This form explains the risks, benefits, consequences, and alternatives to a Dental Implant Placement procedure; a procedure that involves screwing artificial teeth into your jawbone. The form also obtains the patient's consent to perform the procedure.
Informed Consent Discussion for Dental Implant Placement
Facts for Consideration
Surgical implant placement involves making a small hole in your jaw bone, threading the implant into place in the same manner as a common screw might be inserted into wood. The implants are allowed to settle or "integrate" to the bone for several months. After integration, the implants may be placed into service anchoring crowns, bridges, or dentures.
Dental implants can restore single or several missing teeth to help prevent drifting, decay, gum disease, and premature loss of remaining teeth. Multiple implants can be used to replace removable dentures where there is inadequate bony ridge to allow your dentures to stay in place by themselves. There are alternatives to implants procedures as noted below.
Risks of Dental Implant Placement, NOT Limited to the Following
I understand my gums may bleed or swell and I may experience moderate discomfort for several hours after the anesthesia wears off and there may be slight soreness for a few days which may be treated with pain medications. I will notify the office if condition persists beyond a few days.
I understand that I will receive a local anesthetic and/or other medications. In rare instances, patients have a reaction to the anesthetic, which may require emergency medical attention, or find that it reduces their ability to control swallowing. This increases the chance of swallowing foreign objects during treatment. In case of swallowing or aspiration of a foreign object, a chest x-ray and examination by my medical doctor may be necessary to determine the location of the object and proper treatment. Depending on the anesthesia and medications administered, I may need a designated driver to take me home. Rarely, temporary or permanent nerve injury can result from an injection.
I understand that all medications have the potential for accompanying risks, side effects, and drug interactions and that it's critical that I tell my dentist about all medications I am currently taking.
I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it more difficult for me to open wide for several days. However, this can occasionally be an indication of a further problem. I will notify the office if this or other concerns arise.
I understand that because treatment may involve contact with bacteria and non-sterile tissue in my mouth, I may also experience an infection, which would be treated with antibiotics. I will immediately contact the office if I experience fever, chills, sweats or numbness.
I understand that because everybody has different bone density, there may be inadequate bone to hold implants, or alternatively, bone may be too dense to allow safe insertion. Sometimes irregular or inadequate bone structure allows implants to "stick out" from the bone, causing soreness and possibly requiring modification or removal. If the bone is inadequate to support implants, my doctor may have to harvest additional bone from other areas of my mouth, leaving an additional wound to heal.
I understand that upper implants may extend close to sinuses, and it is not possible to know exactly where the sinuses are located. Placing implants into this area may lead to sinus complications that may require further treatment, or may cause the implants to fail and requiring their removal.
I understand that implant placement may result in damage to the nerves that run through my jaw, causing itching, tingling, burning, or the loss of all sensation in the area. I understand that these changes could last from several weeks to several months or in some cases, indefinitely.
I understand that implant placement may cause a fracture in the surrounding bone, causing the surgical procedure to become more complex.
I understand that the instruments used in placing an implant may unavoidably chip or damage adjacent teeth or dental restorations.
I understand that Implants, once securely in place, may loosen over time and require surgical removal.
I was advised that every effort is made to evaluate my situation for known risk factors that may cause complications. I was advised because the healing process varies for each individual it's not possible to guarantees the final results.
I understand that unexpected additional treatment may become necessary due to complications of surgery. If unexpected difficulties occur during treatment, I may be referred to an oral surgeon or periodontist, who are specialists in the areas of oral surgery and periodontal surgery respectively.
I understand that unforeseen complications may increase the cost of proposed treatment, or may cause additional costs involved in treatment complications, including costs involved in removal of implants should that become necessary.
I understand that every reasonable effort will be made to ensure that my condition is treated properly, although it's not possible to guarantee perfect results. By signing below, I acknowledge that I have received adequate information about the proposed treatment, that I understand this information and that all of my questions have been answered to my satisfaction.
Alternatives to Dental Implants
Please Sign Here (Patient)
I attest that I have discussed the risks, benefits, consequences, and alternatives to this treatment with the patient who had the opportunity to ask questions, and I believe my patient understands what has been explained.
Please Sign Here (Dentist)
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