I understand that my dental treatment could include one or more of the following:

Composite Resin Fillings: more aesthetic in appearance than silver amalgam. Procedure: Usually under local anesthesia and possibly Nitrous Oxide (Laughing Gas) and even Valium and in an effort to restore form, function, aesthetics etc. the dentist will carefully remove the decayed or rotten part of the tooth until a solid tooth layer is reached. The cleaned cavity is then layered with (in the case of deep cavities, a soothing pulp cap liner layer which may incur an additional charge) priming and bonding agents and then filled with white composite resin filling material and cured or hardened. The tooth is then shaped and polished. If, after decay removal and during treatment of my tooth, it is determined that insufficient tooth structure remains, a crown may be recommended. After treatment: Care should be taken so that you do not bite yourself while you are numb. When the numbness wears off you may notice the tooth feeling different. Contact our office if you hit your filling before your other teeth, if food gets impacted between the filling and adjacent tooth too easily, or if your floss gets shredded easily.

Crown and build up or post: more durable and in many cases more aesthetic than fillings. Procedure: First Visit: Usually under local anesthesia and possibly Nitrous Oxide (Laughing Gas) and even Valium and in an effort to restore form, function, aesthetics etc. the dentist will carefully remove the decayed or rotten part of the tooth until a solid tooth layer is reached. If the tooth has rotted into the nerve chamber then a root canal may be recommended. If there is not sufficient tooth structure to support the build up, a post may be added to the treatment plan. The cleaned cavity is then layered with (in the case of deep cavities, a soothing pulp cap liner layer which may incur an additional charge) priming and bonding agents and then filled with white composite resin filling material and cured or hardened. The outer layer of the tooth is shaped so that a crown or firm covering made out of gold, zirconia or other material may slide onto the tooth. Impressions before and after preparation ensure that a temporary tooth and the final crown may be fabricated and placed. The temporary tooth will be loosely bonded to the prepared tooth and a second appointment will be made.

After Treatment: During the time between the initial visit and the final crown seat, the temporary tooth may become dislodged and come off. To avoid this we recommend not eating sticky foods and avoiding flossing between the temporary and the adjacent teeth. If your crown does come off, try to put it back on. It should be tight enough that the natural friction will hold it on. If it does not go back on, call us and we will re cement it. Drug stores sell temporary cement if you can't make it in. The temporary cement takes a few hours to set so the first few hours after the temporary is placed is the most critical. Care should be taken so that you do not bite yourself while you are numb.

Second Visit: When the final crown is finished we will do the crown seat appointment where we remove the temporary crown and cement the final crown. It is uncommon to numb for this procedure, but sensitivity or gingival overgrowth may necessitate numbing and/or gingival trimming. Care should be taken so that you do not bite yourself while you are numb. Contact our office if you hit your crown before your other teeth, if food gets impacted between the crown and adjacent tooth easily or if your floss gets shredded easily.

Bridge: replacing a missing tooth by crowning the adjacent teeth and bonding a tooth in between.

I understand that there is the possibility of failure to achieve the results which may be desired or expected even though my treating dentist in rendering this treatment will exercise their best care and diligence. These risks include possible unsuccessful results and/or failure, which are associated with, but not limited to the following:

Nitrous Oxide (laughing gas) and Valium: I have the option of using Nitrous oxide and valium sedation for my procedure to help with anxiety, pain, gagging and medical conditions. I understand that the administration of medication and the performance of conscious sedation with nitrous oxide and/or valium carries certain hazards, risks and potential unpleasant side effects which are infrequent but nonetheless may occur. They include but are not limited to excessive perspiration, expectoration, excessive talking, vivid dreaming, shivering, and nausea or vomiting. I understand that when on Nitrous Oxide the office may keep me until they feel like I can drive home safely or they will find a ride for me. I understand that when on Valium and Nitrous Oxide I am required to come to the office with a designated driver and leave the office with a designated driver. Pain: After any treatment, the prepared teeth and surrounding tissues may exhibit pain. The sensitivity may be mild to severe. The pain may last only a short period of time or may last for much longer periods of time. Fracture: Inherent in the placement or replacement of any restoration is the possibility of the creation of small fracture lines in tooth structure. Sometimes these fractures may not be apparent at the time of removal of tooth structure and/or the previous filling and placement or replacement, but may manifest at a later time necessitating further treatment.

Injury to the nerves: There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral facial tissues from any dental treatment, particularly those involving the administration of local anesthetics. The resulting numbness, which may occur, is usually temporary, but in rare instances could be permanent. Aspiration: Inhaling of teeth or tooth fragments or materials used during the procedure. Further treatment: When restorations are placed or replaced, the preparation of the teeth for fillings often necessitates the removal of tooth structure adequate to ensure that the diseased or otherwise compromised tooth structure provides sound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma to underlying pulp tissue. Should the pulp not heal, which oftentimes is exhibited by extreme sensitivity or possible abscess, root canal treatment or extraction may be required. New Technology and Health Issues: technology continues to advance, but some materials yield disappointing results over time and some treatments may have to be replaced by better, improved materials. Some patients believe that having metal fillings replaced will improve their general health. This notion has not been proven scientifically and there are no promises or guarantees that the removal of silver fillings and the subsequent replacement with other white materials will improve, alleviate or prevent any current or future health condition.

Follow Up Care: Successful completion of treatment does not prevent future decay fracture or periodontal disease. It is my responsibility to maintain my teeth with regular cleanings and daily hygiene practices. Adverse reactions: Medications, anesthesia or substances used may not work as expected with your body type. Updated information: I understand that it is my responsibility to update the dentist on any health changes before treatment and to notify this office should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed. Infection: Systemic infection such as fever, sepsis and (in extremely rare cases) death may occur. Procedural complications: Breakage of root canal instruments, perforation of the root canal and other complications are part of the process of receiving endodontic treatment. Root canal treatment is 80% successful and referral to a specialist may be required if the treating doctor sees that as prudent.

I understand that Lifetime Family Dental is working hard to make my experience before, during and after treatment more comfortable. The resources that Lifetime Family Dental has to make this a more comfortable experience include the following:

Pain Control: Traditional OTC painkillers and narcotics may be used for mild to severe pain. Mild Pain: regular strength Ibuprofen or Tylenol can be taken excluding those who have contraindications as discussed with their physicians (liver or kidney damage etc.) Severe Pain: Tylenol and Ibuprofen used in conjunction have been shown to have more pain reduction than narcotics. For a normal healthy adult, the most powerful regimen is to take up to 800 mg Ibuprofen (usually 4 tablets otc ibuprofen) and then two hours later two regular strength Tylenol (acetaminophen) and then start over two hours later with the ibuprofen then tylenol rotating every two hours. This is a lot of pain killers for a healthy person so do this cautiously and not long term. If pain persists, consult the dentist and potentially a physician. Narcotics: Narcotics are not recommended due to the addiction tendencies that can arise due to their use. It has been found that dentists are the main cause of drug addiction because peoples first exposure to narcotics are from the dentist's office after third molar extractions. If you get a narcotic pain killer, please use caution. Do not drive or operate heavy machinery. Dispose of pills properly to prevent misuse. Follow the instructions given by your pharmacist. Narcotics can not be called into the pharmacy. If you would like a narcotic then you will need to get it during regular office hours or be prepared to pay for an after hours visit.

Infection Control: Antibiotics: Many times, pain comes from an abscess or other infection. If your tooth abscesses or becomes infected please let your dentist know. It is important that you remind your healthcare provider of any allergies to antibiotics. Unlike pain pills that should be taken until pain goes away, it is important to take the entire course of antibiotics to ensure complete destruction of the bacteria. Chlorhexidine Mouthwash: Mouth sores and cuts are susceptible to infection. Because of that we recommend keeping your mouth clean with regular brushing and flossing. Mouthwash can be an effective additional supplement. Chlorhexidine mouthwash kills bacteria and has been shown to last long after rinsing. If you use more than one bottle, it will stain the teeth superficially. Polishing can remove the stain. To prevent the staining we recommend using one bottle of prescription chlorhexidine mouthwash and then changing to Listerine if you still like using mouthwash.

Comfort: Stitches: You may have received stitches as part of your treatment. Unless otherwise instructed, your dentist has used resorbable sutures. Sutures should stay in for at least three days, after which time the stitches will dissolve and either be swallowed or you will thread them out. Notify the doctor if you have any concerns about your stitches. Gauze: Gauze may be used to help in blood clot formation. Please discard the gauze after 15 minutes. You are welcomed to replace it if you like, but It is common to have a little blood mixed with saliva. This is not an emergency and it should resolve within 24 hours. If your bleeding is abnormal, or does not slow its flow, please contact your doctor or go to the hospital. Hot and Cold: Temperature changes have been shown to decrease inflammation due to the body's increased response to flush the area. We are happy to provide hot and cold packs that can be alternated every 15 minutes. Other items that we can provide to help things be more comfortable include: Breath fresheners, chapstick, face towels and water.

By signing this form, I do acknowledge the following:

I have been informed of the common risks and benefits of my treatment and I am freely giving my consent to authorise Lifetime Family Dental to render the services they deem necessary or advisable to treatment of my dental conditions. I agree to receive the administration and/or prescribing of any anesthetic agents and/or medications as discussed with my dentist. I voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired and/or any results from the treatment to be rendered to me. The estimated fee(s) for these services have been explained to me and I accept them as satisfactory. I am aware that if my insurance does not cover the estimated portion of the procedures that I will be responsible for the payment. I have been given the opportunity to ask any questions regarding the nature and purpose of my treatment including alternative treatment options and my questions have been answered to my satisfaction.

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