Irwindale Dental

Dental Office of Xeres Desiree Pleyto, DDS, Inc

Informed Consent or Refusal for Dental Treatment

X-RAYS CLEANING SCALING

Benefits Benefits
More complete and accurate diagnosis Look nicer
Can find hidden problems Clean mouth
Helps improve treatment outcome Eliminate odors
X-rays are taken by qualified personnel Prevent odors
Possible complications Prevents gum disease
Exposure to x-ray radiation Some portions may be performed by auxiliary
X-ray pictures remain the property of this office personnel
Consequences of no x-rays Possible complications
Cannot perform dental service or diagnosis Sensitive teeth
Alternatives Feeling of spaces between teeth
No x-rays Filling may be loosened, requiring replacement at
additional cost. (Normal if filling was failing)
Sensitive gums
Consequences of no treatment
Initials Date Stains on teeth
Odors
Gum disease
LOCAL ANESTHETICS
Shorter life span for your teeth
Benefits Alternatives
Avoid pain during treatments and procedures No cleaning
Less post-operative pain
Possible complications
Extended numbness may last indefinitely
Nerve damage resulting in altered sensations Initials Date
such as tingling, burning, or partial numbness
which may last indefinitely
GUM TREATMENT
Bruising or swelling (hematoma)
Benefits
In rare instances, possible consequences may
include all those applicable to General
Eliminate infection
Anesthesia, including allergic reactions up to and
Extend life of teeth
including death
Reduce food pockets around teeth
Consequences of no anesthetic
Eliminate foul odors
Mild to severe pain during and after treatment
Can eliminate tartar effectively
Prolonged or indefinite post-operative pain
Possible complications
Alternatives
May need to be repeated after a time
Pain during treatment, and prolonged pain after
Tooth sensitivity
No treatment
Might lose teeth if they do not respond to
treatment
Consequences of no treatment
Initials Date
Will lose teeth sooner
May not eliminate infection
PATIENT RELEASE FORM Higher risk of some systemic diseases
Alternatives
I have received a copy of the Dental Materials More frequent appointments for scaling
Fact Sheet as required by law. Regular cleaning
No treatment

Signature Date
Initials Date
 CROWNS (CAPS) FIXED BRIDGEWORK
Benefits Benefits
Beautify your smile(cosmetic) Beautify your smile (cosmetic)
Repair a tooth which is badly broken down Replace missing teeth
Protect a tooth from fracturing Stabilize your bite and prevent tooth collapse
Eliminate a space where food is being trapped Missing teeth are not removable
Hold a false tooth in place as part of a bridge Some of the same advantages as Crowns
Make a solid structure to attach a partial Can improve chewing efficiency
denture Possible complications
Splint loose teeth together to strengthen them Same as crowns
Restore a tooth that no longer can be filled Flossing under a bridge ins necessary
Possible complications (at additional cost) Consequences of no treatment
Porcelain portion of crown may fracture Teeth may drift and lean over leading to tooth
Tooth may also require root canal and a post loss
Crown may come off and need to be re- More cavities due to shifting and tipping
cemented More periodontal problems (gum disease)
Tooth may abscess and require further Can reduce chewing efficiency
treatment (may not show up until later) Alternatives
Future decay may require a filling or new crown Partials
Consequences of no treatment Temporary partials
Tooth can fracture Implants
Decay may spread No treatment
Tooth may need to be extracted
May need root canal in addition to the crown
May need bridgework or denture Initials Date
Alternatives
Extraction
Large filling (not always possible)
Temporary crown ROOT CANALS
Steel crown Benefits
No treatment Eliminate infection
Relieve pain
Save a tooth
Initials Date Possible complications
Undiagnosable root fracture means failure and
extraction
CAST POSTS Undiagnosable auxillary canal means failure
Benefits May require re-treatment at additional cost
Allow a root-canalled tooth to be crowned May require surgery at additional cost
Possible complications Complications during treatment may require a
Root fracture leading to tooth loss specialist to treat at additional cost
Root perforation leading to tooth loss May require extraction
Difficult to remove Consequences of no treatment
Consequences of no treatment Possible need for extraction of tooth
May not be able to crown the tooth Pain
Alternatives Impossible to restore both
Pre-fabricated post Spread of infection, abscess
Plug post Alternatives
No post Extraction

Initials Date Initials Date

 SEALANTS PRRs
Benefits (Preventive Resin Restoration)
Prevent cavities Benefits
Stop small cavities Eliminate possible decay
Extend the life span of teeth by delaying or Enhance cosmetics by treating stained grooves
eliminating the need for filings Prevent a cavity from developing
Seal deep, narrow grooves by bonding Repair natural or environmental defects in teeth
Protect PRRs and other resin fillings which often lead to cavities, such as deep,
Possible complications narrow grooves which trap bacteria
Temporary uneven bite Conserve tooth structure by eliminating the need
Sealant may fall out for significant drilling for a filling
Sealant may deteriorate with age and need Increase the healthy life span of a tooth
replacement Bond and seal grooves
Consequences of no treatment Discover hard to detect cavities
May develop cavities Possible complications
Alternatives Temporary uneven bite
Fillings No insurance coverage
PRRs Occasional need to refresh the sealant at
No treatment additional cost
Tooth may be sensitive to temperature changes
Restoration may discolor with age
Initials Date Old restorations may need to be replaced
Consequences of no treatment
FILLINGS May develop a cavity
Benefits May require a filling or more advance treatment
Eliminate decay Decay may grow and spread
Relieve pain Alternatives
Fill in a hole or space in a tooth Standard fillings
Cover eroded area Sealants
Protect a sensitive surface No treatment
Possible complications
Tooth may abscess from the filling
May fracture the tooth
Tooth may be sensitive to temperature change Initials Date
Toxicity from silver fillings is alleged by some
Filling may fallout
Fillings will discolor with age BONDED FACINGS (Veneers)
Old fillings may need to be replaced
Benefits
Consequences of no treatment
Beautify your appearance (cosmetic)
May lose tooth
Cover crooked teeth
Tooth may fracture
Close spaces and gaps
Decay will get worse
Cover discolored teeth
May result in need for a root canal and/or crown
Possible complications (additional fees)
Alternatives
Edges can stain after a time an need repair
Temporary filling
May fall off requiring re-cementation
Extraction
Breakage can occur, resulting in need for remake
Crown
Difficult to remove
Inlay
Consequences of no treatment
Onlay
None (other than appearance)
No treatment
Alternatives
Crowns

Initials Date
Initials Date
 IMMEDIATE DENTURES FULL DENTURES
Benefits
Benefits
Never be without teeth
Improve chewing
Improve chewing
Protect extractions sites Restore a natural look
Minimize changes in your facial appearance (tongue, Support your lips and cheeks
lips, cheeks) that can occur when your natural teeth Stabilize your bite
are removed Possible complications
Restore a natural look Can cause gum irritations or soreness
Shorten your transition to dentures by avoiding May require many appointments for
having to learn to speak and chew with no teeth adjustments
Support your lips and cheeks
Can cause jawbone to shrink
Stabilize your bite
Possible complications (vs. full dentures) May look unnatural
Require more office visits and adjustments May be difficult to use
May require at-home rest time Can break
Difficult to eat in the beginning Can loosen over time requiring relines or
May require bone contouring replacement at additional cost
Can cause more gum irritation or sore spots Consequences of no treatment
May loosen quickly after extractions and need to be No teeth
relined or rebased due to tissue and bone changes Sunken facial appearance
during healing
Trauma to gums from eating without teeth
May require a complete new denture 2-6 months
later at additional cost (may not be full cost)
Alternatives
Relines and rebases are an additional cost Implants
Consequences of no treatment Implant supported appearance
May have to be with no teeth for a while Partial dentures if there are still savable teeth
Alternatives Temporary dentures
Regular full dentures No treatment
Implants
Implant supported dentures
Temporary dentures
Initials Date
No treatment

DENTURE RELINES
Initials Date Benefits
Denture fit better and tighter
May eliminate the need to use adhesives
PARTIALS (Removable Bridgework) Re-establish proper bite level
Benefits Stabilize your bite
Cost Possible complications
Improve chewing Can cause new gum irritation and soreness
Stabilize your teeth and bite May require appointments for adjustments
Possible complications May not offer much change due to lack of bone
Can cause wear on teeth May require tissue conditioning prior to relining
Can stress teeth and may loosen natural teeth at additional cost
Can cause jaw bone under partial to dissolve Can still loosen over time requiring new relines
Metal clasps are sometimes visible or new dentures at additional cost
Decay can occur under clasps or rests Consequences of no treatment
Usually some amount of movement from the Loose dentures
partial Excess trauma causing jaw bone to dissolve
Consequences of no treatment faster
Same as under Bridgework Alternatives
Alternatives New dentures
Bridgework Rebase
Implants Implants
Temporary partial Implant supported dentures
Not treatment No treatment

Initials Date Initials Date

 NIGHTGUARDS EXTRACTIONS
Benefits Benefits
Minimize or eliminate clenching and grinding Last resort for non-salvageable tooth
Protect teeth Eliminate pain
Relieve muscle stress Remove teeth that are out of position
Protect the TMJ (jaw joint) Eliminate infection
Break destructive habits Possible complications
Provide comfort at night Fractured particles may remain
Possible complications Irritation to nerves may cause temporary or
May wear out and need replacement permanent numbness, or altered sensations
May not fit well after time and need replacement such as tingling, burning, or partial numbness
May be hard to get used to which may last indefinitely
May not break habits Part of all tooth may be lodged in sinus,
Degree of benefits varies requiring more surgery
No guarantees, refunds, or exchange An opening to the sinus can occur
Consequences of no treatment Complications during treatment such as broken
Worsening TMJ disorder symptoms root tips or difficult anesthesia may require a
Damage to teeth resulting in tooth loss specialist to treat at additional cost
Damage to TMJ and muscles requiring specialized Other crowns or bridges may break or come lose
treatment or surgery requiring replacement at additional cost
Alternatives Jaw may be stiff and difficult to open for at time
Ororafacial pain specialist consultation If jawbone is very weak, it may fracture
Stress counseling pain
No treatment Consequences of no treatment
spread of infection
Initials Date swelling
pain
TAKE-HOME BLEACHING inability to complete treatment plan
Benefits Alternatives
Brighter teeth and smile (cosmetic) No treatment
Eliminate stains and discoloration
Possible complications
May take several applications to achieve the desired Initials Date
result. Some types of colors and stains are more easily
treated than others.
Different results will be achieved with different people
due to tooth chemistry. One persons result should not
be compared to anothers
White patches or mottling may not disappear
Tooth sensitivity. If sensitivity occurs, it is temporary
(usually 1-2 days), and can be treated in a few different
ways
Gum irritation. If the bleaching material comes in contact
with your gums for too long, you may experience
temporary gum inflammation.
Sore throat. Avoid excess leaching gel
Tooth injury due to defective, leaking fillings
Old fillings no longer match your tooth color and may
need to be replaced at additional cost
No guarantees, no exchanges, no refunds. If you change
your mind, choose a different form of whitening, or are
not satisfied with the results, you are not eligible to
receive a refund
Consequences of no treatment
None other than the color of your teeth
Alternatives
No treatment

Initials Date
 CONSENT

Name of Patient

I have read the above statements, received a copy of them if I requested, and recognize their importance in helping
me make decisions. My initials in each section indicate that the information was also fully explained to me.

I recognize that failures and complications can occur for various reasons in any procedure. I also understand that, for
example, where decay has occurred, or a tooth has fractured or abscessed, that these same forces may still be
working on the tooth even after it has been restored. Therefore, decay or fracture can still occur as the restored tooth
is no better than what nature had provided originally.

If for any reason a conflict or disagreement should arise, I will first present such conflict or disagreement to my
attending dentist in order to resolve the problem. If we are unable to agree on a solution, then I agree to take the
problem to a reconciliation/mediation board such as local dental society and agree to accept their resolution in lieu
of pursuing remedies by way of litigation. I also understand that this agreement is binding on my heirs and all other
family members.

I give my consent to the attending dentist to render to me the dental treatment discussed. I also agree to reimburse
the attending dentist of all services rendered to me, and I am aware that the payment for these services is due at the
time they are rendered. I know that no dental treatment is guaranteed to succeed and that I am financially
responsible regardless of the results. I know there are no refunds given for services, appliances, and products for any
reason

PLEASE SIGN AND DATE IF YOU AGREE:

Signature Date

REFUSAL

Name of Patient

I have read and been explained the consequences of no treatment under each section above and fully understand
what may happen if I choose not to accept the treatment recommended to me. I fully relieve my dental health and
any systemic consequences which may arise from my refusal of treatment.

I ACCEPT FULL RESPONSIBILITY FOR THE CONSEQUENCES OF REFUSAL:

Signature Date