I understand that my child is having the following treatment performed:
Silver Diamine Fluoride treatment to stop cavities from progressing or treat hypersensitivity.
I may refuse this treatment. Other treatment options may include: fluoride varnish, fillings, tooth removal, or advanced procedures.
My dentist will: Dry the tooth. Put a small amount of Silver Diamine Fluoride on the cavity. This will help to stop the cavity.
This may need to be done again at future appointments. I understand that treated teeth may still need other treatments, such as fillings, crowns, or tooth removal.
I will tell my dentist if I might have a silver allergy.
I will tell my dentist if I have had ulcerative gingivitis or stomatitis in the past.
- The cavity will irreversibly change color to brown or black. This means the treatment is stopping the cavity. The dark stain is like a scar. Healthy tooth enamel will not stain.
- Fillings and crowns may also change color if Silver Diamine Fluoride gets on them.
- If Silver Diamine Fluoride touches the skin or gums, they may turn brown. The stain will not harm my child. The stain will not wash off. It will go away in 1-3 weeks.
- These side effects may not include all of the possible situations reported by the manufacturer. I will let my dentist know if I notice any other side effects.
After the Silver Diamine Fluoride treatment, I will avoid food and drink for one hour. This will help the treatment to work better.
I AGREE THAT: I HAVE READ AND UNDERSTOOD THIS FORM. MY DENTIST EXPLAINED AND ANSWERED MY QUESTIONS ABOUT THE TREATMENT: BENEFITS, SIDE EFFECTS, AND RISKS. MY DENTIST TOLD ME ABOUT OTHER OPTIONS AND THEIR RISKS AND BENEFITS. I HAVE HAD THE CHANCE TO ASK QUESTIONS. I CONSENT TO THIS TREATMENT.