Consent for Dental Implant Placement - ProSites

[Pages:2]Consent for Dental Implant Placement

After a careful oral examination and study of my dental condition, my periodontist has advised me that one or more of my missing teeth may be replaced with artificial teeth supported by a dental implant. I understand that the procedure for placement of a dental implant involves placing the dental implant into one of my jawbones. I understand that there is a surgical phase, wherein the dental implant is actually placed, a healing phase, and a prosthetic phase, wherein the artificial tooth or teeth is/are secured onto the dental implant.

I understand during the surgical phase I will be administered a local anesthetic with a vasoconstrictor which will make my mouth numb, decrease bleeding, and avoid pain. Incisions will be made in my gum tissue to allow access to my jawbone. The dental implant will then be secured by placing it into a hole in my jawbone prepared with a drill. My gum tissue will then be repositioned over or around the dental implant and secured with sutures. Healing will be allowed to occur for a period of two (2) to six (6) months.

I further understand that if, during surgery, clinical conditions present unfavorably for the use of this dental implant system or prevent placement of the dental implant, my periodontist will make a professional judgment on the management of this situation. The procedure may need to be cancelled or may involve the use of bone grafts or other types of grafts to build up the ridge of my jawbone to allow placement, security, and gum closure of the dental implant. I have discussed the risks and benefits of any type of regenerative material and authorize its use during my surgery. I also understand that if a bone graft is required, it may delay placement of the dental implant while the graft is attempting to regenerate my lost bone. For dental implants requiring a second surgical phase, my overlying gum tissues will be opened at the appropriate time and stability of the dental implant will be determined. If satisfactory, an attachment (or abutment) will be secured onto the dental implant. Plans and procedures to connect an artificial tooth or prosthetic may then begin. I understand that at this point, I will be referred back to my general dentist or prosthodontist for fabrication and attachment of the artificial tooth or prosthetic appliance. I understand that the cost for the restorative procedures is not included in the charge for this surgery.

I understand that dental implants should last for many years but that no guarantee of success for any specific period can be or have been given. I also understand that this treatment may not be successful, that problems may arise during the procedure which may prevent placement of one or more dental implants, and that rejection of any dental implant is possible, which would necessitate its removal. Should this occur, it may be possible to insert other dental implants after a suitable healing period, and that an additional charge may apply for this new procedure. I am also informed that although a good cosmetic result is desired, it cannot be guaranteed.

Additional surgical procedures for the gum tissue may be necessary to achieve better esthetics. This procedure will be done at an additional cost, however, no guarantee for gingival appearance around the dental implant or teeth can be or have been given to me.

I understand that despite the best of care, dental implants can fail requiring removal from my jawbone. This situation may occur as a result of infection, change in my health status, trauma, and/or improper use. I understand that I must maintain my teeth and dental implants in a clean and hygienic manner.

Failure to attend regular dental examinations and maintenance appointments may result in failure of the dental implant. I also understand that tobacco use, alcohol consumption, and sugar intake may affect gum healing and limit the success of the dental implant. I understand that there will be no refund of the fees in the event of failure of the dental implant.

I understand that complications may result from any periodontal surgery, drugs, or anesthetics administered. These complications include but are not limited to: postsurgical infection, bleeding, bruising, swelling and pain, clicking or pain in the jaw joints, injury to the adjacent teeth, inflammation of a vein, jawbone fractures, penetration of the sinus, and transient, but on occasion, permanent numbness of the jaw, lip, tongue, teeth, chin or gums.

I have been informed of the alternative treatment options to the use of dental implants including: no treatment, use of conventional crown and bridge restoration, and partial or complete removable prosthesis (dentures).

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT. I CHOOSE TO PROCEED WITH THE DENTAL IMPLANT PLACEMENT SURGERY FOR TREATMENT OF MY PERIODONTAL CONDITION AS DESCRIBED ABOVE.

______________ Date

______________ Date

____________________________________ (Printed Name of Patient/Guardian)

____________________________________ (Signature of Patient/Guardian)

___________________________________ (Printed Name of Witness)

___________________________________ (Signature of Witness)

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