Atlas of cosmetic and reconstructive periodontal surgery 3rd edition. My signature below signifies that all questions have been answered to my satisfaction regarding this consent and i fully understand the risks involved in the proposed surgery and anesthesia. The root surfaces are then thoroughly cleaned and the gum tissue is then replaced to its original position. Seamons to perform the following surgical treatments as indicated below. I have been fully informed of the nature of periodontal surgery, the procedure to be utilized, the risks, complications, and benefits of periodontal surgery, the alternative treatments available, and the necessity for follow up and self care. Patient consent i have been fully informed of the nature of periodontal surgery, the procedure to be utilized, the risks and benefits of periodontal surgery, the alternative treatments available, and the necessity for followup and selfcare. I have been informed that my periodontal case type is.
Using his own cases as illustrations, sato author and dental practitioner in japan elucidates clinically effective procedures step by step, comparing his clinical results to those of related studies, and comparing many therapeutic outcomes over time. There are a number of disadvantages and contraindications to periodontal surgery. Dental cleaning and periodontal treatment consent form owner responsibility. After careful oral examination and study of my dental condition my dentist has. I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. Pain is a subjective feeling and one of the defense and alerting mechanisms of the body, which is distinguished from the body senses, including touch sensation and perception. My endorsement signature to this form indicates that i have read and fully. The security and privacy of your personal data is one of our primary concerns and we have taken.
Studies show people with untreated periodontal disease are about 6 times more likely to lose teeth than ones that have successful periodontal pocket reduction surgery. I have had an opportunity to ask any questions i may have in connection with the treatment. Oral surgery consent form for extractions, implants, bone grafting and gum. This is a treatment in which we aim to through regular, professional cleanings, medicine, oral hygiene education and information, create a clean environment.
This document is designed to outline this treatment, its risks, expected outcomes, alternatives and your responsibilities. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. Alternatives to periodontal osseous surgery include. Zidile has advised me of the need for periodontal surgical treatment. 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. Periodontal dressing, postoperative instructions to the patient. Spgi scaling in the presence of gingival inflammation, full mouth debridement. Type i gingivitis type ii early periodontitis type iii moderate periodontitis type iv advanced periodontitis type v refractory periodontitis recurring after surgery initials i have received education and literature brochures books about my condition. Consent form for periodontal surgery, periodontist beverly. Nonsurgical gum treatment consent form, periodontist. Some authors use inhalatory sedation in the form of nitrous oxideoxygen 10. These forms are intended to be used when a patient refuses the treatment. An explanation of your need for periodontal flap surgery, the procedure and postoperative care, its purpose and benefits. Informed consent for the orthodontic patient orthodontics and dentofacial orthopedics is the dental specialty that includes the diagnosis, prevention, and correction of malocclusion, as well.
Informed consent periodontal surgery proposed treatment about the proposed treatment. I understand that i have a form of periodontal disease that has caused damage to the soft tissue andor bone around my teeth and is endangering the health of. Patient consent for periodontal treatment patient name. After a careful oral examination and study of my dental condition, dr. Periodontal scaling and root planing informed consent the disease process has been explained to me and i understand that it is caused by several factors. Using his own cases as illustrations, sato author and dental. Treatment of periodontal disease includes scaling and root planing, effective home care, possible referral to a periodontist gum specialist, and possible surgery. Catherine ha, dmd, pa dba carolina dental associates 5400 s. I understand that periodontal disease weakens the support of my teeth by separating the gum from the teeth.
American association of oral and maxillofacial surgeons. Hemorrhage because periodontal surgery ordinarily involves only small blood vessels, significant hemorrhage is not a frequent complication of periodontal surgery when. Khansari and his employees, agents and other auxiliary personnel to perform periodontal gum surgery. You must be aware that this treatment is not a cure as currently there is no cure for periodontal disease. Download instructions following extraction form pdf instructions following implant surgery. I understand that any questions i may have will be answered prior to surgery. Treatment of periodontal disease may include periodontal scaling and root planning, either as a therapeutic procedure or preliminary to more extensive treatment.
When esthetics is the priority and periodontal health is good then surgical root coverage is a potentially useful therapy. Grand rapids, sedation dentistry, periodontist, gum surgery, muskegon, michigan, holland, grandville, dental implant, dental implants, denture, dentist, cosmetic dentistry, gum graft, jake lueder, jacob leuder, jake leuder, dds, missing teeth, misse. Grandville periodontist dentist dental imlant jake lueder dds ms keywords. I herby consent to the performance of periodontal surgery as presented to me during consultation and as. Informed consent for the orthodontic patient orthodontics and dentofacial orthopedics is the dental specialty that includes the diagnosis, prevention, and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature facial structure. Explores the multitude of options in periodontal surgery with an emphasis on contemporary regenerative procedures. After a careful oral examination and study of my dental condition, my periodontist has advised me that i have periodontal disease. I refuse to give my consent for the proposed treatments as described above. Consent for periodontal surgery treatment diagnosis after a careful oral examination and study of my dental condition, my periodontist has advised me that i have periodontal disease. Download instructions following implant surgery form pdf instructions following periodontal.
I consent to photographs of my oral and facial structures and their publication for educational and scientific purposes. Sebastian has advised me that i have bone loss and gum pockets around my teeth from. To accomplish this procedure, the gum tissue is reflected back allowing the surgeon to visualize the teeth and bone. Authorizationandinformedconsentto periodontal surgery patient. Informed consent for periodontal gum surgery i hereby authorize my doctor to perform periodontal surgery upon. Authorizationandinformedconsenttoperiodontalsurgery patient. Effect of prophylactic administration of novafen for. A type of surgery used to remove excessive tissue or reduce pockets.
Find a periodontist listing form for members aap connect your member community visit aap connect to access libraries of aap resources, open forum for online casesharing, and. I consent to the circled surgical periodontal treatments described above by dr. Disadvantages and contraindications of periodontal surgery. I understand that home care administered by myself or a designated caretaker may be required to achieve best overall success. Find a periodontist listing form for members aap connect your member community visit aap connect to access libraries of aap resources, open forum for online casesharing, and discussions with your colleagues on topics of interest. Periodontal surgery consent form markham, ontario tc. Periodontal scaling and root planing informed consent. The surgeon will describe the specifics of any procedure not covered in this consent form.
After a careful oral examination and study of my dental condition, my periodontist has advised me that i have gingival disease, occlusal. An explanation of your need for periodontal flap surgery, the procedure and postoperative care, its purpose and benefits, possible complications as well as alternatives to this proposed treatment were discussed with you and we obtained verbal consent to undergo this procedure. Benefits of nonsurgical periodontal treatment, not limited to the following. The surgery is intended to help me keep my teeth in the operated areas and to make my oral hygiene more effective. It is my responsibility to notify friendship animal hospital before altering the doctors recommendations. Consent for periodontal surgery after a careful oral examination and study of my dental condition, my periodontist has advised me that i have periodontal disease.
These forms were shared with nnoha from safetynet clinics throughout the country for use in your dental program. Principles of periodontal surgery preoperative evaluation of the patient, informed consent and. Consent forms perio artist ricardo raschkovsky, dds. A surgical consent form should be completed in all cases, and. You have the right, as a patient, to be informed about your condition and the recommended treatment to be. Preface periodontics is both an art and a science, and this textbook is. Numerous therapeutic solutions for recession defects. A description of these procedures is on the reverse of this form. Grand rapids, sedation dentistry, periodontist, gum surgery. Periodontal surgery consent form markham, ontario tc fok. I have been fully informed of the nature of periodontal surgery, the procedure to be utilized, the risks, complications, and. Consent for periodontal scaling and root planning patient name. I have had an opportunity to ask any questions i may have in connection with the treatment and to. The purpose of periodontal surgery is to reduce infection and inflammation and to restore my gum and bone to the extent possible.
No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the conditions listed above. Atlas of cosmetic and reconstructive periodontal surgery. Contact our beverly hills, california dental implant and periodontics specialist. The american association of oral and maxillofacial surgeons aaoms, the professional organization representing more than 9,000 oral and maxillofacial surgeons in the united states, supports its members ability to practice their specialty through education, research, and advocacy.
Periodontal scaling and root planing informed consent blake. Patient consent i have been fully informed of the nature of periodontal surgery, the procedure to be utilized, the risks and benefits of periodontal surgery, the alternative treatments available. Principles of periodontal surgery preoperative evaluation of the. I understand that periodontal disease weakens the support of my teeth by separating the gum from the teeth and possibly destroying the bone that supports the roots of the teeth. I have had an opportunity to ask any questions i may have in connection with the treatment and to discuss my concerns with dr. I have been advised of alternatives to surgical therapy, including maintenance. I am able to read and write in the english language. The american association of oral and maxillofacial surgeons aaoms, the professional organization representing more than 9,000 oral and maxillofacial surgeons in the united states. Nonsurgical gum treatment consent form, periodontist beverly. I have had an opportunity to ask any questions i may have in connection with the. Surgical periodontal treatment can help to create a clean environment in which your gums. Diagnosis your dentist has made a diagnosis that you have periodontal disease and has made a recommendation that you require periodontal treatment.
It involves not only removal of the tissue, but scaling and root planning of the affected teeth. After you have completed the form, please make sure to bring it on your visit to our office. Cutting and lifting up a small area of the gums around the teeth to view the underlying structures bone, root for disease or injury. An explanation of your need for periodontal flap surgery, the procedure and postoperative care, its purpose and benefits, possible complications as well as alternatives to this proposed treatment. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it. Periodontal surgery consent form informed consent is a process to explain benefits, risks, and alternatives of a procedure. Regenerative surgery osseous grafts andor guided tissue regeneration 3. After thorough deliberation, i hereby consent to the performance of periodontal surgery as presented to me during consultation and in the treatment plan presentation.
1473 185 523 1180 485 1564 548 487 550 1486 1269 501 1433 1006 1545 1497 746 1319 1606 1076 1503 792 639 554 1649 820 1217 560 893 651 613 1148 533 52 1044 214 1238 980