Dr. Mike Starkey, DDS
  The Sedation Dentistry Practice



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Informed Consent
for Fillings, crowns, bridges, onlays and inlays

I understand there are risks involved with restoring teeth. By restoring, I understand it to mean fillings, crowns, onlays, and bridges.

The risks include the need for root canal therapy after the work is completed. This is because the tooth worked on can be damaged by the drill or because the dental work was deep and close to the nerve.

Also sensitivity to hot and cold that could last for a long time after the work is done. Most of the time it is just for a few days. There could also be tenderness to bite and the bite may need to be adjusted.

When temporaries are needed they may fall off or may break, and sometimes they are swallowed accidentally. I will call the office if my temporary comes off so the staff may replace it for me.

Build ups are large fillings usually done instead of a crown for cost saving purposes or as a long term temporary. Build ups and fillings can be done on back teeth that have had root canal treatment. The dental profession is in agreement that crowns are required for such teeth.

For some restorations, crown lengthening may be required. It is usually before the restorative work but sometimes can be done afterwards. Crown lengthening is when the gum and sometimes the bone is reduced so that the crown or other restoration fits better and prevents gum problems.

Some patients may have TMJ problems, that is jaw joint problems from keeping their mouth open or from a change in the bite. Usually this is limited and rare.

I have been given options including doing nothing and I have been told the risks.

This is what I think Dr. Starkey will do for me:
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Patient signature ______________________________Date__________

Witness signature ______________________________

All of my questions have been answered for me and I choose to give Dr. Starkey to provide the above dental services for me.