Inwood Dental PC

implant + Braces Center

Patient Registration

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Consent forms

Implant Risks and benefits-informed consent

. The purpose of dental implant(s) is to provide stability, support and/or retention for a crown, fixed bridge, fixed denture or removable denture in the absence of natural teeth. Based upon thorough examination and discussion, I request the fabrication of implant prosthesis. I approve any future modification in prosthetic design, materials or treatment if, in the doctor’s professional judgment, he feels that it is in my best interest

 2. I have been informed and afforded the time to fully understand the purpose and the nature of the implant restorative procedure. I understand what is necessary to accomplish the restoration of the implant previously inserted into or onto the bone and under the gum.

3. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire implant prosthesis to help secure the replacement of my missing teeth. The entire procedure has been fully explained, including the benefits and possible risks. I have been given the opportunity to ask questions regarding the procedure and they have been answered to my satisfaction. I have not asked for, nor have I received from anyone, a guarantee of the outcome of this procedure.

 4. The possible risks and complications for fixed prostheses include: compromised appearance and/or lack of support of the lip(s) and cheek(s) as a result of inadequate bone; air escaping underneath the prosthesis while talking which may adversely affect speech and/or food entrapment underneath the prosthesis since space is necessary for homecare of implant. The possible risks for removable prostheses include: sore gums, food entrapment, wearing of attachments, replacement of attachment components, and initial problems with speech.

 5. Excessive forces, as grinding or clenching my teeth, on the implant(s) may lead to loosening and/or fracture of the retaining screws or cement; fracture of the porcelain, metal or acrylic on the prosthesis; loosening and/or fracture of the implant(s); and/or loss of bone around the implant(s). Any of these may cause loss of this implant(s). Additional treatment and associated costs will be involved should this occur, including, but not limited to occlusal guards.

 6. I understand that if nothing is done any of the following could occur: loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth followed by necessity of extraction. Also possible are temporomandibular joint, jaw problems, headaches, referred pains to the back of the neck and facial muscles and fatigued muscles when chewing. In addition, I am aware that if nothing is done at the present time, future bone loss may cause the inability to place implant(s) at a later date due to changes in oral or medical condition(s).

 7. It has been explained that in some instances implant(s) fail and must be removed. I have been informed and understand that the practice of dentistry is not an exact science; therefore, I understand there are no guarantees or assurances as to the outcome of treatment results.

 8. Follow-up care for the implants and prosthesis is extremely important to the success. It will be necessary to return to the office at regular intervals for examination and service. It has been made clear that failure on my part to keep my mouth, implant post(s) and prosthesis thoroughly clean may jeopardize the success of my implant(s). I realize that unforeseen longterm factors may necessitate additional surgery, modification of the implant(s) or even surgical removal of the implant(s). I also understand that I will be financially responsible for long term maintenance and/or any modifications required, including but not limited to cleanings, attachment replacements, x-rays, and examinations.

9. To my knowledge, I have given an accurate report of my physical and mental health history. I understand that excessive smoking, alcohol, or blood sugar may affect gum healing and may limit the success of the implant(s) and restoration. I will report any significant change in my health should it occur.

10. If an unforeseen condition arises in the course of treatment which calls for the performance of procedures in addition to or different that now contemplated. I further authorize and direct my doctor, associate or assistant to do whatever they deem necessary and advisable under the circumstances, including the decision not to proceed with the implant restoration.


I  UNDERSTAND that treatment of dental conditions requiting CROWNS and/ or FIXED BRIDGEWORK includes certain risks and possible unsuccessful results, with even the possibility of failure.  I agree to assume those risks, possible unsuccessful results and/or failure associated with, but not limited to the following.  (Even though care and diligence is exercised in the treatment of conditions requiring crowns and bridgework and fabrications of same, there are no promises or guarantees of anticipated results of the longevity of the treatment).

1.       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 the crowns (caps) and/ or bridges may be placed upon them.  Tooth preparation will be done as conservatively as practical.  In preparation of teeth, anesthetics are usually needed.  At times there may be swelling, jaw muscle tenderness, or even a resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues which is usually temporary, or, rarely, permanent.

2.       Sensitivity of teeth:  Often, after the preparation of teeth for the reception of either crown or bridges, the teeth may exhibit sensitivity.  It may be mild to severe.  This sensitivity may last only for a short period of time of may last for much longer periods.  If it is persistent, notify us in as much as this sensitivity may be from some other source.

3.       Crowned or bridge abutment teeth may require root canal treatment:  Teeth after being crowned may develop a condition known as pulpitis or pulpal degeneration.  The tooth or teeth may have been traumatized from accident, deep decay, extensive preparation, or other causes.  It is often necessary to do root canal treatments in these teeth.  IF teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary.  Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction.

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

5.       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 prosthesis.

6.       Esthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns of bridges in place prior to final cementation.   When satisfactory, this fact is acknowledged by an entry into the patient’s chart initialed by patient.

7.        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.  Additionally, 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.

8.       It is a patient’s responsibility to seek attention from the dentist should any undue or unexpected problems occur.  The patients must diligently follow any and all instructions, including the scheduling and attending all appointments.  Failure to keep the cementation appointments can result in ultimate failure of the crown/ bridge to fit properly and an additional fee may be assessed.  If a crown needs to be remade after 60 days, the patient will pay for the lab fee remake.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of crown and/or bridge treatment and have received answers to my satisfaction.  I voluntarily assume any and all possible risks including those as listed above and including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved.  NO guarantees or promises have been made to me concerning the results.  The fee(s) for service have been explained to me and are satisfactory.  By signing this document, I am freely giving my consent to allow and authorize Dr. Kachepa and/or his associates to render any treatment necessary and/or advisable to my dental conditions including the prescribing and administering any medications and/or anesthetics deemed necessary to my treatment.

Oral surgery (extraction)

I fully understand this consent for surgery and the reasons why the recommended treatment is necessary.  I have been given the opportunity to ask questions regarding the recommended treatment and have been given satisfactory answers.  I understand that no guarantee regarding the treatment has been made or implied.

TREATMENT: __________________________________________________________ _______________________________________________________________________

B. TREATMENT ALTERNATIVES I elected the treatment listed above even though the following alternatives have been explained to me as being both practical and possible.

TREATMENT ALTERNATIVES: ___________________________________________ ________________________________________________________________________

C. ANESTHESIA/MEDICATIONS I also authorize the recommended treatment to be performed with the following anesthetics and/or medications: _____ Local anesthesia only _____ Local anesthesia with nitrous oxide and oxygen

D. RISKS AND CONSEQUENCES I understand that there are risks associated with the administration of medications and performance of the recommended surgery such as the items check below:

_____ Drug reactions and side effects

_____ Post-operative bleeding and pain

_____ Necessary removal of bone during tooth extraction

_____ Post-operative infection or bone inflammation

_____ Possible damage to the sinus when upper back teeth are removed which may require surgical repair at a future date

_____ Possible nerve damage when lower wisdom teeth are removed which can result in either temporary or permanent tingling or numbness in the lower lip

_____ Fracture of the mandible

_____ Jaw joint (TMJ) pain, malfunction and/or difficulty in opening mouth due to muscle spasms, following removal of lower teeth