Crown & Bridge Consent Form
I understand that treatment of dental conditions requiring crowns and/or fixed 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, but not limited to the following: (Even though care and diligence is exercised in the treatment of conditions requiring crowns and bridgework and fabrication of the same, there are no promises or guarantees of anticipated results or the longevity of the treatment).
1. Reduction of tooth structure:
In order to replace decayed or otherwise traumatized teeth, it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as practical. In preparation of teeth, anesthetics are usually needed. At times, there may be swelling, jaw muscle tenderness or even a resultant numbness of the tongue, lips, jaws and/or facial tissues which is usually temporary, or rarely, permanent.
2. Sensitivity of teeth:
Often, after the preparation of teeth for the reception of either crowns or bridges, the teeth may exhibit sensitivity. It may be mild or severe. This sensitivity may only last for a short period of time or may last for much longer periods. If it is persistent, notify us in as much as this sensitivity may be from some other source.
3. Crowned or bridge abutment teeth may require root canal treatment:
Teeth after being crowned may develop a condition known as pulpits or pupal degeneration. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, extensive operative history or other unknown causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction. Patient understands that additional UN-foreseen treatments that become necessary are neither a part of the previous treatment nor optional.
Crowns and bridges may possibly chip or break. Many factors could contribute to this situation such as chewing excessively hard materials, changes in biting forces, trauma to the mouth, etc. Unobservable cracks may develop in crowns from these causes, but the crowns/bridges may not actually break until chewing soft foods or possibly for no apparent reason. Breakage or chipping seldom occurs due to defective materials or construction unless it occurs soon after placement.
5. Uncomfortable or strange feeling:
This may occur because of the differences between natural teeth and the artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminable periods of time following placement of the prosthesis.
- Esthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in place prior to final cementation. It is understood that while an effort will be made to match the new restorations to existing tooth color when appropriate, it may be extremely difficult or impossible to achieve an exact match and a difference may be noticeable.
7. Longevity of crowns and bridges:
There are many variables that determine how long” crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. Additionally, general health, good oral hygiene, regular dental checkups, diet, etc., can affect longevity. Patient understands that crown &/or bridge treatment does not make the remaining tooth/teeth immune to additional dental disease, and that proper hygiene must be maintained to prevent this occurrence.
8. Changes to treatment plan:
Treatment plans are developed based on information available from radiographic and intraoral examination. While every effort has been made to produce a complete and comprehensive treatment plan, situations may arise where while treatment is being performed, additional findings may be observed which necessitate changes to existing treatment plans. It is understood that treatment rendered up to the point when changes occur are the responsibility of the patient, whether or not previous treatment would have been necessary in light of new findings. Furthermore, before starting treatment, patient recognizes and accepts this possibility.
9. It is a patient’s responsibility to seek attention from the dentist should any undue or unexpected problems occur. The patient must diligently follow any and all instructions, including the scheduling and attending of all appointments. Failure to keep the cementation appointment can result in ultimate failure of the crown and bridge to fit properly and an additional fee may be assessed.
Informed Consent: I have been given the opportunity to ask any question regarding the nature and purpose of crown and/or bridge treatment and have received answers to my satisfaction. I voluntarily assume any about all possible risks including those listed above and including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning the results. The fee(s) for services have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow Dr.McAllister to render any treatment necessary and/or advisable to my dental conditions including the prescription and administration of any medications and/or anesthetics deemed necessary to my treatment.
Patient Signature, Date______________________________________
Witness Signature, Date_____________________________________