Download Informed Consent – Cosmetic Porcelain Veneers

Informed Consent – Cosmetic Porcelain Veneers
INFORMED CONSENT FOR COSMETIC PORCELAIN VENEERS
I have been made aware of the condition of my tooth/teeth requiring fabrication of porcelain veneers in the opinion of my dentist:
Teeth #’s: ___________________________________________________________________________________________________________
Procedure
Cosmetic Porcelain Veneers are thin layers of porcelain that are placed on the front surfaces of teeth in order to change the appearance of your smile. Teeth
that are discolored, chipped, rotated, or spaced can be transformed with veneers. Porcelain veneers are fabricated at a laboratory by expert ceramists
from a model of the prepared teeth. Composite veneers are directly bonded on the teeth in your dentist’s office.
Alternative Treatment Options
Alternative treatment options may include composite resin veneer(s), porcelain crown(s), composite resin fillings, orthodontics (for slight alignment
correction with veneers), or no treatment at all.
Risks, Complications and Limitations
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It may be necessary to reduce or roughen the surface of the tooth to which the veneer(s) may be bonded. This preparation will be done as
conservatively as possible, but once this is done, the patient is committed to veneers or crowns for the duration of life. If the veneer covering
breaks or comes off, the uncovered tooth may become susceptible to decay if the veneer is not replaced in a timely manner.
Sensitivity of teeth: Through the process of modifying teeth to accept veneers, there is the possibility of the development of tooth sensitivity
which may last for days or months following tooth preparation. In most cases, this sensitivity will alleviate over time but in rare instances is
permanent.
Chipping, breaking or loosening of the veneer may occur any time following placement. Many factors may contribute to this happening such as:
chewing of excessively hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; failure of the bond between the veneer
and tooth; and other such conditions over which the dentist has no control.
Alteration in speech: Since the veneers may be wider and/or longer than the natural teeth they are covering, a difference in speech may be
evident. Many times the patient will adapt to the change and speech returns to normal very shortly after placement. The veneers may need to
be adjusted in order to alleviate problems with speech.
Esthetics/Appearance: Every attempt possible will be made to match and coordinate both the form and shade of veneers, which will be placed to
be cosmetically pleasing to the patient. However, there are some differences, which may exist between that which is natural and that which is
artificial making it impossible to have the shade and/or form perfectly match your natural dentition. Once veneers are bonded to place on the
teeth, should the patient desire any changes later a fee may be assessed to cover any extensive adjustments or remakes.
Longevity: It is impossible to place any specific time criteria on the length of time that veneers should last. Once the tooth structure is prepared
for veneer placement, the patient is committed to veneers for life. Should the veneers become damaged, leaky, or stained, they will need to be
replaced.
Veneers are susceptible to staining just like natural teeth. The veneers may need to be replaced if excessive staining, marginal leakage, or
chipping occurs. Stain inducing foods and drinks should be avoided.
An acrylic lab fabricated night guard may be indicated to help protect your veneers from damage due to night time clenching and grinding.
INFORMED CONSENT: I understand 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 have been informed of and am fully aware of all alternative treatment options. 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. I understand that the practice of dentistry is not an exact science and no procedure is 100% successful. The doctors and/or staff at
Advanced Dental Concepts will take every action to provide the highest level of care, but have made no guarantees of a successful outcome. If a problem
develops, it is my responsibility to notify the doctors and/or staff of Advanced Dental Concepts. Through this notification, Advanced Dental Concepts will be
able to act on my behalf. Attempts to correct a problem may occur at this office or a referral to another health care practitioner may be warranted. Any
medications dispensed or prescribed are my responsibility to understand before taking. Particular attention should be given to possible allergic reactions,
drug interactions with current medications and their specific side effects. I understand that antibiotics may interfere with birth control medication, and
further measures to prevent pregnancy may be necessary. The fees for proposed 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 Advanced Dental Concepts 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.
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Patient Name (Printed)
Date of Birth
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Patient (Parent/Guardian) Signature
Date
__________________________________________________/___________________________________________________________________________
Doctor/Staff Signature
Date
Advanced Dental Concepts
10780 Randolph Street  Crown Point, IN 46307
www.ADC4Smiles.com  [email protected]
(219)663-6878
Informed Consent – Cosmetic Porcelain Veneers
POST-OPERATIVE INSTRUCTIONS FOR COSMETIC PORCELAIN VENEERS
Do not eat for at least 2 hours or until the anesthesia has worn off.
Temporary Restorations:
Temporaries are acrylic or composite veneers that are placed on the prepared teeth for protection during the time the porcelain veneers
are constructed in the lab. A temporary serves several important purposes: it protects the exposed dentin to minimize sensitivity, prevents
the tooth from shifting, and last but not least, restores tooth contour and appearance. The temporary is placed with cement that is
designed to come off easily so avoid chewing sticky foods such as gum or taffy. Use your toothbrush to clean the temporary as you
normally do your natural teeth. You may also floss or, if there is more than one veneer and the temporaries are fused, you may need a
floss threader. To avoid loosening the temporary, it is best to pull the floss through the contact rather than pulling it down through the
contact.
If your temporary comes off between appointments, slip it back on and call our office so that we can recement it for you. A small amount
of denture adhesive placed inside the veneer can help to hold it in place in the interim.
Sensitivity:
Sensitivity, especially to cold, is common for a time following treatment.
For the first few days avoid extremely hot or cold foods and beverages. If your gums were recontoured during treatment they may be
tender after the anesthesia wears off. Rinsing with warm salt water by dissolving 1/2 teaspoon of salt in 8 oz. of warm water will help. An
analgesic such as Tylenol or Advil will also increase your level of comfort.
Your New Smile:
After the cementation of your porcelain veneers, it may take a few days to get used to the new veneers. Your bite and the way your teeth
come together may feel different, especially if we changed the length, shape and/or thickness of your teeth. If your bite feels unbalanced,
please be sure to call our office for an appointment to make an adjustment.
Home Care:
To maintain the veneers and your new smile, it is important to remember that the underlying teeth are still vulnerable to decay, especially
at the gum line where the tooth and veneer meet. It is important to resume regular brushing and flossing immediately. Daily home care
and regulating your intake of sugar-containing foods will increase the longevity of your new restorations.
For some patients that exhibit signs of clenching or grinding of their teeth, a custom, lab-fabricated, acrylic night guard may be
recommended in order to protect your veneers from chipping or cracking.
We truly hope that your satisfaction with your new smile will encourage you to tell your friends and family about
Advanced Dental Concepts. We promise to provide the same level of care and service for those that you refer to
our office.
Advanced Dental Concepts
10780 Randolph Street  Crown Point, IN 46307
www.ADC4Smiles.com  [email protected]
(219)663-6878