Recommended Treatment

I hereby give consent to the doctor to perform Composite Dentistry procedure(s) on me or my dependent as follows: and any such additional procedure(s) as may be considered necessary for my well-being based on findings made during the course of the Recommended Treatment. The nature and purpose of the Recommended Treatment have been explained to me, and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.

Treatment Alternatives

Alternative methods of treatment have been explained to me, such as: but I wish to proceed with the Recommended Treatment described above.

Risks and Complications

1. Decalcification (permanent markings), decay or gum disease.
2. Root resorption resulting in teeth being shortened during treatment.
3. Pre-existing, non-vital, devitalization, traumatized teeth may cause damage to the nerve requiring a root canal on the affected tooth. Severe cases may result in tooth loss.
4. TMJ (temporo-mandibular joint) pain which may include jaw joint noises, discomfort and facial pain related to the jaw during or after treatment.
5. Discomfort due to adjustment and application of appliances.
6. Oral surgery/extractions, which may be needed to correct jaw imbalances or to remove third molars that may develop and change alignment.
7. Teeth may become impacted (trapped below gums or bone), fail to erupt, or ankylosed (fused to bone), which may require extraction, surgical transplantation/exposure, or prosthetic replacements.