INFORMED CONSENT REMOVAL OF CROWNS AND BRIDGES

PURPOSE: There are three primary reasons to remove an individual crown or bridge that has been previously cemented to place:

1. Attempt to preserve and reclaim crowns and/or bridges that have fractured while in the mouth.
2. To render some type of necessary treatment to a tooth that is difficult or impossible to perform render treatment without removing the existing crown or bridge.
3. Confirm the presence of dental decay or other pathology that may be difficult to detect or may be obscured while the crown/bridgework is in place.

I UNDERSTAND that REMOVAL OF CROWNS AND BRIDGES includes possible inherent risks such as, but not limited to the following, and understand that no promises or guarantees have been made or implied that the results of such treatment will be successful.

1. Fracture or breakage: Many crowns and bridges are fabricated either entirely in porcelain or with porcelain fused to an underlying metal structure. In the attempt to remove these types of crowns there is a distinct possibility that they may fracture (break) even though the attempt to remove them is done as carefully as possible.
2. Fracture or breakage of tooth from which crown is removed: Because of the leverage or torque pressures necessary in removing a crown from a tooth, there is a possibility of the fracturing or chipping of the tooth. At times these fractures are extensive enough to necessitate extracting the tooth.
3. Trauma to the tooth: Because of the pressure and/or torque necessary in some cases to remove a crown, these pressures or torque may result in the tooth being traumatized and the nerve (pulp) injured which may necessitate a root canal treatment in order to preserve the tooth. Instruments used to remove crowns and bridges may inadvertently lacerate the gums, other tissues within the mouth, and tongue.
4. Failure of conventional methods in removing crowns: There are certain methods and instruments which are utilized in conventional attempts to remove crowns from teeth. In some instances, none of these methods or instruments will effectively remove the crown. It may then become necessary in these instances to resort to removing the crown by cutting the crown from the tooth which will either severely damage or destroy the crown. This will require a new crown to be made.

INFORMED CONSENT:: I acknowledge that I have been given the opportunity to ask any questions regarding the nature and purpose of removing crowns and/or bridges and have received answers to my satisfaction. I do 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 results, which may or may not be achieved. By signing this form, I am freely giving my consent to allow and authorize the doctor and/or his associates to render any treatment advisable to my dental conditions including any, and all anesthetics and/or medications.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me.
• I had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.