INFORMATIONAL INFORMED CONSENT

I UNDERSTAND that placing of SILVER AMALGAM FILLINGS includes possible inherent risks. Furthermore, no promises or guarantees of results can be made or should be expected.

These risks include, but are not limited to the following:

1. Silver amalgam has been used for decades as a filling material for teeth and there are no proven scientific studies accepted by the American Dental Association which supports the belief by some opponents to the material that there is a possibility, although unproven, that silver amalgam may have an effect on the general health of a person due to its mercury content. However, silver amalgam continues to be endorsed by the ADA as an acceptable filling material.
   
   
2. The teeth treated may remain sensitive or even possibly quite painful both during and after completion of treatment. If the pain is severe or extreme sensitivity persists for an extended period of time, please call the office for an examination.
   
   
3. Numbness. There may be a numbness in the tongue, lips, teeth, jaws, and/or facial tissues resulting from the anesthetic administration or other treatment procedures. If this numbness persists for a period of time longer than 24 hours, please call the office.
   
   
4. Fracture or breakage: Should a tooth require a large amalgam filling because of the extent of the decay or for other reasons, there is a possibility of the filling breaking or loosening. It may then be required to place a crown in order to preserve the tooth. If the tooth structure retaining the filling breaks, it may also be necessary to crown the tooth in order to preserve it.
   
   
5. Root canal or Extraction: Should the decay have invaded the tooth to the extent that even after it has been filled, it remains or becomes excessively painful, it may be necessary to either perform root canal treatment or possibly even extract the tooth.
   
   
6. Fragility of Silver Amalgam: Silver amalgam is quite fragile until it has completely solidified. It is necessary to avoid chewing on recently placed amalgam fillings for approximately 24 hours.
   
   
7. Amalgam tattoos: Occasionally shavings generated by placement or carving of silver amalgam fillings may work their way into the surrounding gum tissues and become lodged. Over an extended period of time gray spots or tattoos may become visible within the mouth.
   
   
8. My responsibility: It is my responsibility to immediately contact the office should any of the aforementioned or other adverse results occur after treatment.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of silver amalgam fillings and have received answers to my satisfaction. I do voluntarily assume any and all reasonable medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of standard procedures involving silver amalgam restorations in hopes of obtaining the potential desired results, which may or may not be achieved. No promises of guarantees have been made to me concerning the results. The fee(s) for this service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow and authorize Dr. Wahlen and/or his/her associates or agents to render any treatment necessary and/or advisable to my dental conditions, including the administration and/or prescribing of any medications.