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Dental Treatments Consent


As the patient, I have the right to make decisions regarding my health care. My doctor can provide me with the necessary information, advice, alternative treatment options, etc. However, I must participate in the decision making process. This form will acknowledge my consent to the treatments recommended by my doctor. And I understand I may choose to have no treatment done, “to having no treatment done” is one of my alternative options. I understand I may need the following diagnosis or treatments. I hereby authorize Dr. Chen and/or her associate/s, hygienist/s, assistant/s to render these diagnosis/treatments on me.


  • X-ray/CT scan: Having a 2D/3D X-ray image/s is critical on diagnosing my dental conditions. One of the risks is radiation. Our office uses modern equipment, the amount of radiation you will be exposed to will be kept at minimum. It is approximately the equivalent to the exposure you would get from a few hours to a few days in the sun. While parts of your anatomy beyond your mouth and jaw may be evident from the scan, your dentist is not qualified to diagnose conditions that may be present in those areas, nor will your dentist be looking for any abnormal conditions other than those normally diagnosed by a dentist involving the area of the mouth and jaw. Therefore, the mere fact that other structures may be evident on the scan does not mean that they are being examined by a professional to determine whether they are normal. Your dentist is not a physician or a specialist qualified to make those determinations.

  • Medications/Anesthetics: This includes any medication my doctor will use or prescribe on me. I understand they can cause allergic reactions and may lead to redness, swelling of tissue, pain, vomiting, and/or anaphylactic shock. Administering of local injection for numbing can cause injury to the nerve. This may cause numbness of the lips; the tongue; any tissues of the mouth; and/or cheeks or face. This numbness which occurs may be of a temporary nature, lasting a few days, a few weeks, a few months, or permanently.

  • Change in treatment: 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. For example, a cavity can be deeper than what it shows on the X-ray, resulting in a change of the treatment from a filling to a root canal. I give my permission to my dentist to make any/all changes and additions as necessary.

  • Scaling & Root Planning (deep cleaning): This procedure treats gum disease. The inflammation of my gum and bone needs to be treated or I may lose my teeth. As a result of this treatment, the following may happen: gums will be more receded; portions of the roots will be exposed; teeth may be more sensitive; food may collect more easily between teeth; teeth may be looser. My body may have no response/improvement after this treatment. I need to follow up with my dentist 2-3 month after the initial treatment.    

  • Filling: We are a mercury-free office. We only offer our patients tooth-colored composite fillings. However, one of the disadvantages is sensitivity of a newly placed filling. The sensitivity will slowly go away by itself. If the cavity was very deep, my tooth may not respond to the filling. Then a root canal may be required. Certain spots on the teeth are hard to work on. The dental drill may injure to the surrounding hard/soft tissue. Fillings do not stay well on certain locations of the teeth (For example: on the edge/corner). If the filling chipped, I may consider alternative treatment such as a crown. Efforts will be made to closely approximate the natural tooth color/shape. However, due to the fact that there are many factors which affect the color/shape of teeth, it may not be possible to exactly restore the original appearance. Fillings do not last forever, over a period of time micro leakage can cause recurrent decay. The fillings will then need to be replaced. This is due to the mastication force, mouth fluids, diets, smoking, etc. My dentist has no control over these factors. 

  • Pulpotomy / Pulpectomy / Endodontic treatment: These are treatments to the nerve of the tooth. Pulpotomy (baby tooth root canal) is the removal of the never tissue in the crown part of the tooth, and leaving the remaining nerve in the roots alive. Pulpectomy is complete removal of nerve tissue from within the tooth. Endodontic treatment (root canal) is cleaning, shaping, & filling of the nerve space within the root of the tooth after pulpectomy. If the nerve of the tooth is irritated/exposed to the cavity on your tooth for a long time, your tooth may still be symptomatic after any of these treatments. After any of these treatments, the tooth will be weakened and more susceptible to fracture. This is due to the nature of the procedure and/or that the tooth injury or disease which necessitated the procedure. A filling/crown is needed to protect your remaining tooth structure, and is not part of the root canal treatment. There is no guarantee that root canal therapy will save my tooth. Complications can occur from the treatment and occasionally root canal filling material may extend through the tooth which does not necessarily effect the success of the treatment. I understand that endodontic files are very fine instruments and stresses from their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). In rare instances the tooth may need to be removed so I understand the tooth may be lost in spite of all efforts trying to save it.

  • Buildup with/without post: This is needed when little natural tooth structure remains. Your dentist needs to build up the shape of your tooth to finish the final restoration, usually a crown. Due to the extensive loss of tooth structure, this procedure may not work, and it may fall off with/without a crown. The risk of this procedure can lead the tooth to receive a root canal or an extraction. 

  • Inlay / Onlay / Crown / Bridge / Veneer: These are all Fixed Restorations (FR). The tooth needs to be trimmed to receive the final FR. Due to the trimming/the previous cavity on the tooth, it may exhibit sensitivity after the final cementation of the FR. Sometimes a root canal is needed on the tooth, and the access hole of the root canal has to be made through the FR. The FR can chip/break due to many factors: excessive chewing force, grinding teeth, etc. There are many variables that determine “how long” the FR can be expected to last. General health, good oral hygiene, regular 6 month dental checkups, diet/medication can affect the longevity of the FR. The only area on a tooth with a FR where decay can occur is at the edge/seam line, which is where the tooth and the FR meet (usually along the gum line), so be sure to brush & floss this area well. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth, especially on the teeth that are in the front. The final opportunity to make changes in my FR (shape & color) will be before cementation. It is also my responsibility to return for the permanent cementation within 21 days from tooth preparation. Excess delays may allow for tooth movement. This may necessitate a remake of the FR. I understand that there will be additional charges for remakes due to my delaying of permanent cementation. Prefabricated Stainless Steel Crowns (SSC) are meant to restore baby teeth only. 

  • Removal of teeth: Alternatives to removal have been explained to me (root canal therapy, periodontal surgery, etc.). I understand the risks involved in having teeth removed, some of which are: pain, swelling, spread of infection, dry socket, bruising on my face, injury to adjacent teeth, scar on gums, stress on jaw joints, fracture jaw/roots/bone/instruments, sinus involvement, injury to the nerve that cause loss of feeling/taste in my teeth, lips tongue and surrounding tissue. I understand that I may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my responsibility. 

  • Denture: I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty eating are some common problems. An immediate denture (placement of denture immediately after extractions) requires relines. A final hard reline will be needed and isn’t included in the denture fee. Fabricating partial dentures requires grinding/modification of my own remaining teeth. The materials used for fabrication of dentures can break. This does not mean the materials used were defective/poor quality. The oral tissues may exhibit allergic symptoms to the materials used in the construction of dentures.


I understand there are potential risks, complications, and side effects associated with any dental procedures. Although it’s impossible to list every one of them, I have been informed of some of the possible risks, complications, and side effects.

These could include but may not be limited to:


-Prolonged/Permanent numbness of chin/lip/cheek/gums/tongue/face

-Tissue discoloration                                       

-Injury to adjacent teeth

-Bruising of the face                                         

-Sinus penetration; Bone/jaw fractures

-Restricted ability to open/close                     

-Additional surgeries needed

-Stress on the jaw joints                                  

-Nose bleeding; Chronic/acute sinusitis

-Dental work failure                                          

-Contour change/Scar on gums; Gum recession


Although these risks may occur rarely, they do sometimes occur and cannot be predicted or prevented by the doctor preforming the procedure. These potential risks could result in the need to undergo additional dental/medical/surgical treatment, hospitalization, blood transfusions and very rarely, result in permanent disability or death.


Most procedures have good results, I understand that no guarantee has been made to me about the result of these procedures or the occurrence of any risk, complications, and side effects. 


Confirm consent: I certify that I have read or had read to me the contents on both side of this form. I confirm that I understand this form and the information contained here. I understand the potential risks and have decided to proceed with these procedures after considering the possibility of both known and unknown risks. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

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