GENERAL DENTAL INFORMED CONSENT
We would like for the patient/POA to have general knowledge of dental procedures. We ask that you review the procedures listed and want you to know that we will have you sign an informed consent prior to each dental procedure.
1. Low Dose X-rays: Low dose x-rays are an important tool to aid the dentist in detecting potential issues and disease not visible to the naked eye. We utilize protective shields and aprons for patient safety. Low dose x-rays are required for all new patients of record and will be taken every 6 months.
2. Drugs and Medication: Antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or prophylactic shock (severe allergic reaction).
3. Silver Diamine Fluoride (SDF): SDF has been used extensively around the globe for decades. It helps with relief from dentinal hypersensitivity, kills pathogenic organisms, hardens softened dentin making it more acid and abrasion resistant, and can provide important clinical feedback due to its potential to stain visible or hidden cavities. SDF does not stain healthy tooth structures.
4. Changes in Treatment: During treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. The presence of dental tooth decay, gum disease, or any dental infection has been shown to affect many other body parts, such as joints and the heart, so it is important to treat any dental infection as soon as possible.
5. Local Anesthesia: Local anesthesia may affect your body such as dizziness, nausea, vomiting, accelerated heart rate, slow heart rate, or various allergic reactions potentially requiring hospitalization. Injury to the nerves that can result in pain, numbness, or tingling to the chin, lip, cheek, gums, or tongue may be present for weeks, monthly and rarely be permanent.
6. Fillings: In some situations, more extensive restoration than originally planned may be required due to additional conditions discovered during tooth preparation. Significant changes in response to temperature may occur after tooth restoration such as temporary sensitivity or pain. If the tooth does not respond to treatment with a filling, further treatment such as root canal therapy or crown may be necessary. Fillings may require periodic replacement with additional fillings and/or crowns.
7. Extractions: Alternatives will be explained to you (root canal therapy, crowns, and periodontal surgery, etc.) The removal of teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. Some of the risks are pain, swelling, spread of infection, dry socket, loss of feeling in teeth, lips, tongue and surrounding tissue that can last for an indefinite period of time (days or months) or fractured jaw. Further treatment by a specialist or even hospitalization may be needed if complications arise during or following treatment which would be your financial responsibility.
8. Crowns and Bridges: Sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. You may wear temporary crowns, which may come off easily so avoid sticky food and candies. You will need to be careful to ensure that they are kept on until the permanent crowns are delivered. The final opportunity to make changes to a new crown, or bridge (including shape, fit, size, or color) must be done at the preparation appointment.
9. Dentures (complete and partials): Removable prosthetic appliances include risks and possible failures. This includes gum tissue pressure, jaw ridges not providing adequate support and/or retention, excessive saliva or excessive dryness of the mouth, and general psychological, behavioral, and physical problems interfering with success. We are not responsible for failures of these types. Breakage is possible by dropping the dentures or chewing on foods that are excessively hard. Full dentures become loose when there is a change in gum tissues. Our obligation is to create a functioning, well fitting device. Patients must wear the device consistently in order for the dentist to make appropriate and accurate adjustments. Any denture fit issues must be brought to our attention within 30 days of the final denture delivery. Adjustments after 30 days are an additional charge.
10. Immediate/Interim Dentures: After the extractions and delivery of the prefabricated immediate denture, there is fast bone loss resulting in space between the dentures and gums. This leads to rapidly increasing looseness and sore spots which must be adjusted frequently. The dentist may recommend a soft or hard reline (additional charge) if the patient experiences discomfort during the healing period to improve fit.
11. Endodontic Treatment (Root Canal): There is no guarantee that root canal treatment will save a tooth. Complications can occur from the treatment and occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. Occasionally additional surgical procedures may be necessary following root canal treatment.
12. Teledentistry: If allowable in your area, you consent to utilizing synchronous (live chat via video) and asynchronous teledentistry (not live). Asynchronous teledentistry utilizes a dental assistant or dental hygienist to collect clinical data and information in-person on behalf of a licensed dentist. This information is sent asynchronously (not live) to the licensed dentist to review and provide recommendations. The results of this exam are then communicated to the patient or responsible party. The dentist may not see the patient in-person. You may request to communicate in real-time with the dentist about these findings within 30 days of the consult.
13. COVID-19: Our clinical teams follow all CDC, state dental board, and OSHA guidelines relating to COVID-19. There is exists a potential risk of exposure with any human interaction given community spread. Our protocols and procedures err on the side of caution.
AUTHORIZATION
I authorize Dr. Michelle Juanatas Bowens and/or such associates or assistants as she may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments.
I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation.
I understand that as part of the dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completion of treatment. Dental materials and medications may trigger allergic or sensitivity reactions.
After lengthy appointments, jaw muscles may also be sore or tender. Holding one’s mouth open can, in a predisposed patient, precipitate a TMJ disorder. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required.
I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal. I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past, such as Phen-Fen. I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva or Actonel, may result in complications of nonhealing of the jaw bones following oral surgery or tooth extractions.
I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.
Consent will be made verified before any procedure. Consent can be withdrawn at any time.