I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Damage to adjacent teeth or tooth restorations.
3. Sensitivity of teeth.
4. Chipping, breaking or loosening of the veneer.
5. Injury to soft tissues adjacent to veneer due to bonding or bleaching agents.
6. Necessity for a more extensive restoration, such as a crown, than originally diagnosed.
7. Inability to exactly match tooth coloration.
8. Changes in the shade, aesthetics, and appearance of the restoration, which may occur over time.
9. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
10. Changes in speech (which are usually temporary).
11. Changes to the bite or position of the temporomandibular joint which may require further treatment or adjustment.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Damage to adjacent teeth or tooth restorations.
3. Necessity for root canal therapy due to injury of pulp tissue.
4. Breakage or dislodgement in buildup failure of restorative material.
5. Necessity for a more extensive restoration, such as a crown, than originally diagnosed, due to additional decay or unsupported tooth structure found during preparation.
6. Inability to exactly match tooth coloration.
7. Changes in the shade of the composite restoration over time as a result of the oral environment.
8. Sensitivity of teeth.
9. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Reduction of tooth structure.
2. Sensitivity of teeth.
3. Crown or bridge abutment teeth may require root canal treatment.
4. Breakage.
5. Uncomfortable or strange feelings, which is typically temporary. In limited situations, muscle soreness or tenderness of the jaw may persist following placement of the prosthesis.
6. Unsatisfactory aesthetics or appearance.
7. Unsatisfactory longevity of crowns and bridge.
8. As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection and/or bone infection. Bruising and/or swelling, delayed healing, restricted mouth opening for several days or weeks.
3. Damage to adjacent teeth or tooth restorations.
4. Possible involvement of the sinus cavity and creation of an opening from the mouth into the nasal or sinus cavity, which may require additional treatment or surgical repair at a later date.
5. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia, resulting in altered or loss sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve over time, but in some cases, may be permanent.
6. Inability to place the implant due to the local anatomy or implant failure.
7. Discoloration and appearance changes of the gum tissue or unsatisfactory cosmetic result.
8. Bone loss around the implant(s) and/or adjacent teeth, which may result in loss of implant and/or adjacent teeth and which may necessitate bone grafting
9. Jaw fracture.
10. As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

DISCUSSION OF TREATMENT

The Recommended Treatment works by removing bacteria from the hollow space inside the tooth, and by sealing off the inside of the tooth to prevent re-infection. Although the Recommended Treatment has a very high success rate, it is a biological procedure and cannot be guaranteed. Occasionally, a tooth which has had root canal treatment may require retreatment, additional surgery, or extraction.

TREATMENT ALTERNATIVES

Alternative methods of treatment have been explained to me, such as extraction of the involved teeth, or postponement of root canal therapy, but I wish to proceed with the Recommended Treatment described above.

RISKS AND COMPLICATIONS

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment.  
These potential risks and complications, include, but are not limited to, the following:

1. Instrument breakage in the root canal.
2. Inability to negotiate canals due to prior treatment or calcification.
3. Perforation to the outside of the tooth.
4. Irreparable damage to the existing crown or restoration.
5. Cracking or fracturing of the root or crown of the tooth.
6. Pain, infection and swelling.
7. Difficulty opening and closing.
8. Temporomandibular Dysfunction resulting in jaw pain.
9. Nerve injury resulting in temporary or permanent numbness, itching, burning or tingling of the lip, chin, tongue or teeth.
10. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Tooth sensitivity.
2. Pain from treatment.
3. Infection.
4. Swelling.
5. Dark spaces between teeth where there is no longer any gum tissue.
6. Changes in how long my teeth appear (due to re-contouring).
7. Gum tissues may shrink or recede. This change may make some previous dental restorations (i.e., crowns, fillings) more noticeable and the restorations may need to be replaced for cosmetic purposes.
8. Loss of bone or tissue graft.
9. Possible involvement of the nerves of the lower jaw resulting in temporary or permanent tingling of the lower lip, chin, tongue or surrounding structures.
10. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
11. Future bone or tooth loss.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-treatment bleeding, oozing, and infection.
3. Bruising and/or swelling, delayed healing, restricted mouth opening for several days or weeks.
4. Varying lengths and degrees of sensitivity.
5. Increased spacing between teeth due to removal of hard deposits.
6. Revealing of recessed gums.
7. Increased mobility of teeth.
8. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-operative bleeding, oozing, infection and/or bone infection.
3. Bruising and/or swelling, restricted mouth opening for several days or weeks.
4. Loss or removal of bone during tooth extraction.
5. Damage to, or fracture of, adjacent teeth or tooth restorations.
6. Root tips may break during the oral surgery process. These root tips may be left in the bone to avoid more aggressive surgery. However, this more aggressive surgery may be needed and you may be referred for this procedure.
7. Delayed healing, including but not limited to, dry socket, necessitating post-operative care.
8. Possible involvement of the sinus during the removal of the upper posterior teeth, which may require additional treatment or surgical repair at a later date.
9. Possible involvement of the nerves of the lower jaw during the removal of teeth resulting in temporary or permanent tingling/numbness of the lower lip, chin, tongue or other surrounding structures.
10. Jaw fracture.
11. If you are taking medications to make your bones stronger (such as bisphosphonates) or if you have received radiation therapy to the head or neck area for tumors/cancer, then you are at a higher risk for poor bone healing or bone death that may never completely resolve.
12. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection and/or bone infection.
3. Bruising and/or swelling, delayed healing, restricted mouth opening for several days or weeks.
4. Damage to adjacent teeth or tooth restorations.
5. Possible involvement of the sinus cavity and creation of an opening from the mouth into the nasal or sinus cavity, which may require additional treatment or surgical repair at a later date.
6. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia, resulting in altered or loss sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve over time, but in some cases, may be permanent.
7. Discoloration and appearance changes of the gum tissue or unsatisfactory cosmetic result.
8. Failure, loss, infection, or rejection of the graft or membranes used to contain the graft.
9. If I have elected a banked bone or bone substitute graft, there is a rare chance of disease spread from the processed bone.
10. Jaw fracture.
11. As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

I hereby give consent to Dr. Lim to perform recommended treatment and any such additional procedure(s) as may be considered necessary for my well-being based on findings made during the course of the recommended treatment on me or my dependents. The nature and purpose of the recommended treatment have been explained to me and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the recommended treatment. I also consent to the administration of local anesthesia during the performance of the recommended treatment.