Dental fillings informed consent

MM slash DD slash YYYY
Patient name:

Silver amalgam has been used for decades as a filling material for teeth and there are no proven scientific studies accepted by the Canadian & American Dental Association which supports the belief by some opponents to the material that there is a possibility, although unproven, that silver amalgam may have an effect on the general health of a person due to its mercury content (50%). However, silver amalgam continues to be endorsed by the CDA & ADA as an acceptable filling material. However, there is no scientific evidence that having satisfactory silver fillings removed will consistently result in improved health. In pregnant and lactating women, it is an accepted precaution in numerous countries to refrain from using silver filling materials for new fillings due to concern about possible developmental effects of mercury content in the fetus.

Disadvantages of silver fillings:

  • Silver amalgam is quite fragile until it has completely solidified. If it is necessary to avoid chewing on recently placed amalgam fillings for approximately 24 hours.
  • Occasionally shavings generated by placement or carving of silver amalgam fillings may work their way into the surrounding gum tissues and become lodged. Over an extended period of time gray spots or tattoos may become visible within the mouth. Over a period of time the tooth itself may assume a grey and darker appearance even in areas not immediately adjacent to the silver filling.
  • Posterior composite resin fillings, which are more aesthetic in appearance than some of the conventional materials, such as silver amalgam or gold, may entail certain risks. There is also the possibility of failure to achieve the results, which may be desired or expected.

Composite resin fillings offer two main advantages:

  • They are bonded to the components of the tooth, which may add additional strength to the tooth structure.
  • They are tooth colored and thus allow for a more esthetic restoration.

Disadvantages of posterior composite resin fillings:

  • Posterior composite resin fillings take more time, skill and effort to complete than amalgam (silver) restorations. Therefore, it may be necessary for the dentist to charge a higher fee for placing them.
  • Inherent in the placement of composite resin fillings is the potential for bond failure or fracture which may result in leakage and potential for rapid development of decay.

The risks include possible unsuccessful results and/or failure:

Necessity for Root Canal Therapy: When any type of fillings are placed or replaced, the preparation of the teeth for fillings often necessitates the removal of tooth structure 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 oftentimes is exhibited by extreme sensitivity or possible abscess, root canal treatment or extraction may be required.

Injury to the Nerves: In any type of dental work, 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 which could occur is usually temporary, but in rare instances could be permanent.

Aesthetics or Appearance: Aesthetics are not a consideration in the case of silver filling material. When composite materials are used, effort will be made to closely approximate the natural tooth color. However, due to the fact that there are many factors, which affect the shades of teeth, it may not be possible to exactly match the tooth coloration. Also, over a period of time, the composite fillings, because of mouth fluids, different foods eaten, smoking, etc. may cause the shade to change. The dentist has no control over these factors.

Breakage, dislodgement or bond failure: Due to extreme chewing pressures or other traumatic forces, it is possible for fillings to be dislodged or fractured resulting in leakage and recurrent decay. The dentist has no control over these factors.

Longevity of fillings, crowns, and bridges: There are many variables that determine "how long" fillings, 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 fillings, crowns and/or bridgework will last. Because crowns and bridges are statistically more reliable over a longer period of time than fillings, in the case of access restricted patients, consideration will be given to choosing a crown or bridge more often than a repair or filling involving the interproximal areas.

Regardless of which material is utilized, the teeth treated may remain sensitive or even possibly quite painful after completion of treatment. You may need an adjustment on the filling if the area feels uncomfortable or high. If the pain is severe or if extreme sensitivity persists for an extended period of time, please call the office immediately. I understand and agree to assume the risks which may occur even though care and diligence will be exercised by my treating dentist in rendering this treatment.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

MM slash DD slash YYYY