There is no method that will accurately predict or evaluate how the gum and bone will heal before the surgery is done. I understand that there may be a need for a second surgery if the initial results are not satisfactory. In addition, the success of periodontal procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and medications (including over-‐the-‐counter medications such as aspirin, nutritional supplements and herbs that I may be taking). To my knowledge, I have reported to my doctor any prior drug reactions, allergies, diseases, symptoms, habits, or conditions that might in any way relate to this surgical procedure. I have also told my doctor about any present or prior head and neck radiation therapy and present or prior use of bisphosphonate (for osteoporosis) medications. Some common brand names are Zometa, Aredia, Boniva, Fosamax, and Actonel.
5. Alternatives to Suggested Treatment.
Alternative treatment to gum grafting surgery include: No treatment, continued monitoring for progressive recession, and modification of technique for brushing my teeth.
6. Necessary Follow-up Care and Self-Care.
I understand that it is important for me to continue to see my regular dentist. Existing restorative dentistry can be an important factor in the success or failure of gingival augmentation. I recognize that natural teeth and appliances 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 so that my periodontist can evaluate and report on the outcome of surgery upon competition 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 my periodontist and (2) to see my periodontist and dentist for periodic examination and preventive treatment. Maintenance may also include adjustment of prosthetic appliances.
7. Unforeseen Conditions.
During the surgery, unforeseen conditions could be discovered which would call for a modification or change from the anticipated surgical plan. These may include, but are not limited to termination of the procedure prior to completion of all of the surgery originally scheduled. I therefore consent to the performance of such additional or alternative procedures as may be deemed necessary in the best professional judgment of my periodontist.
8. No Warranty or Guarantee.
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 periodontist cannot predict certainty of success. There is a risk of failure, relapse, additional treatment, or worsening of my present condition, including the possible loss of certain teeth, despite the best care.
9. Use of Records for Reimbursement and Publication Purposes.
I authorize photos, video recordings, x-‐rays, slides, or any other viewings of my care and treatment during or after its completion to be used for the advancement of dentistry, educational use in lectures or publications and reimbursement purposes. My identity will never be revealed to the general public.
10. Females only.
Antibiotics may interfere with the effectiveness of oral contraceptives (birth control pills), which can result in pregnancy. Therefore, I understand that I will need to take extra precautions and use some additional form of birth control when taking antibiotics. Furthermore, I have informed my periodontist of my pregnancy and/or nursing status.