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Consent for Occlusal Equilibration

Occlusal equilibration is the selective reshaping of the chewing surfaces of teeth with the intention to reposition the mandible and stress relieve the muscle in the head and neck suspension apparatus.

I, the undersigned, have sought or have been referred to the above named dentist for occlusal equilibration, which I understand is a means of altering the chewing surfaces of some or all of my teeth, so that when my teeth come together, the temporomandibular joints (jaw joints) are in better anatomical position. I fully understand the importance of the history that I have given to the dentist, which together with the dentist’s examination, indicated that the symptoms I have reported to the dentist may be improved.

I understand that the dentist does not guarantee any outcome as a result of changing the chewing surfaces of my teeth, and in fact, I have been informed by the dentist that there are possible complications that can occur despite the exercise of the dentist’s skill and care. These complications include but are not limited to loss of a portion of tooth enamel; the possibility that a tooth or teeth may prove unsound and require restoration, including the replacement of existing restorations; the rebuilding of a tooth or teeth by removing additional amounts of tooth structure and replacing it with a crown, which may require additional cost; pain in the face and jaw; chewing difficulty; joint noise; and sensitive teeth.

I further understand that additional dental services may be required in the future such as additional equilibration and additional recommended dental care and treatment as set forth in the treatment plan presented by the dentist, if one has been discussed and agreed upon. I further understand that if extensive equilibration is required there may be some change in the appearance of the teeth and mouth and some increased sensitivity to temperature extremes. The dentist has explained to me that there are other approaches to occlusal equilibration, such as occlusal appliance therapy, orthodontics, reconstructive dentistry and orthognathic surgery. Although all these options have been discussed and offered to me, I have selected occlusal equilibration.

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