The Recommended Treatment works by removing bacteria from the hollow space
inside the tooth, and by sealing off the inside of the tooth to prevent re-infection.
Although the Recommended Treatment has a very high success rate, it is a biological
procedure and cannot be guaranteed. Occasionally, a tooth which has had root canal
treatment may require retreatment, additional surgery, or extraction.

Alternative methods of treatment have been explained to me, such as extraction of the involved teeth, or postponement of root canal therapy, but I wish to proceed with the Recommended Treatment described above. 

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Instrument breakage in the root canal.
2. Inability to negotiate canals due to prior treatment or calcification.
3. Perforation to the outside of the tooth.
4. Irreparable damage to the existing crown or restoration.
5. Cracking or fracturing of the root or crown of the tooth.
6. Pain, infection, and swelling.
7. Difficulty opening and closing.
8. Temporomandibular Dysfunction resulting in jaw pain.
9. Nerve injury resulting in temporary or permanent numbness, itching, burning, or tingling of the lip, chin, tongue, or teeth.
10. As a result of the injection or use of anesthesia, there may be swelling, jaw
    muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
11. Root canal treatment may weaken the remaining tooth, a crack or fracture may occur, resulting in a poor prognosis. A crown is recommended to maintain the remaining tooth structure
12. Multiple appointments may be required to adequately clean the infected canals
    

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection and/or bone infection. Bruising
and/or swelling, delayed healing, restricted mouth opening for several days or weeks.
3. Damage to adjacent teeth or tooth restorations.
4. Possible involvement of the sinus cavity and creation of an opening from the
mouth into the nasal or sinus cavity, which may require additional treatment or
surgical repair at a later date.
5. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia, resulting in altered or loss sensation, numbness, pain, or
altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue
(including loss of taste). Such conditions may resolve over time, but in some
cases, may be permanent.
6. Inability to place the implant due to the local anatomy or implant failure.
7. Discoloration and appearance changes of the gum tissue or unsatisfactory
cosmetic result.
8. Bone loss around the implant(s) and/or adjacent teeth, which may result in loss
of implant and/or adjacent teeth and which may necessitate bone grafting
9. Jaw fracture.
10. As a result of the injection or use of anesthesia, at times there may be swelling,
jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth,
jaws and/or facial tissues, which is typically temporary, but in rare instances, may
be permanent.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Damage to adjacent teeth or tooth restorations.
3. Sensitivity of teeth.
4. Chipping, breaking or loosening of the veneer.
5. Injury to soft tissues adjacent to veneer due to bonding or bleaching agents.
6. Necessity for a more extensive restoration, such as a crown, than originally
diagnosed.
7. Inability to exactly match tooth coloration.
8. Changes in the shade, aesthetics, and appearance of the restoration, which may
occur over time.
9. As a result of the injection or use of anesthesia, there may be swelling, jaw
muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws
and/or facial tissues, which is typically temporary, but in rare instances, may be
permanent.
10. Changes in speech (which are usually temporary).
11. Changes to the bite or position of the temporomandibular joint which may require
further treatment or adjustment.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Reduction of tooth structure.
2. Sensitivity of teeth.
3. Crown or bridge abutment teeth may require root canal treatment.
4. Breakage.
5. Uncomfortable or strange feelings, which is typically temporary. In limited
   situations, muscle soreness or tenderness of the jaw may persist following
   placement of the prosthesis.
6. Unsatisfactory aesthetics or appearance.
7. Unsatisfactory longevity of crowns and bridge.
8. As a result of the injection or use of anesthesia, at times there may be swelling,
   jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth,
   jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
9. Recurrent decay along the margin of restoration is possible. Routine oral hygiene is required to maintain a long term restoration

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:
1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection and/or bone infection.
3. Bruising and/or swelling, delayed healing, restricted mouth opening for several
days or weeks.
4. Damage to adjacent teeth or tooth restorations.
5. Possible involvement of the sinus cavity and creation of an opening from the
mouth into the nasal or sinus cavity, which may require additional treatment or
surgical repair at a later date.
6. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia, resulting in altered or loss sensation, numbness, pain, or
altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue
(including loss of taste). Such conditions may resolve over time, but in some
cases, may be permanent.
7. Discoloration and appearance changes of the gum tissue or unsatisfactory
cosmetic result.
8. Failure, loss, infection, or rejection of the graft or membranes used to contain the graft.
9. If I have elected a banked bone or bone substitute graft, there is a rare chance of disease spread from the processed bone.
10. Jaw fracture.
11. As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following: 

1. Drug reactions and side effects. 
2. Damage to adjacent teeth or tooth restorations. 
3. The necessity for root canal therapy is due to injury of the pulp tissue. 
4. Breakage or dislodgement in buildup failure of restorative material. 
5. The necessity for a more extensive restoration, such as a crown, than originally diagnosed, due to additional decay or unsupported tooth structure found during preparation. 
6. Inability to exactly match tooth coloration. 
7. Changes in the shade of the composite restoration over time as a result of the oral environment. 
8. Sensitivity of teeth. 
9. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.  

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Atypical reaction to sedation medications, which may require emergency medical
attention and/or hospitalization.
3. Altered mental states.
4. Allergic reactions.
5. Nausea and/or vomiting
6. As a result of the injection or use of anesthesia, there may be swelling, jaw
muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be
permanent.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

It is the patient’s responsibility to:

1. Follow brushing and oral hygiene instructions that are given, so no harm will
   come to tissues and teeth;
2. Adhere to food restrictions to keep from damaging teeth and orthodontic
   appliances;
3. Timely come to all appointments;
4. Wear elastics, retainers, and headgear, if they are necessary, so treatment time
   will be as short as possible and to achieve best results; and
5. Visit the general dentist at least every six months for cleaning and examination.

Additional orthodontic charges may be incurred for replacement of appliances due to
patient neglect, or excessive extension of treatment caused by failure of patient
cooperation. Patient cooperation is critical.

I understand that there are risks and complications associated with the administration
of medications, including anesthesia, and performance of the Recommended
Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Decalcification (permanent markings), decay or gum disease.
2. Root resorption resulting in teeth being shortened during treatment.
3. Pre-existing, non-vital, devitalization, traumatized teeth may cause damage to
   the nerve requiring a root canal on the affected tooth. Severe cases may result in tooth loss.
4. TMJ (temporo-mandibular joint) pain may include jaw joint noises,
   discomfort, and facial pain related to the jaw during or after treatment.
5. Discomfort due to adjustment and application of appliances.
6. Oral surgery/extractions, which may be needed to correct jaw imbalances or to remove third molars that may develop and change alignment.
7. Teeth may become impacted (trapped below gums or bone), fail to erupt, or
   ankylosed (fused to bone), which may require extraction, surgical
   transplantation/exposure, or prosthetic replacements.
8. Minimal imperfections in the way your teeth meet, which may result in a
   procedure to grind the teeth or a procedure to remove a small amount of enamel in between the teeth.
9. Allergic reaction to medicine and orthodontic materials.
10. The total time for treatment can be delayed beyond our estimate.
11. Injury from appliances and headgear including injury to the face or eyes. Additionally, orthodontic appliances may be accidentally swallowed or aspirated or may irritate or damage oral tissue.
12. Return of the original problem.
13. Additional treatment may be required due to unforeseen circumstances (such as abnormal growth or gum disease).

It is understood that treatment can be terminated for failure to cooperate, missing
appointments, not wearing appliances, excessive breakage, failure to keep financial
commitments, relocation, personal conflicts or for any reason the dentist feels
necessary. If termination is necessary, the patient will be given ample time to locate
another dentist to continue treatment or the braces will be removed.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration
of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Nausea and vomiting.
2. Temporary tingling in the fingers, toes, cheeks, lips, tongue, and head or neck
   area.
3. Temporary warm feeling throughout the body with accompanying
   flushing/blushing.
4. Temporary detachment or “out of body” sensation.
5. Temporary sluggishness in motion and/or speech.
6. Shivering (usually at the end of the procedure).
7. As a result of the injection or use of anesthesia, there may be swelling, jaw
   muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be
   permanent.

Alternative methods of treatment have been explained to me, but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with administering medications, including anesthesia and performance of the Recommended Treatment. These potential risks and complications include, but are not limited to, the following:

1. Tooth sensitivity.
2. Pain from treatment.
3. Infection.
4. Swelling.
5. Dark spaces between teeth where there is no longer any gum tissue.
6. Changes in how long my teeth appear (due to re-contouring).
7. Gum tissues may shrink or recede. This change may make some previous dental restorations (i.e., crowns, fillings) more noticeable, and the restorations may need to be replaced for cosmetic purposes.
8. Loss of bone or tissue graft.
9. Possible involvement of the nerves of the lower jaw resulting in temporary or
   permanent tingling of the lower lip, chin, tongue, or surrounding structures.
10. As a result of the injection or use of anesthesia, there may be swelling, jaw
    muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be
    permanent.
11. Future bone or tooth loss.

I hereby give consent to perform Scaling and Root Planing procedure(s) on me or my dependent and any such additional procedure(s) as may be considered necessary for my well-being based on findings made during the course of the Recommended Treatment. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.

Alternative methods of treatment have been explained to me, but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration
of medications, including anesthesia and performance of the Recommended
Treatment. These potential risks and complications include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-treatment bleeding, oozing, and infection.
3. Bruising and/or swelling, delayed healing, restricted mouth opening for several
   days or weeks.
4. Varying lengths and degrees of sensitivity.
5. Increased spacing between teeth due to removal of hard deposits.
6. Revealing of recessed gums.
7. Increased mobility of teeth.
8. As a result of the injection or use of anesthesia, there may be swelling, jaw
   muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws
   And/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia and performance of the Recommended Treatment. These potential risks and complications include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-operative bleeding, oozing, infection, and/or bone infection.
3. Bruising and/or swelling, restricted mouth opening for several days or weeks.
4. Loss or removal of bone during tooth extraction.
5. Damage to, or fracture of, adjacent teeth or tooth restorations.
6. Root tips may break during the oral surgery process. These root tips may be left in the bone to avoid more aggressive surgery. However, this more aggressive surgery may be needed, and you may be referred for this procedure.
7. Delayed healing, including but not limited to, dry socket, necessitating post-operative care.
8. Possible involvement of the sinus during the removal of the upper posterior teeth, which may require additional treatment or surgical repair at a later date.
9. Possible involvement of the nerves of the lower jaw during the removal of teeth resulting in temporary or permanent tingling/numbness of the lower lip, chin, tongue, or other surrounding structures.
10. Jaw fracture.
11. If you are taking medications to make your bones stronger (such as
    bisphosphonates) or if you have received radiation therapy to the head or neck area for tumors/cancer, then you are at a higher risk for poor bone healing or bone death that may never completely resolve.
12. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
13. Osteonecrosis of the Jaw: Specific medications are major risk factors of this negative outcome. A complete systemic medical history is of utmost importance to limit this risk.