CROWN AND BRIDGE PROSTHETICS

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 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
• 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 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.
• Following crown preparation and placement for either individual teeth or bridge abutments, the involved tooth or teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. Usually this cannot be 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
• 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 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. Custom shade match and staining is available for an additional lab fee of $200.

• Longevity of crowns and bridges: There are many variables that determine “how long” crowns and bridges can be expected to 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.
• Opening the Bite: In some cases, years of wear on the teeth will create a situation where the patient overcloses or loses length of the face. A full mouth reconstruction where all existing teeth are crowned will enable the dentist to reopen the bite to the proper length. As a result the patient may experience some temporary discomfort and the crowns will be more subject to wear and If a nightguard is recommended or made but not worn by the patient, there will be an increased risk of breakage or fracture of the porcelain.

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 crown and/or bridge treatment and have received answers to my satisfaction. I voluntarily assume any and all possible risks, 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 this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr.Perez and/or his/her associates to render treatment pertaining to crown and bridge prosthetics considered necessary and/or advisable to my dental conditions, including the prescribing and administering of any medications and/or anesthetics deemed necessary for my treatment.

CONSENT FOR FINAL CEMENTATION

1. The nature and type of material used in my crown(s) or bridgework, for example porcelain-fused-to-metal, all porcelain, has been explained to me. By signing below I acknowledge and authorize the material to be used in my mouth.
2. I have been given the opportunity to view my crown(s) and/or fixed bridgework in place prior to final placement. I approve the color, shape, feel and overall appearance of my crown(s) or fixed bridgework. I understand that once the crown/fixed bridgework is placed in my mouth, the factors of color, shape, feel and overall appearance cannot be changed without additional and possibly significant time being taken and fees assessed. I further understand that removing cemented crowns or fixed bridgework may create the risk of injury or breakage to the underlying teeth.

Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff
are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative
patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you
should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These
are seldom serious enough to indicate that you should not have treatment; however, all patients should seriously
consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to
orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic
treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning
treatment.

Patient Cooperation – The Most Important Factor in Completing Treatment on Time
The improper wearing of elastics, removable appliances, headgear or neck-strap; broken appliances and missed
appointments may prevent our obtaining the desirable tooth position anticipated. These are factors which can
lengthen treatment time and adversely affect the quality of treatment results.

Decalcification and Dental Caries – Tooth Discoloration
Excellent (not just good) oral hygiene is essential during orthodontic treatment as are regular visits to your family
dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/or
decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an
individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the
benefit of fluoridated water or its substitute, or if the patient often consumes sweetened beverages or foods.

Results of Treatment
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best
results for every patient. However, we cannot guarantee that you will be completely satisfied with your results, nor
can all complications or consequences be anticipated. The success of treatment depends on your cooperation in
keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the
orthodontist’s instructions carefully.

Length of Treatment
The length of treatment depends on a number of issues, including the severity of the problem, the patient’s
growth and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment
time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are habits affecting
the dentofacial structures, if periodontal or other dental problems occur, or if patient cooperation is not adequate.
Therefore, changes in the original treatment plan may become necessary. If treatment time is extended beyond
the original estimate, additional fees may be assessed.

Phase II Treatment (If indicated)
I am aware that a second phase of orthodontic treatment may be needed after the completion of Phase I
treatment and the eruption of all permanent teeth. Patient or Parent/Guardian Initials ____________

Discomfort
The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction
of orthodontic appliances. Non-prescription pain medication can be used during this adjustment period.
Extractions
Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks
associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior to the
procedure.
Nonvital Teeth – Usually the Result Of An Injured Tooth
The nerve of an injured tooth can die over a period of time, with or without orthodontic treatment. This tooth may
become infected (abscessed) during orthodontic movement and may require root canal treatment. Discoloration
of a tooth may be noticed after treatment has started or following appliance removal. Devitalization is seldom due
to orthodontics. Patient or Parent/Guardian Initials ____________
Root Resorption – Shortening of Root Ends
The roots of some patient’s teeth become shorter (resorption) during orthodontic treatment. It is not known
exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many
patients have retained teeth through-out life with severely shortened roots. If resorption is detected during
orthodontic treatment, your dentist may recommend a pause in treatment or the removal of the appliances
prior to the completion of orthodontic treatment.

Nerve Damage
A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the
tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases, root canal
treatment may be necessary. In severe cases, the tooth or teeth may be lost.

Impacted, Ankylosed, Unerupted Teeth – Teeth Unable to Erupt Normally
Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to erupt.
Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of
these conditions depends on the particular circumstance and the overall importance of the involved tooth, and
may require extraction, surgical exposure, surgical transplantation or prosthetic replacement. In attempting to
move impacted teeth, especially canines, various problems are sometimes encountered that may lead to loss of
the tooth, the teeth nearby or periodontal (gum) problems. The length of time required to move such a tooth can
vary considerably. Occasionally permanent second molars (twelve-year molars) may be trapped under the crowns
of permanent first molars (six-year molars). Consequently, the removal of third molars (wisdom teeth) may be
necessary. Sometimes, impacted molars may cause relapse.
Temporomandibular Joints (TMJ) – The Sliding Hinge Connecting The Upper And Lower Jaws
Problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing pain, headaches or ear
problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or face),
arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly balanced bite,
and many medical conditions. Jaw joint problems may occur with or without orthodontic treatment. Any jaw joint
symptoms, including pain, jaw popping or difficulty opening or closing, should be promptly reported to the
orthodontist. Treatment by other medical or dental specialists may be necessary.

Growth Patterns – Facial Growth Occurring During Or After Treatment
Uncorrected finger, thumb, tongue or similar pressure habits; unusual hereditary skeletal pattern; and insufficient
or undesirable growth can all influence our results, affect facial change and cause shifting of teeth during or
following retention. Surgical procedures are sometimes necessary to correct these problems. On rare occasions it
may be necessary to recommend a change in our original treatment plan.
Periodontal Disease – Gum Inflammation, Bleeding and Periodontal Disease
Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but
most often due to the lack of adequate oral hygiene. You must maintain monitor your periodontal health during orthodontic treatment every three to six months. If
periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.
Unusual Occurrences – Injury From Orthodontic Appliances
Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. This can
result in orthodontic appliances being inhaled or swallowed by the patient. You should inform your dentist of
any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of
a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when orthodontic appliances are removed.
This problem may be more likely when esthetic (clear or tooth colored) appliances have been selected. If damage
to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.

Ceramic (Clear) Braces
The newer esthetic clear ceramic brackets have been requested by some of our patients. These are made of a
ceramic material and offer an alternative to metal brackets. These brackets are nice to look at, however, there is
some additional information you should know before deciding to request ceramic braces. Ceramic brackets can be
more difficult to work with. Because ceramic braces are not as strong as metal braces, lighter forces must be used
to correct alignment and rotations; this may lengthen treatment time or necessitate more frequent appointments.
There is a slight but definite risk of tooth enamel fracture upon bracket removal. This is not a problem with metal
brackets because they do not require the same force to remove. There is the potential for some discomfort when
removing ceramic brackets. This is also due to the greater force necessary for their removal. Ceramic brackets are
capable of shattering and could pose a risk from the splinters. Special precautions are taken when removing these
brackets. There have been and will continue to be improvements in the brackets, cements and debonding
procedures, but it is necessary that you are aware of problems that have been noted with this type of bracket. We
have participated in surveys distributed by the manufacturers and have voiced our concerns about currently
recommended debonding methods. 

Occlusal Adjustment
You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal
equilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion. It may also
be necessary to remove a small amount of enamel in between the teeth, thereby “flatting” surfaces in order to
reduce the possibility of a relapse.

Non-Ideal Results
Due to the wide variation in the size and shape of the teeth, missing teeth, etc., achievement of an ideal result (for
example, complete closure of a space) may not be possible. Restorative dental treatment, such as esthetic
bonding, crowns or bridges or periodontal therapy, may be indicated. You are encouraged to ask your about adjunctive care.

Third Molars
As third molars (wisdom teeth) develop, your teeth may change alignment. 

Allergies
Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This
may require a change in treatment plan or discontinuance of treatment prior to completion. Although very
uncommon, medical management of dental material allergies may be necessary.

General Health Problems
General health problems such as bone, blood or endocrine disorders, and many prescription and non-prescription
drugs can affect your orthodontic treatment. It is imperative that you inform your dentist of any changes in
your general health status.

Use of Tobacco Products
Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing after
oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement
during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised
orthodontic result.
Relapse- Movement of Teeth Following Treatment
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers
will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear
your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often
necessary for several years following orthodontic treatment. However, changes after that time can occur due to
natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that
continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the
lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in
some cases, surgery. Some situations may require non-removable retainers or other dental appliances.

All necessary dentistry must be completed prior to our starting orthodontic therapy. It is essential that the patient
maintain his/her regular dental examinations during the orthodontic treatment period on 3-6 month intervals.

If any of the complications mentioned above do occur, a referral may be necessary to another dental or medical specialist for treatment. Fees for these services are not included in the cost for orthodontic treatment.

ACKNOWLEDGEMENT
I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in
this form. I also understand that there may be other problems that occur less frequently than those presented, and
that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with
the undersigned dentist and have been given the opportunity to ask any questions. I have been asked to
make a choice about my treatment. I further understand that, like the other healing arts, the practice of
orthodontics is not an exact science and, therefore, results cannot be guaranteed. I hereby consent to the treatment proposed and authorize the dentist indicated below to provide the treatment. I also authorize the dentist to provide my health care information to my other health care providers. I understand that my
treatment fee covers only treatment provided by this office, and that treatment provided by other dental or
medical professionals is not included in the fee for my orthodontic treatment.

CONSENT TO UNDERGO ORTHODONTIC TREATMENT
I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic
treatment, and to the above doctor(s) and, where appropriate, staff providing orthodontic treatment described by
the above doctor(s) for the above individual. I fully understand all of the risks associated with the treatment.

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
I hereby authorize the above doctor to provide other health care providers with information regarding the above
individual’s orthodontic care as deemed appropriate. I understand that once released, the above doctor(s)
and staff has (have) no responsibility for any further release by the individual receiving this.

CONSENT TO USE OF RECORDS
I hereby give my permission for the use of orthodontic records, including photographs, made in the process of
examinations, treatment, and retention for purposes of professional consultations, research, education, or
publication in professional journals as well as promotional purposes (office promotions, Facebook, Instagram, etc.).
Please indicate:   Yes   No

I have been informed that I have gum or periodontal disease. In Greek “peri” means around (think periscope) and “odnt” means tooth (think orthodontics).  Broadly defined, periodontal disease is inflammation and infection affecting the gums, bone and supporting tissues “around the teeth”. Sometimes the gums separate from the teeth.

In addition to inadequate brushing and flossing, periodontal disease can be caused by smoking, diabetes, stress, medications, illness, hormonal or systemic changes, and genetics (it can run in your family) You can have periodontal disease even with good hygiene. This disease may be painless with no symptoms, but the usual indicators include deep pockets surrounding the tooth (3mm or less is healthy – the dentist or hygienist measures these pockets with a dental instrument), bleeding gums (especially upon brushing/flossing), puffy gums, bone loss visible on x-rays, receding gum tissue and loose teeth.

Dentists characterize periodontal disease in four categories:

• Type I – Gingivitis
• Type II – Early Periodontitis
• Type II – Moderate Periodontitis
• Type IV – Advanced Periodontitis

Like most disease, periodontal disease is progressive. Left untreated, it will worsen and can cause serious health effects both inside the mouth and throughout the body.

Inside the Mouth

Periodontal disease (and not decay) is the leading cause of tooth loss among American adults over the age of 35. Unless you follow your dentist’s recommendations, you may lose some or all of your teeth. Other complications may include bad breath, loose of teeth and bone loss (which may impact your future ability to wear dentures or have implants placed).

Throughout the Body

The U.S. Surgeon General and other studies report that periodontal disease has been linked to heart disease, stroke, diabetes and other medical aliments.

UNTREATED PERIODONTAL DIEASES CAN LEAD TO SERIOUS ILLNESS AND EVEN BE LIFE THREATENING!

Periodontal disease may be permanent in nature and require life-long care. In some cases you can treat, but never “cure”, the disease.

Patients with no periodontal issues typically see their dentist every six months. Patients with periodontal disease, however, often need treatment every three or four months.

LOCAL ANESTHETIC

I understand there are risks of local anesthesia that may affect my body such as dizziness, nausea, and vomiting, accelerated heart rate, slow heart rate, or various types of allergic reactions. It may also cause injury to nerves that can result in pain, numbness, tingling that may persist for several weeks, months or rarely, be permanent. I have informed my doctor of my complete medical history including and recent surgeries or changes in my medical history.  

The Scaling and Root Planing Procedure

A hygienist will use specialized instruments to remove calculus, bacterial plaque and diseased tissues, both above and below the gum level. Some or all teeth in a quadrant (upper right; lower right; upper left; lower left) may need this treatment. Local anesthetic is recommended for this procedure. The goal is to reduce pocket depths, remove unhealthy tissue and thoroughly clean the root surfaces of the teeth. A “regular” cleaning will NOT treat gum disease, since the roots cannot be accessed.

Potential Risks (usually temporary, but may be permanent)

        Increased gum recession

        Increased sensitivity to hot, cold and sweets

        Exposed roots may stain more readily

        Loose teeth may become looser, before tightening

        Pain, soreness, swelling, bruising, infection and/or bleeding

        Numbness is some tissues or teeth

INFORMED CONSENT FOR ZOOM!® TOOTH WHITENING TREATMENT

INTRODUCTION

 

This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching”) of my teeth.

 

DESCRIPTION OF THE PROCEDURE

Zoom! in-office tooth whitening is a procedure designed to lighten the color of my teeth using a

combination of a hydrogen peroxide gel and a specially designed ultraviolet lamp. The Zoom!

treatment involves using the gel and lamp in conjunction with each other to produce maximum

whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the Zoom! lamp for three (3), 15-minute sessions. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e., my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to either the gel or light. Lip balm (SPF rating: 30+) may also be applied as needed and I will be provided an ultraviolet light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

 

ALTERNATIVE TREATMENTS

I understand I may decide not to have the Zoom! treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include:

Whitening Toothpastes/Gels Other In-office Whitening Treatments Take-Home Whitening Kits

 

COST

I understand that the cost of my Zoom! treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my Zoom! treatment.

 

RISKS OF CONSENT FOR TREATMENT

I also understand that Zoom! treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from Zoom! whitening treatments and significant whitening can be achieved in most cases. I understand that Zoom! whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative

 

Page 1 of 3 Patient’s Initials: ________

materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or and may not whiten at all. I understand that teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternatives. I understand that provisionals or temporaries made from acrylics may become discolored after exposure to Zoom! treatment.

I understand that Zoom! treatment is not recommended for pregnant or lactating women, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemotherapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. I understand that the Zoom! Lamp emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing Zoom! treatment.

 

 I understand that the results of my Zoom! Treatment cannot be guaranteed. I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the Zoom! whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:

Tooth Sensitivity/Pain – During the first 24 hours after Zoom! treatment, some patients can

experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a Zoom! treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after Zoom! treatment.

 

Gum/Lip/Cheek Inflammation – Whitening may cause inflammation of your gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel or the ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or ultraviolet light.

 

Dry/Chapped Lips – The Zoom! treatment involves three, 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E cream.

 

Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the Zoom! treatment.

 

Page 2 of 3 Patient’s Initials: ________

 

Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my Zoom! treatment.

 

Root Resorption – This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures.

 

Relapse – After the Zoom! treatment, it is natural for the teeth that underwent the Zoom! treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the Zoom! treatment. I understand that the results of the Zoom! treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth. The safety, efficacy, potential complications and risks of Zoom! treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of Zoom! treatment, the list of complications in this form is incomplete. The basic procedures of Zoom! treatment and the advantages and disadvantages, risks and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction. In signing this informed consent I am stating I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the Zoom! treatment and that I agree to undergo the treatment as described by my dentist.

I hereby give permission to Vineyard Dental to surgically place DENTAL IMPLANT(S) and such additional procedures as are considered necessary on the basis of findings during the course of said treatment.

I have been informed of alternative treatment options, benefits and possible risks and after the dentist’s explanation, I have chosen said treatment.

I understand there are various inherent or potential risks that can occur as a result of said procedure despite all efforts to the contrary which include but are not limited to:

1. pain, swelling, bleeding, and/or bruising which may require further treatment
2. changes in occlusion (biting) and/or damage to existing restoration which may require replacement
3. stiffness of the nearby muscles or cramps in the jaw muscles
4. it might be hard to open my mouth for several days. This might be from swelling and muscle soreness, or from stress on the jaw joints (TMJ)
5. damage to nearby teeth during said procedure that may require additional treatment or even result in tooth loss
6. an infection after said procedure which may require additional treatment or cause loss of the implant
7. stretching of the corners of the mouth that might cause cracking and bruising and might heal slowly
8. drug reactions and side effects to any medications or materials used in said procedure
9. during the surgery, pieces of bone, synthetic bone or synthetic membranes may be placed which may become infected or devitalized and require antibiotics or additional surgery
10. post-operative bleeding or infection that may require treatment
11. involvement of the nerve within the lower jaw resulting in temporary (but possible permanent) loss of taste, tingling and/or numbness in the lip, chin, tongue, gums, cheeks, and teeth

 

1. the jaw may break and require additional surgical treatment for repair
2. the use of other materials such as synthetic membranes that might require removal at a later date
3. bone loss around implants and/or adjacent teeth
4. fracture of the implant or restorative parts
5. loss of an implant or implants
6. aspiration and/or swallowing of foreign objects
7. involvement of the sinus of the upper jaw requiring possible surgery for repair at a future date

I understand that my gum tissue will be opened to expose the bone, and one or more implants will be threaded into holes made in the bone. The implants will be the support for one or more missing tooth replacements to hold a crown, bridge, partial denture or complete denture. The doctor has explained the procedure to me.

Sometimes dental implants remain covered by the gum tissue during the initial healing period. If the implant is covered by gum tissue, it will have to be surgically uncovered before it can be restored by the dentist. Sometimes dental implants are left exposed through the gum tissue when placed. Gum tissue grafting or trimming may be necessary before or after restoration by the dentist.

No one has promised how long the implants will last. I have been told that once the implant is placed, I need to follow through with the entire treatment plan and finish it within the time period that is set by my doctors. If this is not done, the implants may fail.

If my doctor finds a different condition than expected and feels that a different surgery or more surgery needs to be done, I agree to have it done.

I am aware the practice of dentistry is not an exact science and acknowledge that no promises or guarantees of results have been made nor are expected. I have read and understand the above and give my consent to surgery. I have given a complete and truthful medical history, including all medicines drug use, pregnancy, etc. 

I understand that bone gaffing and barrier membrane procedures include inherent risks such as but not limited to the following:

1. Pain. Some discomfort is inherent in any oral surgery procedure. Grafting with materials that do not have to be harvested from your body are less painful because they do not require a donor site surgery. If the necessary bone is taken from your chin or wisdom tooth area in the back of your mouth there will be more pain. It can be largely controlled with pain medications.

 

2. Infection. No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile oral environment, for infections to occur postoperatively. At times, these may be of a serious nature. Should severe swelling occur, particularly accompanied with fever or malaise, professional attention should be received as soon as possible.

 

3. Bleeding, bruising, and swelling. Some moderate bleeding may last several hours. If profuse, you must contact us as soon as possible. Some swelling is normal, but if severe, you should notify us. Swelling usually starts to subside after about 48 hours. Bruises may persist for a week or so.

 

4. Loss of all or part of the graft. Success with bone and membrane grafting is high. Nevertheless, it is possible that the graft could fail. A block bone graft taken from somewhere else in your mouth may not adhere or could become infected. Despite meticulous surgery, particulate bone graft material can migrate out of the surgery site and be lost. A membrane graft could start to dislodge, If so, the doctor should he notified. Your compliance is essential to assure success.

 

5. Types of graft material. Some bone graft and membrane material commonly used are derived from human or other mammal sources. These grafts are thoroughly purified by different means to be free from contaminants. Signing this consent form gives your approval for the doctor to use such materials according to his knowledge and clinical judgment for your situation.

 

6. Injury to nerves. This would include injuries causing numbness of the lips; the tongue; any tissues of the mouth; and/or cheeks or face. This numbness which could occur, may be of a temporary nature, lasting a few days, a few weeks, a few months, or could possibly be permanent, and could be the result of surgical procedures or anesthetic administration.

 

7. Sinus involvement. In some cases, the root tips of upper teeth lie in close proximity to the maxillary sinus. Occasionally, with extractions and/or grafting near the sinus, the sinus can become involved. If this happens, you will need to take special medications. Should sinus penetration occur, it maybe necessary to later have the sinus surgically closed.

 

8. It is your responsibility to seek attention should any undue circumstances occur post-operatively and you should diligently follow any pre-operative and post-operative instructions.

Informed Consent: As a patient, I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of harm, if any, which maybe 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 my recovery and results of the treatment to be rendered to me. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. Richard Perez and his associates to render any treatment necessary or advisable to my dental conditions, including any and all anesthetics and/or medications.

 This treatment is an alternative procedure for patients who cannot tolerate CPAP and or Mandibular Advancement Devices.  Nightlase has been found to be a therapy that is beneficial in reducing snoring and OSA or its side effects by opening the airway. 

Type of Dental Intervention:

Erbium: Yag Laser non ablative (non cutting) treatment of the intra-oral mucosa , lips and peri-oral area.

Procedures and Protocol:

• Treatment Consent
• Photo / Video Consent     
• Pre-op Photos                    
• Fill out Pre-treatment evaluation
• Laser treatment (Approx. 30 min.)
• 2 or more repetitions of Laser treatment -3 weeks
• Post operative photos

1. Procedure:

The intra-oral use of Erbium: Yag Laser.

Post operatively; with Smoothlase , you may feel a sensation similar to a mild  irritation  or dryness for a day or two.  With Liplase, you may experience surface peeling of the lips.

Benefits:

1. No injections / needles
2. No facial redness or scabbing
3. No down time or pain
4. Natural smoothing of lines and wrinkles, improvement in tissue tone for a more youthful appearance.
5. Fuller , plumper and rejuvenated lips

Unusual Occurances:

As with any form of medical or dental treatment, unusual occurances can and do happen.  Mouth sores, muscle spasms and sore jaw muscles are all possible occurances.  Most of these complications and unusual occurances are infrequent. Additional medical and dental risks that have not been mentioned may occur.  Good communication is essential for the best treatment results.  Please call or come to the office if you have any questions or problems regarding treatment.

Unusual Occurances:

As with any form of medical or dental treatment, unusual occurrences can and do happen.  Mouth sores, muscle spasms and sore jaw muscles are all possible occurrences.

Botox® Post- Treatment Instructions

 The guidelines to follow post treatment have been followed for years, and are still employed today to prevent the possible side effect of ptosis (drooping of the eyelids). These measures should minimize the possibility of ptosis.

• No straining, heavy lifting, vigorous exercise for 3-4 hours following treatment. It is known that it takes the toxin approximately 2 hours to bind itself to the nerve to start its work, and because we do not want to increase circulation to that area to wash away the Botox® from where it was injected.
• Avoid manipulation of area for 3-4 hours following treatment (For the same reasons listed above.) This includes not doing a facial, peel, or micro-dermabrasion after treatment with Botox®. A facial, peel or micro-dermabrasion can be done in the same appointment only if they are done before the Botox®.
• Facial exercises in the injected areas is recommended for 1-hour following treatment. This is to stimulate the binding of the toxin only to the localized area.
• It can take 2-10 days to take full effect. It is recommended that the patient contact the office no later than 2 weeks after treatment if desired effect was not achieved and no sooner to give the toxin time to work. 

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 that have been traditionally used, such as silver amalgam or gold, may entail certain risks. There is the possibility of failure to achieve the desired or expected results. I agree to assume those risks that may occur, even if care and diligence is exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure of the filling associated with, but not limited to, the following:

1.       Sensitivity of teeth

Often after preparation of teeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. The sensitivity can be mild or severe. The sensitivity can last only for a short period of time or last for much longer periods of time. If such sensitivity is persistent or lasts for an extended period of time, I will notify the dentist because this can be a sign of more serious problems.

2.        Risk of fracture

Inherent in the placement or replacement of any restoration, is the possibility of the creation of small fracture lines in the tooth structure. Sometimes these fractures are not apparent at the time of removal of the tooth structure and/or the previous fillings and placement or replacement, but they can appear at a later time.

3.       Necessity for root canal therapy

When fillings are placed or replaced, the preparation of the teeth often requires the removal of tooth structures adequate to ensure 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 often 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 that can occur is usually temporary, but in rare instances it could be permanent.

5.       Aesthetics or appearance

When a composite filling is placed, effort will be made to closely approximate the appearance of natural tooth color. However, because many factors affect the shades of teeth, it may not be possible to exactly match the tooth coloration. Also, the shade of the composite fillings can change over time because of a variety of factors including mouth fluids, foods, smoking, etc. The dentist has no control over these factors.

6.        Breakage, dislodgement or bond failure

Because of extreme masticatory (chewing) pressures or other traumatic forces, it is possible for composite resin fillings or aesthetic restorations bonded with composite resins, to be dislodged or fractured. The resin-enamel bond can 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 the subsequent replacement with composite fillings will improve, alleviate or prevent any current or future health conditions.

Informed consent

I understand that it is my responsibility to notify Vineyard Dental 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 voluntarily accept any and all possible risks, including the risk of substantial harm, if any, that may be associated with any phase of this treatment in hopes of obtaining

the desired outcome. By signing this document, I authorize Dr. Perez and his associates to render any services deemed necessary or advisable in the treatment of my dental condition, including the prescribing and administration of any medically necessary anesthetic agents and/or medications.

Informed Consent CBCT Scan

 A CBCT Scan, also known as Cone Beam Computed Tomography, is an x-ray technique that produces 3D images of your skull that allows visualization of internal in cross section rather than as overlapping images typically produced by conventional x-ray

 

2. Advantages of a CBCT Scan over conventional x-rays: A conventional x-ray of your mouth limits your dentist to a two-dimensional or 2D visualization. Diagnosis and treatment planning can require a more complete understanding of complex three-dimensional or 3D anatomy. The CBCT scan enhances your dentist’s ability to see what needs to be done before treatment is

 

3. Radiation: CBCT scans, like conventional x-rays, expose you to radiation. The dose of radiation used for CBCT examinations is carefully controlled to ensure the smallest possible amount is used that will still give a useful result. The dosage per scan is equivalent to 2 regular dental x-rays. However, all radiation exposure is linked with a slightly higher risk of developing cancer. The advantages of the CBCT scan outweigh this

 

4. Pregnancy: Women who are pregnant should not undergo a CBCT scan due to the potential danger to the fetus. Please tell the dentist if you are pregnant or planning to become

 

5. CBCT scans image the entire head and most of the neck. As dentists, we evaluate teeth, jaws and surrounding bone, using the CBCT for those limited purposes. Our training and dental license does not provide for evaluation and diagnosing outside of those areas. However, since CBCT imaging can cover a broader area we offer you the opportunity to have your CBCT scan ready by a radiologist trained to evaluate and diagnose a broader area. CBCT imaging may show evidence of disease of the cervical spine, skull or arteries. At your request, we will send your CBCT scan to a radiologist for evaluation. The cost for this service is $95, which may or may not be covered by your insurance. Please initial below to indicate whether or not you would like to have your CBCT scan read by a radiologist.

 

             Yes, I would like to have my CBCT scan read by a radiologist and I understand that I am responsible for additional cost of $95.

 

             No, I understand the risks and benefits of having my CBCT scan read and interpreted by a radiologist, however I knowingly decline the referral. If, at a later date, I decide I would like to have this service, I understand that I can contact the office and request this service.

 

PLEASE DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT, UNDERSTAND IT, AND AGREE TO ACCEPT THE RISKS AND ADANTAGES NOTED.

 

I,                                                                                                      being 18 years or older, certify that I have ready the above statement. I understand the procedure to be used and its benefits, risks and alternatives. I have been given the opportunity to have my questions answered and accept the risks of the CBCT scanning procedure as described above. I therefore give my consent to have Dr. Perez or a designated trained staff member perform a CBCT Scan.

 

Triazolam (Halcion), although usually prescribed as a sleeping pill, is a medication that can greatly minimize anxiety that may be associated with going to the dentist. In a relaxed state, you will be able to communicate with the dentist while treatment is being performed. Even though it is safe, effective, and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations.

________ NO EATING 6 HOURS PRIOR TO APPOINTMENT. YOU MAY DRINK A SMALL

                 AMOUNT WHEN TAKING THE MEDICATION. ABSOLUTELY NO CAFFFIENE!

 ________ WEAR COMFORTABLE, NON-RESTRICTING CLOTHING

________ PAPERWORK & FINANCIALS: This consent form and the dental treatment consent form      should be signed before you take the medication. They are invalid if signed after you take the pills.

________ NO DRIVING OR OPERATING MACHINERY: The onset of Triazolam 15 to 30 min. Do not drive after you have taken the medication. The peak effect occurs between 1 and 2 hours. After that it starts wearing off and most people feel normal after 6-8 hours. For safety reasons and because people react differently, you should not drive or operate machinery the remainder of the day. Wait until tomorrow!

 ________ MEDICATION SHOULD BE BROUGHT TO YOUR APPOINTMENT

 ________THE DAY OF THE PROCEDURE, YOU MUST HAVE A CAREGIVER WITH YOU FOR   THE REMAINDER OF THE DAY.

________ DO NOT BRING VALUABLES OR WEAR JEWELRY TO YOUR APPOINTMENT

 ________ NO CHEWING GUM OR STIMULATING ACTIVITY DURING THE FIRST HOUR

 

1. This medication should not be used if:
   1. you are hypersensitive to benzodiazepines (Valium, Ativan, Versed, etc.)
   2. you are pregnant or breast feeding
   3. you have liver or kidney disease

 

Tell the doctor if you are taking the following medication as they can adversely interact with Triazolam: Nefazodone (serzone); Cimetidine (Tagamet, Tagamet HB, Novocimetine, or Peptol); Levodopa (Dopar or Larodopa) for Parkinson’s disease; antihistamines (such as Benedryl and Biaxin, or Sporanox); HIV drugs Indinavir and Nelfinovir; and Alcohol. Of course, taking recreational / illicit drugs can also cause untoward reactions.

 

1. Side effects may include light-headedness, headache, dizziness, visual disturbances, amnesia, and nausea. In some people, oral Triazolam may not work as desired.
2. Smokers will probably notice a decrease in the medications ability to achieve desired results.
3. Nitrous oxide (laughing gas) may be used in conjunction with Triazolam and a local anesthetic.
4. Eating food or intake of caffeine can make absorption into your system unpredictable.
5. On the way home form the dentist; your seat in the car should be in the reclined position. When at home, lie down with your head slightly elevated. Rest comfortably until the medication has worn off, usually within 6-8 hours. 

 

I understand these considerations and am willing to abide by the conditions stated above. I have had an opportunity to ask questions and have them answered to my satisfaction.

I, _____________________________________, understand that the patient is being released to my care.  I understand that patient will need to be monitored for 6 hours following the procedure and is not to be left alone for 6 hours following the procedure.  I understand that patient will need to drink plenty of fluids and that I am to call with any questions or if further instruction is needed.

Caregiver: ________________________________________________   Date:  ______________________

1. I accept and understand that Nitrous Oxide is commonly called laughing gas and provides relaxation. I understand that I (or my child) will be awake, fully conscious, aware of my surroundings, and able to respond rationally to questions and directions.

 

2. I accept and understand that Nitrous Oxide is an elective procedure and not required to provide the necessary dental treatment. I am aware that the alternative to completing the necessary treatment with Nitrous Oxide is to use local anesthetic ONLY.

 

3. Please advise the doctor and staff of your complete medical history, including any surgeries. Advise them of any changes in your medical history including if you or your child has a cold, upper respiratory infection, asthma, or difficulty breathing, this may affect how well the nitrous oxide will work.

 

4. Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. Local anesthesia will also be required for most procedures.

 

5. I have been advised of the possible complications associated with Nitrous Oxide. They include, but are not limited to:
6. Nausea and vomiting: This is the most frequent of the side effects of nitrous oxide sedation but its frequency is still quite low.  In order to use nitrous oxide sedation, you (or your child) must not have eaten or drank anything for the 6 hours prior to the procedure.  For this reason your appointment will be first thing in the morning.

 

1. Temporary tingling in the fingers, toes, cheeks, lips, tongue and head or neck area

 

1. Temporary warm feeling throughout the body with accompanying flushing/ blushing.

 

1. Temporary detachment or “out of body” sensation.

 

1. Temporary sluggishness in motion and/or speech.

 

1. Shivering – usually at the end of the procedure.

 

6. Nitrous oxide sedation is very effective for many people, however; some people may not like the feeling it produces, or it may produce increased activity in some people, at which time you or the dentist may decide to discontinue nitrous oxide sedation.

 

7. For some people nitrous oxide sedation may not calm them adequately to allow a dental procedure to be done. These people may require referral for other sedation techniques.

 

I hereby certify that I understand this authorization and the reasons for the above named sedative procedure and its associated risks.  I am aware that the practice of dentistry is not an exact science.  I acknowledge that every effort will be made in my (or my child’s) behalf for a positive outcome from sedation, but no guarantees have been made as to the result of the procedure authorized above.

I hereby give permission to Vineyard Dental to perform TOOTH EXTRACTION(S) and such additional procedures as are considered necessary on the basis of findings during the course of said treatment.

I have been informed of alternative treatment options, benefits and possible risks and after the dentist’s explanation, I have chosen said treatment.

I understand there are various inherent or potential risks that can occur as a result of said procedure(s) despite all efforts to the contrary which include but are not limited to:

1. pain, swelling, bleeding, sensitivity, infection and/or bruising which may require additional treatment
2. changes in occlusion (biting), jaw muscle cramps and/or damage to existing restoration which may require replacement
3. damage to nearby teeth during said procedure that may require additional treatment
4. drug reactions and side effects
5. post-operative bleeding or infection that may require additional treatment
6. involvement of the nerve within the lower jaw resulting in temporary (but possible permanent) tingling and/or numbness in the lip, chin, tongue, gums, cheeks and teeth
7. stiffness of the nearby muscles
8. root tips may fracture and be left in place or could be displaced into the sinuses and/or spaces nearby requiring additional surgery
9. aspiration and/or swallowing of foreign objects
10. delayed healing (dry socket) necessitating additional post-operative care
11. necessary removal of bone during tooth extraction.
12. involvement of the sinus of the upper jaw requiring possible surgery for repair at a future date.

I understand that I should notify the dentist if any of these symptoms are present for more than 48 hours.

I understand that the administration of anesthesia and/or medications carry certain inherent risks, such as, but not limited to:

1. drug interactions and/or side effects that may cause drowsiness and lack of coordination
2. bruising and/or numbness including the sites of the injection
3. antibiotics may inhibit the effects of birth control pills and other methods of contraception must be utilized during the treatment period

I further understand that this procedure(s) can also be performed by a specialist and prefer that this treatment be rendered in this office by a general dentist.

The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure. I may ask the attending dentist for a more complete explanation.

This is my consent for said procedure(s), anesthetics and x-rays to be taken.

I hereby acknowledge I have completely read and understand the forgoing; have been given the opportunity to discuss this form and question the dentist concerning the nature of treatment, the inherent risks of the treatment, and the alternatives to this treatment, and have been given satisfactory answers and agree to proceed with recommended procedure(s). I am aware the practice of dentistry is not an exact science and acknowledge that no promises or guarantees of results have been made nor are expected.

This consent form does not encompass the entire discussion I had with the dentist regarding the proposed treatment

Informed Consent for NightLase® Laser Snoring and Sleep Apnea Reduction

Information:

You have a significant snoring issue and if you have been diagnosed with Obstructive Sleep Apnea you either cannot tolerate or choose not to tolerate CPAP or a Mandibular Advancement Device, or are choosing to use this treatment in conjunction with other treatments as a co-therapy. If you do not have a previous diagnosis, we have reviewed with you the medical disorders that may be related such as high blood pressure, weight gain, hormone imbalances, stroke, cancer, and coronary artery disease to name a few. If appropriate we have recommended that you seek medical care for screening for OSA with your medical practitioner/sleep doctor.

Purpose:

This treatment is an alternative procedure for patients who cannot tolerate CPAP and or Mandibular Advancement Devices. Or, has been recommended as a co-therapy/adjunct therapy. NightLase® has been found to be a therapy that is beneficial in reducing snoring and OSA or its side effects by opening the airway. Studies show that NightLase® can reduce snoring by 50% on average. 95.2% of people state improvement in snoring and 57.1% reported significant improvement in snoring after treatment. (Journal of the Laser and Health Academy ISSN 1855-9913 Vol 2013, No.1). CBCT analysis shows an average of 20-22% increase in airway volume. (Evaluation of a non-ablative Er:YAG laser procedure to increase the oropharyngeal airway volume: A pilot study. ISSN: 205B-5314.)

Type of Dental Intervention:

Erbium: Yag Laser non ablative (non-cutting) treatment of the soft palate and surrounding area.

Procedure and Protocol:

1. Treatment Consent
2. Photo/Video Consent
3. Pre- Op Photos
4. Fill out pre-treatment evaluation
5. Laser treatment ( 30-60 min)
6. 3-4 or more repetitions of laser treatment 21 days apart, or as recommended by Dr. Perez
7. Post Op Photos

            A: Unfamiliar Procedure

 The intra-oral use of Erbium: Yag Laser.

 Post operatively; you may feel a sensation similar to a mild throat irritation for a day or two.

B: Duration

Treatment will consist of three+, 30-60 min sessions 21 days apart.

C: Risks

There are no risks other than that you may not perceive an improvement in your symptoms.

 Possible Benefits:

•  Improved Sleep Quality
•  Reduced Fatigue
•  Weight Loss
•  Happier Spouse/Family
•  Increase in Airway Volume
•  Reduction in Sleep Apnea
•  Improved Nasal Breathing
•  Postural Changes

Length of Treatment

The NightLase® treatment is strictly a therapy to help maintain a more open airway during sleep and daytime hours. It does not cure snoring or sleep apnea. Due to patient variation the treatment may last from 6-12 months and in most cases requires some re-treatment/maintenance. Over time it is possible that snoring can develop into sleep apnea. Sleep apnea may also become worse for many reasons (weight gain, muscle tone gets weaker as we age, hormonal imbalances, pregnancy, etc.) Therefore, it is important to be screened yearly. If unusual symptoms occur, you are advised to schedule an office visit to evaluate the situation. Individuals that have been diagnosed with having sleep apnea may notice that after NightLase® treatment they feel more refreshed and alert during the day. This is only subjective evidence of improvement of OSA and may be misleading. The only way to accurately measure whether the NightLase® treatment has assisted in keeping oxygen levels sufficiently high to prevent abnormal heart rhythms and other problems is to be retested with a sleep study that is read by a board certified sleep doctor. It is recommended that you wait 60 days after the last treatment before re-testing for sleep apnea or snoring as it can take this long for tissues to fully respond and to see optimal results.

Confidentiality:

All data will be kept confident, only the results will be tabulated or research according to standard protocols.

Risk to Refuse of Withdraw:

You have the right to withdraw before completion of the treatment. Premature withdrawal from treatment and/or lack of compliance will reduce the maximum benefit of treatment outcome and you may not experience any benefit.

Alternate Treatment

Other accepted treatments for sleep disordered breathing (such as snoring and sleep apnea) include behavior modifications, weight loss, hormonal therapy, myofunctional therapy/frenectomy, surgical procedures, and CPAP appliance/oral appliances. You have chosen NightLase® therapy to treat your particular problem and are aware that it may not be completely effective or as effective for you if not used in conjunction with other treatments.

Pre-Op Recommendations:

• Stay hydrated: Drink 1/2 body weight in ounces 1 week prior to treatment.
• Avoid excessive alcohol consumption 2-3 days before treatment and avoid smoking cigarettes or marijuana the day of treatment.
• Download Snorelab on smart phone and record 3 nights with no intervention, and 3 nights using nose cones, breathe right strips, or mouth tape. Please email results to drp@perezsmiles.com prior to procedure date. Failure to do this could result in postponing of treatment or alteration of recommended treatment plan.

Usual Occurrences/ Post Op Recommendations:

During the procedure most people feel slight warming or stinging of the tissue, this is normal and means that the treatment is working . Some people feel nothing at all. You may experience a burning smell (this is normal). Gagging may also happen during procedure as we may need to push tongue down to access appropriate tissues. Once we start the procedure you will not be allowed any bathroom breaks or opportunities to take a break (this is because the tissue needs to stay warm for the treatment to work,) so please take bathroom breaks BEFORE the start of treatment. It is important that you communicate if the treatment is too painful or you wish to discontinue treatment during procedure so we can accommodate your needs. After the procedure it is normal to feel a slight sore throat or dryness in the tissues. This should only last a few days and does not need further treatment. Coconut oil swishing/gargling can help with any discomfort. You may want to avoid hot and spicy/salty foods after treatment (your own discretion is advised.) Some patients report increased ability to breathe through nose. If this happens and the nose is still partially blocked due to inflammation or physical obstruction, nasal snoring may occur after treatment because of improvement in nasal breathing. Touch up treatments will be needed yearly or as recommended by Dr. Perez and the initial cost of treatment does NOT include touch up treatments. NightLase® is not a permanent treatment and because of this typically needs 1-2 treatments yearly to maintain results, or as indicated by Dr. Perez. Touch up treatment fees are not included in initial treatment pricing and are due at time of service.

Unusual Occurrences:

As with any form of medical or dental treatment, unusual occurrences can and do happen. Mouth sores, muscle spasms, and sore jaw muscles are all possible occurrences. Most of these occurrences are infrequent. Additional medical and dental risks that have not been mentioned may occur. Good communication before, during, and after treatment is essential for the best treatment results. Please call or come to the office if you have any questions of problems regarding treatment.

Part II: Certificate of Consent

I have read the foregoing information, or it has been read to me. I have had the opportunity to ask questions about it and any questions that I have asked have been answered to my satisfaction. I consent voluntarily and understand that I have the right to withdraw from the treatment at any time without in any way affecting my medical care. I consent to the taking of photographs, videos, and any necessary x-rays/exams before, during and after treatment, and their use in scientific papers, demonstrations or discussions of the procedures in social media, print and online. I recognize that my treatment will not be as successful if I do not complete the appropriate number of treatments in the time recommended by Dr. Perez. I recognize that this is a cosmetic procedure and may alter my cosmetic appearance. I agree and understand that I am 100% responsible for financial arrangements and that payment for full treatment is needed prior to the start of treatment. Because results may vary, no refund will be given after completion of treatment. I understand that this treatment will most likely NOT be covered my insurance and I am prepared to pay for treatment out of pocket.

I hereby give permission to Vineyard Dental to perform ROOT CANAL THERAPY and such additional procedures as are considered necessary on the basis of findings during the course of said treatment.

I have been informed of alternative treatment options, benefits and possible risks and after the dentist’s explanation, I have chosen said treatment.

I understand there are various inherent or potential risks that can occur as a result of said procedure(s) despite all efforts to the contrary which include but are not limited to:

1. pain, swelling, bleeding, sensitivity, infection and/or bruising which may require additional treatment
2. changes in occlusion (biting), jaw muscle cramps and/or damage to existing restoration which may require replacement
3. damage to nearby teeth during said procedure that may require additional treatment
4. drug reactions and side effects
5. post-operative bleeding or infection that may require additional treatment
6. involvement of the nerve within the lower jaw resulting in temporary (but possible permanent) tingling and/or numbness in the lip, chin, tongue, gums, cheeks and teeth
7. referred pain to ear, neck and head; delayed healing; sinus perforation
8. treatment failure; complications resulting from the use of dental instruments (broken instrument, perforation of tooth, root and/or sinus); discoloration of the face
9. additional treatment may be necessary
10. drainage

I understand that I should notify the dentist if any of these symptoms are present for more than 48 hours.

I understand that the administration of anesthesia and/or medications carry certain inherent risks, such as, but not limited to:

1. drug interactions and/or side effects that may cause drowsiness and lack of coordination
2. bruising and/or numbness including the sites of the injection
3. antibiotics may inhibit the effects of birth control pills and other methods of contraception must be utilized during the treatment period

I understand root canal therapy is a procedure to retain a tooth which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require additional treatment, surgery or even extraction.

I also understand root canal therapy is a filling of the internal canal of the tooth and that a final outside restoration (usually including a build-up and crown) will be necessary following root canal treatment. Since the blood supply is removed from the tooth, it has a tendency to become more brittle and may discolor.

I understand that a series of appointments will be necessary to complete the root canal therapy, as well as additional appointments for the final restoration.

I further understand that this procedure(s) can also be performed by a specialist and prefer that this treatment be rendered in this office by a general dentist.

The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure. I may ask the attending dentist for a more complete explanation.

This is my consent for said procedure(s), anesthetics and x-rays to be taken.

I hereby acknowledge I have completely read and understand the forgoing; have been given the opportunity to discuss this form and question the dentist concerning the nature of treatment, the inherent risks of the treatment, and the alternatives to this treatment, and have been given satisfactory answers and agree to proceed with recommended procedure(s). I am aware the practice of dentistry is not an exact science and acknowledge that no promises or guarantees of results have been made nor are expected.

This consent form does not encompass the entire discussion I had with the dentist regarding the proposed treatment.

Consent for Night Guard/Bite Splint
What is a night guard or bite splint and its benefits?
A night guard or bite splint (referred to as a splint) is an appliance made out of acrylic that fits to either the
upper or lower arch of teeth. The purpose is to keep the teeth from biting into one another. This is important if
the patient has a clenching or grinding habit that is wearing down the teeth. It is also used to reduce the
amount of activity in the chewing muscles. If these muscles are allowed to “rest” then symptoms such as jaw
joint pain, muscle pain and headaches may be reduced or eliminated. In this more relaxed position the bite
can be analyzed to determine how the teeth should come together.
What are the risks?
1. Tolerating the splint: It should be expected that initially wearing a splint will feel odd. Most patients
adapt to it in a short amount of time. Others never do and give up trying to wear it. If that happens
then the patient forfeits the potential benefits of the splint. There is no refund for an inability to wear the
splint.
2. A different bite: Since the muscles, TMJ joint and teeth all work as a unit, if the muscles or TMJ
achieve a more relaxed and proper position it may result in the bite feeling different. That’s okay. The
teeth, fillings, and crowns will then need to be equilibrated (adjusted) to match with the new jaw position
3. TMJ symptoms: While wearing the splint the jaw is kept in a slightly open position. This may cause
TMJ soreness that involves the TMJ joint, muscles and surrounding structures. Ceasing the wearing of
the splint will reverse these symptoms.
4. Referral to a specialist: Due to the multifactorial causes of TMJ problems, a TMJ specialist, physical
therapist or other health care professional may be needed to treat your condition.
What are my alternatives?
1. See a TMJ specialist: Since TMJ problems are complex, you may choose to see a TMJ specialist for
initial treatment.
2. Anterior Discluding Appliance: In an effort to keep teeth from biting a smaller appliance may be used
such as an NTI device. This too has its risks and benefits. If this device was more applicable to your
condition, the doctor would have prescribed it instead.
3. No Treatment: Always an option but it too has its risks and benefits.
INFORMED CONSENT: I can read and write English and have been given the opportunity to ask any
questions regarding the nature and purpose of the proposed treatment and have received answers to my
satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, which
may be associated with any phase of this treatment in hopes of obtaining the desired result. The fees 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 the doctors and staff at Cross Timbers Dental in rendering any services they deem
necessary or advisable to treat my dental conditions, including the administration and/or prescribing of any
anesthetic agents and/or medications.
Medications: Any medications dispensed or prescribed are the patient’s responsibility to understand before
taking. Medication inserts are available from our office upon request. Particular attention should be given to
possible allergic reactions, drug interactions with current medications and their specific side effects.
Guarantees: The practice of dentistry is not an exact science and no procedure is 100% successful. The
doctors and/or staff at Cross Timbers Dental have made no guarantees of a successful outcome.
Notifications: If a patient develops a problem it is the patient’s responsibility to notify the doctors and/or staff
of Cross Timbers Dental. Through this notification we will be able to act on the patient’s behalf. Attempts to
correct a problem may occur at our office or a referral to another health care practitioner may be warranted.