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.    Necessity for root canal therapy due to injury of pulp tissue.

4.    Breakage or dislodgement in buildup failure of restorative material.

5.    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. 

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, post crown treatment that may last up to several months before subsiding.

3. Crown or bridge abutment teeth may require root canal treatment.  

4. If tooth has not been previously root canal treated it may require a root canal in the future.

5. Breakage.

6. 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.  

7. Unsatisfactory aesthetics or appearance.

8. Unsatisfactory longevity of crowns and bridge.

9. 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.

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.

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.

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.

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:

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. I understand that the practice of dentistry is not an exact science. I have been informed that in some instances implants fail. No guarantee or assurance as to the outcome of the results of treatment can be, or is being made. I further acknowledge that the list of possible complications, of which I have been advised, is not intended to be, nor do I consider it to be complete.

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. The doctor has specifically advised me of the consequences of SMOKING during the course of my implant procedure. I have been advised that I MUST refrain from smoking a minimum of 48 hours before treatment and abstain from all forms of tobacco products until the doctor advises me that healing is complete. Failure on my part to follow these recommendations could result in serious complications including possible infection, necrosis (destruction) of tissue, and loss of implants and /or bone graft.

10.  Bone grafting, ridge augmentation or soft tissue grafts may be needed to complete the implant(s). These products are collected from volunteer donors whose legal next-of-kin have given written consent for the donation. Each individual donors history is carefully reviewed to reduce the possibility of disease transmission and ensure product integrity. These products are made from donors found non-reactive to serological tests for hepatitis B surface antigen, HTLV-III antibody and syphilis. These products may be used in any situation where the doctor believes that a bone and/or soft tissue procedure will promote healing or facilitate applicable surgical procedures. These products have been determined to be properly prepared in accordance with the current requirements of the FDA. 

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.

12.I have given my doctors a report of my physical and mental history including my use of any drug (including alcohol). I have advised him of any allergic reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other condition relating to my health. I acknowledge that the doctor has relied on my representations as to my health and has used this information in determining the course of my treatment and that I have fully disclosed my
medical history.

I understand that I have periodontal disease, a condition resulting in the destruction of the gum and bone supporting my teeth.  The disease process has been explained to me and I understand that it is caused by several factors: poor home care and neglect, bacterial toxins found in plaque, and my body's immune response to these toxins.

Periodontal disease is a progressive disorder.  If untreated, it leads to the loss of teeth.  Early detection and aggressive treatment are critical to stopping or slowing the progression of the disease to the point of tooth loss.

Treatment of periodontal disease includes scaling and root planing, effective home care, possible referral to a periodontist (gum specialist), and possible surgery.  Scaling and root planing can be a corrective procedure, or it may be a preliminary step to more invasive treatment by a specialist, ie. surgery.

Scaling and root planning is the removal of calculus (tarter), bacterial plaque and toxins, diseased cementum (the outer covering of the root surface) and diseased tissue from the inner lining of the crevice surrounding the teeth (the gingival sulcus).  The purpose of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by the immune system.

We can help, but the greater responsibility lies with you and your conscientious commitment to the recommended treatment.  Excellent home care and continual professional maintenance will be essential for long term success.  Optimum results are achieved only when appointments are kept.  Deferring your appointments can lead to prolonged treatment, additional appointments, poor results, and possibly additional charges.

The consequences of no treatment may include, but are not limited to the following:

1. Worsening of the disease with increased bone loss and eventual tooth loss
2. Possible systemic (general health) problems: there is an established link between periodontal disease, cardiovascular disease, premature birth, and low birth weight babies
3. Worsening of gum bleeding, pain, and soreness

The prescribed treatment for periodontal disease varies according to severity, but generally includes the following:

1. An initial comprehensive examination, including all necessary x-rays.

2. Periodontal charting - record probing depths, gum recession, tooth mobility, etc.

3. Home care instructions - brushing, flossing, rinsing

4. Initial debridement - removal of superficial calculus deposits to begin the healing

5. 1-4 appointments for root planing and scaling

6. Irrigation

7. Re-evaluation of periodontal condition in 4 weeks- repeat step # 2

8. Introduce adjuncts such as Laser therapy or Antibiotic therapy

9. Introduce Genetic testing of the bacterial flora to determine the best course of action

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. Increased gum recession with increased root surface exposure

2. Increased tooth sensitivity to hot, cold, or sweet foods/liquids. This may require further treatment, may fade with time, or may persist no matter what is done.

3. Exposed roots may acquire stain more readily without diligent home care.

4. Food may collect between teeth. Proper cleaning techniques will be necessary.

5. If teeth were loose before treatment, they will be loser immediately after. After healing the looseness may decrease but it may persist long term, and splinting may be necessary to reduce mobility.

6. Some pain, swelling or bruising may be experienced initially after treatment.

Periodontal therapy and periodontal maintenance help to create a healthy foundation for future treatments that may be necessary to restore your teeth to good function and health.

My diagnosis, recommended treatment(s), the risks and benefits of such treatment(s), the risks of no treatment, my role in treatment success, and any alternative treatment(s) have been explained to me. All of my questions have been answered.

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.

1. I understand that the purpose of oral conscious sedation is to more comfortably receive necessary dental treatment and that it has limitations and risks, and its absolute success cannot be guaranteed.

2. I understand that oral conscious sedation is a drug induced state of reduced awareness and may decrease my ability to respond. The sedative will not put me to sleep and I will be capable of responding during the procedure. My ability to respond normally will return when the effects of the sedative wear off.

3. I understand that the sedative prescribed will be a pill that I will take approximately  30 minutes before my scheduled appointment. The effects of this sedative will last approximately 4-8 hours.

4. I understand that the alternatives to oral conscious sedation are:
a. No sedation: Treatment is performed using a local anesthetic, or not, and the patient is fully aware of surrounding activity.
b. Anxiolytics: A sedative pill is taken prior to treatment to reduce anxiety and fear.
c. Nitrous oxide sedation: Provides relaxation through inhalation of the gas, and the patient is still generally aware of surrounding activity. Its effects are rapidly reversed with the administration of oxygen. 
d. Intravenous sedation: The slow injection or drip of a sedative into to a vein.(Not offered in this office)
e. General anesthetic: Generally used in a hospital setting, it requires breathing to be supported and the patient has no awareness of his surroundings. (Not offered in this office)

5. I have been informed that there are risks and limitations to all dental procedures. Additionally, with the use of oral sedation, the following risks are also present:
a. Inadequate sedation with the initial dosage which may require undergoing the procedure without full sedation, or having to reschedule the procedure.
b. Atypical reaction to the sedative drug which may require emergency medical
attention and/or hospitalization such as, but not limited to: altered mental state, adverse physical reaction, allergic reaction or other unforeseen sicknesses.
c. The inability to discuss treatment options during the procedure should the
circumstance arise, that requires the Doctor to change the treatment plan.

6. I have had the opportunity to discuss oral conscious sedation with the attending Dentist and have had my questions answered to my satisfaction.

7. I understand and agree to follow all of the instructions given to me.

8. I have informed the attending Dentist of and/or agree to the following:
a. I am not pregnant or breast feeding.
b. I have disclosed all medications and supplements that I currently take.
c. I have disclosed any known allergies.
d. I am of sound mental and physical ability to make the decision to use oral
conscious sedation, and I understand what it is and what it is not.
e. I will not consume alcohol within 24 hours of using oral conscious sedation.
f. I understand that I will not be able to drive or operate machinery for 24 hours after completion of my treatment.
g. I have made arrangements for transportation to and from my scheduled
appointment, and for a responsible adult to stay with me for 12 hours following any appointments during which I have been sedated.

I consent to the use of oral conscious sedation to be used in conjunction with my dental treatment.

I UNDERSTAND THAT REMOVABLE PROSTHETIC APPLIANCES (PARTIAL DENTURES and FULL ARTIFICIAL DENTURES) include risks and possible failures associated with such dental treatment. I agree to assume those risks and possible failures associated with, but not limited to, the following: (even though the utmost care and diligence is exercised in preparation for, and fabrication of, prosthetic appliances, there is the possibility of failure with patients not adapting to them):

1. Failure of full dentures: there are many variables which may contribute to this possibility, such as: (1) gum tissues which cannot bear the pressures placed upon them resulting in excessive tenderness and sore spots; (2) jaw ridges which may not provide adequate support and/or retention; (3) musculature in the tongue, floor of the mouth, cheeks, etc., which may not adapt to and be able to accommodate the artificial appliances; (4) excessive gagging reflexes; (5) excessive saliva or excessive dryness of mouth; (6) general psychological and/or physical problems interfering with success.

2. Failure of partial dentures: Many variables may contribute to unsuccessful utilizing of partial dentures (removable bridges). The variables may include those problems related to failure of full dentures, in addition to: (1) natural teeth to which partial dentures are anchored (called abutment teeth) may become tender, sore, and/or mobile; (2) abutment teeth may decay or erode around the clasps or attachments; (3) tissues supporting the
abutment teeth may fail.

3. Breakage: Due to the types of materials which are necessary in the construction of these appliances, breakage may occur even though the materials used were not defective. Factors which may contribute to breakage are: (1) chewing on foods or objects which are excessively hard; (2) gum tissue shrinkage which causes excessive pressures to be exerted unevenly on the dentures; (3) cracks which may be unnoticeable and which occurred previously from causes such as those mentioned in (1) and (2); or the dentures having being dropped or damaged previously. The above may
also cause extensive denture tooth wear or chipping.

4. Loose Dentures: Full dentures normally become looser when there are changes in the supporting gum tissues. Dentures themselves do not change unless subjected to extreme heat or dryness. When dentures become “loose”, relining the dentures may be necessary. Normally, it is necessary to charge for relining dentures. Partial dentures become loose for the listed reasons in addition to clasps or other attachments loosening.
Sometimes dentures feel loose for other reasons (see paragraph 1).

5. Allergies to dental materials: Very infrequently, the oral tissues may exhibit allergic symptoms to the materials used in the construction of either partial dentures or full dentures, over which we have no control.

6. Failure of supporting teeth and/or soft tissue: Natural teeth supporting partials may fail due to decay; excessive trauma; gum tissue or bony tissue problems. This may necessitate extraction. The supporting soft tissues may fail due to many problems including poor dental or general health.

7. It is the patient’s responsibility to seek attention when problems occur and do not lessen in a reasonable amount of time; also, to be examined regularly to evaluate the dentures, condition of the gums, and the patient’s oral health.

I acknowledge that there are potential risks and complications that could result in additional medical or dental treatment or procedures, tooth loss, hospitalization, blood transfusions, or, very rarely, permanent disability or death if I have chosen to accept the above recommeneded treatment.

I have considered both the recommended and alternative forms of diagnosis and/or treatment for my condition/s. I understand that each of these alternative forms of diagnosis or treatment has its own potential benefits, risks and complications. I have been given an opportunity to ask questions and have them fully answered. I understand the nature of the recommended treatment, alternate treatment option and the risks of the recommended treatment.

I acknowledge that I have read this document in its entirety, that I fully understand it and that all blank spaces have been completed or crossed off prior to my signing.
I do understand the recommended treatment and accept all consequences if I do not proceed with the recommended treatment above.