Sealants are a plastic resin that is flowed into and bonded to the natural grooves that occur on the chewing surfaces of the back primary and permanent teeth. This procedure helps prevent cavities from occurring in the pits and fissures in the chewing surface of the back teeth.

I understand that the placement of sealants is intended to prevent dental cavities (tooth decay) in the pits and fissures (grooves) of the chewing surfaces of the teeth. I understand that unsuccessful results and/or failure of dental sealants involve, but are not limited to the following:

1. Loosening, dislodging or leaking: Sealants can become loose or dislodged over a period of time. This time is indeterminable because of many variables including, but not limited to the following: a. The forces of mastication (chewing). These forces differ from patient to patient. b. The types of food or other substances that are eaten or 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 dislodgment. 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 or allowing a cavity to develop underneath.

2. The entire tooth is not protected with sealants: Sealants are applied to the pits and fissures (grooves) that are on the chewing surfaces of the teeth. Sealants do not protect the areas between the teeth, so thorough brushing and the use of dental floss in these areas is still necessary.

3. Sealant repair: Routine examinations by the Dentist are recommended to allow ongoing assessment of the sealants placed. This will allow the Dentist to repair any sealants as deemed necessary. As a service to our patients, we will repair any of the sealants placed by our office for no additional fee, as long those patients return for their 6-month check-up visits on a consistent basis.

I have been given the opportunity to ask questions regarding the nature and purpose of sealants and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with sealant placement in hopes of achieving the desired results from the treatment rendered. By signing this form, I am freely giving my consent to authorize the staff at Mountain View Pediatric Dentistry to place sealants, including the administration and/or prescribing of any anesthetic agents and/or medications.