Download Periodontal Surgery Consent Form

INFORMED CONSENT FOR PERIODONTAL SURGERY
DIAGNOSIS: After a careful examination of my dental condition, Doctor Maxfield has
advised me that I have periodontal disease. I understand that this condition weakens
the support of my teeth by separating the gum and bone attachment away from my
teeth. The “pockets” formed by this separation allow more bacteria and tartar to
accumulate under the gum and cause further deterioration. Untreated, this condition can
cause a painful abscess or infection as well as tooth loss.
RECOMMENDED TREATMENT: In order to treat this condition, it has been
recommended that periodontal surgery be performed in certain areas of my mouth. I
understand that local anesthesia will be used as part of the treatment. I understand that
unforeseen conditions may call for changes in the anticipated surgical plan and that
these may include extraction of hopelessly infected teeth to enhance the healing of
adjacent salvageable teeth.
EXPECTED BENEFITS: The purpose of the procedure is to reduce the gum infection
and resultant inflammation and to restore my gum and bone to a healthy state. The
surgery is intended to help me keep my natural teeth and to make my home care and
dental hygiene visits more effective.
PRINCIPAL RISKS: I understand that a small number of patients do not respond
successfully to periodontal surgery and that, despite the doctor’s best efforts, involved
teeth may be lost. Periodontal surgery may not be successful in restoring the function or
appearance of my teeth. Exposure of the root surfaces or the collars/margins of
caps/crowns may occur. At my own cost, I may wish to have additional dental treatment,
such as new crowns or bridges, from my regular dentist to correct these unavoidable
problems. I understand that periodontal surgery does not “cure” the disease. It does help make
home care more effective and allows my dentist and hygienist to better care for my
teeth. I understand that complications may result. These include, but are not limited to
(1) post-surgical infection, (2) bleeding, swelling, and pain, (3) facial discoloration, (4)
transient or occasional tooth sensitivity to hot, cold, sweet, or acidic foods, (5) allergic
INITIALS ___________
reactions, (6) short term or permanent numbness, and (7) accidental swallowing of foreign
matter. The exact duration of any complication can’t be determined, and they may be
irreversible. There is no method to accurately predict how my procedure will heal. I understand
that a second procedure may be needed if the initial procedure proves to be unsatisfactory. In
addition, the success of periodontal surgery can be adversely affected by (1) medical
conditions, (2) smoking, (3) excessive alcohol consumption, (4) diet and nutrition problems, (5)
clenching and grinding of my teeth, (6) inadequate oral self-care, and (7) medications that I
may be taking. To the best of my knowledge, I have told Doctor Maxfield about any prior
drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any
way relate to this surgical procedure. I understand that my diligence in providing my
personal daily self-care and taking my medications as prescribed are important to the
ultimate success of this surgery.
NECESSARY FOLLOW-UP CARE AND SELF-CARE: I understand that it is important
for me to continue to see my regular dentist. From time-to-time, Doctor Maxfield may
recommend (1) the replacement or modification of existing dental restorations by my
regular dentist, (2) extraction of certain teeth, (3) root canal therapy, (4) or orthodontic
tooth movement. I understand that failure to follow these recommendations may
adversely affect the outcome of the proposed periodontal treatment. I recognize that
natural teeth and dental appliances should be maintained daily in a clean and hygienic
manner. I will need to come back for follow-up appointments so that my healing can be
monitored. Smoking or excessive alcohol consumption may adversely affect periodontal
surgery and may limit the success of my surgery.
NO WARRANTY OR GUARANTEE: I understand that it is illegal for Doctor Maxfield to
guarantee any dental/medical treatment. Due to individual differences, there always is
a risk of failure, relapse, additional treatment, or even worsening of my condition despite
the best possible care.
I have read this form and all of my questions were answered to my satisfaction
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Patient’s Signature
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Date