Informed Consent for Mercury Removal

I _____________________ givemy dentist Dr. Carol E. Layton

permission to remove serviceable dental amalgam fillings and other non precious metals from my teeth and replace them with dental materials considered to be biocompatible based on existing scientific research. These materials may include, but are not limited to, composite resins, ceramic, porcelain, gold alloys and titanium.

My dentist has provided me with a personal copy of the book Dentistry Without Mercury, which explains the pros and cons on the use of amalgam as a dental material and also gives the position of the American Dental Association on the safety of dental amalgam. Any questions I had that were not answered by this book were subsequently answered to my satisfaction by my dentist.

My dentist has explained to me that:

  1. 1. Although one or more of my subjective or objective signs or symptoms may resemble the signs or symptoms of mercury toxicity, I understand that this does not mean that I am suffering from the effects of mercury either directly or indirectly.
  2. There is no scientific evidence that removal of my amalgam dental fillings will cure or improve any signs, symptoms, problems or health conditions that I have.
  3. Any sign, symptom, problem or health condition that I have outside that mouth may involve a general health or medical question. My dentist is limiting advice to the mouth, and recommends that I consult a physician for any general health or medical concerns or questions which I have. Further, my dentist has not told me or represented to me that replacing my amalgam fillings or nonprecious metals would have any beneficial health effect on me at all.

If a posterior composite resin is the material chosen to replace dental amalgam and other non precious materials, the advantages and disadvantages of the material chosen have been explained to me, including the fact that there has not been a sufficient number of years of use to scientifically prove its wear characteristics. Accordingly, at this time, it is not known if posterior composites will last as long as dental amalgam and therefore may have to be replaced more frequently than amalgam. The pros and cons of other available dental materials has been explained to me.

As might occur with the placement of amalgam, composite, or any other dental material, I understand that there are situations beyond the control of my dentist that may necessitate endodontic treatment (root canal treatment) or even removal of an existing tooth despite precautions taken and proper procedures utilized. In addition, I understand that during the removal and replacement of dental materials, it is possible to have an allergic type reaction which is like a general sickness. Should I begin feeling poorly for no explained reason, I understand that it is my responsibility to advise my dentist immediately and to seek medical treatment.

My questions concerning the treatment plan recommended by my dentist and agreed to by me have been fully answered and I have read this statement and am satisfied that I have fully informed.

Signature______________________________________________ Date____________

Please Print Name:________________________________________________

Witness_______________________________________________ Date____________

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