Informed Consent for Periodontal Surgery

Informed Consent for Periodontal Surgery

Precautions must be taken for periodontal surgery in certain circumstances. You MUST inform the dentist prior to treatment if you:
1) have any of the following medical conditions:
• coagulopathy;
• heart condition;
• history of rheumatic heart disease;
• artificial heart valves;
• blood clotting disorders (Haemophilia, Von Willebrand’s disease, etc.);
2) are taking any of the following:
• blood thinning medication (Warfarin, Aspirin, etc.);
• medication affecting the bone (for osteoporosis, bone cancer, Paget’s disease).

Potential Complications
Periodontal surgery has some inherent risks. Potential complications that can occur during periodontal surgery include:
• Damage to adjacent teeth – Periodontal surgery may inadvertently cause damage the crown and/or root of the adjacent tooth.
• Nerve damage – Periodontal surgery can be in very close proximity to nerves that give feeling to your teeth, lips, and tongue. These nerves can potentially be damaged during the procedure, and can cause numbness to the areas they supply. Depending on the severity of the damage, the numbness can be temporary or permanent.
Potential complications that can occur shortly after periodontal surgery include:
• Pain – Some discomfort is inherent in any periodontal surgery procedure.
• Bleeding – This can occur especially if taking blood thinning drugs (such as Warfarin, Aspirin, Clopidogrel, or Dipyrdamole).
• Delayed healing and wound infection – Any surgical procedure introduces bacteria into the operative site and can result in wound infection. This can delay both the healing and progression of the treatment plan.
• Swelling and bruising – The local area may become swollen and bruised, but this will typically resolve in 7 days with maximal swelling from the third to fourth day after the procedure.
• Increased gum recession/spacing between teeth – Periodontal surgery may cause further damage to the surrounding healthy tissue and result in increased recession and/or spacing between the teeth.
• Scarring of tissue – This can occur where the incisions were made inside the mouth.
• Increased gum recession/spacing between teeth – Periodontal surgery may potentially cause damage to the surrounding healthy tissue and result in increased recession and/or spacing between the teeth.
• Tooth looseness – It is rare, but possible, for the teeth receiving periodontal surgery to become more loose after periodontal surgery.

Necessary Follow-up Care and Self Care
• Appointments are required after periodontal surgery, which may be for follow-up procedures or post-operative evaluation. Patient attendence at these appointments are critical for appropriate healing and success of the procedure. After the procedure has been completed, it is importance to return for periodic examination and preventative treatment to facilitate continued success of periodontal surgery.
• The success of periodontal surgery can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and certain medications. Accurate reporting of any prior drug reactions, allergies, diseases, symptoms, habits, or conditions is imperative. Also, diligence in maintaining personal daily oral care recommended after the procedure and taking all prescribed medications is important for the success of the procedure.

Alterative Treatment Options
There are several alternatives to periodontal surgery. This can include:
• No treatment – This may compromise the outcome of the teeth needing periodontal surgery.
• Orthodontic extrusion – If periodontal surgery is performed to elongate the teeth to allow a restoration to be placed, orthodontic extrusion to gradually pull the tooth further out of the bone may be possible.
• Extraction – If the tooth has a moderate to poor prognosis, the tooth can be extracted.

The total cost of periodontal surgery is as outlined in the treatment plan. The full amount for periodontal surgery is due on the day of the service.

Periodontal surgery sites:

• I have read and understand the conditions and information in this Consent Form.
• I have discussed the information contained in the Consent Form concerning periodontal surgery with my dentist, and am satisfied with the answers that I have received.
• To my knowledge, I have given an accurate report of my physical and medical history.
• I have had explained to me the cost of the treatment and I accept responsibility for that cost.
• I understand the dentist has a special interest in periodontics, but is not a periodontist.
• I authorise my dentist to provide me with periodontal surgery.