5152 Blazer Memorial Parkway, Suite 100, Dublin, OH 43017 (614) 889-8222
5101 Forest Drive, Suite B, New Albany, OH (614) 933-9800 Consent to Surgery
Our practice is committed to providing patients with exceptional care. We want the very best results, but healing can be different from person to person. We must inform you of the positive and negative possibilities of treatment as well as alternatives to dental treatment. Please do not be offended by having to sign this form. We are guided by our obligation to you and the ethical standards of our profession to inform you of the possible risks and complicatons.
Type of Surgical Treatment to be Completed
_____ Periodontal Surgery _____ Implant placement
_____ Bone grafting for tooth preservation _____ Sinus Lift (Augmentation)
_____ Gingival Augmentation _____ Socket Preservation or Ridge Augmentation
_____ Frenulectomy _____ Surgical Exposure
_____ Other ________________________
In order to treat my current periodontal condition, my periodontist has recommended that my treatment may include any of the the surgical procedures as noted above. I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of my treatment. I further understand that antibiotics and other substances may be applied to the roots of my teeth. During this procedure my gum will be opened to permit better access and will then be sutured back into position. I consent to the use of grafting materials that are tested and safe. This may include materials from bovine, porcine and human (allografts) origins.
_____ Periodontal Surgery and Bone Grafting: The purpose periodontal surgery is to reduce infection and inflammation and to restore my gum and bone to the greatest extent possible. The surgery is intended to help me keep my teeth longer in the treated areas and to make my oral hygiene more effective. It should also enable professionals to better clean my teeth.
_____ Crown Lengthening: I understand that crown lengthening may be done for my dentist to better restore my tooth or teeth. It may also be done for cosmetic reasons in some cases.
_____ Gingival Augmentation: The reason for gingival grafting is to increase the amount of gum and to reduce the likelihood of further recession. In some cases root coverage may decrease the risk of root decay and sensitivity.
_____ Removals: I understand the reason for the removal of my tooth or teeth. I have agrees to the benefit of removing my tooth or teeth. The removal of a tooth may deem necessary for the following reasons: being non-restorable, having a root fracture, significant periodontal disease or its inability to be used in restoring my mouth with functioning teeth.
_____ Implant Related Procedures: The purpose of gingival augmentation, bone grafting, sinus augmentation and implant procedures are to be able to replace some teeth with implant supported crowns, bridges or dentures. This process can take significant time for healing.
Principle Risks and Complications: I understand that a small number of patients do not respond successfully to periodontal or implant surgery. In such cases, the involved teeth or implants may be lost. The procedure may not be successful in preserving and/or achieving function or appearance. Each patient’s condition is unique, long-term success may not occur. I understand that complications may result from the surgery, drug or anesthetics. These complications include but are not limited to post surgical infection, bleeding, swelling, pain, facial discoloration (bruising), transient but on occasion permanent numbness of the jaw, lip, tongue, teeth, chin or gum, jaw joint injuries or associated muscle spasm, transient but on occasion permanent increases in tooth looseness, tooth sensitivity to hot, cold, sweet, or acidic foods, shrinkage of gum upon healing resulting in elongation of some of the teeth (negative cosmetic changes),open gum spaces between teeth, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, impact of speech, allergic reactions, and accidental swallowing of foreign matter. The exact duration of any complications cannot be determined and they may be irreversible.
I understand that there may be a need for other procedures if the results are not satisfactory. In addition, the success of periodontal procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding teeth, inadequate oral hygiene and medications that I may be taking. To my knowledge, I have reported to my periodontitis any prior drug reactions, allergies, diseases, symptoms, habits, or conditions, which might in any way relate to the surgical procedure. I understand that my diligence in providing the personal daily care recommended by my periodontist and taking all prescribed medication are important to the ultimate success of the procedure.
Stoner Periodontic Specialists
5152 Blazer Memorial Parkway, Suite 100, Dublin, OH 43017 (614) 889-8222
5101 Forest Dr, Suite B, New Albany, OH 43054 (614) 933-9800
Alternatives to Suggested Treatment: I understand the alternatives to treating periodontal disease and gum recession include, no treatment – with the expectation of possible advancement of my condition which may result in premature loss of teeth.
Alternatives to implant related procedures such as partial dentures and fixed bridges have been discussed, and I understand the reasons that I have chosen this treatment. I understand the crowns on the implants are completed by my restorative dentist and his or her fees are separate. Necessary Follow-Up Care and Self Care:I understand that it is important for me to continue to see my regular dentist. Existing restorative dentistry can be an important factor in the success or failure for therapy. From time to time, my periodontist may make recommendations for the placement of restorations, replacement or modification of existing restorations, the joining together of two or more of my teeth, the removal of one or more teeth, the performance of root canal therapy, or the movement of one, several or all teeth. I understand that the failure to follow such recommendations could lead to ill effects, which would become my sole responsibility.
I recognize that natural teeth and appliances should be maintained daily in a clean hygienic manner. I will need to come for appointments following my surgery so that my healing may be monitored and so that my periodontist can evaluate and report on the outcome of surgery upon completion of healing. Smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery. I know that it is important (1) to abide by the specific prescriptions and instructions given by the periodontist and (2) to see my periodontist and dentist for examination and preventative treatment. Maintenance may also include the adjustment of prosthetic appliances.
No Warranty or Guarantee:I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefits in reducing the cause of my condition and should produce healing which will help me keep my teeth or replace teeth with dental implants. Due to individual patient differences, however, a periodontist cannot predict certainty of success. There is risk of failure, relapse, additional treatment, or even worsening of my present condition, including the possible loss of certain teeth, despite the best of care.
Publication of Records: I authorize photos, slides, radiographs or any other viewings of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes. My identity will not be revealed to the general public, without my permission.
Patient’s Statement of Consent:
I have been fully informed of the nature of the proposed surgery, the procedure to be utilized, the risks and benefits of the surgery, the alternative treatment available, and the necessity for follow-up self care. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with my periodontist. After thorough deliberation, I hereby consent to the performance of periodontal surgery as presented to me during consultation and in the treatment plan presentation as described in this document. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my periodontist.
I have read and understand all of the above.
Patient’s Name (please print): ________________________________________________