Consent for gum graft surgery

MM slash DD slash YYYY
Patient name:(Required)

Diagnosis. After a careful oral examination and study of my dental condition, my Dentist has advised me that I have significant gum recession. I understand that with this condition, a further recession of the gum may occur. In addition, for fillings at the gum-line or crowns with edges under the gum line, it is important to have sufficient width of attached gum to withstand the irritation caused by the fillings or edges. Gum tissue may also be placed to improve the appearance and to protect the roots of the teeth.

Recommended Treatment. To treat this condition, my Dentist has recommended that gingival augmentation procedures be performed in areas of my mouth with significant gum recession. I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of my treatment. This surgical procedure involves the transplanting of a thin strip of gum from the roof of my mouth or from the adjacent teeth. The transplanted strip of gum can be placed at the base of the remaining gum, or it is placed to partially cover the tooth-root surface exposed by the recession. A periodontal bandage or dressing may be placed.

Expected Benefits. The purpose of gingival augmentation is to create an amount of attached gum tissue adequate to reduce the likelihood of further gum recession. Another purpose for this procedure may be to cover exposed root surfaces, to enhance the appearance of the teeth and gum line, or to prevent or treat root sensitivity or root decay.

Principal Risks and Complications. I understand that some patients do not respond successfully to gingival augmentation. If a transplant is placed to partially cover the tooth-root surface exposed by the recession, the gum placed over the root may shrink back during healing. In such a case, the attempt to cover the exposed root surface may not be completely successful. Indeed, in some cases, it may result in more recession with increased spacing between the teeth. I understand that complications may result from gingival augmentation or anesthetics. These complications include but are not limited to post-surgical infection, bleeding, swelling, and pain, facial discoloration, transient but on occasion permanent tooth sensitivity to hot, cold, sweet, or acidic foods, allergic reactions, and accidental swallowing of foreign matter. Other complications may include trauma to the nerve tissue or blood vessels that may lead to loss of sensation of lip tongue check or other tissues in the mouth or altered sensation or pain. No method will accurately predict or evaluate how my gums and bone will heal. I understand that there may be a need for a second procedure if the initial surgery is not satisfactory. Also, the success of gingival augmentation can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and medications that I may be taking.

To my knowledge, I have reported to my Dentist any prior drug reactions, allergies, diseases, symptoms, habits, or conditions, which might in any way relate to this surgical procedure. I understand that my diligence in providing the personal daily care recommended by my Dentist and taking the prescribed medications are important to the ultimate success of the procedure.

Alternatives to Suggested Treatment. My Dentist has explained alternative treatments for my gum recession. These include no treatment, continued monitoring for the progressive recession, and the modification of technique for brushing my teeth.

Necessary Follow-up Care and Self-Care. I understand that it is important for me to continue to see my regular dentist. Existing restorative dentistry can be an important factor in the success or failure of gingival augmentation. I recognize that natural teeth and appliances should be maintained daily in a clean, hygienic manner. I will need to come for appointments following my surgery so that my healing may be monitored and so that the Dentist can evaluate and report on the outcome of the surgery. Smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery.

I know that it is important:
1. To abide by the specific prescriptions and instructions given by my Dentist.
2. To see my Dentist for periodic examination and preventive treatment. Maintenance may also include adjustment of prosthetic appliances.

No Warranty or Guarantee. I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit in reducing the cause of my condition and should produce healing which will help me keep my teeth. Due to individual patient differences, however, a Dentist cannot predict the absolute certainty of success. There exists the risk of failure, relapse, additional treatment, or worsening of my present condition, including the possible loss of certain teeth, despite the best of care.

Publication of Records. I authorize photos, slides, x-rays, or any other viewing of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes. My identity will not be revealed to the general public, however, without my permission.


I have been fully informed of the nature of gingival augmentation surgery, the procedure to be utilized, the risks and benefits of periodontal surgery, the alternative treatments available, and the necessity for follow-up and self-care. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with my Dentist. After thorough deliberation, I hereby consent to the performance of gingival augmentation surgery as presented to me during the consultation and in the treatment plan presentation as described in this document. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my Dentist.

I certify that i have read and fully understand this document. I have also had all of my questions answered so that i am aware of all of the risks and benefits of the treatment above.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

MM slash DD slash YYYY