Form

Dental Sealant(s) Consent Form

Sealants help to prevent caries (decay) in the pits and grooves of posterior (back) teeth. They do not prevent decay on all surfaces of the tooth. Proper brushing and flossing is still necessary, or decay can develop.

We use sealant material which bonds chemically and micromechanically to tooth structure. It also releases small amounts of fluoride which increases enamels resistance to bacteria and has antibacterial properties.

In order to help keep your child’s mouth open and reduce risk of accidental injury due to sudden mouth closure, our office uses a mouth-prop. This device is used to provide a comfortable method for the child to rest his/her mouth in an open position.

Prevention of decay on the biting surfaces of back teeth.

Replacement every few years, which is commonly needed but may or may not be covered by dental insurance.

Breakage of sealants, which is common with certain habits such as chewing ice or other hard foods.

Early loss of sealants, which can be caused by bruxism (toothgrinding). Damage to adjacent teeth and/or tissues.

I understand that my child’s diet and oral hygiene will influence the longevity of dental sealants. Decay can form around sealants. Replacement may or may not be covered by my dental insurance.

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