I UNDERSTAND that in the dental treatment of CHILDREN, there are possible inherent risks such as, but not limited to the following, including the understanding that no promises or guarantees of results have been made nor are expected.

1. Treating children often presents special problems: Perhaps the most difficult problem is that of controlling the child in order that no injury accidentally occurs as a result of the child making some abrupt or uncontrolled movements during treatment. In some cases, it may be advisable to recommend medication to sedate the child prior to treatment.
2. Numbness: There will be numbness in the tongue, lips, teeth, jaws, and/or facial tissues resulting from the administration of local anesthetic that may persist following treatment up to 2 hours or more. During this period of numbness, the child should be constantly monitored and reminded to not bite on or chew on the lips or the tongue.
3. Dental 'Fillings': Decay dissolves the tooth, and if not treated, will result in an abscessed tooth causing pain and infection. A mouth prop', which is a rubber or metal device is placed in the child's mouth to prevent closing when a child has difficulty maintaining an open mouth or refuses to open. The doctor will remove the decay and weakened part of the tooth and replace it with tooth colored material to strengthen the tooth. A local anesthetic may be used that will 'numb' the area being treated for one or two hours.
4. Stainless Steel Crowns: If a tooth is badly destroyed by decay, a filling will not stay in place. Therefore, a tooth is trimmed around the sides and a preformed crown or 'cap' is placed over the tooth to protect it from breaking. Furthermore, anytime a Pulpotomy (See description below) is performed, a stainless-steel crown will need to be placed. As with fillings, the area is usually treated with an anesthetic to help the child remain comfortable for one to two hours or more.
5. Caries susceptibility: Because of the thinness of the enamel on deciduous (baby) teeth, a tendency for children to consume excessive sweets, difficulty in brushing and flossing regularly, etc., there can often occur large cavities very quickly in children's teeth. Special care must be taken to avoid these problems. Preventive measures would include fluoride treatments, placing sealants, thorough brushing and flossing, control of diet, regular dental checkups.
6. Fracture or breakage: Due to the fragility of deciduous teeth it is often difficult to retain fillings, especially large fillings, in these teeth no matter how well the fillings have been placed. If the child has a difficult time retaining fillings or if the cavities are initially very large it may be advisable to place stainless steel crowns on the teeth in order to preserve them until they should be normally exfoliated.
7. Pulpotomy: Due to the thinness of the enamel, large pulp (nerve) chambers, and rapid spread of caries (decay in deciduous teeth, the dentist may drill into the pulp chamber during decay removal. Upon such pulpal or nerve exposure, extraction may often be avoided by rendering a treatment in which the pulp tissue in the upper part of the tooth is removed and replaced with various filling materials and the tooth preserved to maintain space and chewing capability until the permanent tooth replaces the deciduous tooth. This procedure is called a pulpotomy. At times, no matter how well done, these teeth may become infected and require extraction.
8. Abscesses: Deciduous teeth are particularly susceptible to a condition known as abscessing. Abscesses can occur if there has been deep invasion of caries into the tooth causing pulp tissue to become infected. The tooth usually becomes very sore and/or painful and swelling appears in the tissues near the root of the tooth. Abscesses may also occur from a traumatic injury to the tooth. The office should be contacted at once if this occurs. Pulpotomy as described above is generally not performed on an abscessed tooth and other alternatives must be considered.
9. Extraction and space maintenance: At times it is impossible to save a tooth. In such cases, the only alternative is to resort to extraction. Depending upon the necessity to maintain space for the eruption of permanent teeth it may be necessary to insert appliances known as space maintainers. These space maintainers may be either fixed or removable.
10. Responsibility: I acknowledge that it is my responsibility to immediately contact this office should any of the aforementioned or other adverse results occur following treatment. It is also my responsibility to set and keep appointments and follow instructions as given in order that proper dental health may be maintained for my child.

Behavior Management Techniques: I authorize the dentist to use their judgement to decide when behavior management techniques are necessary to obtain cooperation for my child. Cooperation is necessary when performing dental procedures to allow for the safest possible treatment outcome. I give my written consent for the following procedures when necessary.

Tell-Show-Do: This technique is used to explain what is expected during each visit. We tell parent/child what will be done, show them how it is done and then do what we have explained. Praise is used to reinforce cooperative behavior.

• Voice Control: The attention of a disruptive child is gained by changing the tone or increasing the volume of the dentist voice without getting angry.
• Restraint: Active restraint by dental personnel protects the child from injury during a dental procedure. The dentist, staff or parent (if willing to) restrains the child by holding their head, arms or legs to prevent harmful movements.
• Nitrous Oxide: Nitrous Oxide or (laughing gas) is routinely administered to an anxious child through a small breathing mask, which is placed over the child's nose. This allows your child to relax but does not put them to sleep. The effects of this treatment will wear off after the mask is removed in approximately 5 minutes. There are minimal chances of complications such as allergic reaction.
• Sedation/Operating Room: If we are unable to gain your child's cooperation with the above procedures, the dentist may refer out the treatment to a specialist under sedatives or general anesthesia.
• Mouth Props: A rubber or metal device placed in the child's mouth to prevent closing when a child refuses to open their mouth or has difficulty maintaining an open mouth.
• Parental Presence/ Absence: Parents are welcome in the treatment area. The primary role of the parent in the treatment area is to be a silent observer, unless invited by the dentist or staff to help or participate in treatment. Occasionally, the parent may be asked to step out of the room. If asked to leave, please be prepared to do so. The objective is to gain the child's attention, establish communication, and avert negative or avoidance behavior.

I understand that treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Behavior will be guided using praise, explanation and demonstration of procedures and instruments, using variable voice tone and loudness. I understand that should the patient become uncooperative during dental procedures with movement of the head, arms and/or legs, dental treatment cannot be safely provided.

During such disruptive behavior, it may be necessary for the assistant(s) to hold the patient’s hands, stabilize the head and/or control leg movements. I further understand that should the patient become uncooperative during the dental procedures, temporary fillings may be placed, and your child may be referred to a pediatric dentist for continuation of care.

I have read the above behavior management techniques and I give consent to the doctor for use of the techniques if necessary.

Consent of Use and Disclosure of Health Information-HIPPAA Privacy

Every reasonable effort will be made to ensure that your child's dental condition is treated properly, although it is not possible to guarantee perfect results. By signing below, you acknowledge that you have received adequate information about the proposed treatment, benefits, alternatives and risks of procedure(s) and the consequences of not performing the procedure(s), that you understand this information and that all your questions have been answered fully.

Although their occurrence is not frequent, some risks and complications are known to be associated with dental or oral surgery procedures. Most common include children biting and injuring their tongue or lip following administration of local anesthesia. Less common include numbness, infection, swelling, prolonged bleeding, discoloration, nausea, vomiting, allergic reactions, injury to treatment site, swallowing or aspiration of a crown form or extracted tooth. I further understand and accept that complications may require additional medical, dental, or surgical treatment and may require hospitalization and may even result in death.

I have had full opportunity to read and consider the contents of this consent and the office's Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to this office's use and disclosure of my protected health information to carry out treatment, payment activities, and health care options.