INFORMATIONAL INFORMED CONSENT COMPOSITE RESIN FILLINGS
I UNDERSTAND that the treatment of my dentition involving the placement of composite resin fillings which may be more aesthetic in appearance than some of the conventional materials which have been traditionally used to fill front and back teeth, such as silver amalgam or gold, may entail certain risks. There is also the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks which may occur even though care and diligence will be exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure which are associated with, but not limited to the following:
Advantages of composite resin fillings over silver fillings:
Amalgam (silver) remains an acceptable restorative material for both front and back teeth. However, composite resin fillings offer two main advantages: (1) They are bonded to the components of the tooth which may add additional strength to the tooth structure; (2) They are tooth colored and thus allow for a more esthetic restoration.
2. Disadvantages of composite resin fillings:
(1). Composite resin fillings take more time, skill and effort to complete than amalgam (silver) restorations. Therefore, it may be necessary for the dentist to charge a higher fee for placing them. (2) Often after placement of composite resin fillings, the involved teeth may exhibit sensitivity. The sensitivity may be mild to severe. The sensitivity may last only for a short period of time or may last for much longer periods of time. If such sensitivity is persistent or lasts for much extended periods of time, I agree to notify the dentist inasmuch as this may be the sign of more serious problems. (3) Inherent in the placement of composite resin fillings is the potential for bond failure or fracture which may result in leakage and potential for rapid development of decay. Should any change or discoloration be noted, the dentist should be contacted immediately.
3. Necessity for Root Canal Therapy:
When any type of fillings are placed or replaced, the preparation of the teeth for fillings often necessitates the removal of tooth structure adequate to insure that the diseased or otherwise compromised tooth structure provides sound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma to underlying pulp tissue. Should the pulp not heal, which oftentimes is exhibited by extreme sensitivity or possible abscess, root canal treatment or extraction may be required.
4. Injury to the Nerves:
There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue, or other oral or facial tissues from any dental treatment, particularly those involving the administration of local anesthetics. The resulting numbness which could occur is usually temporary, but in rare instances could be permanent.
5. Aesthetics or Appearance:
Effort will be made to closely approximate the natural tooth color. However, due to the fact that there are many factors which affect the shades of teeth, it may not be possible to exactly match the tooth coloration. Also, over a period of time, the composite fillings, because of mouth fluids, different foods eaten, smoking, etc. may exhibit a change in shade. The dentist has no control over these factors. Tooth lightening may also result in fillings in front teeth becoming relatively darker.
6. Breakage, dislodgement or bond failure:
Due to extreme chewing pressures or other traumatic forces, it is possible for composite resin fillings or esthetic restorations bonded with composite resins to be dislodged or fractured. The resin-enamel bond may fail, resulting in leakage and recurrent decay. The dentist has no control over these factors.
7. New Technology and Health Issues:
Composite resin technology continues to advance but some materials yield disappointing results over time and some fillings may have to be replaced by better, improved materials. Some patients believe that having metal fillings replaced with composite fillings will improve their general health. This notion has not been proven scientifically and there are no promises or guarantees that the removal of silver fillings and subsequent replacement with composite fillings will improve, alleviate, or prevent any current or future health condition.
8. Insurance Related Issues:
Some insurance carriers pay for all fillings placed in back teeth based on their table of allowances for amalgam (silver) fillings. This means that the patient share of the fee for posterior composite resin fillings may be more than what normally would be expected for amalgam fillings. If a patient elects to have posterior composite resin fillings placed in lieu of silver fillings, the patient understands that insurance benefits may be less and the patient's portion of the fee may be relatively higher. The dentist is obligated to report the actual material used to the insurance carrier and will not substitute silver for composite resin on billing statements. If composite resin is placed, the billing statement will state “composite resin.”
9. I understand that it is my responsibility to notify this office should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.
I have been given the opportunity to ask any questions regarding the nature and purpose of composite 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. Okuyama 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.
Signature of patient, legal guardian, Date or authorized signator
Date Format: MM slash DD slash YYYY
Witness to signature
Date Format: MM slash DD slash YYYY