CONSENT FOR SILVER DIAMINE FLUORIDE

I authorize West Grande Prairie Dental's licensed practitioners to administer Silver Diamine Fluoride as needed for the proper care of my teeth.

Silver Diamine Fluoride (SDF) is an antibiotic material that binds to cavities and helps stop tooth decay. It can also be used to treat tooth sensitivity.

It is important to know with SDF that:

  • The affected area of decay will stain black permanently. Healthy tooth structure will not stain.
  • Tooth-colored fillings and crowns may also discolor if SDF is applied to them. Normally this color change is temporary and can be polished off.
  • If SDF touches the skin or gums, a brown stain may appear that causes no harm. It will disappear in 1-3 weeks.
  • The tooth can still get cavities, just like any tooth can by not improving brushing, flossing and attending regular dental cleanings. In that case the tooth will require further treatment, such as repeated SDF, a filling or crown or extraction.

You should not be treated with SDF if allergic to silver, or there are painful sores or raw areas on your gums or in your mouth.

Alternative treatment options, including no treatment, have been discussed and understood. No guarantees have been made as to the results of treatment. A full explanation of all complications is available to me upon request from the dentist.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH, IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.