X-Rays:

Proposed treatment: taking of intraoral and extraoral radiographs. Benefits of treatment: taking x-rays enables us to view dental cavities, abnormalities, development and eruption of teeth. They are also necessary for proper diagnosis and evaluation purposes. Alternatives of treatment: none, limited visual examination. Common risks: radiation exposure to soft and hard tissues. Consequences of not performing treatment: missed diagnosis.

Proposed treatment: involves thorough cleaning of teeth to help heal inflamed or infected gum tissue. It involves removal of soft plaque build-up and harder calculus deposits above the gum line. Benefits of treatment: healthy oral environment; also, reduction/elimination of bleeding, odor, and periodontal disease. Alternatives of treatment: referrals for periodontal (gum) surgery according to the severity of condition. Common risks: bleeding, soreness, swelling, infection of tissue, hot and cold sensitivity, stiff or sore jaw joint. Consequences of not performing treatment: discontinued or interrupted treatment could result into further inflammation and infection of gum tissues, lead to more tooth decay, and deterioration of surrounding bone structure which could lead to tooth loss.

Anesthetic:

Proposed treatment: injection of anesthetic to surrounding oral tissues. Benefits of treatment: numbness of tissue and muscle surrounding area of treatment to eliminate pain sensation. Alternatives to treatment: dental restorations performed with no anesthetic resulting in severe sensitivity and pain. Common risks: allergic reaction, irritation to nerve tissue, stiff or sore jaw joint, selling of tissue, bruising and may cause temporary or permanent paralysis. Consequences of not performing the treatment: severe pain sensitivity.

Fillings:

Proposed treatment: to remove tooth decay and/or ill fitting filling and replace with filling material to regain proper tooth anatomy. Benefits of treatment: restore tooth structure for proper function. Alternatives of treatment: temporary filling, crown, extraction. Common risks: allergic to filling material, tooth sensitivity, filling may come out. Consequences of not performing the treatment: further spread of decay, requiring root canal treatment or severe destruction resulting in tooth loss.

I understand that sensitivity is a common after-effect of a newly placed filling and some cases may last for several months.


Root canal treatment and Pulpotomy:

Proposed treatment: to remove infected pulp tissue and replace with root canal filling material. Benefits of proposed treatment: eliminate pain, infection, swelling and further destruction of tooth structure. Alternatives of treatment: extraction. Common risks: recurrence of symptoms requiring further treatment, breakdown of tooth structure. Consequences of not performing the treatment: increase in severity of pain, swelling, infection, and possible hospitalization and rare instances death.
 

Crown, Bridge and Veneer:

Proposed treatment: to strengthen a tooth damaged by decay or previous restoration, and protect a tooth that has had root canal treatment. Improve biting surface, appearance of damaged, discolored, poorly spaced and/or missing teeth. Benefits of proposed treatment: to restore or improve the appearance and strength of tooth. Alternatives of treatment: extraction or Orthodontic treatment (only in proper spacing, not damaged teeth). Common risks: irritation to surrounding tissue, inflammation, irritation to nerve tissue, stiff or sore jaw joint, sensitivity to hot and cold, also possible root canal treatment. Consequences of not performing the treatment: further destruction, nerve exposure, loss of tooth function, root canal treatment.

 
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the final crowns are delivered. I realize that the final opportunity for me to make changes in my new crowns, bridge or cap (including shape, fit, size, and color) will be done before cementation. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures. It is also my responsibility to return for final cementation of final restoration within the time frame that has been recommended to me. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown or bridge. I understand there will be additional charges for remakes due to me delaying final cementation.


Dentures-Complete or Partial:

I realize that full or partial dentures are artificial, constructed of plastic, metal and/or porcelain. The problems of wearing those appliances have been explained to me including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new denture (including shape, fit, size, and color) will be “teeth in wax” try-in visit. I understand that most dentures require continual maintenance and modification after initial placement, the cost of which is my responsibility.


Drugs, Medication and Sedation:

I have been informed and understand that antibiotic, analgesic (pain), and other medications can cause allergic reactions causing redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). They may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection, pain, and potential resistance to treatment of my condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives.


Temporomandibular Joint Dysfunctions (TMJ):

I understand that symptoms of popping, clicking, locking and pain can intensify or develop in the jaw joint subsequent to routine dental treatment wherein the mouth is held in open position. However, symptoms of TMJ associated with dental treatment are usually temporary in nature and well tolerated by most patients. I understand that should the need for treatment arise, then I may be referred to a specialist for treatment, and the cost of which is my responsibility.

 
Changes in Treatment plan:

I understand that during treatment, it may be necessary to change or add procedures because of conditions found while working on teeth that were not discovered during initial examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any or all changes and additions as necessary.

I understand that dentistry is not an exact science, therefore: reputable dental care providers cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized for myself and or my dependents.  I understand that each Dentist is an individual practitioner and is individually responsible for dental care rendered to me.

By signing this form and scheduling an appointment I am consenting to treatment for myself or for my child/person I am legally responsible for by the staff members of Piper Family Dentistry.