Facts for Consideration

1. A bridge is an appliance (prosthesis) usually composed of a metal or ceramic framework, artificial teeth and acrylic, ceramic or metal materials. It fills in the spaces created by missing teeth and restricts other teeth from shifting. A bridge is a fixed cemented appliance (prosthesis) that allows one or more missing teeth to be replaced with an artificial tooth. Two or more teeth will undergo modification (removing tooth structure) for the placement of crowns serving as abutments or "anchors” for the bridge.
2. Treatment of teeth with a crown may involve restoring damaged areas of the tooth above and below the gum line with a crown. The process often requires placement of a temporary crown. In the event CAD-CAM is used to fabricate a crown, a temporary crown may not be utilized.

3. Once a temporary (interim) crown has been placed, it is essential to return to have the permanent crown placed as the temporary crown is not intended to function as the permanent crown. If the temporary crown breaks, comes loose or if the tooth is uncomfortable, this should be reported to the dentist immediately. Failing to replace the temporary (interim) crown with the permanent crown could lead to decay, gum disease, infections, problems with my bite and loss of the tooth/teeth.

4. Restoration of a tooth with a crown may require two phases: 1) preparation of the tooth, making an impression or mold (which is used for fabrication of the final crown), sending that mold to a dental lab, then construction and temporary cementation of a temporary (interim) crown or in some cases the use of CAD-CAM (computer-aided scanning of the dental arch and teeth to fabricate the crown) or 2) removal of the temporary (interim) crown (if required), ad|ustment and cementation of the permanent crown after aesthetics and function have been verified and accepted.

Benefits of Bridge(s) and Crown(s), Not Limited to the Following:

1. I understand that a reasonable aesthetic appearance may be achieved.

2. Establishes an occlusal or ‘chewing” surface with opposing teeth. It may serve to reduce or restrict the drifting or movement of opposing teeth caused by a missing tooth.

3. A crown is typically used to strengthen and restore a tooth damaged by decay, fracture or previous fillings (restorations). It can also serve to protect a tooth that has had root canal treatment and may improve the way your other teeth fit together.

4. Crowns may be used for the purpose of improving the appearance of damaged, discolored, misshapen, malaligned or poorly spaced teeth.

Risks of Bridge(s) and Crown(s), Not Limited to the Following:

1. I understand that preparing a tooth for a crown or as an abutment crown for a bridge may further irritate the nerve tissue (called the pulp) in the center of the tooth, leaving my tooth feeling sensitive to heat, cold or pressure. Such sensitive teeth may require additional treatment including endodontic or root canal treatment.

2. I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it difficult for me to open wide for several days, sometimes referred to as trismus. However, this can occasionally be an indication of a more significant condition or problem. In the event this occurs, I must notify this office if I experience persistent trismus or other similar concerns arise.

3. I understand that a crown may affect the way my teeth fit together and make my |aw |oint feel sore. This may require adjusting my bite by altering the biting surface of the crown, adjacent teeth or opposing teeth.

4. I understand that the edge of a crown is usually near the gum line, which is in an area prone to gum irritation, infection or decay. Proper brushing and Glossing at home, a healthy diet and regular professional cleanings are some preventive measures essential to helping control these problems.

5. I understand there is a risk of aspirating (inhaling) or swallowing the bridge(s) or crown(s) during treatment.

6. I understand that I may receive a local anesthetic and/or other medication. In rare instances, patients may have a reaction to the anesthetic, which could require emergency medical attention, or find that it reduces their ability to control swallowing. This increases the normal chance of swallowing foreign objects during treatment. Depending on the anesthesia and medications administered, I may need a designated driver to take me home. Lastly, temporary or permanent nerve injury can result from an injection.

7. I understand that ALL medications have the potential for accompanying risks, side effects and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking, which are:

8. I understand that every reasonable effort will be made to ensure the success of my treatment. There is a risk that the crown procedure will not save the tooth and therefore success is not guaranteed.
9. Post-op infection, bacterial or viral, that may require further treatment.

Consequences if No Treatment Is Administered Are Not Limited to the Following:

I understand that if no treatment is performed, I may experience symptoms that may increase in severity and could lead to decay, gum disease, infections, problems with my bite and loss of the tooth/teeth. I also understand that with no treatment the cosmetic appearance of my teeth will not change and may deteriorate.

Alternatives to Bridge(s) or Crown(s) Are Not Limited to the Following:

I understand that depending on the reason I have a bridge or crown placed, alternatives may exist including the replacement of missing teeth with implants or removable types of restorations. I have asked my dentist about them and their respective expenses. My questions have been answered to my satisfaction regarding all of 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.

Check the boxes below that apply to you:

Consent

• I have been informed, both verbally and by the information provided on this form, of the risks and benefits of the proposed treatment.

• I have been informed, both verbally and by the information provided on this form, of the material risks and benefits of alternative treatment and of electing not to treat my condition.

• I certify that I have read and understand the above information that the explanations referred to are understood by me, that my questions have been answered and that the blanks requiring insertions or completion have been filled in. I authorize and direct Dr. to do whatever he/she deems necessary and advisable under the circumstances.