There is no method that will accurately predict or evaluate how my gum and bone tissues will heal. I understand that there may be a need for additional therapies or procedures if the initial results are not satisfactory to maintain health. In addition, the success of any periodontal procedure can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and/or grinding of teeth, inadequate oral hygiene, and medications that I may be taking. To my knowledge, I have reported to my doctor any prior drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any way relate to this surgical procedure. I understand that failure to do so may compromise surgical results.
I understand that alternatives to oral surgery include: 1) no treatment, 2) root canal therapy of the tooth/teeth in question with the knowledge that this may not fully eliminate the infection and the tooth may still be lost, 3) placement of a filling or crown (cap) on the tooth/teeth in question with the knowledge that the tooth may still be lost, 4) performance of periodontal surgery on the tooth/teeth in question with the knowledge that the tooth in question may still be lost. I understand that failure to receive the care recommended by my doctor may result in a worsening of my dental condition, additional bone loss at the tooth/teeth in question and/or adjacent teeth, increased health risks due to the spread of infection, increased treatment time and expense, and destruction of underlying oral structures to yield fewer treatment options should I decide on surgical treatment at some point in the future.
I understand that it is important for me to continue to be seen for regular dental care. In most cases, replacement of extracted teeth should be completed as soon as possible to minimize movement of adjacent teeth and to maintain as much dental function as possible. I understand that the failure to follow such recommendations could lead to ill effects, which would be my sole responsibility.
I recognize that natural teeth and appliances should be maintained daily in a clean, hygienic manner. I will need to comply with appointments following the surgery so that my healing may be monitored and so that my doctor can evaluate and document the outcome of surgery upon completion of surgical post-operative healing. Smoking, alcohol intake, and/or poor nutrition may adversely affect the gum and bone healing and may limit the success of my surgery. I know that it is important 1) to abide by the specific prescriptions and instructions given to me by my doctor and 2) to see my doctor for periodic examination and preventative 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 would be successful. Due to individual patient differences, the certainty of success cannot be predicted. There is a risk of failure, relapse, need for additional treatment, or even worsening of my present condition, including the loss of teeth, despite the best care.
I authorize photos, slides, x-ray films, or any other viewing of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes.
I have been fully informed of the nature of the dental extraction(s) to be performed, the specific procedure to be utilized, the risks and benefits of the surgery, the alternative treatments available, and the necessity for follow-up and 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 doctor. After thorough deliberation, I hereby consent to the performance of oral surgery as presented to me during consultation and in the treatment plan presentation as described in the document. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my doctor.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.