Plum Drive Dental

Dr Bill Skinner

showusyoursmile@mchsi.com

showusyoursmile.com

(515) 278-2888

General Consents (1-6 in computer consent forms  as program will only allow a small amount of data, and therefore rather than signing 6 times, only one signature  will be required)

I. WORK( TO BE DONE: I understand that I am having the following work done: Fillings and/or, Bridges and/or, Crowns and or , X-rays and/or, Extractions and/or, Impacted teeth removed and/or, Root Canals and/or, Dentures and/or, Other procedures included but not listed above . 2. DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/'or anaphylactic shock.  3. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. For example, root canal therapy following routine restorative procedures. I give my permission to my dentist to make any/all changes and additions as necessary.  4. REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, nothing, etc.) And I authorize the dentist to remove teeth: Alternatives to Surgery:  Risks to my health if the above procedure is not performed include but are not limited to:

           Infection;

           Cyst or tumor formation;

           Periodontal (gum) disease; and

           Increased risk for complications if removal is required at a later time.

    Possible Complications which have been discussed with me include but are not limited to:

           1.Injury to the nerves, to the lower lip, and tongue causing numbness which could be permanent;

           2.Bleeding and/or bruising which may be prolonged;

           3.Dry socket;

           4.Involvement of the sinus above the upper teeth;

           5.Infection;

           6.Decision to leave a small piece of root in the jaw when its removal would require extensive surgery and increased risk of complications;

           7.Injury to adjacent teeth or fillings; and

           8.Unusual reaction to medications given or prescribed.

    9. fractured jaw

    10. removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment.

I understand that a perfect result cannot be guaranteed.  If any unforeseen conditions arise during the procedure, I request and authorize the doctor to do whatever he deems advisable to correct the condition.

I agree to cooperate completely with Dr.Skinner, his staff and any associates,  and will follow the post operation instructions to the best of my ability for my own comfort and safety.  I have had the opportunity to ask questions concerning these procedures.

I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips tongue and surrounding tissue  that can last for an indefinite period of time (could be either temporary or permanent) or fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my responsibility. 5. CROWNS, BRIDGES, AND CAPS: I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further  understand that I may be wearing temporary crowns, which may come off easily, may be sensitive to temperature, certain foods, or biting pressure,  and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown bridge, or cap (including shape, size, and color) will be before cementation. It is also my responsibility to return for permanent cementation within 21 days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown, bridge, or cap. l understand that there will be additional charges for remakes due to my delaying permanent cementation. 6. ENDODONTIC TREATMENT (ROOT CANAL): The doctor  has advised me that his/her opinion for root canal treatment is indicated.  The doctor has advised me in his/her opinion and the consequences of not treating this condition include but are not limited to: worsening of the disease, infection, cystic formation, swelling, pain, loss of tooth, and/or other systemic disease manifestations.  The doctor has advised me of alternative treatments, benefits, and risks which include are not limited to: extraction of the infected tooth (teeth) or not treatment.  I, however, believe that the root canal as noted above would be my preferred choice of treatment.

The doctor has advised me that there are certain risks and potential consequences of any treatment and such risks would include but are not limited to:

-A certain percentage (approximately 5-10%) of root canals fail, necessitating re-treatments, root surgery, or extraction.

-Postoperative discomfort, swelling, restricted jaw opening which may persist several days or longer.

-Breakage of root canal instrument during treatment which may, in the judgment of the doctor, be left in the treated root canal or require surgery for removal.

-Perforation of the root canal with instruments which may require additional surgical corrective treatment or result in loss of tooth.

-Premature loss of tooth due to progressive periodontal (gum) disease.

-Root canal treatment relies heavily on radiographic information.  Since radiographs are         essentially 2-dimensional shadows which provide reliable but not infallible information, this may lead to root canal failures.

-Successful completion of the root canal procedure does not prevent future decay or fracture.  The endodontically treated tooth will be more brittle and may discolor and that a crown and post filling is recommended after completion of the root canal to prevent fracture and/or improve esthetics.

           -identification of crown or root fracture during or after treatment

           -damage to existing crowns, bridges, or other appliances

           -root canal filling material which extends beyond the end or the root

           -blocked root canals which may prevent successful treatment

           -loss of tooth structure/weakening of tooth

           -post-operative pain, swelling, and /or infection

           -possibility of future need of re-treatment or removal of tip of root(s) (apicoectomy) if failure occurs

           -Jaw pain, popping, clicking from opening for a long period of time

           -temporary or permanent numbness from root canal and or anesthesia

The benefits of successful root canal treatment include the relief of pain, removal of infection and the ability to retain the tooth in comfort and function.

Treatment alternatives include:   No treatment,  Extraction, etc.

I understand that during treatment, complications (including and not limited to those stated previously) may arise which complicate or make treatment more difficult, or which may require additional dental surgery.

I understand that root canal treatment weakens the crown of the tooth.  The dentist has explained to me the need for a restoration which adequately protects the tooth after root canal treatment has been completed.  I understand that no guarantee of success has been or can be given.  All of my questions have been answered by the dentist and I fully understand all the above statements contained in this consent form.

7. PERIODONTAL LOSS (TISSUE AND BONE): I understand that I have a serious condition, causing gum and bone inflammation or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedure may have a future adverse effect on my periodontal condition.  I UNDERSTAND that PERIODONTAL PROCEDURES (treatment involving the gum tissues and other tissues supporting the teeth) include risks and possible unsuccessful results from such treatment. Even though the utmost care and diligence is exercised in the treatment of periodontal disease and associated conditions through scaling and root planning and related procedures, there are no promises or guarantees as to anticipated results. I agree to assume those risks and possible unsuccessful results associated with, but not limited to, the following:

l. Response to treatment: Because of many variables within each patient’s physiological make-up, it is impossible lo precisely determine whether or not the healing process, in which tissue response is vital element, will achieve the results desired by both Dr. Skinner and or his associates, und the patient. Should the desired results not be attained, extractions or further periodontal surgery therapies may be required.

2. Postoperative patient responsibility for cure: With the types of treatment required in correcting periodontal problems, it is mandatory that the patient exercise extreme diligence in performing the home care required after treatment, as instructed by Dr Skinner and or his associates or hygienists without the necessary follow-up care by the patient, the probability of unsatisfactory results is greatly increased.

3. Pain, soreness and sensitivity: There may be post-operative discomfort which may be transitory or permanent, related to hot and cold stimuli, Contact with teeth, and sweet and sour foods. The gums will also be sore immediately following treatment.

4. Bleeding during or after treatment: Laceration or tearing of the gums may occur, which might require suturing. The gums may bleed as well during or after treatment.

5. Recession of the gums after treatment: After healing occurs, there may be gum recession which exposes the margin or edge of crowns or fillings, or root surfaces and will increases sensitivity of the teeth, create esthetic or cosmetic changes in teeth which results in longer teeth and wider interproximal spaces visible as a black triangle. These wider interproximal spaces are more likely to trap food.

6. Broken curettes, Sealers or other instruments, and post-treatment infection: It may be necessary to retrieve broken instruments surgically. Post treatment infection may also result from calculus being lodged in the tissue which may also require surgical intervention.

7. Increased mobility (looseness) of the teeth during the healing period.

8. Noise and water spray: Ultrasonic instrumentation is noisy and the water used may cause cold sensitivity during treatment on un anesthetized teeth not in the treatment field.

9. Post-treatment complications: Cracking or stretching of the lips/comers of the mouth during treatment is possible. There is the possibility that additional surgical treatment may be necessary after root planning.

10.Placement of local drug delivery: tetracycline antibiotic is used,  There may be an adverse reaction to the antibiotic even if a known allergy exists or not.

 8. FILLINGS: I understand that the treatment of my dentition involving the placement of composite resin fillings which may be  more aesthetic in appearance than other materials which  have been traditionally used, such as silver amalgam or gold, and  may entail certain risks. There is also the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks which may occur even though care and diligence will be exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure which are associated with, but not limited to the following: Sensitivity of Teeth: Often after preparation of teeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. The sensitivity may be mild to severe. The sensitivity may last only for a short period of time or may last for much longer period s of time. If such sensitivity is persistent or lasts for much extended periods of time, I agree to notify the dentist inasmuch as this may be a sign of more serious problems.  Risks of 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. Necessity for Root Canal Therapy: When fillings are places or replaced, the preparation of the teeth for fillings often necessitates the removal of tooth structure adequate to insure 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 often times is exhibited by extreme sensitivity, biting discomfort or possible abscess, root canal treatment or extraction may be required. I understand that care must be exercising in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling. 9. DENTURES IMMEDIATE COMPLETE DENTURES AND PARTIAL DENTURES

I UNDERSTAND that the process of fabricating and fitting IMMEDIATE REMOVABLE PROSTHETIC APPLIANCES

(PARTIAL DENTURES and/ or COMPLETE ARTIFICIAL DENTURES) includes risks and possible failures.  Even though the utmost care and diligence is exercised in preparation for and fabrication of immediate prosthetic appliances, there is the possibility of failure with  patients not adapting to the new dentures.  I agree to assume those risks and possible failures associated with but  not limited to the following:

1.Failure of immediate complete 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, especially during the healing following extraction and denture placement ; (2 ) jaw  ridges which may not provide adequate support and/or retention as shrinkage occurs following extractions;  (3) musculature in the tongue, floor of the mouth,

cheeks, etc., which may not  adapt to  and be able to  accommodate the new  artificial appliances; (4) excessive gagging reflexes as the mouth adapts to the new  dentures;  (5)  excessive saliva or excessive dryness of  mouth; (6 ) general

psychological and/or physical problems interfering with success.

2.Failure of removable partial dentures:

Many  variables may contribute to the unsuccessful utilizing of  immediate partial

dentures (removable bridges).  The variables may include those problems related to failure of complete dentures, in addition to: (1) natural teeth to which partial dentures are anchored (called abutment teeth) may become tender, sore and/or mobile as support  of  the ridge changes during healing; ( 2) abutment  teeth may decay or erode around the clasps

or attachments; (3 ) tissues supporting the abutment  teeth may  fail after healing is complete.

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, especially as the tissues heal and change; (3) cracks which may be unnoticeable and

which occurred previously from causes such as those mentioned in (1) and (2); (4) use of porcelain teeth as part of the denture, or the dentures having been  dropped or damaged previously in the event of the dentures are relined.  The above factors listed may also cause extensive denture tooth wear or chipping.

4.Loose dentures:

Immediate complete dentures normally  become less secure over the initial months as healing progresses and the ridge changes.  Dentures themselves do not change unless subjected to extreme heat or dryness.  After several months once healing is complete, the dentures will generally be quite loose and a reline or even rebase (replacement of

all tissue colored material supporting the teeth) will become necessary.  During the healing process some chair side relines may be performed, but  eventually  a laboratory processed reline or rebase will be necessary.  It will be necessary to charge a fee for relining or rebasing dentures and  I understand that the fee for immediate dentures does not cover this

reline or rebase fee.  Immediate partial dentures may become loose for the same reasons listed.

5.Allergies to denture materials:

Infrequently , the oral tissues may exhibit allergic symptoms to the materials used in

construction of either partial dentures or full dentures.

6.Failure of supporting teeth and/or soft tissues.

  Nitrous oxide: The purpose of this Informed Consent Form is to provide an opportunity for patients (and/or their parents or guardians) to understand and give permission for the use of Nitrous Oxide when provided along with dental treatment.

1.I accept and understand that Nitrous Oxide is commonly called laughing gas and provides relaxation, although I will be awake, fully conscious, aware of my surroundings, and able to respond rationally to inquires and directions.

2.I accept and understand that the use of Nitrous Oxide is not required to provide the necessary dental care.

3. I accept and understand that the purpose of Nitrous Oxide is to make it more comfortably for me to receive the necessary dental care with less pain and/or anxiety.  I also accept and understand that the use of Nitrous Oxide has limitations and risks and absolute success cannot be guaranteed. (See also #5, below.)

4.I accept and understand that Nitrous Oxide will be administered by way of the inhalation route.

5.I accept and understand that the alternatives to Nitrous Oxide are:

 a. No Nitrous Oxide: The necessary procedure is performed under local anesthetic only.

 b.Anxiolysis: A pharmacologically induced state of consciousness where an individual is awake but has decreased anxiety to facilitate coping skills, retaining interactive ability.

c.Oral Conscious Sedation: Sedation via pill form that will put me in a minimally depressed level of consciousness.

d.Intravenous (IV) Sedation/General Anesthetic: Commonly called deep sedation or general, a patient under general anesthetic has no awareness and must have his/her breathing temporarily supported.  General anesthesia is appropriate for more invasive procedures but has its own inherent risks and possible complications

6. The use of Nitrous Oxide has been fully explained to me, including all risks involved.  I have been fully informed that temporary complications may include, but are not exclusive of: tingling in the fingers, toes, cheeks, lips, tongue, head or check area; heaviness in the thighs and/or legs, followed by a lighter floating feeling; resonation in the voice or carry a hyper nasal tone; warm feeling throughout body, with flush cheeks; fits of uncontrollable laughter or giddiness; detachment or disassociation from environment may occur; intense and uncomfortable warm and/or hot feeling throughout body; lightweight or floating sensation with an accompanying “out of body” sensation; sluggishness in motion and slurring and/or repetition of words; feeling of nausea; vomiting; agitation; and/or hallucination.  All of these complications are temporary.

Bleaching: IN-OFFICE  And Take Home BLEACHING

We provide this information to give you insight into Professional Teeth Whitening.  Your cooperation and understanding of the material is necessary as we strive to achieve the best results for you.  The safety of Professional Teeth Whitening in general is very high  Like all professional health care there are limitations and risks, and absolute success is variable and cannot be guaranteed.

EXPECTATIONS:

Significant Whitening can be achieved in many cases, but there is no definite way to predict how light your teeth will get.  Candidates with Yellow or Yellow/Brown teeth tend to whiten better and quicker than people with Gray or Gray/Brown teeth.  Teeth discolored by antibiotics, decalcification (white spots), root canal therapy, or trauma do not always respond as quickly or predictably, and may require additional treatment.  On the other hand, if your teeth are already a light shade of white, for example-shade A-1/B-1 of the Vita Shade Guide, your whitening results could be minimal.  The level of whiteness varies with each individual; therefore, you may or may not achieve a higher degree of whitening.

MAINTENANCE:

It may appear that there is a slight change in the shade of your teeth within 24-48 hours.  This is due to the reformation of saliva coating.  Also, through the normal staining process of a day-to-day eating and drinking, you may experience a slight regression of shade.  This will depend on the frequency of your use of: 

TOBACCO, COFFEE, TEA, RED WINE

This can generally be managed by using a maintenance program at home.  We recommend the use of Sensodyne Whitening  toothpaste after meals, or in the morning and at night to maintain the whiteness and help with any sensitivity you might have

POTENTIAL RISK/PROBLEMS:

Teeth Whitening have some risks and limitations.  Complications that can occur in Professional Teeth Whitening are generally infrequent and are usually minor in nature.

a.)            Tooth Sensitivity:  You may experience some teeth sensitivity.  The sensitivity is usually mild if your teeth are not normally sensitive.  If your teeth are normally sensitive, you can experience EXTREME sensitivity.  We cannot eliminate this risk.  In some cases, we may suggest taking an Ibuprofen 400 mg before beginning the procedure.  Please let us know if you experience any discomfort during the procedure.  If your teeth become or stay sensitive following the procedure, Tylenol, Ibuprofen or Advil will usually be effective in helping you feel comfortable.  This sensitivity generally goes away in 12-24 hours.  If this persists for more than 24 hours, please contact our office.

b.)            Gum and soft tissue irritation:  Temporary inflammation of the gums and other soft tissues of the mouth can occur during the procedure.  This is generally the result of the whitening gel coming in contact with these tissues.  Protective materials are placed in the mouth to prevent this, but despite our efforts, it can still occur.  Usually, this will go away within 1-2 hours following the procedure but can take several days for the tissue to return to normal.  The irritation is generally short in duration and is very mild.  If discomfort persists for more than 24 hours, please contact our office.

c.)            Fillings and other Dental Restorations:  Tooth colored fillings (composite), Composite Veneer/Bonding, Porcelain Crowns, and/ or Porcelain Veneers will not whiten at all.  We may be able to remove certain stains (tobacco) from the surface of the restorations.  All Dental restorations that show when you smile may need to be replaced at your expense.  Please be sure to discuss this with us prior to beginning treatment.

YOUR TREATMENT RESPONSIBILITIES:

            Follow all Directions:  Please take time to read all written instructions, and listen carefully to all oral instructions.  You are welcome and encouraged to ask us any questions you may have.

            Communicate any problems or questions that should arise

(General consent for forms 1-6 on computer or multiple page hard copy as computer will only allow small amount of data in forms and thus to eliminate multiple signatures,  condensed form has been formed)   I hereby authorize Dr Skinner and/or any dental auxiliaries to proceed with and perform the dental treatments as explained to me. I understand that this is only an estimate and subject to modifications depending on unforeseen or undiagnosible circumstances that may arise during the course of treatment. l understand that regardless of any dental insurance coverage I may have, I am responsible for payment of all dental fees. I agree to pay any attorney`s fees, interest charges at 2% per month, collection fees, or court costs, that may be incurred to satisfy this obligation.