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Alex Morgan · Fictional case · #13 MO + #14 MOL
Benefits of Fillings Procedure, NOT Limited to the Following:
Fillings are used to protect a sensitive surface of the tooth, to replace tooth structure, relieve pain, cover an eroded area and fill in a hole or space in the tooth structure.
I understand that care must be exercised in chewing after the placement of filings, 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 present at the time of treatment.
Following a filling, there may be sensitivity of the teeth that can last for short period of time. If the sensitivity continues. I will notify my dentist as this can be a sign of more serious problems.
During the preparation for a filling, the removal of tooth structure may lead to exposure or trauma to underlying nerve or pulp tissue. Extreme sensitivity or possible abscess often indicate that the pulp did not heal. If that is the case, a root canal treatment or extraction may be required.
Because of extreme masticatory (chewing) pressures or other traumatic forces, it is possible for fillings to become dislodged or fracture. The resin-enamel bond that adheres the filing material to the tooth structure can also fail resulting in leakage and recurrent decay.
I understand that delaying treatment may cause harm, the dental disease may progress, further damage to teeth may occur and swelling and infection may occur creating additional treatment and associated expenses.
In connection with my dental work, local anesthetic may be used for pain control during dental procedures. All anesthetics create risks and possible side effects. These include, but are not limited to swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction and altered sensation that may lead to biting the lip or tongue. Partial or complete numbness may linger after the dental appointment. In rare cases, it can last for an extended time and occasionally may be permanent.
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Resin or white fillings have an advantage of allowing a more "conservative’1 tooth preparation, can have a strengthening effect on the tooth, have improved aesthetics and virtually blend in with the natural tooth. Risks involved with composite fillings include, but not limited to, shade variation of the filling, breakage, accelerated wear or bond failure because of chewing pressures or other traumatic forces.
I understand that by signing below I am authorizing the procedure(s) to be performed and I have read and understand the entirety of this form, including the possible risks and complications of the chosen procedure(s) and the available alternatives.
I acknowledge that I have received adequate information about the proposed treatment, that I understand this information and that all my questions have been answered to my satisfaction. I contest to the procedure.
I understand that depending on the reason I have a restoration placed, alternatives may exist.
I have asked my dentist about them and their respective expenses. My questions have been answered to my satisfaction regarding the procedures and their risks, benefits, and costs.
I understand that if no treatment is performed, I may continue to experience symptoms which may increase in severity, and the cosmetic appearance of my teeth may continue to deteriorate.
I understand that depending on the reason I have a restoration placed, alternatives may exist. I have asked my dentist about them and their respective expenses. My questions have been answered to my satisfaction regarding the procedures and their risks, benefits, and costs.
No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above.
I understand that I need to return to cement my permanent restoration within weeks from the initial preparation appointment to make sure that the new restoration fits well. I understand that if I don't return on time, the new restoration may not fit and I will be responsible for any additional fees and expenses related to the fabrication of a new restoration.
I acknowledge that I have received adequate information about the proposed treatment, that I understand this information and that all my questions have been answered to my satisfaction. I contest to the procedure.
In providing the best possible dental care for you, we may need to use x-rays to help us with proper diagnosis. We may need combinations of panoramic, bitewing, periapical, or occlusal x-rays to maximize our ability to diagnose conditions underneath structures in the mouth. With use of lead shields, dental x-rays provide minimal radiation exposure and provide valuable information necessary for your health. Our equipment are maintained and inspected annually for optimum performance and safety. Use of x-rays will help to identify following conditions: periodontitis, abscess, cyst, abnormal anatomy, impacted teeth, extra teeth, resorption of bone, resorption of teeth, fractured teeth, fractured bone, TMJ joint disorder, missing teeth, abnormal growth that can be benign or malignant. The benefit we receive from x-rays far outweighs the minimal risk associated with it.
However you have the option to refuse x-ray and allow us to perform limited examinations visually.
I understand that this is against medical advice and will significantly hinder the doctor from properly diagnosing conditions I may have. I will not hold the doctor or the practice liable for any failure to diagnose or improper treatment choices that directly results due to lack of x-ray information.
I understand that local anesthesia may be used during the dental treatment. This consent form is designed to make you aware of the following risks involved with local anesthesia. These include but are not limited to:
I authorize the Dentist or designated staff treating me to perform such diagnostic aids deemed appropriate to make a proper and thorough diagnosis of my dental needs. Upon such diagnosis I authorize the dentist to perform all recommended treatments, procedures, and medication administrations as prescribed by the dentist and agreed upon by me, or my legal guardian. I assign all dental insurance benefits to which I am entitled to the extent permitted under my insurance to the dentist, and authorize All Smiles to submit claim forms and receive payments directly with the notation “signature on file.” I authorize release of my treatment records, x-rays, and others deemed pertinent to my insurance as requested. I agree to be responsible for payment of all services rendered on my behalf to my dependants. I agree that I am responsible for any unpaid claims.
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