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 the 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:
1. Reduction of tooth structure: In order to replace decayed or otherwise traumatized teeth it
is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be
placed upon them. Tooth preparation will be done as conservatively as possible.
2. 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 required.
3. Local Anaesthesia: In order to reduce tooth structure without causing undue pain during the
procedure, it will be necessary to administer local anaesthetic. 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.
4. 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 severe. 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.
5. Risk of Further Treatment: 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 predetermined. 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.
6. 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 unless it
occurs soon after placement.
7. 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.
8. Aesthetics or appearance: Patients will be given the opportunity to observe the appearance
of crowns or bridges in their mouths prior to final cementation. 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.
9. Longevity of crowns and bridges : There are many variables that determine "how long"
crowns and bridges can be expected to last. Among these are some of the factors mentioned in
preceding paragraphs. 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.
10. Opening the Bite: In some cases, years of wear on the teeth will create a situation where
the patient over closes 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 breakage. If a night-guard 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 FOR CROWN & BRIDGE PROSTHETICS AND FOR FINAL CEMENTATION:
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. The
nature and type of material used in my crown(s) or bridgework, for example porcelain-fusedto-
metal, all porcelain, etc. has been explained to me.
By signing this form, I am freely giving my consent to allow and authorize Dr._______________(please write the name of the doctor below)
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 anaesthetics deemed necessary for my treatment.