Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing.
___ 1. I have been treated with oral Bisphosphonate drugs and understand that there is a small risk (< 1 %) of developing osteonecrosis of the jaw (bone cell death) that can occur subsequent to dental treatment including routine extraction of teeth. The jaw bones usually heal completely, but in some patients taking Bisphosphonate drugs, the ability of the bone to heal may be altered, interfering with the jaw's ability to heal normally. This risk is minimally increased in procedures like tooth extraction, tissue surgery, implant placement or other procedures that cause damage to the bone. If the bone cannot tolerate and heal this injury, osteonecrosis (dead bone cells) can occur leading to infection and the need for further treatment.
___2. I understand that the risk of osteonecrosis can be increased by certain medical conditions including diabetes, immune suppression, and cancer as well as social habits like chronic smoking.
___ 3. My medical/dental history is very important. I have given an accurate list of the medications that I have received or taken before, and are receiving or taking now. I have provided a thorough and accurate medical history, including the names of all of my physicians.
___ 4. The decision to stop oral Bisphosphonate drug therapy before dental treatment should only be made after talking with my medical doctor and treating oral surgeon.
___ 5. If a complication occurs, antibiotic therapy may be used to help control infection. For some patients, such therapy may cause allergic responses or have undesirable side effects such as stomach discomfort, diarrhea, swelling of the colon, etc.
___ 6. In the rare circumstance where osteonecrosis occurs, in some cases, treatment may be long and difficult. I might need ongoing intensive therapy that could include hospitalization, taking antibiotics for a long time, and removal of dead bone. Reconstructive surgery may be needed, including bone grafting, metal plates and screws, and/or skin flaps and grafts.
___ 7. Even if there are no immediate complications from the proposed dental treatment, the area may be subject to breakdown at any time due to the unstable condition of the bone. Even the smallest trauma from a toothbrush, chewing hard food, or denture sores may set off a complication. This risk is higher the longer the bisphosphonate medications have been taken.
____ 8. I may need to see my surgeon on a long-term basis after surgery to check my condition. It is very important that I keep all of my scheduled appointments. Regular and frequent dental check-ups with my dentist are important to try to prevent a breakdown in my oral health.
____ 9. I have read the information above and understand the possible risks of having my planned treatment. I understand and agree to the following treatment plan:
____ 10. I realize that even though the doctors will take all precautions to avoid complications; the doctor can’t guarantee the result of the proposed treatment.
I understand that the treatment I am about to undergo may be impacted by the medications I have taken. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form.
Patient’s (or Legal Guardian’s) Signature Date
Doctor’s Signature Date
Witness’ Signature Date