This form explains the risks, benefits, consequences, and alternatives to Bone Graft Transplant surgery; a procedure designed to repair bone defects resulting from damage to gum and bone tissue surrounding the teeth. The form also obtains the patient's consent to perform the procedure.
Informed Consent for Bone Graft Transplant Surgery
Facts for Consideration
I have been informed and afforded the time to fully understand the purpose and the nature of the bone graft surgery procedure. I understand what is necessary to accomplish the placement of the bone graft under the gum or on/in the bone. My doctor has examined my mouth and x-rays have been taken. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire a bone graft to help secure the replaced missing teeth.
Bone Graft is the procedure designed to repair bone defects resulting from damage to gum and bone tissue surrounding the teeth. A bone graft involves placing sterile bone constituents or minerals that may be synthetic, bovine or originating from human donors. After placement into the affected area, the bone graft is then covered by a membrane and sutures to keep it in place. Allergic responses or disease transmission resulting from this procedure have never been reported but still possible.
Bone Transplant or Bone Augmentation procedure is usually recommended when it's necessary to repair a bone defect resulting from damages to gums and bone tissue surrounding teeth or when there is a severe bone loss following the loss of teeth. This procedure involves removing a piece of bone from the patient's jaw bones (chin/back of lower jaw) - donor site and placing it into the bone defect/affected area - recipient site. The donor site(s) may be filled with sterile bone constituents or minerals that may be synthetic, bovine or originating from human donors to aid in the regeneration of that bone. A special membrane may be placed to cover and protect transplanted sites.
I understand that the dentist providing treatment is a general practitioner with advanced training in this field and 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 Bone Graft 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 this 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 bone graft. 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 with 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, 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 must notify your 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 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.
It has been explained that in some instances bone grafts fail (mal-union, delayed union, or non-union of the donor bone graft to the recipient bone site) and must be removed. It also has been explained to me that lack of adequate bone growth into the bone graft replacement material could result in failure. I am aware that there is a risk that the bone graft surgery mail fails, which might require further corrective surgery or the removal of the bone graft with possible corrective surgery associated with the removal. If the bone graft surgery fails, alternative prosthetic measures may have to be considered.
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 were administered or ongoing treatment was interrupted or discontinued, my condition would continue and probably worsen. I also understand that not placing a bone graft/transplant into the affected area may prevent a future restoration of this area with a bridge, denture or implant.
Alternatives to Surgical Periodontal Treatment
I elected the treatment listed above even though the alternatives 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 bone graft transplant 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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