1429 Sunset Blvd.
West Columbia, SC 29169


Consent for Treatment

TREATMENT TO BE PERFORMED/CHANGES IN TREATMENT PLAN. I understand that I am to have dental treatment performed as detailed in the treatment plan. During treatment, it may be necessary to change or add procedures because of conditions found while working on my teeth that were not discovered during the dental examination. I give Dr, Kenley J. Loftis, DMD, pemmissich to change the treatment plan as necessary.

ANESTHETICS AND MEDICATIONS. I understand that the dental anesthetics, nitrous oxide (laughing gas), antibiotics, pain medication, and other medication may.cansé allergic or other adverse reactions such as swelling, redness, itching, nausea, vomiting, dizziness, changes-in blood pressure, or rarely, anaphylactic shock. I have informed Dr. Kenley J. Loftis, DMD, of all medication that I’am currently taking as well as any know allergies to medications.

X-RAYS. I understand that x-rays are often necessary to properly diagnose many conditions in the mouth. Digital x-rays reduce radiation exposure to pationts by 70% over traditional film x-rays. Refusal to have x-rays taken when recommended may result in failure to diagnose significant dental or medical conditions in the mouth, and may result in the need for more extensive and expensive treatment in the furure.

CROWNS, FIXED BRIDGES, AND PORCELIN VENEERS. Once started, temporary or, veneers will be placed on the teeth while waiting for the permanent restoration to be retumed from the lab. It is essential the all patients return in a timely. manner to have the permanent restoration placed on the teeth. Crowns, bridges, and veneers typically lest for many years. However, porcelain will occasionally breek, which may result in the need to replace the restoration. Occasionally teeth may break underneath a crown or bridge, resulting in additional treatment.

DENTAL EXTRACTIONS, AND OTHER DENTAL SURGERIES. Alternatives to tooth extraction and options for replacing missing teeth have been explained to me. I authorized Dr. Kenley J. Loftis, DMD, to extract the teeth listed in my treatment plan. Possible complications of dental extractions and other dental surgeries include, but are not limited to pain, swelling, excessive bleeding, bruising, dry socket, exposed sinuses, bone fractures, and temporary or in very rare cases, permanent loss of feeling in the teeth, lip, tongue, or surrounding tissue.

FILLINGS. I understand that there may be occasional sensitivity or tenderness after placing a filling in a tooth. Occasionally during tooth preparation, crack or more extensive decay that was originally diagnosed may be discovered. This may require more extensive treatment such as crowns or root canal therapy to restore the tooth.

FULL AND PARTIAL DENTURE. Dentures will not chew as efficiently as natural teeth. Over time, the shape of your mouth changes, and the denture will become loose and may create sore sports in your mouth. Because of this, your denture will need to be relined from time to time. It may be necessary to use dental adhesive to help stabilize the denture in your mouth. Occasionally dentures may break and require repair or replacement. Dental implants have been explained to me as an alternative or additional treatment.

IMPLANTS. Dental implants are highly successful. However, from time to time they may fail to heal properly and require replacement or removal. Tobacco use, systemic diseases, or 2 weakened immune system may lower the chance of success for dental implants.

PERIODONTAL DISEASE. Periodontal disease is bacterial infection in the gums that may have few or no symptoms. Left untreated, it will cause loss of the supporting bone which holds the teeth in the mouth. This may eventually result in pain or swelling and/or tooth loss. Recent research shows that untreated gum disease increases home care. However depending on the severity of the disease, the effectiveness of home care, and other risks factors, no surgical treatment may not be sufficient to control periodontal disease and it may be necessary to refer you to a specialist (periodontal) for future treatment.

ROOT CANAL THERAPY. Although itis usually highly successfull, root canal therapy may not save & tooth. Complications leading to failure of root canal therspy include but are not limited to unseen fractures in the tooth, blocked canals, or extra canals. The tooth may be tender during treatment and may remain tender for some time after treatment. Occasionally an instrument used in treatment may fracture inside the tooth, lowering the chance of successful treatment. If root canal therapy fails, it may be necessary to refer you to a specialist (endodontist) for further treatment.

WHITENING. Tooth whitening will result in a considerable color change for the typical dental paticat. However, results may vary widely and some patients will see little change in tooth cplor, especially those patients with tetracycline stains. Bleaching may cause tooth sensitivity and/or irritation of the gum tissue which will subside when the treatment is discontinued.

AGREEMENT. I understand the recommended treatment for my condition, the risk of the treatment, any alternatives and their risks as well as the consequences of doing nothing. All fees have been explained to me and all of my questions have been answered. I have been given no guarantees with regards to this treatment.