This form explains the risks, benefits, consequences, and alternatives to installing Crowns, Onlays, Bridges or Veneers; a treatment that involves restoring damaged areas of the tooth above and below the gum line with a crown or similar indirect restoration. The form also obtains the patient's consent to perform the treatment.
Informed Consent for Crowns, Onlays, Bridges, and Veneers
Facts for Consideration
Treatment involves restoring damaged areas of the tooth above and below the gum line with a crown or similar indirect restoration such as onlay, inlay, bridge or veneer.
This treatment consists of two steps: 1) preparation of the tooth, taking an impression to send to the lab, fabrication, and cementation of a temporary restoration; 2) removal of the temporary restoration, adjustment and cementation of the completed restoration when esthetics and function have been verified.
Once a temporary restoration has been placed, it is essential to return to have the new restoration placed as soon as it is ready because leaving a tooth with only a temporary restoration for a prolonged period of time could lead to decay, gum disease, infections, problem with your bite, and even loss of the tooth.
Benefits of Crowns, Onlay/Inlays, Bridges and Veneers, NOT Limited to the Following:
A crown or onlay/inlay is typically used to strengthen a tooth damaged by decay, fracture, or previous restorations. It can also serve to protect a tooth that has had root canal treatment or improve the way your other teeth fit together. Bridges are used to replace missing teeth and prevent other teeth from shifting and causing poor bite or bite interferences.
Crowns and veneers will be used for the purpose of improving the appearance of damaged, colored, misshapen, misaligned, or poorly spaced teeth.
Risks of Crowns, Onlays/Inlays, Bridges, and Veneers, NOT Limited to the Following:
I understand that preparing a damaged tooth may further irritate the nerve tissue (called the pulp) in the center of the tooth, leaving my tooth feeling sensitive to heat, cold or pressure. Such sensitive teeth may require additional treatment including endodontic or root canal treatment.
I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it difficult for me to open wide for several days. This can occasionally be an indication of a further problem. I will notify the office if this or other concerns arise.
I understand that a crown, onlay/inlay or veneer may alter the way my teeth fit together and make my jaw joint feel sore. This may require adjusting my bite by altering the biting surface of the crown, onlay/inlay or veneer or adjacent teeth.
I understand that the edge of a crown is usually near the gum line, which is an area prone to gum irritation, infection, or decay. Proper brushing and flossing at home, a healthy diet, and regular professional cleanings are some preventative measures essential to helping control these problems.
I understand that my restoration may fail before time due to new decay if plaque is not controlled. I understand that porcelain used to make my restoration is brittle and may fracture due to normal use.
I understand that if porcelain fractures, the entire restoration will need to be replaced.
I understand that I may receive a local anesthetic and/or other medication. In rare instances, patients may have a reaction to the anesthetic, which could require emergency medical attention, or find that it reduces their ability to control swallowing. This increases the normal chance of swallowing foreign objects during treatment. Depending on the anesthesia and medications administered, I may need a designated driver to take me home. Rarely, temporary or permanent nerve injury can result from an injection.
I understand that all medications have the potential for accompanying risks, side effects, and drug interactions and that it is critical that I tell my dentist about all medications I am currently taking.
Consequences if NO Treatment is Administered, NOT Limited to the Following:
I understand that if no treatment is performed, I may continue to experience symptoms which may increase in severity, and the cosmetic appearance of my teeth may continue to deteriorate.
I understand that depending on the reason I have a restoration placed, alternatives may exist. I have asked my dentist about them and their respective expenses. My questions have been answered to my satisfaction regarding the procedures and their risks, benefits, and costs.
No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above.
I understand that I need to return to cement my permanent restoration within weeks from the initial preparation appointment to make sure that the new restoration fits well. I understand that if I don't return on time, the new restoration may not fit and I will be responsible for any additional fees and expenses related to the fabrication of a new restoration.
[x] I consent to the crown/onlay/inlay/bridge/veneer preparation and placement as described above.
Please Sign Here (Patient)
[x] I attest that I have discussed the risks, benefits, consequences, and alternatives to this treatment with the patient who had the opportunity to ask questions, and I believe my patient understands what has been explained.
Please Sign Here (Dentist)
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