Discussion and Informed Consent for Bone Grafting and/or Regeneration

Discussion and Informed Consent for Gingival Graft
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Treatment:
Facts for Consideration

Patient's initials required
I have been informed that I have a mucogingival (gum) problem around some of my teeth. This may mean I have insufficient attached gum tissue or a muscle attachment that could potentially cause the premature loss of teeth. I understand that where there is insufficient attached gingiva (gum), bacteria and food can become lodged under the gum line and this may result in further recession of the gum or localized infection (gum abscess). I also understand that where there are fillings at the gum line or crowns (caps) with edges under the gum line, it is important to have sufficient width of attached gingiva (gum) so that the edges of the fillings or crowns or the material from which they are made do not cause significant irritation to the gum. I have been advised and understand that gingival graft surgery can help this problem.
Initial
It has been explained to me that the surgical procedure involves the removal of a thin strip of gum generally from my mouth (usually the roof of the mouth) and transplanted/placed near the area of gum recession. The transplant can be placed at the base of the remaining gum or it can be placed to partially cover the tooth root surface exposed by the recession. If the latter is attempted, I understand that the gum placed over the root may shrink back during healing and that the attempt to cover the exposed root surface may not be completely successful.
Initial
After a local anestheticby injection has numbed the area to be operated, the gums will be reflected (incised) to expose the teeth and the roots of theteeth will then be cleaned and smoothed. Antibiotics and/or other chemicals maybe applied to the roots to decontaminatethem before the graft material is placed in the area(s).
Initial
Benefits of Gingival Graft, Not Limited to the Following:

Patient's initials required
The goal of the gingival grafting procedure is to strengthen the grafting site(s) by adding new keratinized (denser) attached gingiva to the area that can resist any future breakdown. This procedure can also cover exposed root surfaces, enhancing the appearance of the teeth and gum line and treating and minimizing root sensitivity or decay.
Initial
Risks of Gingival Graft, Not Limited to the Following:

Patient's initials required
I understand with surgery that there may be postoperative bleeding, swelling, pain, infection, facial discoloration and temporary or, on occasion, permanent tooth sensitivity to hot, cold, sweet or acidic foods. A temporary or permanent numbing of the surgical areas, including the gums, lips and chin, may occur.
Initial
I understand that a small number of patientsdo not respond successfully to gingival grafting. If a transplantis placed to partially cover the tooth root surface exposed by recession, thegum placed over the root may shrink backduring the healing. In sucha case, the attempt to cover the exposed root surface may not be completelysuccessful resulting in more recession or increased spacing between the teeth.The graft may appear different in colorand thickness from the adjacent soft tissue.
Initial
I understand that I will receive a local anesthetic by injection and/or other medication(s). 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. Depending on the anesthetic and medications administered, I may need a designated driver to take me home. Rarely, temporary or permanent nerve injury can result from an injection resulting in loss of feeling in the chin, lips, gums and tongue and loss of taste.
Initial
I understand that all medications have the potential for accompanying risks, side effects, and drug interactions. Therefore, it is critical that I tell my dentist of all medications, and supplements that I am currently taking, which are:
I understand that smokingand/or chewing tobacco and/or alcohol intake may affect my ability to have normalgum and/or bone healing and may limit the potential for a successful outcome ofmy surgery. Smoking may adversely affect the extraction site healing and maycause “dry socket” (an infection of the bone of the socket walls). Smokers areat higher risk for “dry socket” and have more dry sockets than non-smokers. I agree to follow my dentist’s instructions related to daily care of my mouth, teeth and gums.
Initial
________ currently or in the past taken bisphosphonates for the purpose of treating osteoporosis.

I am I am NOT
Alternatives to Suggested Treatment:

Patient's initials required
I understand that alternatives to gingival grafting may include (1) no treatment, with the expectation of chronic inflammation resulting in the advancement of recession, which is commonly associated with increased sensitivity of the teeth to temperature extremes and other irritants, increased risk of decay in root surfaces exposed by the recession and possibly the premature loss of teeth; (2) attempts to insulate teeth to control sensitivity by placing fillings in or on root surfaces with the expectation of further recession as a result of this procedure; (3) nonsurgical scraping of tooth roots and lining of the gum (root planing and curettage) with the expectation that this will result in only a partial and temporary reduction of inflammation and infection, will not stop recession, will require more frequent professionalcare and may result in the worsening of my condition and the premature loss of teeth; (4) extraction of teeth involved with recession and a lack of attached gum tissue, which may need replacement with bridges, crowns or dental implants.
Initial
Check the boxes below that apply to you:
Consent
Refuse
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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.

Discussion and Informed Consent for Anesthesia/Sedation
Facts for Consideration

During dental treatment, patients may have difficulty understanding the procedure and/or its management because of either psychological issues, a cognitive, physical or medical disability, or fear and anxiety. Considering patient safety and comfort, they may benefit from behavior management through communication techniques or immobilization. In addition, the dentist may also identify the need for sedation medication and anesthesia for the patient’s comfort and behavior management. Anesthesia is a method of providing medication to reduce patient anxiety, awareness of the surgery or treatment and reduction or elimination of pain associated with surgery or treatment. Patients may require local anesthesia, or light to moderate conscious sedation, for their comfort during the performance of dental restorations or surgical procedures. The depth of anesthesia, except for local anesthesia, is a matter of degrees beginning at a low level called “light” and adjusted to lighter or deeper levels depending on the patient’s tolerance for the procedure and discomfort. Your dentist will recommend and explain to you which type of anesthesia might be appropriate for your individual medical/dental needs. In the case of a minor (anyone under the age of 18), the administration and monitoring of anesthesia may vary depending on the type of procedure, the typeof practitioner, the age and health of the patient and the setting in which anesthesia is provided. Risks may vary with each specific situation. You are encouraged to explore all the options available for your child’s anesthesia for his or her dental treatment, and consult with your dentist or pediatrician as needed.
Option 1: Local Anesthesia
Anesthetizing agents,(medications) are injected into a small area with the intent of numbing the area to receive dental treatment. They also can be injected near a nerve to act as a nerve block causing numbness to a larger area of the mouth beyond just the site of injection.
Initial
Risks include but are not limited to: It is normal for the numbness to take time to wear offafter treatment, usually two or three hours. This can vary depending on thetype of medication used. However, in some cases, it can take longer, and insome rare cases, the numbness can be permanent if the nerve is injured. Infection, swelling, allergic reactions,discoloration, headache, tenderness at the needle site, dizziness, nausea,vomiting, and cheek, tongue, or lip biting can occur.
Initial
Potential benefits: The patient remains awake and can respond to directions and questions. Pain is lessened or eliminated during the dental treatment.
Initial
Option 2: Conscious Sedation
Conscious sedation is a controlled, drug induced, minimally depressed level of consciousness or awareness that allows the patient to breathe independently and continuously respond appropriately to physical stimulation and/or verbal command, e.g., “open your eyes.”
Initial
Local anesthetic is still required to numb the area of treatment. This type of anesthesia may be administered orally (a drink or a pill), injected into a muscle or via a needle inserted into a vein.
Initial
Risks include but are not limited to: Infection, swelling, discoloration, bruising, headache, tenderness at the needle site and vein (phlebitis), dizziness, nausea and vomiting can occur. Adverse reactions to medication including allergic and life-threatening reactions are possible, though rare. Complications may require hospitalization or even result in brain damage or death. With any patient, reflexes are delayed. Children: Patients can have an immediate response to oral conscious sedation similar to being upset before the medication calms them. Adults: Patients must not drive a car or operate machinery for 24 hours after the termination of treatment, because the effects of sedation remain in the system even after the patient is awake and mobile.
Initial
Potential benefits: Pain is lessened or eliminated during dental treatment. Stress and anxiety can be greatly reduced and often there is no memory of the treatment.
Initial
Alternative Treatments, Not Limited tothe Following:
If a particular level of anesthesia does not relieve the patient’s anxiety or pain, in the dentist’s clinical judgment, and if the individual patient can tolerate it, another level of anesthesia may be needed. Not every dental office or dentist is equipped or trained to administer every type of anesthesia. It may be necessary to refer the patient to another facility or to another dentist who has the appropriate equipment or credentials, or an anesthesiologist may be utilized in the office. Those types of services may result in additional charges.
Initial
For All Female Patients
Because anesthetics,medications and drugs may be harmful to the unborn child and may cause birthdefects or spontaneous abortion, every female must inform the provider ofanesthesia if she could be or is pregnant. Anesthetics, medications and drugsmay affect the behavior of a nursing baby. In either of these situations, theanesthesia and treatment may be postponed.
Initial
For All Patients
Check the boxes below that apply to you: Consent

I have been informed, both verbally and from the information provided on this form, of the risks and benefits of the proposed treatment. I have been informed, both verbally and from the information provided on this form, of the material risks and benefits of both alternative treatment and of electing not to treat my condition. I certify that I have read and understand the above information that the explanations referred to are understood by me, that my questions have been answered and the blanks requiring insertions or completion have been filled in. I authorize and direct this dentist to do whatever he/she deems necessary and advisable under the circumstances. I consent to have agreed upon the following treatment: While the treatment may be covered by my medical and/or dental insurance; I accept any financial responsibility for this treatment and authorize treatment.
OR
Refusal

I refuse to give my consent for the proposed treatment(s) as described above and understand the potential consequences associated with this refusal.
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Discussion and Informed Consent for Gingival Graft

Facts for Consideration

Benefits of Gingival Graft, Not Limited to the Following:

Risks of Gingival Graft, Not Limited to the Following:

Alternatives to Suggested Treatment:

Check the boxes below that apply to you:

Discussion and Informed Consent for Anesthesia/Sedation

Facts for Consideration

Option 1: Local Anesthesia

Option 2: Conscious Sedation

Alternative Treatments, Not Limited tothe Following:

For All Female Patients

For All Patients

OR