This form explains the risks, benefits, consequences, and alternatives to an Apicoectomy procedure; a procedure that is performed when a root canal filling has failed and a lesion is present at the end of the root that needs to be removed. The form also obtains the patient's consent to perform the procedure.
Informed Consent for Apicoectomy (Root Surgery)
I have been informed and afforded the time to fully understand the purpose and the nature of the apicoectomy procedure. My doctor has examined my mouth and x-rays have been taken. Alternatives to this treatment have been explained.
Apicoectomy or root resections is the procedure that is performed when a root canal filling has failed and a lesion is present at the end of the root that needs to be removed. The procedure involves making a small window in the bone near the root tips after reflecting the gum. The root tip is cut and usually, but not always, a different kind of filling is placed at the root end. The procedure is performed in an attempt to save the tooth from extraction. However, the tooth may still need to be extracted if other structural failures, such as root fracture, are found during the procedure. The procedure is between 50% to 75% successful, based on various studies and is not 100% guaranteed. Depending on the extent of the lesion or bone loss, a bone graft may be used to fill the area. This bone graft may require a separate fee.
I understand that the dentist performing this procedure is a general practitioner with advanced training in this field, and is not an oral surgeon or periodontist. I also understand that this procedure may not be covered by my dental insurance and I may be responsible for the entire fee. I had the opportunity to discuss fees and my financial responsibility with the office before the procedure was performed.
Risks of Apicoectomy Procedure, NOT Limited to the Following:
I understand that 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 the condition persists beyond a few days. I understand that smoking, alcohol, oral hygiene and blood sugar may affect gum healing and may limit the success of the procedure. I agree to follow my doctor's home care instructions and report back for regular examinations and follow up appointments.
I have further been informed of the possible risks and complications involved in this surgery, drugs, and anesthesia. Such complications include numbness of the lip, tongue, chin, cheek, or teeth. The exact duration may not be determinable and may be irreversible. Also, other possible risks are thrombophlebitis (inflammation of the vein), injury to the teeth present, bone fractures, sinus penetration, and delayed healing.
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.
My doctor has explained to me that there is no method to predict accurately the gum and bone healing capabilities in each patient following the placement of a bone graft. It has been explained to me that bone, in its healing process, remodels and there is no method to predict the final volume of bone, thus additional grafting may be 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.
Consequences if NO Treatment is Administered, NOT Limited to the Following:
I understand that if no treatment was administered or ongoing treatment was interrupted or discontinued, my condition would continue and probably worsen. I understand that I may choose to do nothing. In that case, the infection may continue and cause pain in the future. I also understand that I can have the tooth extracted and restore the areas with a bridge, denture, or implant.
Alternatives to Surgical Periodontal Treatment
I elected the treatment listed above, even though there are alternatives that have been explained to me.
No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above.
[x] I consent to the apicoectomy root surgery as described above.
Please Sign Here (Patient)
[x] 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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