Mark B. Hughes, DDS PC 6591 W. Thunderbird Rd. Ste. C1 Glendale, AZ Phone: (623) Fax: (623)

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1 Mark B. Hughes, DDS PC 6591 W. Thunderbird Rd. Ste. C1 Glendale, AZ Phone: (623) Fax: (623) CONSENT FOR ORAL SURGERY OR TEETH EXTRACTION Extraction of teeth is an irreversible process and whether routine or difficulties a surgical procedure. As in any surgery, there are some risks. They include, but are not limited to the following items listed below. Swelling and/or bruising and discomfort in the surgery area. Stretching of he corners of the mouth resulting in cracking or bruising. Possible infection requiring additional treatment. Dry Socket jaw pain beginning a few days after the surgery, usually requiring additional care. It is more common from lower extractions, especially those with large fillings or caps. Numbness or altered sensation in the teeth, gums, lips, tongue and chin, due to returns closeness of the tooth roots to the nerves which can be bruised or damaged. Sensation almost always returns but may be permanent is rare cases Trismus limited jaw opening due to inflammation or swelling, most common after wisdom teeth removal. Sometimes it is a result jaw discomfort, especially when TMJ disease already exists. Bleeding significant bleeding is not common, but persistent oozing can be experienced for several hours. Sharp ridges or bone splinters may form later at the edge of the socket. These usually require another surgery to smooth or remove. Incomplete removal of tooth fragments to avoid injury to vital structure such as nerves or sinus, sometimes small root tips may be left in place. Sinus involvement the roots of the upper back teeth are often close to sinus ad sometimes a piece of root can displaced into the sinus or an opening may occur into the mouth which may require additional care. Jaw fracture while quite rare, it is possible in difficult or deeply impacted teeth. Most procedures are very routine and serious complications are not expected. Those that do occur are most often minor and can treated. I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND EXPLANATION WITHIN THE ABOVE CONSENT FORM TO THIS OPERATION; THAT BLANKS HAD BEEN FILLED IN BEFORE I SIGNED. I ALSO DECLARE THAT I SPEAK; READ AND WRITE ENGLISH OR I AM SIGNING THIS AS THE LEGAL GAURDIAN OF THE LISTED PATIENT. I agree to the removal of teeth # Patient Name D.O.B / / Signed By Witness

2 MARK B. HUGHES DDS PC 6591 W. Thunderbird Rd. Ste. C1 Glendale, AZ INFORMED CONSENT FOR ZOOM! TOOTH WHITENING TREATMENT INTRODUCTION/CONSENT This Information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as bleaching ) of my teeth. DESCRIPTION OF THE PROCEDURE Zoom! in-office tooth whitening is a procedure designed to lighten the color of my teeth using a combination of a hydrogen peroxide gel and a specially designed ultraviolet lamp. The Zoom! treatment involves using the gel and lamp in conjunction with each other to produce maximum whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from Zoom! Lamp for three (3), 15-minute sessions. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, checks, and tongue) will be covered to ensure they are not exposed to either the gel or light. Lip balm (SPF rating: 30+) may also be applied as needed and I will be provided an ultraviolet light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded. ALTERNATIVE TREATMENT I understand I may decide not to have the Zoom! Treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include: Whitening Toothpastes/Gels, Other In-office Whitening Treatments, and Take- Home Whitening Kits. COST I understand that the cost of my Zoom! Treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my Zoom! Treatment. RISKS OF CONSENT FOR TREATMENT I also understand that Zoom! Treatment may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from Zoom! Whitening treatments and significant whitening can be achieved in most cases. I understand that Zoom! Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative Patient s Initials: Materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or and may not whiten at all. I understand that teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternative. I understand that provisionals or temporaries made from acrylics may become discolored after exposure to Zoom! Treatment. I understand that Zoom! Treatment is not recommended for pregnant or lactating woman, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photo chemotherapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. I understand that the Zoom! Lamp emits ultraviolet radiation (UVA) and that patient taking any drugs that increase photosensitivity should consult with their physician before undergoing Zoom! Treatment. I understand that the results of my Zoom! Treatment cannot be guaranteed. I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the Zoom! Whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to: Tooth Sensitivity/Pain During the first 24 hour after Zoom! Treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a Zoom! Treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after Zoom! Treatment.

3 Gum/Lip/Cheek Inflammation Whitening may cause inflammation of you gums, lips or check margins. This is due to inadvertent exposure of a small are of those tissues to the whitening gel or the ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or ultraviolet light. Dry/Chapped Lips The Zoom! Treatment involves three, 15-minute during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or check margins, which can be treated by application of lip balm, petroleum jelly or vitamin E cream. Patient s Initials: Cavities or Leaking Fillings Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my filling re-done before undergoing the Zoom! treatment. Cervical Abrasion/Erosion These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notched and/or depressions, which appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my Zoom! Treatment. Root Resorption This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures. Relapse After the Zoom! Treatment, it is natural for the teeth that underwent the Zoom! Treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated be exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the Zoom! Treatment. I understand that the results of the Zoom! treatments are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth. The safety, efficacy, potential complications and risks of Zoom! Treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of Zoom! treatment, the list of complications in this form is incomplete. The basic procedures of Zoom! treatment and the advantages and disadvantages, risks and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction. In signing this informed consent I am stating I has read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from Zoom! treatment and that I agree to undergo the treatment as described by my dentist. Patient s Initials: By signing this document in the space provided I indicate that I have read and understand the entire document and that I gave my permission for Zoom! treatment to be preformed on me. Patient s Signature Patient s Name (Printed) Mark B. Hughes DDS PC/Staff _

4 INFORMED CONSENT DISCUSSION FOR ANESTHESIA/SEDATION Patient Name: Patient s Weight: of Birth: DIAGNOSIS: Facts for Consideration Anesthesia is a matter of degrees on a continuum beginning at a low level called light and adjusted to lighter or deeper levels depending on the patient s tolerance for pain and/or response to the drugs used. Occasionally, during dental treatment patients cannot understand or cooperate due to psychological or emotional immaturity, a cognitive, physical or medical disability, or fear and anxiety. Under such conditions they may become dangerous to themselves, the staff, and the dentist. In addition to behavior management through communication techniques or immobilization to provide safe delivery of dental treatment, the dentist may also identify the need for a chemical sedation or anesthesia for the patient s comfort and behavior management. Patients may require local anesthesia, light to moderate conscious sedation, deep sedation, or general anesthesia for their comfort during the performance of dental restorations or surgical procedures. Your dentist will recommend and explain to you which type of anesthesia might be appropriate for your individual medical/dental needs. Option 1: Nitrous Oxide/Oxygen Inhalation Sedation Patient s/patient s Representative s Initials required Nitrous oxide/oxygen inhalation is a mild form of conscious sedation used to calm an anxious patient. A colorless, odorless gas that has no explosive or flammable properties, it can act as a pain buffer as well. Oxygen is given simultaneously with nitrous oxide through a small mask placed over the nose. Pure oxygen, given at the end of treatment, is intended to flush the nitrous oxide out of the patient s system and minimize the effects of the gas. The patient is observed while nitrous oxide is administered and until the patient is fully recovered from its effects. Risks, included but are not limited to: An early effect is an inability to perceive one s spatial orientation and temporary numbness and tingling. Nausea and vomiting may occur. If the patient will not accept the mask, nitrous oxide/oxygen cannot be used. Potential benefits: The patient remains awake and can respond to directions and questions. Nitrous oxide helps overcome apprehension, anxiety, or fear. Option 2: Local Anesthesia Anesthetizing agents are infiltrated into a small area or injected as a nerve block directly into a larger area of the mouth with the intent of numbing the area to receive dental treatment. Risks, include but are not limited to: It is normal for the numbness to take time to wear off after treatment, usually two or three hours. However, it can take longer and rarely the numbness is permanent if the nerve is injected. Infection, swelling, allergic reactions, discoloration, headache, tenderness at the needle site, dizziness, nausea, vomiting and cheek, tongue, or lip biting can occur. Potential benefits: The patient remains awake and can respond to directions and questions. Pain is lessened or eliminated during the dental treatment. 1

5 Option 3: Conscious Sedation Option 4: Deep Sedation Option 5: General Anesthesia: Conscious sedation is a controlled; drug induced minimally depressed level of consciousness that allows the patient to breathe independently and continuously respond appropriately to physical stimulation and/or verbal command, e.g., open your eyes. This type of anesthesia may be administered orally (a drink) or through a tube to a needle in the vein. Risks, included but are not limited to: Infection, swelling, discoloration, bruising, headache, tenderness at the needle site and vein, dizziness, nausea, and vomiting can occur. Adverse reactions to medication including allergic and life-threatening reactions are possible though rare. Complications may require hospitalization or even result in brain damage or death. With any patient, reflexes are delayed. Children: Patients can have an immediate response to oral conscious sedation similar to a temper tantrum before the medication calms them. Adults: Patients should not drive a car or operate machinery for 24 hours because the effects of sedation remain in the system even after the patient is awake and mobile. Potential benefits: Pain is lessened or eliminated during the dental treatment. Stress and anxiety are greatly reduced and often there is no memory of the treatment. Deep sedation is a controlled, drug induced state of depressed consciousness from which the patient is not easily aroused, which may be accompanied by a partial loss of protective reflexes, including the ability to maintain an open airway independently and/or respond purposefully to physical stimulation or verbal command. This type of anesthesia is called a light general anesthesia and is usually administered in a dental office setting. Risks, include but are not limited to: Infection, swelling, discoloration, bruising, and tenderness at the needle site may occur. Dizziness, nausea, and vomiting can occur. Adverse reactions to medication including allergic and life-threatening reactions are possible though rare. Complications may require hospitalization or even result in brain damage or death. A responsible escort must bring the patient to the office and take the patient home. Patients should not drive a car or operate machinery for 24 hours because the effects of the sedative remain in the system even after the patient is awake and mobile. Potential benefits: Pain is lessened or eliminated during the dental treatment. Stress and anxiety are greatly reduced and often there is no memory of the treatment. General anesthesia is a controlled, drug induced state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including an inability to independently maintain an airway and/or respond purposefully to physical stimulation or verbal command. This type of anesthesia is called a light general anesthesia and is usually administered in a dental office setting. Risks, include but are not limited to: Infection, swelling, discoloration, bruising tenderness at the needle site may occur. Dizziness, nausea, and vomiting can occur. Adverse reactions to medication including allergic and life-threatening reactions are possible though rare. Complications may require hospitalization or even result in brain damage or death. A responsible escort must bring the patient to the office and take the patient home. Patients should not drive a car or operate machinery for 24 hours because the effects of sedation remain in the system even after the patient is awake and mobile. 2

6 Patient Name: Patient s Weight: of Birth: _ Potential benefit: Pain is eliminated and the patient has no recall of the surgical procedure. Alternative Treatment, Not Limited to the Following: If a particular level of anesthesia does not relieve the patient s anxiety or pain, in the dentist s clinical judgment and if the individual patient can tolerate it, another level of anesthesia may be needed. Not every dental office or dentist is equipped or trained to administer every type of anesthesia. It may be necessary to bring an anesthesiologist into the dental operatory or refer the patient to another facility or to another dentist who has the appropriate equipment or credentials. Those types of services may result in additional charges. For All Female Patients Because anesthetics, medications and drugs may be harmful to the unborn child and may cause birth defects or spontaneous abortion, every female must inform the anesthesiologist and the dentist is she could be or is pregnant. Anesthetics, medications and drugs absorbed in the mother s milk may temporarily affect the behavior of the nursing baby. In either case, the anesthesia and treatment may be postponed. For All Patients I have been given the opportunity to ask questions about the recommended method of anesthesia and believe that I have sufficient information to give my consent as noted below. I give my consent for the use of anesthesia, as explained above When Dr. determines it is indicated in the treatment of. (Patient s Name) I refuse to give my consent for proposed anesthesia. I have been informed of and accepted the consequences if no treatment is administered because I do not agree to the proposed anesthesia modality. The consequences include, but not limited to: tooth loss, infection, decay and the need for additional restorations. Patient or Patient s Representative s Signature I attest that I have discussed the risks, benefits, consequences, and alternatives of anesthesia with (Patient or Patient s Representative) who has had the opportunity to ask questions, and I believe understands what has been explained. Dentist s Signature Witness s Signature 3

7 Mark B. Hughes DDS PC Thunderbird Ranch Professional Building 6591 W. Thunderbird Rd. Ste. C1 Glendale, AZ Phone: (623) Fax: (623) CROWNS, ONLAYS, INLAYS BRIDGES & IMPLANT RESTORATION Patient Name: I understand that sometimes it is not possible to match the natural teeth exactly with artificial teeth. I further understand that I will be wearing temporary crowns that may come off easily; and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I also realize that the final opportunity to make changes in my new crown, bridge, onlay, etc. (including shape, fit, size, and color) will need to be made prior to cementation. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during an examination. I give my permission to the dentist to make any and all changes or additions as necessary to provide the best oral health care. I understand that dentistry is not an exact science and that a reputable practitioner cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I also understand that I am ultimately responsible for payment for services rendered. As a courtesy the doctor s office will bill PPO dental insurance companies for payment and the patient portion of the services is due at the time of service. If a secondary dental insurance is available then billing and collecting that insurance company becomes my responsibility as the patient. I certify that I have had the opportunity to read and fully understand this form and ask any questions. DATE: I consent to the proposed treatment of TREATMENT: PATIENT SIGNATURE: WITNESS SIGNATURE:

8 Mark B. Hughes, D.D.S., P.C. Thunderbird Ranch Professional Building 6591 W. Thunderbird Rd. Ste #C1 Glendale, AZ Phone: (623) Fax: (623) TREATMENT CONSENT FOR ROOT CANAL THERAPY Patient Name: Patient SSN: Diagnosis: Facts for Consideration Root canal treatment, also called endodontic treatment involves removing the nerve tissue (called pulp) located in the center of the tooth and its root or roots (called the root canal). Treatment involves creating an opening through the biting surface of the tooth to expose the remnants of the pulp, which then are removed. Medications may be used to sterilize the interior of the tooth to prevent further infection. Root canal treatment may relieve symptoms such as pain and discomfort. If any unexpected difficulties occur during treatment, I may refer you to an endodontist, who is a specialist in root canal treatment. Twisted, curved, accessory, or blocked canals may prevent removal of all inflamed or infected pulp. Since leaving any pulp in the root canal may cause your symptoms to continue or worsen this might require an additional procedure called an apicoectomy. Through a small opening cut in the gums and surrounding bone, any infected tissue is removed and the root canal is sealed. An apicoectomy may also be required if your symptoms continue and the tooth does not heal. Once the root canal treatment is completed, it is essential to return promptly to begin the next step in treatment. A temporary seal is designed to last only a short time, failing to return as directed to have the tooth sealed permanently with a crown or filling can lead to other problems such as deterioration of the seal, resulting in decay, infection, gum disease, fracture, and the possible premature loss of the tooth. Benefits of root canal treatment, not limited to the following: Root canal treatment to allow you to keep your tooth for a longer time, which will help to maintain you natural bite and the healthy functioning of your jaws. This treatment has been recommended to relieve the symptoms of the diagnosis described above. Risks of root canal treatment, not limited to the following: I understand that following treatment I may experience bleeding, pain, swelling, and discomfort for several days, which may be treated with pain medication. It is possible infection may accompany root canal treatment and must be treated with antibiotics. I will immediately contact the office if conditions worsen or if I experience fever, chills, sweats, or numbness. I understand that all medications have the potential for accompanying risks, side effects, and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking, which are:. I understand that occasionally a root canal instrument may break off in a root canal that is twisted, curved, or blocked with calcium deposits. Depending on its location, the fragment may be retrieved or it may be necessary to seal it in the root canal (these instruments are made of sterile, non-toxic surgical stainless steel, so this usually causes no harm). It may also be necessary to perform an apicoectomy, as described above, to seal the root canal. I understand that during treatment the root canal filling material may extrude out the root canal into the surrounding bone and tissue. Occasionally, an apicoectomy may be necessary for retrieving the filling material and sealing the root canal.

9 I understand teeth that receive root canal treatment may be more prone to cracking and breaking over time, which may require removal and replacement with a bridge, partial denture or implant. In some cases, root canal treatment may not relieve all symptoms. The presence of gum disease (periodontal disease) can increase the chance of losing a tooth even though root canal treatment was successful. I understand that root canal treatment may not relieve my symptoms, ad I may need my tooth extracted. Consequences if NO Root Canal Treatment is administered, not limited to the following: I understand that if I do not have root canal treatment, my discomfort may continue and I may face the risk of a serious, potentially life-threatening infection, abscesses in the tissue and bone surrounding my teeth and eventually, the loss of my tooth and/or adjacent teeth. Alternative treatment if Root Canal Treatment is not the only solution, not limited to the following: I understand that depending on my diagnosis, alternative to root canal treatment may exist which involve other disciplines in dentistry. Extracting my tooth is the most common alternative to root canal treatment. It may require replacing the extracted tooth with a removable or fixed bridge or an artificial tooth called an implant. I have asked my dentist about the alternative and associated expenses. Alternatives discussed:. My questions have been answered to my satisfaction regarding the procedures, their risks, benefits, and costs. No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above. I consent to the root canal treatment as described above by Dr. I refuse to give my consent for the proposed treatment as described above. I have been informed of and accepted the consequences if no treatment is administered. Patient s Signature I attest that I have discussed the risks, benefits, consequences, and alternatives to root canal with (patient s name) who has had the opportunity to ask questions, and I believe my patient understands what has been explained. Dentist s Signature Witness Signature

10 Complete each time the examination is performed and place in the patient s file Our practice continually looks for advances to ensure that we are providing the optimum level of oral health care to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidence and mortality rates of oral cancer continue to increase. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such lifestyle risk factors. Oral cancer risk by patient profile is as follows: Increased risk: patients ages High risk: patients age 40 and older; tobacco users (any age, any type within 10 years) Highest risk: patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol use); previous history of oral cancer We have recently incorporated ViziLite Plus into our oral screening standard of care. We find that using ViziLite Plus along with a standard oral cancer examination improves the ability to identify suspicious areas at their earliest stages. ViziLite Plus is similar to proven early detection procedures for other cancers such as mammography, Pap smear, and PSA. ViziLite Plus is a simple and painless examination that gives the best chance to find any oral abnormalities at the earliest possible stage. Early detection of precancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. The ViziLite Plus exam will be offered to you annually. This enhanced examination is recognized by the American Dental Association code revision committee as CDT-5 procedure code D0431; however, this exam might not be covered by your insurance. The fee for this enhanced examination is. Yes. I authorize the clinician to perform the ViziLite Plus exam along with the standard oral cancer examination. I accept financial responsibility for this enhanced examination. Print name: Signature: : No. I would prefer not to have the ViziLite Plus exam at this time. Print name: Signature: : VLP004 2/06

11 Patient ID Clinician lip labial mucosa right left right left tongue (ventral) floor of mouth buccal mucosa hard palate soft palate buccal mucosa gingiva vestibule vestibule gingiva labial mucosa lip Highest Risk Sites Lateral border of tongue Lip Anterior floor of mouth Soft palate tongue (dorsum) lateral border