Complications from the Pinhole Surgical Technique may include but are not limited to: bleeding, bruising and swelling, pain, infection, transient or even permanent tooth sensitivity, temporary and even permanent numbness of the lips, chin and gums, allergic reactions and accidental swallowing of foreign matter. The exact duration of any complications cannot be determined and they may and they may be irreversible. To my knowledge I have reported to the periodontist 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 the personal daily care recommended by my periodontist and taking all prescribed medications is important to the ultimate success of the procedure.
Alternatives to Suggested Treatment: My periodontist has explained alternative treatments for my gum recession and modifications of techniques for brushing my teeth.
Necessary Follow-up Care and Self-Care: I understand that it is important for me to continue to see my regular dentist. I recognize that natural teeth and their artificial replacements should be maintained daily in a clean, hygienic manner. I will need to come for appointments after my surgery so that my healing may be monitored and so that my periodontist can evaluate and report on the outcome of the Pinhole Surgical Technique. I know that it is important to abide by the specific prescriptions and instructions given by the periodontist and to see my periodontist and dentist for periodic examinations.
No Warranty or Guarantee: I hereby acknowledge that 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 optimum healing which will help me keep my teeth. Due to individual patient differences, a periodontist cannot predict certainty of success. Rarely, there is a risk of failure, relapse, additional treatment or even a worsening of my present condition including the possible loss of certain teeth, despite the best of care.
Use of Records: I authorize photos, slides, x-rays or any other viewing of my care and treatment during or after its completion to be used for reimbursement or teaching purposes.