Consent for the Use of Bone Regenerative Procedures

Diagnosis. After a careful oral examination and study of my dental condition, my periodontist has advised me that I have periodontal disease. I understand that periodontal disease weakens support of my teeth by separating the gum from the teeth and possibly destroying some of the bone that supports the tooth roots. The pockets caused by this separation allow for greater accumulation of bacteria under the gum in hard to clean areas and can result in further erosion or loss of bone and gum supporting the roots of my teeth.

If untreated, periodontal disease can cause me to lose my teeth and can have other adverse consequences to my health.

Recommended Treatment. In order to treat this condition, periodontist has recommended that my treatment includes bone regenerative surgery. I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of the treatment. I further understand that antibiotics and other substances may be applied to the roots of my teeth.

During this procedure, my gum will be opened to permit better access to the gum roots and to the eroded bone. Inflamed and infected gum tissue will be removed, and the root surfaces will be thoroughly cleaned. Bone irregularities may be reshaped.

Graft material will be placed in the areas of bone loss around the teeth. Various types of graft materials may be used. These materials may include my own bone, synthetic bone substitutes, or bone obtained from tissue banks (allografts). Membranes may be used with or without graft material – depending on the type of bone defect present. My gum will be sutured back into position over the above materials, and a periodontal bandage or dressing may be placed.

I further understand that unforeseen conditions may call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, (1) extraction of hopeless teeth to enhance healing of adjacent teeth, (2) the removal of a hopeless root of a multi-rooted tooth to preserve the tooth, or (3) termination of the procedure prior to completion of all the surgery originally outlined.

Expected Benefits. The purpose of bone regenerative surgery is to reduce infection and inflammation and to restore my gum and bone to the extent possible. The surgery is intended to help me keep my teeth in the operated areas and to make my oral hygiene more effective. It should also enable professionals to better clean my teeth. The use of bone, bone graft material, or the placement of a membrane in intended to enhance bone and gum healing.

Principal Risks and Complications. I understand that some patients do not respond successfully to bone regenerative procedures. The procedure may not be successful in preserving function or appearance. Because each patient’s condition is unique, long-term success may not occur. In rare cases the involved teeth may ultimately be lost.

I understand that complications may result from the periodontal surgery involving bone regenerative materials, drugs, or anesthetics. These complications include, but are not limited to post-surgical infection, bleeding, swelling and pain, facial discoloration, transient but on occasion permanent numbness of the jaw, lip, tongue, teeth, chin or gum, jaw joint injuries or associated muscle spasm, transient but on occasion permanently increased tooth looseness, tooth sensitivity to hot, cold, sweet or acidic foods, shrinkage of the gum up on healing resulting in elongation of some teeth and greater spaces between some teeth, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, adverse impact on speech, allergic reactions, and accidental swallowing of foreign matter. In the event that donated tissue is used for the graft, the tissue should have been tested for hepatitis, syphilis, and other infectious disease. Nevertheless, there is a remote possibility that tests will not determine the presence of diseases in a donor tissue. The exact duration of any complications cannot be determined, and they may be irreversible.

There is no method that will accurately predict or evaluate how my gum and bone will heal. I understand that there may be a need for a second procedure if the initial surgery is not entirely successful. In addition, the success of bone regenerative procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of the teeth, inadequate oral hygiene, and medications that I may be taking. To my knowledge I have reported to my periodontist my prior drug reactions, allergies, diseases, symptoms, habit, 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 medications as prescribed are important to the ultimate success of the procedure.

Alternatives to Suggested Treatment. Alternatives to periodontal surgery with bone regenerative surgery include: (1) no treatment – with the expectation of possible advancement of my condition which may result in premature loss of teeth, (2) extraction of a tooth or teeth involved with periodontal disease, (3) non-surgical scraping of tooth roots and lining of the gum (scaling and root planning), with or without medications, in an attempt further to reduce bacteria and tartar under the gum line – with the expectation that this may not fully eliminate deep bacteria and tartar, may not reduce gum pockets, will require more frequent professional care and time commitment, and may not arrest in the worsening of my condition and the premature loss of teeth.

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 periodontal therapy. From time to time, my periodontist may make recommendations for the replacement of restorations, the replacement of existing restorations or their modification, the joining together of two or more of my teeth, the extraction of one or more teeth, the performance of root canal therapy, or the movement of one, several, or all of my teeth. I understand that the failure to follow such recommendations could lead to ill effects, which would become my sole responsibility.

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 following my surgery so that my healing may be monitored and so that the periodontist can evaluate and report on the outcome of surgery upon completion 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 preventative treatment. Maintenance also may include adjustment of prosthetic appliances.

No Warranty of 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, 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 the absolute certainty of success. There exists the risk of failure, relapse, and additional treatment or worsening of my present condition, including the possible loss of certain teeth, despite the best of care.

Use of Records for Reimbursement Purposes. I authorize photos, slides, x rays or any other viewings of my care and treatment during or after its completion to be used for reimbursement purposes.