Facts for Consideration: Silver diamine fluoride (SDF) is an antibiotic liquid. We use SDF on cavities to help stop tooth decay. We also use it to treat tooth sensitivity. SDF application every 6 to 12 months if necessary. The procedure: Dry the affected area. 2. Place a small amount of SDF on the affected area. 3. Allow SDF to dry for a minute. 4. Rinse. Treatment with SDF does not eliminate the need for dental fillings or crowns to repair function or esthetics. Additional procedures will incur a separate fee. I should not be treated with SDF if: I am allergic to silver. There are painful sores or raw areas on my gums (I.e., ulcerative gingivitis) or anywhere in my mouth (ie., stomatitis). Benefits of receiving SDF: SDF can help stop tooth decay. SDF can help relieve sensitivity Risks related to SDF include, but are not limited to: The affected area will stain black permanently. Healthy tooth structure will not stain. Stained tooth structure can be replaced with a filling or crown. Tooth-colored fillings and crowns may discolor if SDF is applied to them. Color changes on the surface can normally be polished off. The edge between a tooth and filling may keep the color. If accidentally applied to the skin or gums, a brown or white stain may appear that causes no harm, cannot be washed off and will disappear in one to three weeks. You may notice a metallic taste. This will go away rapidly. If tooth decay is not arrested, the decay will progress. In that case the tooth with require further treatment, such as repeat SDF, a filling or crown, root canal treatment or extraction. These side effects may not include all of the possible situations reported by the manufacturer. If you notice other effects, please contact your dental provider. Every reasonable effort will be made to ensure the success of SDF treatment. There is a risk that the procedure will not stop the decay and no guarantee of success is granted or implied. Alternatives to SDF, not limited to the following: No treatment, which may lead to continued deterioration of tooth structures and cosmetic appearance. Symptoms may increase in severity. Depending on the location and extent of the tooth decay, other treatment may include placement of fluoride varnish, a filling or crown, extraction or referral for advanced treatment modalities. I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT AND ALL MY QUESTIONS WERE ANSWERED:Name* First Last Signature*