Diagnosis:  After a careful oral examination and study of my dental condition, my periodontist has advised me that I have deficiency in either the amount of gum tissue and/or gum recession.  I understand that with this condition, new or advancing gum recession may occur.  It is also important that there is sufficient gum tissue around fillings and crowns to withstand irritation that may occur around these restorations.  Gum tissue may also be needed to improve appearance or protect the surface of tooth roots.

Recommended Treatment:  In order to treat this condition, my periodontist has recommended care that includes periodontal 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 tissue will be prepared to receive the graft(s).  Inflamed and infected gum tissue may be removed, and the surfaces of tooth roots thoroughly cleaned. Donor tissue for graft(s) will be taken from my mouth and placed in prepared area(s). The use of membranes or other biologic materials intended to enhance healing may be used. My gum tissue will then be sutured into an appropriate position, and a bandage or dressing may be placed if needed.

Unforeseen Conditions: I further understand that unforeseen conditions may call for a modification or change from the anticipated surgical plan.  This may include, but is not limited to: 1) extension or reduction of surgical site, 2) use of additional donor site(s), 3) Need for bone grafts or, 3) termination of the procedure prior to completion of the surgery originally planned. There will be additional fees for bone grafts as needed.  

Expected Benefits:  The purpose of periodontal surgery is to restore and/or regenerate 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.  When possible the surgery is intended to also improve appearance of gum tissues.  In certain cases, efforts will be made to correct gum recession and cover exposed root surfaces. Additional benefits may include decreased root sensitivity, correction and/or prevention of root decay, and prevention of future recession

Principal Risks and Complications:  I understand that a small number of patients do not respond successfully to periodontal surgery, and in such cases, the involved teeth may be lost.  Periodontal surgery may not be successful in preserving function or appearance.  Because each patient’s condition is unique, long-term success may not occur.

I understand that complication may result from the periodontal surgery, gum grafts, membranes, biologic materials, drugs, or anesthetics.  These complications include, but are not limited to post-surgical infections, 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 permanent increased tooth looseness, tooth sensitivity to hot, cold, sweet or acidic foods, shrinkage of the gum upon 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, impact on speech, allergic reactions, and accidental swallowing of foreign matter.  The exact duration of any complications cannot be determined, and they may be irreversible.  While it is expected that donated tissues have been tested for infectious disease, there is a remote chance that an infectious material may be present and produce consequences of unknown duration that 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 results are not satisfactory. In addition, the success of periodontal procedure can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and medications that I may be taking.  To my knowledge, I have reported to my periodontist prior drug reactions, allergies, disease, symptoms, habits, or conditions that 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 are important to the ultimate success of the procedure.  

Alternatives to Suggested Treatment.  I understand that alternatives to periodontal 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 teeth involved with

periodontal disease, and 3) non-surgical treatment of tooth roots with or without medication, and may result 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 placement of restorations, the replacement or modification of existing restorations, 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 appliances 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 my 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 the periodontist and 2) to see my periodontist and dentist for periodic examination and preventive treatment. Maintenance also may include adjustment of prosthetic appliances.    

No Warranty or Guarantee.  I hereby acknowledge that no guarantee, warrantee, or assurance has been given to me that the proposed treatment will be successful.  In most cases, the treatment will provide benefit in reducing the cause of my condition and produce healing that will help me keep my teeth.  Due to individual patient differences, however, a periodontist cannot predict certainty of success. There is a risk of failure, relapse, additional treatment or even worsening of my current condition, including the possible loss of certain teeth, despite the best of care.

Publication of Records.  I authorize photographs, radiographs (x-rays) or any other viewings of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes. My identity will not be revealed to the general public, however, without my permission.

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 follow-up and self-care.  I have had an opportunity to ask any questions I may have in connection with treatment and to discuss my concerns with my periodontist.  After thorough deliberation, I hereby consent to the performance of periodontal surgery as presented to me during consultation and treatment plan presentation as described in this document.  I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my periodontist.



J. Jay Uemura, D.D.S.
Philip Vassilopoulos, D.D.S., D.M.D.