CONSENT PROSTHETIC FORM

I understand that the treatment of my teeth may involve one or more of the following procedures:

Root Canal Therapy: Usually under local anesthesia and possibly Nitrous Oxide (Laughing Gas) and even Valium and in an effort to disinfect the pulpal tissues, the dentist will remove the canal tissue along with disinfecting the canal space. This is followed by sealing the canal space to encourage long term healing. This is followed by restoration over the pulpal canal. After Care: Care should be taken so that you do not bite yourself while you are numb. Many times the pain associated with root canal treatment goes away immediately after treatment, however, antibiotics and painkillers can be used to help eliminate pain that may linger. 2. Pulpotomy: Usually under local anesthesia and possibly Nitrous Oxide (Laughing Gas) and even Valium and in an effort to disinfect the pulp tissues, the dentist will partially remove the canal tissue. This is followed by a permanent restoration over the pulpal canal. After Care: Care should be taken so that you do not bite yourself while you are numb. Many times the pain associated with pulpal therapy goes away immediately after treatment, however, antibiotics and painkillers can be used to help eliminate pain that may linger.

Pulpectomy: Usually under local anesthesia and possibly Nitrous Oxide (Laughing Gas) and even Valium and in an effort to ease pain and disinfect the pulp tissues, the dentist will remove the canal tissue. Disinfectants will be left inside the tooth and this is followed by a temporary restoration over the pulpal canal until definitive treatment may be performed. After Care: Care should be taken so that you do not bite yourself while you are numb. Many times the pain associated with pulpal therapy goes away immediately after treatment, however, antibiotics and painkillers can be used to help eliminate pain that may linger.

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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