Crown and Bridge Consent Form

WORK TO BE DONE: I understand that I am having the following work done

1. DRUGS AND MEDICATIONS: I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction)
2. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being Root Canal Therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.

Restoration of a tooth with a crown requires two phases:

1. preparation of the tooth, an impression sent to the lab, construction and temporary cementation of a temporary crown; and later
2. removal of the temporary crown, adjustment, and cementation of the permanent crown after esthetics and function have been verified and accepted.

Temporary Crown: Once a temporary 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 well as the permanent crown. Failing to replace the temporary crown with the permanent crown could lead to decay, gum disease, infections, problems with your bite, and loss of tooth.

Risks of Crowns, not limited to the following:

1. I understand that preparing a damaged tooth for a crown 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 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. This can occasionally be an indication of a further problem. I must notify the office if this or other concerns arise.
3. I understand that the crown may alter the way my teeth fit together and may make my jaw joint feel sore. This may require adjusting my bite by altering the biting surface of the crown or adjacent teeth.
4. The edge of a crown is usually near the gumline, which is an area prone to gum irritation, infection or decay. Proper brushing and flossing at home, a healthy diet, and regular professional cleanings are some preventive measures essential to helping control these problems.
5. There is a risk of aspirating or swallowing the crown during treatment.

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my crown or bridge (including shape, fit, size, and color) will be before cementation.

I understand that dentistry is not an exact science and that therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for myself or my minor child. I have had full opportunity to discuss and ask questions regarding the dental treatment and all questions have been answered to my satisfaction.