INFORMED CONSENT FOR GENERAL
DENTAL PROCEDURES
You
have the right to accept or reject dental treatment recommended by Dr. Vitaly
Friedman. This form is intended to provide you with an overview of potential
risks and complications. Prior to consenting to treatment, you should carefully
consider the anticipated benefits, commonly known risks and complications of the
recommended procedures, alternative treatments or the option of no treatments.
It
is very important that you provide 21st Century Dental Care with an
accurate medical history before, during and after treatment. It is equally
important that follow Dr. Vitaly Friedman’s advice and recommendations regarding
medication, pre and post treatment instructions, referrals to other specialists,
and return for scheduled follow up appointments. If you fail to follow the
advice of Dr. Vitaly Friedman, you may increase the chance of poor outcome.
Please read the items below and sign the bottom of this form.
During
your course of treatment the following care may be provided to you. As part of
your initial or semiannual check-up visit examination, x-rays and prophylaxis
will be offered to you, for the rest of the procedures please refer to your
treatment plan.
• EXAMINATIONS AND X-RAYS:
I understand the visit may require
radiographs in order to complete the examination, diagnosis and treatment plan.
• TEMPOROMANDIBULAR JOINT DYSFUNCTION
(TMD): I
understand that symptoms of popping, clicking, locking and pain can intensify or
develop in the joint of the lower jaw(near the ear) subsequent to routine dental
treatment wherein the mouth is held in the open position. However, symptoms of
TMD associated with dental treatment are usually temporary in nature and well
tolerated by most patients. I understand that should the need for treatment
arise, I will be referred to a specialist for treatment, the cost of which is my
responsibility.
• DENTAL PROPHYLAXIS (CLEANING):
I understand the treatment involves removal of plaque and calculus above the gum
line and will not address gum infections below the gum line called periodontal
disease. I understand some bleeding after a cleaning can occur however, should
it persist and if it is severe in nature the office should be contacted.
• PERIODONTAL TREATMENT: I
understand that I have a serious condition causing gum inflammation and/or bone
loss and that it can lead to the loss of my teeth. Alternative treatment plans
have been explained to me, including nonsurgical cleaning, gum surgery and/or
extractions. I understand the success of a treatment depends in part on my
efforts to brush and floss daily, receive regular cleanings as directed,
following a healthy diet, avoid tobacco products and follow other
recommendations. I understand some bleeding after treatment can occur however,
should it persist and if it is severe in nature the office should be contacted.
I understand that periodontal disease may have a future adverse effect on the
long term success of dental restoration work.
• RESTORATIONS (FILLINGS): I
understand that a more extensive restoration than originally diagnosed may be
required due to additional decay or unsupported tooth structure found during
preparation. This may lead to root canal, crown, or both. I understand that care
must be exercised in chewing on fillings during the first 24 hours to avoid
breakage. I understand that sensitivity is a common after effect of a newly
placed filling.
• EXTRACTIONS (REMOVAL OF TEETH):
Alternatives
to removal have been explained to me (root canal therapy, crown, periodontal
surgery, etc.) and I authorize Dr. Vitaly Friedman to remove the teeth listed in
my treatment plan. I understand removing teeth does not always remove all the
infection, if present, and it may be necessary to have further treatment. I
understand the risk involved in having teeth removed, such as pain, swelling,
spread of infection, dry socket, exposed sinuses, loss of feeling in
teeth, lips,
tongue, or surrounding tissue that can last for an indefinite period of time, or
fractured jaw. I understand bleeding could last for several hours.
Should it persist and is severe in nature, it should receive attention and Dr.
Vitaly Friedman must be contacted. I understand I may need further treatment by
a specialist or even hospitalization if complications arise during or following
treatment, the cost of which is my responsibility.
•BONE GRAFT: I
understand that bone grafting and barrier membrane procedures include inherent
risks such as, but not limited to pain, infection, bleeding, bruising, and
swelling, loss of all or part of the graft, injury to nerves, and sinus
involvement. I do understand that I have to contact Dr. Vitaly Friedman in case
if I have any complications as a result of this procedure. I do voluntarily
assume any and all possible risks associated with any phase of this treatment.
• CROWNS, BRIDGES, VENEERS AND BONDING:
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 permanent crowns are delivered. I realize that
the final opportunity to make changes in my new crowns, bridge or cap (including
shape, fit, size, placement, and color) will be done before cementation. It has
been explained to me that, in very few cases, cosmetic procedures may result in
the need for future root canal treatment, which cannot always be predicted or
anticipated. I understand that cosmetic procedures may affect tooth surfaces and
may require modification of daily cleaning procedure.
•
DENTURES: 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, placement and color) will be the “teeth in wax” try-in visit. Immediate
dentures (placement of denture immediately after extractions) may be
uncomfortable at first. Immediate dentures may require several adjustments and
relines. A permanent reline will be necessary later. This is not included in the
initial denture fee. I understand that most dentures require relining
approximately three to twelve months after initial placement. The cost for this
procedure is not included in the initial fee.
• ENDODONTIC
TREATMENT (ROOT CANAL): I
realize there is no guarantee that root canal treatment will save my tooth; that
complications can occur from the treatment; and that occasionally canal material
may extend through the root tip which does not necessary affect the success of
the treatment. The tooth may be sensitive during treatment and even remain
tender for a time after treatment. Hard to detect root fracture is one of the
main reasons root canals fail. Since teeth with root canals are more brittle
than other teeth, a crown may be necessary to strengthen and preserve the tooth.
I understand that endodontic files and reamers are very fine instruments and
stresses can cause them to separate during use. I understand that occasionally
additional surgical procedures may be necessary following root canal treatment.
I understand that the tooth may be lost in spite of all efforts to save it.
2. Drugs and Medications:
I have informed the dentist of any known allergies. I understand that
antibiotics, analgesics, and other medications can cause allergic reactions
causing redness and swelling of tissues; pain, itching, vomiting, and/or
anaphylactic shock (severe allergic reaction). They may cause drowsiness, lack
of awareness and coordination which can be increased by the use of alcohol or
other drugs. I understand and fully agree not to operate any vehicle or
hazardous device for at least 12 hours or until fully recovered from the effects
of the anesthetic, medication and drugs that may have been given me in the
office for my care. I understand that failure to take medications prescribed for
me in the manner prescribed may offer risks of continued or aggravated infection
and pain and potential resistance to effective treatment of my condition. I
understand that antibiotics can reduce the effectiveness of oral contraceptives
(birth control pills).
3. 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 the teeth that were not
discovered during examination, the most common being root canal therapy
following routine restorative procedures. I give my permission to the dentist to
make any/all changes and additions as necessary
4. Insurance: I
give permission to 21st Century Dental Care to bill my dental
insurance provider for the treatment provided, if applicable.
5. Consent:
I have read each paragraph above and
consent to recommended treatment as needed. I understand the
anticipated benefits
and commonly known risks and complications of each procedure.