1. WORK TO BE DONE
I understand that I am having the following work done:
Dental exam, X-rays, Dental cleaning, Fillings and Other dental care.
2. DRUGS AND MEDICATIONS
I understand that antibiotics, analgesics and other medications can produce allergic reactions causing redness and swelling of tissues, pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction).
3. BONE GRAFTING AND BARRIER MEMBRANE
I understand that bone gaffing and barrier membrane procedures include inherent risks such as but not limited to the
1. Pain. Some discomfort is inherent in any oral surgery procedure. Grafting with materials that do not have to be
harvested from your body are less painful because they do not require a donor site surgery. If the necessary bone is taken
from your chin or wisdom tooth area in the back of your mouth there will be more pain. It can be largely controlled with
2. Infection. No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile
oral environment, for infections to occur postoperatively. At times, these may be of a serious nature. Should severe
swelling occur, particularly accompanied with fever or malaise, professional attention should be received as soon as
3. Bleeding,brusing, and swelling. Some moderate bleeding may last several hours. If profuse, you must contact us as
soon as possible. Some swelling is normal, but if severe, you should notify us. Swelling usually starts to subside after
about 48 hours. Bruises may persist for a week or so.
4. Loss of all or part of the graft. Success with bone and membrane grafting is high. Nevertheless, it is possible that the
graft could fail. A block bone graft taken from somewhere else in your mouth may not adhere or could become infected.
Despite meticulous surgery, particulate bone graft material can migrate out of the surgery site and be lost. A membrane
graft could start to dislodge, If so, the doctor should he notified. Your compliance is essential to assure success.
5. Types of graft material. Even we use synthetic bio-reabsorbable graft material in most of cases some bone graft and membrane material commonly used are derived from human or other
mammal sources. These grafts are thoroughly purified by different means to be free from contaminants. Signing this
consent form gives your approval for the doctor to use such materials according to his knowledge and clinical judgment for
6. Injury to nerves. This would include injuries causing numbness of the lips; the tongue; any tissues of the mouth;
and/or cheeks or face. This numbness which could occur, may be of a temporary nature, lasting a few days, a few weeks, a
few months, or could possibly be permanent, and could be the result of surgical procedures or anesthetic administration.
7. Sinus involvement. In some cases, the root tips of upper teeth lie in close proximity to the maxillary sinus.
Occasionally, with extractions and/or grafting near the sinus, the sinus can become involved. If this happens, you will
need to take special medications. Should sinus penetration occur, it maybe necessary to later have the sinus surgically
8. Its your responsibility to seek attention should any undue circumstances occur post-operatively and you should
diligently follow any pre-operative and post-operative instructions.
4. Endodontic Treatment (Root Canal):
Although root canal treatment to retain a tooth or teeth that
otherwise might need to be extracted is a common dental procedure with a reported success rate of more
than 90 percent, there are some risks and complications. The most common include swelling; soreness;
infection; bleeding; trismus (restricted jaw opening); numbness or tingling of the lip, gum, or tongue
(which in rare cases may be permanent); discoloration of adjacent teeth or soft tissue; perforation of the
root; and fractures (splits) of the crown or root of the tooth or restoration. Occasionally, one of the delicate
instruments used to perform a root canal may break in the tooth. A failed root canal may require
additional treatment, surgery, or extraction. Once a tooth has received root canal treatment, it tends to be
more brittle and weak. To minimize the likelihood of a fracture, restoration with a crown is recommended.
There is no guarantee that root canal treatment will save a tooth.
Changes in Treatment Plan: During the course of treatment, procedures may need to be added,
expanded, or changed if the dentist finds conditions that were not identified during examination and first
observed during the course of treatment. The most common scenarios include the need for root canal
therapy and more extensive restorative procedures, like crowns, bridges, or implants. Permission is
hereby given to perform any additional or expanded dental services that the dentist determines to be
necessary. Further, at the dentist’s discretion, I may be referred to a specialist for further treatment, the
cost of which may be my responsibility.
Drugs, Medications, and Sedation: Drugs, medications, or anesthesia/sedation can cause allergic and
other reactions. Examples include, but are not limited to, swelling, redness, itching, vomiting, diarrhea,
and numbness or tingling of the lip, gum, or tongue (which in rare cases may be permanent), as well as,
in rare cases, anaphylactic shock. Since drugs, medications, or anesthesia/sedation also may cause
drowsiness and impair coordination or awareness, patients should not operate a motor vehicle or
hazardous device before achieving full recovery. I have informed the dentist of all drugs and medications I
am taking or have taken within the last 30 days, as well as those that have been prescribed within the last
six months but not taken, and of all allergies and sensitivities of which I am aware. I have been informed
and understand that failure to take drugs or medications as prescribed by my dentist may result in
continued or aggravated infection and pain, and potential resistance to effective treatment. I also
understand that antibiotics can reduce the effectiveness of birth control pills.
5. CHANGES IN TREATMENT PLANS
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination, the most common being root canal therapy, following routine restorative procedures. I give my permission to my assigned dentist to make any and all changes/additions as necessary.
PURPOSE OF IMPLANTS: I have been informed that the purpose of an implant is to provide support
for a crown (artificial tooth), or a fixed or removable denture, or bridge.
ALTERNATIVE TREATMENT: Reasonable alternatives to implants have been explained to me. I have
tried or considered these methods but I desire an implant to help secure the replaced missing teeth.
TYPE OF IMPLANT: I am aware that the type of implant(s) to be used on me is one which is placed into
the jawbone; that this is done by first reflecting a flap of gum, preparing a site in the bone, then inserting
the implant into the bone and finally covering the bone and implant with the gum flap.
SURGICAL PROCEDURES: I understand that multiple surgeries are necessary: one to insert the
implant(s) as described above, one to uncover the top of the implant(s) so that it is exposed and can be
used for attachment of a tooth, bridge, or denture. I also understand that sometimes it is beneficial to
add gum tissue to the implant site, either prior to implant placement, or after the implant(s) has healed. I
also understand that sometimes the implant is covered with a bone graft material, or membrane to
further enhance healing and that this may necessitate an additional procedure to remove the membrane.
RISKS: Risks related to the surgery include, but are not limited to, post surgical infection, bleeding,
swelling, pain, facial discoloration, upper jaw sinus, or nasal cavity perforation during the surgery,
transient numbness of the lip, tongue, teeth, or chin, jaw joint injuries, or associated muscle spasms, bone
fractures and slow healing. Prosthetic risks include, but are not limited to, unsuccessful union of the
implant(s) to the jawbone, stress, or metal fracture of the implant(s). Risks related to the anesthesia
include, but are not limited to, allergic reactions, accidental swallowing of foreign matter, facial swelling,
bruising, pain, inflammation, soreness, discoloration, or blockage along a vein at the injection site
NO WARRANTY OR GUARANTEE: I hereby acknowledge that no guarantee, warranty, or assurance
has been given to me that the proposed implant(s) will be completely successful in function or appearance
(to my complete satisfaction). It is anticipated that the implant(s) will be permanently retained, but
because of the uniqueness of every case and since the practice of dentistry is not an exact science, longterm
success cannot be promised.
CONSENT TO UNFORESEEN CONDITIONS: During treatment, unknown conditions may modify, or
change the original treatment plan such as discovery of changed prognosis for adjacent teeth, or
insufficient bone support for the implant(s). I therefore consent to the performance of such additional or
alternative procedures as may be required by proper dental care in the best judgment of the treating
DRUG EFFECTS AFTER SURGERY: I have been informed that prescribed medications may cause
drowsiness, alone or in combination with alcohol or other sedatives, and I agreed to not drive or operate
dangerous machinery within 12 hours of taking any such medication, or if drowsiness occurs.
Furthermore, if sedative medications are to be administered during surgery, I will not attempt to drive
myself home after the surgery but will arrange to be driven and accompanied home.
COMPLIANCE WITH SELF-CARE INSTRUCTIONS: I understand that excessive smoking and/or
alcohol intake may affect gum healing and may limit the success of the implant(s). I agree to follow
instruction related to my own daily care of my mouth. I agree to report to my doctor for regular followup
examinations as instructed.
SUPPLEMENTAL RECORDS AND THEIR USE: I consent to photography, filming, recording and
radiographs of my oral structures as related to these procedures and for their educational use in lectures,
or publications provided my identity is not revealed.
RISKS ASSOCIATED WITH NON-TREATMENT: I understand that if no treatment is performed,
either that which has been proposed, or any other reasonable alternative treatment, that such a decision
is my sole responsibility. I acknowledge that risks related to my non-acceptance of treatment for my
problem have been explained to me and include, but are not limited to: dissatisfaction with or failure of
other forms of tooth replacements, further deterioration of jaw bone, further gum recession, problems
with my bite including pain, spasm, headaches, or problems with my jaw joints or associated
7. CROWNS, BRIDGES AND VENEERS
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realized that the final opportunity to make changes in my new crown, bridges or cap (including shape, fit, size and color), will be BEFORE cementation.
8. DENTURES – COMPLETE OR PARTIAL
I realize that full or partial dentures are artificial, constructed of plastic, metal and or porcelain. The problems of wearing these appliances have been explained to me including looseness, soreness and possible breakage. I realize the FINAL opportunity to make changes in m new denture (including shape, fit, size, placement and color) will be the "teeth in wax" try-in visit. I understand that most dentures require relining approximately three to twelve months after the initial placement. The cost for this procedure is not included in the initial denture fee.
9. PERIODONTAL LOSS (TISSUE AND BONE)
I understand that I have a serious condition, causing gum and bone inflammation or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacement and or extraction. I understand that not undertaking any dental procedure may have an adverse effect on my future periodontal condition.