Crown & Bridges Consent Form



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 is exercised in the treatment of conditions requiring crowns and bridgework and fabrication of 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.

Crowned or bridge abutment teeth may require root canal treatment subsequently: Teeth after being crowned may develop a condition known as pulpitis or pulpal degeneration. Usually, this cannot be predetermined. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth, particularly if teeth remain appreciably sensitive for a long period of time following crowning. Infrequently, the tooth (teeth) may abscess or otherwise not heal completely. In this event, periapical surgery or even extraction may be necessary.

Breakage: Crowns and bridges may possibly chip or break. Many factors can contribute to this situation such as chewing excessively hard materials, changes in biting forces exerted, traumatic blows to the mouth, etc. Unobservable cracks may develop in crowns from these causes, but crowns/bridges may not actually break until chewing soft foods, or for no apparent reason. Breakage or chipping seldom occurs due to defective materials or construction unless it occurs soon after placement.

Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and the artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminable periods of time following placement of the crown or bridgework.

Esthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in their mouths prior to final cementation. If satisfactory, this fact will be acknowledged by the patient's signature (or signature of legal guardian) on the back of this form where indicated.
Longevity of crowns and bridges: There are many variables that determine "how long" crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. In addition, general health, good oral hygiene, regular dental checkups, diet, etc., can affect longevity. Because of this, no guarantees can be made or assumed to be made concerning how long crown and bridgework will last. Because crowns and bridges are statistically more reliable over a longer period of time than fillings, in the case of access restricted patients, consideration will be given to choosing a crown or bridge more often than a repair or filling involving the interproximal areas.

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 the 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: I have been given the opportunity to ask any questions regarding the nature and purpose of crowns, bridges and fillings and have received answers to my satisfaction. I do 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 and/or any results from the treatment to be rendered to me. The fee(s) for these services have been explained to me and I accept them as satisfactory. By signing this form, I am freely giving my consent to authorize Dr. Babak Chehroudi and/or all associates involved in rendering any services he/she deems necessary or advisable to treatment of my dental conditions, including the administration and/or prescribing of any anesthetic agents and/or medications.
I understand that it is my responsibility to notify Dr. Chehroudi should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.
Informed Consent:

1. I authorize Babak Chehroudi, D.M.D., Ph.D. of Scident family Dental Clinic along with associated professionals to perform upon the above named patient any and all procedures, including but not limited to: local anesthetic, cleaning, x-rays, and any and all procedures that in their judgment may be necessary or advisable for the above patient’s well being and safety.

2. I acknowledge that the nature of my condition and the essence of the proposed health care procedure, together with any alternative method of treatment or non-treatment, have been thoroughly explained to my satisfaction including the chance of substantial risk or harm.

3. I acknowledge that I had a fair opportunity to ask questions about the health care procedures, their alternatives, and or complications.

4. I acknowledge that my questions have been answered in a satisfactory manner, and that I understand the attendant risks involved and voluntarily assume them.

5. It has been explained to me, that during the course of such procedure(s) or operations(s), unforeseen conditions maybe revealed which necessitate either an extension of the aforementioned procedure(s), or modification of them. I authorize and do request that Dr. Chehroudi and Associated Dental Professionals perform any such additional procedure(s), or modifications of them.

6. I have been advised of the following potential complications from oral surgery, extractions, root canal treatment, periodontal surgery and anesthesia and related procedures: Common complications including but not limited to: pain, infection swelling, bleeding, bruising, discoloration, uncommon complications including but not limited: temporary or permanent numbness and tingling of the lip, tongue, chin, gums, cheek and or/teeth; pain and numbness of veins with intravenous injections; injury to or stiffness of the neck and facial muscles; changes in occlusion and/or temporomandibular joint: possible injury to teeth restorations and tissues adjacent to the tooth being treated; referred pain to ear neck and head nausea, vomiting, allergic reaction, fractured bone delayed healing and “dry sockets,: opening into the sinus or nose during and/or following extractions and or surgery.

7 I acknowledge that I have provided complete and accurate health history and have informed Dr. Chehroudi and affiliated Dental Professionals of all major medical and or/ pathological conditions or diseases (no matter how insignificant or small the problem may be and informed Dr. Chehroudi and associates of all medications, prescriptions and over the counter drugs (including: aspirin, Tylenol, cold remedies, etc), and that I am now taking or have taken in the past month. I hereby accept the responsibility to update and correct my health history and medications chart at each and every visit with Dr. Chehroudi and Associates.

8. I understand that Dentistry is not an exact science and that, therefore, a reputable doctor cannot guarantee any specific results. No Guarantee or assurance has been given by Dr. Chehroudi or Associates of the expectations of results that may be achieved.

9. I recognize that Dr. Chehroudi is extending dental services beyond the expected standard of availability for my convenience, comfort and/or physical requirements. I cannot sign away my right to legally pursue any perceived personal wrong but agree that only acts or omissions which are grossly negligent or are willful and wonton will be considered grounds for legal remedy.

“I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desire results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.” I accept and trust Dr. Chehroudi as my dentist. I believe that the only considerations in Dr. Chehroudi’s mind, other than to perform high quality dental services are my personal right to choose and the right to benefit from his best efforts in my behalf. He also works to ensure that I have informed decision-making and consent. , I believe that Dr. Chehroudi will try to do his very best under possibly trying circumstances. I believe and accept that his treatment will represent his best judgment. I believe that this is the essence of the professional relationship and voluntarily enter into it. I specifically authorize the following as dictated by Dr. Chehroudi’s professional judgement: Exam; Necessary x-rays; Cleaning of teeth, Extractions to treat pain and/or infection.