Consent for periodontal surgery

MM slash DD slash YYYY
Patient name:

I understand that I have a form of periodontal disease that has caused damage to the soft tissue and/or bone around my teeth and is endangering the health of my oral tissues. This disease, if left untreated, is generally non-reversible and can be progressive, leading to further damage and possible loss of my teeth.

I also understand that a variety of surgical procedures are used to treat periodontal disease. While these surgical procedures are generally successful, I understand that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be curative and/or successful to my present condition may result despite the treatment.

It has been explained to me that the long-term success of treatment requires my cooperation and performance of effective plaque control (home care) on a daily basis. Equally important are periodic periodontal maintenance visits at a dental office after the proposed surgical treatment is performed. This is because most periodontal disease is chronic in nature and requires continuing treatment to keep it under control. Periodontal disease is rarely curable even with the most effective treatment.

I further understand that the rate of the progression of the disease is variable and unpredictable, but if no treatment is rendered, my present periodontal condition will probably worsen in time, which may result in premature tooth loss.

I have been informed that other possible alternative methods of treatment include: no treatment, nonsurgical treatment (root planning followed by periodic maintenance), other surgical treatment procedures, or extraction.

Although complications from periodontal surgery are rare, they can occur. The most common complications are as follows but are not limited to: post-surgical discomfort, bleeding, swelling, tooth sensitivity, infection, gum recession (shrinkage) with tooth elongation, increased tooth looseness, food impaction between teeth after eating, and/or unaesthetic exposure of crown margins. 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.

DESCRIPTIONS OF PERIODONTAL SURGERIES TO BE PERFORMED:

There are several types of periodontal surgeries that may be performed. Below are some examples of what may be performed:

  • REPLACED FLAP THERAPY - Under local anesthesia, the gum tissue is surgically detached from the teeth and gently retracted to expose the roots. After thoroughly cleaning the root surfaces, the tissue is secured back in place with sutures. Sometimes smoothing or re-contouring the underlying bone is necessary.
  • REGENERATIVE THERAPY - This is a variable of the procedure. In addition to thoroughly cleaning the root surfaces, various materials may be placed under the tissue in an attempt to regenerate the connective tissue and/or bone previously destroyed by the disease process. These materials do not guarantee the regeneration of the lost support but have been demonstrated to be more effective than replaced flap therapy. The following materials are commonly employed:
  • Bone particles obtained by the re-contouring process above are placed into the bony defect to stimulate growth.
  • Inert, man-made “bone crystals”, composed of the same minerals as in natural bone, are used to fill the bony defects.
  • Membranes of Teflon or other substances are placed between the gum tissue and the bone and secured in place with sutures. These aids the repair process by preventing the soft gum tissue from interfering with the new bone formation during the early stages of the healing period. A second surgical phase may be required to remove the membrane after a suitable healing period.
  • One of the most common tissues used today in regenerative techniques is decalcified freeze-dried bone. This material is taken under sterile conditions from donors with no known systemic disease, and blood tests are negative for any infection. The tissue is also tested (cultured), then decalcified and processed under strict laboratory conditions known to kill all bacteria and viruses under experimental conditions. It is then cultured again for any contamination and stored in a vacuum-sealed sterile container until it is ready to be opened during the surgical procedure.
  • CROWN LENGTHENING - The gingival margin (gum-line) is altered to expose more of the tooth. This may be desirable to decrease the pocket depth around the teeth, to improve the ability to clean the area, or to allow the restorative to restore a badly broken down tooth. This procedure often requires the removal of some of the bone around the necks of the teeth.
  • MUCOGINGIVAL SURGERY - Gum tissue may be moved or transplanted from one area of the mouth to another in an attempt to reinforce the gum-line or to cover an area of the exposed root surface. If the roof of the mouth is used as the donor site, a protective plastic liner may be placed to protect that area while it is healing.
  • ROOT RESECTION - In some cases, only one root of a multi-rooted tooth is affected. Rather than remove the entire tooth, the infected root can be removed using surgical procedures described above (replaced flap/crown lengthening). Sometimes a portion of the crown is removed at the same time.
  • OTHER

I understand that risks related to the recommended treatments may include, but are not limited to the following:

11. Allergic reactions to any dental products and materials.
12. Bleeding
13. Swelling, ecchymosis, bruising.
14. Infection
15. Pain
16. Exposure of the root surface (recession) and/or dentinal hypersensitivity
17. Exposure of gaps between the teeth h. Exposure of crown and bridge joints
18. Temporary restriction of mouth opening
19. Increase tooth mobility
20. Possible paresthesia of dental nerves (teeth, lips, tongue, cheeks, palate...)

I understand that refusing treatment of my condition may impact my oral and general health. Consequences may include but are not limited to:

21. Impossibility to do the crown
22. Progression of loss of bone support around tooth/teeth
23. Premature loss of tooth/teeth

I understand the necessity of maintaining good oral hygiene for better healing and the importance of postsurgical appointments. I also understand the importance to strictly follow my Dentist's recommendations. Tobacco and alcohol products may affect healing negatively after periodontal surgeries and may also affect the maintenance of surgical results.

I understand that I have been given no warranty nor guarantee pertaining to the success of the suggested treatment. In most cases, the suggested treatment should reduce the causes of my periodontal condition and may permit me to keep my teeth for a longer period of time. Because of variations with patients’ home self-oral care and medical health, the periodontist cannot positively predict the success of provided treatments. Even with optimal treatments, there are always risks of failure which may require re-treatment. The risks of degeneration of my periodontal condition may be still present and may lead to loss of teeth.

INFORMED CONSENT

I CERTIFY THAT I HAVE FULLY READ AND UNDERSTAND THE ABOVE CONSENT TO THE SURGICAL TREATMENT. I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK ANY QUESTIONS OR REQUEST A MORE DETAILED EXPLANATION, AND TO DISCUSS WITH THE DOCTOR PAST MEDICAL HEALTH HISTORY INCLUDING ANY SERIOUS PROBLEMS, INJURIES, OR ALLERGIES.

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