On careful oral examination and study of my dental condition, Dr._________________________ has advised me that I have periodontal (gum) disease. I understand that periodontal disease weakens support of my teeth by separating the gum from the teeth and can also be destructive for the bone that supports the teeth. This separation of the gums (pockets) allows for greater accumulation of bacteria under the gum and can result in further erosion or loss of bone and gum supporting the roots of my teeth. If untreated, periodontal disease can cause teeth loss and has other adverse consequences.
My dentist has recommended periodontal surgery. I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of the 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 to the roots and to the eroded bone. Inflamed and infected gum tissue will be removed and the root surfaces will be thoroughly cleaned. Bone irregularities may be reshaped and bone regenerative material may be placed around my teeth. My gum will then be sutured back into position and a periodontal bandage or dressing may be placed.
I further understand that unforeseen conditions may call for a modification or change from the anticipated surgical plan. These may include, but are not limited to:
The purpose of periodontal surgery is to reduce infection and inflammation and to restore my gum and bone. The surgery is intended to help me keep my teeth in the operated areas and to make my oral hygiene effective.
I understand that a small number of patients do not respond successfully to periodontal surgery and in such cases, the involved teeth may eventually be lost. Periodontal surgery may not be successful in preserving function or appearance. Because each patient's condition is unique, long-term success may not be possible.
I understand that complications may result from the periodontal surgery, drugs or anesthetics.
These complications include, but are not limited to:
The exact duration of any complications cannot be determined and may be irreversible. There is no method that will accurately predict or evaluate how my gum and bone will heal. I understand that there may be a need for a second procedure if the initial results are not satisfactory.
In addition, the success of periodontal procedures can be affected by medical condition, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene and medications that I may be taking.
To my knowledge, I have reported to my dentist any prior drug reactions, allergies, diseases, symptoms, habits or conditions that might in any way relate to this surgical procedure.
I understand that taking care as recommended by my dentist and medications as prescribed is important to the ultimate success of the procedure.
I understand that alternatives to periodontal surgery include:
I understand that it is important for me to see my dentist on a regular basis. Existing restorative dentistry can be an important factor in the success or failure of periodontal therapy. From time to time, my dentist may make recommendations for the placement of restorations, the replacement or modification of existing restorations, the joining together of two or more of my teeth, the extraction of one or more teeth, the performance of root canal therapy or the movement of one, several or all of my teeth. I understand that the failure to follow such recommendations could lead to ill effects. I recognize that natural teeth and their artificial replacements 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 my dentist 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 dentist and (2) to see my dentist for periodic examination and preventive treatment. Maintenance also may include adjustment of prosthetic appliances.
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 benefit in reducing the cause of my condition and should produce healing which will help me keep my teeth. Due to individual patient differences, however, a dentist cannot predict certain success. There is a 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.
I authorize photos, slides, X-rays 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.
Date: ________________________
Patient: _________________________
Signature: ___________________________
