- Northeast Children's Dentistry

Sealant Consent

Dental Sealant Informed Consent

Pit and Fissure sealants are a resin-based material that is used to seal the pits and fissures of permanent teeth.  It is a preventative measure to help prevent decay in the grooves of the teeth.  They help give children with primary and/or permanent teeth smoother surfaces to keep clean.

Procedure:

The surface of the tooth must be cleaned first.  The tooth is then isolated with cotton rolls to ensure that the tooth is dry.  Then, an etching solution is placed to create a porous surface so the tooth can receive the sealant.  Once the sealant is placed, a curing light (UV) is used to dry the sealant.

Common Risks:

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 the use of an enamel etching technique.  This etching is accomplished in the following way:
Through the use of a special acid solution which 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 movements during the application process there is the possibility that a small amount of the solution may 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.
 
    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 which can impact the life of the sealant including, but not limited to the following:
    A.  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.
    B. The types of foods or other substances that are put in the mouth and chewed.  Very sticky foods such as some types of gum; sticky candies such as caramels; some licorices; very hard substances, etc: may cause loosening or dislodgement of the sealant.
    C. 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 pit 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 which 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.
Alternative Treatment

There is no appropriate alternative to sealants.  If a tooth has decay, it will need a filling or other restoration.
Although it is not possible to guarantee perfect results, every possible effort will be made to ensure that your child’s sealants are properly placed and monitored.  Integrity of sealants is check at each check-up appointment.

I have read and understand the above

No Yes

Nitrous Oxide Informed Consent

Sometimes a child may feel anxious before or during treatment. Your child may need more support than a gentle, caring manner to feel comfortable. Nitrous oxide/oxygen is a safe, effective sedative agent used to calm a child’s fear of the dental visit and enhance effective communication. Additionally, it works well for children whose gag reflex interferes with dental treatment. It is important that children remain calm and still during dental treatment to assure that your child receives high quality, professional dental care. The following information will help parents understand the use of nitrous oxide and oxygen gases for safe analgesia.

    • It is one of the safest routes for anesthesia in the dental office because your child remains awake, responsive and breathes on their own without assistance. It is a 100% reversible and is non-allergenic
  
    • More oxygen is administered than what we breathe in normal room air. This provides a wide margin of safety. The gas is usually breathed via a small mask placed over the nose and is taken into the lungs.

    • Five minutes of pure oxygen is given at the end of the treatment appointment to remove the effects of the Nitrous oxide gas.

    • Sometimes known as “laughing gas” because some patients become so comfortable and relaxed they laugh. They sometimes report dreaming and their arms and legs may feel “tingly.” It raises the pain threshold and may even make the time appear to pass quickly. If your child is worried by the sights, sounds or sensations of dental treatment, he or she may respond more positively with the use of nitrous oxide/oxygen.

    • The child is awake and sometimes remains relaxed after dental treatment but will continue to feel numbness in their lips around the treated area due to the local anesthesia. Please monitor your child after treatment so that they do not bite their cheek, tongue, lips or scratch themselves.

The benefits that my child can expect from Nitrous Oxide include:  
reduced anxiety and discomfort, reduced gag reflex which make it easier for my child to cope with dental treatment.

There are some medical conditions that increase risks when Nitrous Oxide is used. Please notify the Doctor and the Northeast Children’s Dentistry dental team if your child is currently diagnosed with or has a history of:

* Cold, or other conditions that can impede adequate breathing through the nose

* History of middle ear infections, sinus inflammation or blocked Eustachian tubes? Nitrogen diffusion can cause
   pressure buildup and damage the tympanic membrane.

* Obstructed bowel or problematic gas distention? (Severe gas pain can develop)

* Have detached retina or surgical treatment to the ocular area with a gas bubble? (Eye surgeons sometimes inject gas
   during retinal surgery. This can expand with nitrogen diffusion. In rare cases, blindness can result.)

* Pregnancy:   Individuals who may be pregnant will may be allowed in the treatment room during any procedure that
  nitrous oxide is used.

* Bleomycin sulfate therapy                        * Severe cardiac conditions or COPD                        * Sickle Cell Anemia

Potential Side Effects: They include, but are not limited to the following:

    1. Nausea and vomiting:  this is the most common side effect of Nitrous Oxide.  The level of Nitrous Oxide can be adjusted to eliminate this side effect.
    2. Behavioral Problems:  some patients will talk excessively.  It may be difficult to treat child due to patient being so talkative.  Patient could experience vivid dreams associated with physical movement of the body.
    3. Shivering:  it is not common but it may be uncomfortable.  It usually develops at the end of the treatment when the Nitrous Oxide is terminated.
    4. Excessive Perspiration:  sweating may occur during the procedure and the patient could become flushed during the administration of Nitrous Oxide.
    5. Expectoration: removal of secretions may be difficult but can be control by use of suction tip.
    6. The child may become emotional or irritable after the use of laughing-gas.  It should be a short period of time, don’t be alarmed.

What are my alternatives?
No treatment is an option.  However, avoidance of dental care due to fear and anxiety of the dental experience may precipitate further dental and overall health problems.  Proceeding with dental care under a state of anxiety may lead to fainting, palpitation, increased blood pressure and pulse or other heart-related disorders related to the “flight or fight response.”  Other possible alternatives include: 1. Oral conscious sedation, 2. IV sedation, 3. General Anesthesia

I understand that it is my responsibility to notify this office should any unexpected problems occur or if any problems relating to the treatment rendered are experienced.

I have been given the opportunity to ask questions regarding the nature and purpose of nitrous-oxide, and have received answers to my satisfaction. I voluntarily consent to this treatment in hopes of achieving the desired results from the treatment rendered though no guarantees have been made regarding the outcome. I hereby assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of the treatment. The fee(s) for these services have been explained to me and I accept them as satisfactory.

By signing this form, I am freely giving my consent to authorize Northeast Children’s Dentistry and all associates involved in rendering the services or treatment necessary to the existing dental condition, including the administration and/or prescribing of any anesthetic agents and/or medications.

I have read and understand the above

No Yes

By signing below, you acknowledge that you have received adequate information about the proposed procedure (dental sealants on your child, , nitrous oxide gas), that you understand this information, had the opportunity to ask questions, and have received answers to your satisfaction.

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