This form explains the risks, benefits, consequences, and alternatives to Periodontal treatment; Treatments for gum disease. The form also obtains the patient's consent to perform the treatment.
Informed Consent for Surgical Periodontal Treatment
Facts for Consideration
Dental x-rays will be taken to check the condition of the bone that supports your teeth. A thorough examination of your oral cavity will be done measuring the pockets under the gums surrounding the teeth to determine which periodontal treatment(s) your gum condition requires.
One type of surgical treatment called a gingivectomy is the surgical removal of diseased gingival (gum tissue) to reduce or eliminate periodontal pockets that have failed to respond to more conservative treatment such as scaling and curettage. It includes deep scaling and planing of the root surfaces exposed during the surgery.
Sedation or medication might be prescribed prior to surgery. Treatment may also include flap surgery which involves cutting and lifting up a small area of the gums to expose the boney defects around the tooth. The affected tissue may be cleaned out, the bone recontoured, or real or synthetic bone material may be grafted into the site. A barrier membrane may also be inserted and sutured into place, and a periodontal dressing may be placed over the area of surgery. A gingival graft involves moving gum tissue from one site to another. Often this is done to cover an exposed root, or to provide a zone of attached gingiva (gum tissue) around a tooth where the normal tissue has receded. A crown lengthening is a procedure, during which gum and bone tissue are reshaped to expose more of the natural tooth. It may be recommended if your tooth has decayed or broken below the gum line and/or has insufficient tooth structure for a restoration, such as crown and bridge. It may also be recommended for cosmetic reasons when crowns and veneers are placed.
The success of the treatment depends in part on your efforts to brush and floss daily, receive regular cleaning as directed, follow a healthy diet, avoid tobacco products and follow proper home care taught to you by this office.
A topical or local anesthetic is administered depending on the location and depth of the area to be treated.
Benefits of Surgical Periodontal Treatment, NOT Limited to the Following:
Surgical periodontal treatment can: help to create a clean environment in which your gums can heal; help to reduce the chance of further gum irritation or infection; make it easier for you to keep your teeth clean; improve your chance to retain teeth and their function; and decrease the cost of replacing teeth lost due to gum disease. This course of treatment will help to improve your condition and prevent the disease from spreading or worsening.
Risks of Surgical Periodontal Treatment, 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 a 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 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 cleanings involve contact with bacteria and infected 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 as my gum tissue heals, it may shrink somewhat, exposing some of the root surfaces. This could make my teeth more sensitive to hot and cold. I also understand that following treatment, I may have spaces between my teeth at the gumline, which could trap food particles and requires special maintenance. I understand additional surgical procedures are available to protect the sensitive areas.
I understand that depending on my current dental condition, existing medical problems, or medications I may be taking, these methods alone may not completely reverse the effects of gum disease or prevent further problems. Teeth that become loose as a result of periodontal disease may be extracted, which may require replacing the teeth with fixed or removable bridge, denture, or artificial teeth called implants.
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 periodontal condition would continue and probably worsen. This could lead to further inflammation and infection of gum tissues, tooth decay above and below the gumline, deterioration of bone surrounding the tooth and eventually, the loss of teeth.
Alternatives to Surgical Periodontal Treatment
I had the opportunity to discuss any alternatives to this treatment with my dentist. All of my questions were answered to my satisfaction regarding such alternatives and their risks, benefits, and costs.
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 surgical periodontal treatment 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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