Consent for Composite Bonding Veneers

I understand that the treatment of my dentition involves the placement of composite resin fillings. There is the possibility of failure to achieve the desired or expected results. I agree to assume those risks, even if my treating dentist exercises care and diligence in rendering this treatment. These risks include possible unsuccessful results and failure of the filling associated with, but not limited to, the following:

1. Sensitivity of teeth: Often, after preparing the teeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. The sensitivity can be mild or severe. In some cases, the sensitivity can last for longer periods. If such sensitivity is persistent or lasts for an extended time, I will notify the dentist because this can signify more serious problems.
2. Risk of fracture: In the placement or replacement of any restoration, the possibility of small fracture lines in the tooth structure is inherent. Sometimes these fractures are not apparent at the time of removal of the tooth structure and/or the previous fillings and placement or replacement, but they can appear later.
3. Aesthetics or appearance: While placing a composite filling, the dentist will attempt to approximate the appearance of natural tooth colour as much as possible. However, since many factors affect teeth shades, in some cases it may not be possible to match the tooth colouration exactly. Also, the shade of the composite fillings can change over time because of various factors, including mouth fluids, foods, smoking, etc. I understand I am at higher risk if I regularly drink tea, coffee, red wine or smoke. The dentist has no control over these factors. I also understand that polishing the filling may remove staining, but this is not always guaranteed. If stains cannot be removed, the only option will be to replace the filling entirely.
4. Breakage, dislodgement or bond failure: Composite resin fillings or bondings can be dislodged or fractured by traumatic forces, such as extreme masticatory (chewing) pressures. The resin-enamel bond can fail, resulting in leakage and recurrent decay. I understand and agree that the dentist has no control over these factors.
5. Composite bonding success rate varies depending on many factors, including but not limited to diet, chewing forces, and parafunctional habits, such as grinding, clenching, and nail-biting. Evidence suggests a 5-7 years longevity for composite bonding. During this period, small chips may arise and may need restoring.

Informed Consent

I understand that it is my responsibility to notify the dentist should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.

I have asked my questions regarding the nature and purpose of composite fillings and have received answers to my satisfaction.

I voluntarily accept all possible risks, including the risk of substantial harm that may be associated with any phase of this treatment in hopes of obtaining the desired outcome.

By signing this document, I authorize the dentist and any of his associates to render any services deemed necessary or advisable in my treatment, including the prescribing and administration of any medically necessary anaesthetic agents and/or medications.