Patient Informed Consent Form For Sealants printable pdf download

Informed consent for sealants

I understand that the treatment of teeth through the use of sealants is a preventative measure intended

to facilitate the inhibition of dental caries (tooth decay or cavities) in the pits and fissures of the chewing

surfaces of the teeth. Sealants are placed with the intention of preventing or delaying conventional

restorative measures used in restoring teeth with fillings or crowns after the onset of dental caries. I

agree to assume any risks that may be associated with the placement of sealants even though care and

diligence will be exercised by Dr.

while rendering this treatment.

In addition to possible unsuccessful results and failure of the sealant, the risks of the procedure include

but are not limited to the following:

1. Preparation of the teeth

The teeth are prepared through use of an enamel etching technique. This etching is accomplished in

one of two ways:

Through the use of a special acid solution that etches the surface enamel in the area in which the

sealant is to be placed to aid in its retention. The etching solution is somewhat caustic, and if the

patient makes any unexpected movement during the application process, there is the possibility that

a small amount of the solution will attach to the soft tissues of the mouth, which could cause some

slight tissue burns. This seldom occurs, but it is a possibility. If the etching solution contacts the root

surface, the tooth may develop some temporary sensitivity.

Through the use of a technique called “air abrasion.” Air abrasion also slightly etches the surface

of the enamel in the area in which sealant is to be placed to aid in the retention of the sealant. Air

abrasion involves the generation of a powdery dust, which, if inhaled, could cause some discomfort.

2. Loosening and/or dislodging of the sealant

There is the possibility of the sealant loosening or becoming dislodged over time. The length of time

over which this may happen is indeterminable because of the many variables that can impact the life of

the sealant including but not limited to the following:

The forces of mastication (chewing). These forces differ from patient to patient. The forces may be

much greater in one patient than in another. Also, the way teeth occlude (come together in chewing)

may have an effect on the life of the sealants.

The types of food or other substances that are put in the mouth and chewed. Very sticky food,

including some types of gum, sticky candies such as caramels, some licorices, very hard substances,

etc., can cause loosening or dislodgment of the sealant.

Inadequate oral hygiene such as infrequent or improper brushing of the teeth also may allow leakage

around and under the sealant causing it to loosen and allow decay to develop.

3. Entire tooth is not protected with sealants

Sealants are applied primarily to the pits and fissures that are in the chewing surfaces of the

teeth. These pits and fissures are extremely susceptible to decay and can be protected through the

application of sealants that flow into and seal those areas. However, sealants do not protect the areas

between the teeth, so thorough brushing and the use of dental floss in these areas is necessary.

Otherwise, decay could develop in those areas uncovered by the sealants.

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Patient Informed Consent Form For Sealants