Informed Consent for Dental Treatment

I understand that tooth extraction may involve risks including, but not limited to: bleeding, swelling, bruising, infection, dry socket (alveolar osteitis), prolonged pain, damage to adjacent teeth or restorations, fracture of the jaw, sinus involvement (for upper teeth), and temporary or permanent numbness or altered sensation if the tooth is near a nerve.

My dentist has explained the alternatives to extraction (which may include root canal therapy, periodontal treatment, or no treatment) and the consequences of those alternatives, including the possibility that the condition may worsen if untreated.

I understand that after extraction, the missing tooth may need to be replaced (with an implant, bridge, or denture) to prevent shifting of remaining teeth, bite changes, and bone loss. I have had the opportunity to discuss replacement options.

I understand the procedure may require an incision in the gum, removal of bone, and sectioning of the tooth. Stitches (sutures) may be placed.

I understand there is a risk of temporary or permanent numbness or altered sensation of the lip, chin, tongue, gums, or teeth due to proximity of nerves (inferior alveolar and lingual nerves), particularly with lower wisdom teeth. In rare cases this numbness may be permanent.

I understand there is a risk of jaw fracture, TMJ symptoms, sinus communication (for upper teeth), prolonged bleeding, infection, dry socket, swelling, bruising, and limited mouth opening (trismus) for several days.

I agree to follow all post-operative instructions, including diet restrictions, oral hygiene guidelines, and prescribed medications. I will contact the office immediately if I experience uncontrolled bleeding, severe pain, fever, or signs of infection.

I understand that if I have ever taken bisphosphonates (e.g., Fosamax, Boniva, Reclast, Zometa) or other antiresorptive or antiangiogenic medications (e.g., Prolia, Xgeva, Avastin), there is an increased risk of medication-related osteonecrosis of the jaw (MRONJ) following extractions or other bone-involving procedures. I have disclosed all such medications to the dental team.

I understand root canal therapy may involve: instrument separation inside the canal, perforation of the tooth root, incomplete cleaning of complex root anatomy, post-operative pain or flare-up, persistent infection requiring retreatment or surgery (apicoectomy), or in some cases the need for extraction if the tooth cannot be saved.

I understand that a tooth that has had root canal therapy typically requires a crown to protect it from fracture, and that the crown is a separate procedure with separate cost. Without a crown, the tooth is at significantly higher risk of breaking.

My dentist has explained the alternatives, which include extraction with or without replacement (implant, bridge, denture, or no replacement), and the consequences of each option.

I understand the procedure involves removing tooth structure to make room for the crown or bridge. This is irreversible. The tooth may become sensitive to hot, cold, or pressure for a period after treatment.

I understand that in some cases the nerve of a prepared tooth becomes inflamed and may require root canal therapy afterwards. In rare cases the tooth may need to be extracted.

I understand a temporary crown will be placed while the permanent crown is fabricated, and that the temporary can come loose. I will avoid sticky or hard foods on that side and contact the office if the temporary dislodges.

I understand that no dental restoration lasts forever. Crowns and bridges may need replacement over time, and longevity depends on oral hygiene, bite forces, and dietary habits. No specific lifespan is guaranteed.

I understand implant placement is a surgical procedure with risks including infection, bleeding, swelling, bruising, nerve injury (which may cause numbness or altered sensation of the lip, chin, tongue, or gums — temporary or in rare cases permanent), sinus involvement for upper implants, and damage to adjacent teeth.

I understand that implants do not always integrate with bone. Failure rates vary, and factors including smoking, uncontrolled diabetes, certain medications, and bone quality can increase the risk of failure. If the implant fails, it may need to be removed and the site allowed to heal before another attempt.

I understand that if I have ever taken bisphosphonates (e.g., Fosamax, Boniva, Reclast, Zometa) or other antiresorptive or antiangiogenic medications (e.g., Prolia, Xgeva, Avastin), there is an increased risk of medication-related osteonecrosis of the jaw (MRONJ) following implant placement. I have disclosed all such medications to the dental team.

I understand implant treatment is typically completed in phases over several months, may require bone grafting or sinus lift procedures, and that the final crown / bridge / denture attached to the implant is a separate procedure with separate cost.

I understand implants require lifelong meticulous oral hygiene and regular professional maintenance. Peri-implantitis (gum infection around the implant) can lead to bone loss and implant loss if not managed.

I understand scaling and root planing may cause: temporary tooth sensitivity (especially to cold), gum tenderness, minor bleeding, and gum recession that can expose root surfaces and may make teeth appear longer.

I understand that gum disease is a chronic condition. After initial treatment, I will need ongoing periodontal maintenance visits (typically every 3–4 months) to prevent progression. Untreated gum disease leads to bone loss and eventual tooth loss.

I understand that the outcome of scaling and root planing depends on my home care, smoking status, systemic health, and the severity of the disease. In some cases, surgical periodontal treatment or referral to a periodontist may be required.

I understand that after a filling, my tooth may be sensitive to cold, heat, or biting pressure for several days to weeks. This usually resolves on its own. In some cases, sensitivity persists and may indicate the need for additional treatment such as root canal therapy.

I understand that the size and depth of the cavity may not be fully known until the decay is removed. If the decay is deeper or larger than expected, the treatment plan may change — for example, the tooth may need a crown or root canal instead of a filling. I will be informed before any change in plan.

I understand fillings have a finite lifespan and may need to be replaced over time due to wear, fracture, or recurrent decay around the edges.

I understand that dentures require an adjustment period. I may experience sore spots, difficulty chewing, altered speech, increased saliva, and a gagging sensation initially. Multiple follow-up adjustments are typical and are part of normal denture care.

I understand that over time, the bone and gums beneath dentures shrink. Dentures will need to be relined, rebased, or remade periodically (typically every 5–10 years) to maintain proper fit.

I understand dentures are not equivalent to natural teeth. Chewing efficiency is reduced compared to natural teeth or implant-supported prosthetics. No specific outcome regarding appearance, function, or comfort can be guaranteed.

I understand orthodontic treatment may cause: tooth soreness, root shortening (root resorption), gum recession, decalcification or cavities if oral hygiene is poor, TMJ symptoms, and unpredictable response in some patients. Treatment time and final result depend significantly on patient cooperation.

I understand that after active treatment, retainers are required indefinitely to maintain the result. Teeth will shift if retainers are not worn as prescribed.

I understand that clear aligner treatment requires wearing the aligners 20–22 hours per day. Inadequate wear time will compromise the result, may extend treatment, and may require additional aligners or refinements at additional cost.

I understand sedation and anesthesia carry risks including but not limited to: nausea, vomiting, headache, prolonged drowsiness, allergic reaction, respiratory depression, cardiovascular changes, aspiration, and in very rare cases serious complications including brain injury or death. I have been informed of the name and qualifications of the dental professional who will administer the sedation, and I understand that California requires this practitioner to hold the appropriate Dental Board of California permit for the level of sedation being administered.

I have disclosed all current medications (including over-the-counter, herbal supplements, and recreational substances), allergies, and medical conditions to the dental team. I understand that withholding this information may put my safety at risk.

I understand that for oral and IV sedation, I must have a responsible adult drive me home and remain with me for several hours after the procedure. I will not drive, operate machinery, make important decisions, or consume alcohol for 24 hours after sedation.

For oral or IV sedation: I have followed any fasting (NPO) instructions given to me. I understand that failure to fast as instructed may require the procedure to be rescheduled.

I understand that the practice of dentistry is not an exact science and that no dentist can guarantee a specific result. Reasonable efforts will be made to achieve the best possible outcome, but unexpected complications can occur.

I have provided a complete and accurate medical and dental history, including all medications, allergies, and pre-existing conditions. I understand that changes in my health must be reported to the dental team before treatment.

My dentist has explained the proposed treatment, the risks and benefits, the alternatives (including no treatment), and the expected outcome. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I understand that if a condition is discovered during my treatment that was not anticipated, the dental team will stop and discuss the finding with me before performing additional treatment, except in a true emergency where immediate action is needed to prevent serious harm (such as uncontrolled bleeding, airway compromise, or a life-threatening reaction). I do not consent in advance to additional, non-emergency procedures.

I consent to the use of clinical photographs, radiographs (x-rays), and other diagnostic records as part of my dental record for my treatment, including review by other dentists or specialists treating me, and for billing submission to my insurance. I understand these records will be handled in accordance with HIPAA and the California Confidentiality of Medical Information Act (Civil Code § 56 et seq.). Any use of my images for marketing, education outside my care, or research requires a separate written authorization, which I may give or withhold.

I understand that in California, my health information is protected by both HIPAA and the California Confidentiality of Medical Information Act (CMIA, Civil Code § 56 et seq.), which in some cases is stricter than HIPAA. The practice will not disclose my medical information for purposes outside of treatment, payment, or health care operations without my separate written authorization, except where required or permitted by California law.

I understand that I have the right to refuse or withdraw consent for any treatment at any time, for any reason, without penalty to my standing as a patient. The dental team will explain the clinical consequences of stopping or refusing treatment so I can make an informed decision. Refusal will not affect my ability to receive other dental care at this practice.

I acknowledge that the cost of treatment, my insurance coverage, and my financial responsibilities are addressed in a separate Financial Agreement, which I will be asked to sign before treatment begins. Insurance estimates are not guarantees of payment, and I am ultimately responsible for any balance not paid by insurance.