PLANING - I understand that scaling and root planing (deep cleanings) is used to treat the beginning stages of periodontal disease. I understand that periodontitis is a serious gum disease, causing gum and bone inflammation and/or loss, and that can lead to loss of my teeth and other complications. Due to many variables within each patient’s physiology, it is impossible to determine whether or not the healing process will achieve desired results. If these procedures do not produce desired results it may warrant a referral to a specialist for further treatment or tooth extraction at additional costs that would be my responsibility. I understand excellent home care is necessary to increase the likelihood of satisfactory results. Post-operative discomfort and transitory or long term tooth sensitivity may occur. Gums will be sore immediately following treatment and may bleed. Recession of the gums may occur after treatment that may expose margins of restorations, make teeth look longer, and wider spaces between teeth that may cause visible black triangles or food traps. Teeth may be more mobile immediately following treatment.
REMOVAL/EXTRACTION OF TOOTH - I understand that my potential risks include, but are not limited to, the following:
(A) Post-operative pain; swelling; prolonged bleeding; tooth sensitivity to hot or cold; tooth loosening; delayed healing (dry-socket) and/or infection (requiring prescriptions or additional surgery). (B) Injury to adjacent teeth, caps, filling, or injury to other tissues. (C) Limitation of opening; stiffness of facial and/or neck muscles, temporomandibular joint (jaw joint) difficulty (possibly requiring physically therapy or surgery)(D) Possible bone fracture, which may require wiring or surgical treatment. (E) Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery. (F) Injury to the nerve underlying the teeth resulting in itching, numbness, or burning of the lip, chin, gums, cheek, teeth, and/or tongue on the operated side; this may persist for several weeks, months, or, in rare instances, permanently. (G) Possibility of a small fragment of root being left in the jaw that may require more extensive surgery.
If any unforeseen condition should arise during the course of an operation, I authorize the doctor to do whatever they may deem advisable, including referral to another dentist or specialist. I also understand the cost of this referral would be my responsibility.
DRUGS, MEDICATIONS, AND ANESTHESIA - I understand that local anesthetic is used for pain control during dental procedures and this comes with inherent risks and side effects that include, but are not limited to, swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction, and altered sensation that may lead to self- injury. While rare, partial or complete numbness may linger after the dental appointment and can even be permanent.
I understand that Nitrous Oxide may be used to provide relaxation during dental procedures. Nitrous Oxide comes with risks and side effects that include, but are not limited to, tingling in extremities or head and neck, floating feeling, flushed cheeks, detachment or disassociation, uncomfortable warm and/or hot feelings, slurring and/or repetition of words, nausea, vomiting, agitation, and hallucination. All of these effects are temporary.
I understand antibiotics, analgesics, and other prescribed medications may cause adverse reactions, some of which are, but are not limited to itching, vomiting, drowsiness, dizziness, and cardiac arrest. I have been advised not to consume alcohol, nor operate any vehicle or hazardous device while taking medications, and/or drugs, until fully recovered from their effects.
FILLINGS - Fillings involve the removal of decayed and/or broken tooth materials and replacement with a restorative material. It is often not known prior to the procedure how much healthy tooth is left prior to removal of old restorations and decay. If less than half of the tooth is left, more extensive treatment, such as crown and bridge, may be necessary. Sometimes decay or tooth fractures may extend into the nerve of the tooth requiring root canal treatment. Sometimes, even in small restorations, post-operative tooth sensitivity may occur and last for weeks or months post treatment. If this occurs, I will notify the practice in case further treatment is necessary. When tooth colored restorations are used, every effort will be made to match the shade of the existing teeth, but many factors affect shades of teeth and it may not be possible to provide an exact match. Also, it is possible for staining to occur over time and cause the shade match to become less than ideal. I understand that with time and use, fillings will need to be replaced due to gradual wear or fracture of material. It is possible for the bond to fail in bonded restorations resulting in leakage and recurrent decay causing the need for replacement. In cases where very little tooth structure remains, or if any pain or sensitivity persists, I may need to receive more extensive treatment, such as root canal therapy, post and core build-up, and crowns. I understand that fillings under the edges of crowns are intended to try and prolong the life of the current restoration, but no guarantee can be made on how long the existing crown may be saved. I understand that it may be necessary to push back or remove small amounts of gum tissue around areas restorations will be placed that may lead to some temporary post operative pain or soreness adjacent to treated teeth. I understand that without treatment, tooth decay and fractures may worsen and I may need more extensive treatment in the future including, but not limited to, root canal therapy and extractions.
ENDODONTIC TREATMENT (ROOT CANAL THERAPY) - I understand that Root Canal Therapy is a procedure to postpone the loss of teeth which may otherwise require extraction, and as such it cannot be guaranteed. I understand that small instruments used to do root canals can (and do on rare occasions) break inside the tooth, which may adversely affect outcome. Occasionally, a tooth which has had a root canal may require retreatment, surgery, or even extraction. If an "open and medicate” procedure is performed, I understand that this not a final treatment, and I need to pay for, and finish final root canal therapy. If root canal treatment is not finalized I expose myself to infection and/or tooth loss. I understand that any tooth with root canal treatment is prone to fracture, and thus should be protected with a crown or a bridge. If any unforeseen condition should arise during the course of an operation, I authorize the doctor to do whatever they may deem advisable, including referral to another dentist or specialist. I also understand the cost of this referral would be my responsibility.
CROWN, BRIDGE, AND VENEERS- I understand that crown or bridge restorations are used to restore compromised teeth. To replace decayed or otherwise traumatized teeth, it is necessary to modify the existing tooth or teeth so that crowns or bridges may be placed. Tooth preparation will be done as conservatively as practical, but I understand that some existing tooth structure will be removed. Due to existing decay or missing tooth structure it may be necessary to place a build up (filling) and pins in the tooth prior to preparation. If the tooth has had a root canal, a post may be necessary to support the restoration. Pins and posts provide necessary support to restore teeth with large areas of missing tooth structure; however they do weaken the remaining tooth and may lead to tooth fracture over time. Margins may need to be placed under gums that may cause postoperative inflammation of the gum that usually resolves but may linger long term. I understand that having a crown, bridge, or veneer prep often causes mild to severe sensitivity that may last for a short period of time or may linger long term. If discomfort continues, I will notify the practice in case further treatment is necessary. I understand that if my crown is placed due to tooth fracture, the fracture may worsen over time and cause the need for root canal therapy or extraction.
This may also occur in teeth with extensive decay. Although crowns, bridges and veneers are made of highly durable material, it is still possible to chip or break them. Unobservable cracks may develop in crowns, but crowns/ bridges/veneers may not actually break until chewing soft foods, or for no apparent reason. Small chips can be repaired, while larger cracks may require new crown, bridge, or veneer. If sensitivity or pain persists, the tooth involved may require root canal therapy at additional costs. It is possible for muscle soreness or tenderness of the tempromandibular joint (TMJ) to persist for indeterminable periods of time following the placement of a prosthesis. Every effort will be made to match shade of teeth and patients will be given the opportunity to observe the appearance of crowns or bridges in place prior to final cementation. I understand that over time, gum recession may occur and expose margins of crowns, bridges, and veneers that may be less than esthetic. I understand that overtime the cement and/or bond may weaken and cause the restoration to come off. If there is no decay or tooth fracture, the restoration can often be simply recemented. If a crown, bridge, or veneer comes off due to decay or tooth fracture the tooth or teeth involved may require fillings, build ups, root canal treatment, and post and/or pin placement. I understand that if these treatments are necessary to replace a crown I may need a new crown or the tooth may need to be extracted if recementation fails. There are many variables that determine how long recemented restorations can be expected to last. We can offer no warranty, promises, or guarantees concerning the results of recementation. I understand that it may be necessary to push back or remove small amounts of gum tissue around areas restorations will be placed that may lead to some temporary post operative pain or soreness adjacent to treated teeth.
IMPLANT RESTORATIONS - I understand that if my implant has not properly integrated into the bone, there is a risk of the implant being removed at the time of impression for the restoration. I understand that once restored, implants require regular maintenance. Even with regular dental visits, bone loss may still occur around implants leading to implant failure or a gray appearance on the gum adjacent to the restoration. I understand that crowns placed on implants may also need maintenance over time. It is possible that internal screws may become loose and need to be tightened.
NIGHT GUARDS, RETAINERS, AND/OR OTHER APPLIANCES - I understand that these appliances are designed to treat or prevent a problem such as jaw pain, tooth movement, night time grinding and/or clenching. Desired results cannot be guaranteed and further treatment may be necessary at additional expense. I understand not to wash appliances in hot water, not to soak in Listerine or strong chemicals, and damage due to improper care or loss is my responsibility.
BLEACHING – I understand that bleaching may cause mild to severe sensitivity to my teeth that should fade over time. I understand that it is normal for teeth to bleach unevenly and this should even out over time. I understand that results may not be permanent and I may need to bleach again later to maintain results. I understand that every patient’s teeth respond differently to bleach and results are not guaranteed. I understand that if I choose to bleach my teeth crowns, bridges, veneers, and fillings will not lighten with other natural teeth. These will be pointed out by the doctor before impressions are made for bleaching trays. I understand not to wash bleach trays in hot water, not to soak in Listerine or strong chemicals, and damage due to improper care or loss is my responsibility.
COMPLETE AND PARTIAL DENTURES - Persistent sore spots should be immediately examined by the doctor. I understand that surgical intervention such as bone recontouring or implants may be needed for dentures or partials to be properly fitted. I also understand that due to bone loss or other complicating factors, I may never be able to wear dentures or partials to my satisfaction for many reasons including but not limited to jaw ridges that may not provide adequate support and/or retention, musculature in the tongue, floor of mouth, cheeks, etc., which may not adapt to accommodate artificial appliances, excessive gagging reflexes, excessive saliva or excessive dryness of mouth, any remaining teeth that an appliance is anchored to may become tender, sore, or mobile, any remaining teeth may decay, break, or erode around the clasps or attachment, general psychological and/or physical problems interfering with success. I understand that due to the types of materials necessary to construct appliances, breakage may occur without any defects in fabrication. Breakage may occur for many reasons, including but not limited to, chewing on foods or objects that are excessively hard, gum tissue shrinkage which causes excessive and uneven chewing pressures, appliances being dropped or damaged previously, and excessively hard chewing and/or grinding forces. I understand that complete and partial dentures wear over time and may need to be replaced due to this wear. It is impossible to determine how long an appliance may last due to many factors and every patient is different. I understand appliances may become loose over time due to changes in gum tissues; when this occurs it may be necessary to reline. Infrequently, oral tissues may exhibit allergic symptoms to the materials used in construction of these appliances. I understand that there is an adjustment period with new complete or partial dentures, even if I have worn an appliance in the past. I may experience some uncomfortable or strange feelings and/or a feeling of having an over full mouth at first. Most patients become accustomed to these feelings over time. I understand every effort will be made to achieve an esthetic result and I will be given an opportunity to observe the anticipated appearance of the dentures in the mouth, when possible and applicable, prior to processing. I understand it is my responsibility to seek attention when problems occur and to come in for regular visits to examine the condition of the appliance(s), gums, and my overall oral health. If a complete partial or denture needs repair, I understand that would be at my own expense. I understand a soft or hard reline is an attempt to fill a space between the denture and tissue. There is a possibility that a reline may not fit or look exactly as I am expecting it to, or that the appliance may not stay in any better than it did before. I understand that if a tooth needs to be added, it is an attempt to add a tooth where I am missing an additional tooth that the original prosthesis was not designed for or to replace a tooth that has since broken off. I understand that this is not to improve the overall function of the prosthesis and is only to aid with esthetics. I understand that a repair of a fracture is an attempt to repair my appliance and this is in no way ensuring any longevity of the prosthesis and it is not guaranteed that the restoration will hold for any given amount of time. I understand that if this repair fails, a new appliance may be needed. If a clasp is added, I understand that this is an attempt to add a clasp that the original prosthesis was not designed for or to replace a clasp that has since broken off. I understand that this may not improve the overall function of the appliance and may compromise the adjoining teeth.
I have had the opportunity to discuss the recommended treatment with the doctor, the risks and benefits of the recommended treatment, any alternatives to the recommended treatment along with the risks and possible complications to alternative treatments. The doctor has answered any questions I have regarding treatment. I have been giving the approximate costs of the treatment recommended as well as any alternatives.
I understand that that no dental treatment is risk free. The risks have been explained to me and the dentist will take reasonable steps to limit any complications. I understand that no guarantee or assurance has been made that any given treatment will be curative and/or successful. I agree to cooperate with the recommendations of the doctor while under their care, realizing any lack could result in less than optimum results. I certify that I have had an opportunity to read and fully understand the terms and words within the above, and consent to treatments. I understand that it is my responsibility to notify this practice should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or services performed. I voluntarily accept any and all possible risks, including the risk of substantial harm, if any, that may be associated with any phase of this treatment in hopes of obtaining the desired outcome. By signing this document, I authorize Dr. Holmes and/or her associates to render any services deemed necessary or advisable in the treatment of my dental condition.