Composite Filling Form

  • Teeth with caries (decay) may be restored with composite (white) or amalgam (silver) filling material. Dr. Mason only uses composite (white) filling materials. Sealant material is used to help prevent caries (decay) around composite restorations but is not a guarantee against future caries (decay). Sealant material contains and releases a small amount of fluoride, much less than a dental fluoride treatment.

    Composite restorations will be performed using a topical anesthetic (20% benzocaine) and an injectable local anesthetic (2% lidocaine with 1:100,000 epinephrine which contains sulfites). Local anesthetics result in loss of sensation for oral tissues and teeth (typically for 45 minutes up to 3 hours) depending on the type of injection used. I understand that I must watch my child carefully for the full duration of the local anesthetic to ensure they do not bite, pinch, scratch, or otherwise, injure themselves where they are anesthetized. This can include lips, cheeks, gums, and tongue adjacent to where a dental procedure is performed.

    Potential benefits of a composite restoration (white filling):
    1. Replaces tooth structure lost due to caries (decay), trauma, or fracture.
    2. Restores proper form and/or function and provides the ability to better keep tooth structure clean at home with proper oral hygiene.

    Risks include but are not limited to the following:
    1. Need for further treatments in the future, such as nerve treatments, stainless steel crowns or extractions.
    2. Damage to adjacent teeth and/or tissues.
    3. Damage to nerves in the area of local anesthetic administration which can be temporary or permanent.
    4. Changes in occlusion (bite).
    5. Sensitivity to cold, heat or sweets.  This is usually of increased risk with large restorations (fillings) and is often temporary, but may be permanent.

    1. Allergy to dental restorative materials or sealants
    2. Sulfite allergy (component of local anesthetic)
    3. Fluoride allergy (Sealant material contains a small amount of fluoride and is typically placed around composite restorations)
    4. Abscessed (infected) tooth or teeth with spontaneous (unsolicited) pain

    Alternative treatment options are as follows:
    1. No treatment (may increase chance for caries (decay) progression and lead to more extensive treatment needs.
    2. Stainless steel crowns.
    3. Esthetic coated or porcelain crowns.
    4. Extractions and/or space maintenance.

    I understand that my child’s diet and oral hygiene will influence the longevity of dental fillings.  If decay forms around fillings, they may need replacement or more extensive treatment. Such treatment may or may not be covered by my dental insurance.

    I further understand that my dental insurance plan may downgrade coverage for composite (white) restorations. This would result in a higher copay for composite (white) fillings versus amalgam (silver) fillings. My alternative would be to seek a second opinion at an office that provided an option for amalgam (silver) fillings.