Informed Consent for Crown/Bridge Removal

I UNDERSTAND that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGEWORK includes certain risks and possible unsuccessful results, including the possibility of failure. Even though care and diligence are exercised in the treatment of conditions requiring crowns and bridgework and fabrication of the same, there are no promises or guarantees of anticipated results or the longevity of the treatment. Nevertheless, I agree to assume the risks, possible unsuccessful results, and/or failure associated with, but not limited to the following:

Reduction of tooth structure: In order to replace decayed or otherwise traumatized teeth, it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as possible.
Injury: During the reduction of tooth structure or adjustments done to temporary restorations, it is possible for the tongue, cheek, or other oral tissues to be inadvertently abraded or lacerated (cut). In some cases, sutures or additional treatment may be required.
Local Anesthesia: In order to reduce tooth structure without causing undue pain during the procedure, it will be necessary to administer local anesthetic. Such administration may cause reactions or side effects which include, but are not limited to, bruising, hematoma, cardiac stimulation, temporary or, rarely permanent numbness of the tongue, lips, teeth, jaws, and/or facial tissues, and muscle soreness.
Sensitivity of teeth: Often, after the preparation of teeth for the reception of either crowns or bridges, the teeth may exhibit sensitivity, which can range from mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If sensitivity is persistent, this office should be notified immediately such that all possible causes of the sensitivity may be ascertained.
Risk of Further Treatment: Following crown preparation and placement for either individual teeth or bridge abutments, the involved tooth or teeth may require root canal treatment.
Breakage: Crowns and bridges may possibly chip or break.
Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and artificial replacements.
Aesthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in their mouths prior to final cementation.
Longevity of crowns and bridges: There are many variables that determine "how long" crowns and bridges can be expected to last.
Opening the Bite: In some cases, years of wear on the teeth will create a situation where the patient loses or loses the length of the face.
Damage or trauma to teeth during the Replacement of old crowns or bridges.

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

Fracture or breakage of the existing crown or bridge: Many crowns and bridges are fabricated either entirely in porcelain or with porcelain fused to an underlying metal structure.
Fracture or breakage of the actual tooth from which the crown or bridge is removed.
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.
Failure of conventional methods in removing crowns.
Inadvertent extraction of the crowned tooth.

It is the patient's responsibility to seek attention from the dentist should any undue or unexpected problems occur. The patient must diligently follow any and all instructions, including scheduling and attending all appointments. Failure to keep the cementation appointment can result in ultimate failure of the crown/bridge to fit properly and an additional fee may be assessed.

INFORMED CONSENT FOR CROWN & BRIDGE PROSTHETICS REMOVAL:

I have been given the opportunity to ask any questions regarding the nature and purpose of crown and/or bridge treatment and have received answers to my satisfaction. 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 results, which may or may not be achieved. No guarantees or promises have been made to me concerning the results. The fee(s) for this service have been explained to me and are satisfactory. The nature and type of material used in my crown(s) or bridgework, for example porcelain-fused-to-metal, DMLS, all-porcelain, etc., have been explained. By signing this form, I am freely giving my consent to allow and authorize my Dental provider to render treatment pertaining to crown or bridge prosthetics considered necessary and/or advisable to my dental conditions, including the prescribing and administering of any medications and/or anesthetics deemed necessary for my treatment.