Smile Cliniq White Filling Consent Form

Information and Informed Consent form

This information serves to help you come to an informed decision in regards to your dental treatment.

Treatment involving the placement of white fillings (composite fillings) can involve some risks. Side effects and complications are uncommon to rare and we at Smile Cliniq would hope our rate is even less than the norm, due to the techniques and materials we use.  Also bear in mind the, complications are no different to any fillings/restorations you may have had previously, it’s just you are now aware of them.

Possible risks include, but are not limited to the following:

1. Sensitivity – After preparation of teeth for the placement of a white filling, the prepared tooth can exhibit sensitivity. This can be mild to severe. It may last for a short period of time or may last much longer. Your dentist should be informed of persistent sensitivity after placement of a white filling as additional treatment may be required.  Please note we use the Optibond fl (highest bond strength) bonding agent or similar, and low shrinkage, high strength restorative materials to reduce this risk.
2. Risk of fracture – On placing or replacing white fillings there is the possibility that small fracture lines may appear in the tooth. Sometimes these fracture lines are not apparent at the time of treatment. They may appear at a later time. These do not always require further treatment.
3. Possible nerve damage – When white fillings are placed or replaced the preparation of the tooth for these filings often involves removal of sufficient tooth structure in order to removed diseased or otherwise compromised tooth structure. This exposes sound tooth structure for the placement of the white filling. Occasionally, this can lead to exposure or trauma to the underlying pulp tissue. Should the pulp not heal, root canal treatment or extraction may be indicated.  Please note: the placement of white fillings usually needs less tooth destruction  than mercury amalgam (black) fillings
4. Breakage, dislodgement or bond failure – Due to extreme biting pressures or traumatic forces, it is possible for white fillings to be dislodged or fractured. The bond between the white filling and the tooth may fail resulting in leakage and recurrent decay. The dentist has no control over these factors. However, early detection is key and therefore regular check -ups are recommended.
5. Staining – white fillings can become stained due to dietary factors such as, high, tea and coffee intake. These can often be improved by polishing but on occasion, these white fillings may require replacement.

I certify that I have read or had read to me the content of this form and do realise the risks and limitations involved, and consent to orthodontic treatment.