Diagnosis: After a careful oral examination and study of my dental condition, my Periodontist has advised me that I have periodontal disease and that my implant may be reparable with an implant debridement procedure.  I understand that periodontal disease weakens support around my implant(s) by separating the gum and bone from the teeth.  The gap or pocket between the implant and gums can accumulate bacteria that is difficult to remove and can result in further destruction of my gums and bone around my implant(s).  If untreated, periodontal disease can cause me to lose my implant(s) and can have other adverse consequences.

Recommended Treatment:  In order to treat my 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 my implant(s).

During this procedure, my gum tissue will be moved away from the implant(s) to permit better access to the roots and to bone around the teeth.  Inflamed and infected gum tissue may be removed, and the surfaces of the implant(s) thoroughly cleaned.  Bone irregularities may be reshaped, and bone regenerative material may be placed around my implant(s).  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) explantation of hopeless implant(s) to enhance healing of adjacent teeth or implant(s), 2) termination of the procedure prior to completion of the surgery originally planned.

I further understand that if during surgery, clinical conditions turn out to be unfavorable for the scheduled treatment; my Periodontist will make a professional judgment on the management of the situation.  The procedure may need to be canceled or may involve supplemental bone grafts or other type of grafts.  There will be additional fees for grafts as needed.

Expected Benefits:  The purpose of implant debridement/periodontal 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 implant(s) in the operated areas and to make my oral hygiene more effective.  It should also enable professionals to better clean my implant(s).

Principal Risks and Complications:  I understand that a number of patients do not respond successfully to implant debridement/periodontal surgery, and in such cases, the involved implant(s) may be lost.  Implant Debridement 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, 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 and/or implant 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.

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 both 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 implant debridement/periodontal surgery include: 1) no treatment – with the expectation of possible advancement of my condition which may result in premature loss of implant(s), 2) explantation of implant(s) involved with periodontal diseases, and 3) non-surgical treatment of implant(s) with or without medication, in an attempt to further reduce bacteria and calculus (tartar) under the gum line – with the expectation that this may not fully eliminate deep bacteria and calculus (tartar), may not reduce gum pockets, will require more frequent professional care and time commitment, and may result in the worsening of my condition and the premature loss of implant(s).

Principal Risks and Complications: I understand that some patients do not respond successfully to dental implant debridement, and in such cases, the implant may need to be removed.  Implant surgery may not be successful in providing artificial teeth.  Because each patient’s condition is unique, long-term success may not occur.

I understand that complications may result from the implant debridement surgery, drugs and 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 lip, tongue, teeth chin or gum, jaw joint injuries or associated muscle spasm, 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, injury to teeth, bone fractures, nasal sinus penetrations, delayed healing, and accidental swallowing of foreign matter.  The exact duration of any complications cannot be determined, and they may be irreversible.

Necessary Follow-Up Care and Self-Care:  I understand that it is important for me to continue to see my general dentist or Prosthodontist. Restorative dentistry can be an important factor in the success or failure of implant debridement/periodontal therapy. Implants, natural teeth and appliances must be maintained daily in a clean, hygienic manner; Implants and appliances must also be examined periodically and may need to be adjusted.  I understand that it is important for me to abide by the specific prescriptions and instructions given by my Periodontist.

No Warranty or Guarantee:  I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful.  Due to individual patient differences, a surgeon cannot predict certainty of success.  There exists the risk of: failure relapse, additional treatment or worsening of my present condition, including the possible loss of certain teeth or implants, despite the best care.

Publication of Records:  I authorize photos, slides, x-rays, or any other viewings of my care or treatment during or after its completion to be used for the advancement of dentistry and for 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 implant debridement surgery, the procedure to be utilized, the risks and benefits of this surgery, the alternative treatments available, and the necessity for follow-up care and self-care. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with my Periodontist.  After a thorough deliberation, I hereby consent to the performances of dental implant debridement surgery as presented to me during consultation and in the treatment plan presented to me.

I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my periodontist.  If clinical conditions present implant explantation, I defer to my Periodontist’s judgment on the grafts of other types of grafts to build up the ridge of my jaw and thereby to assist in security of my periodontal condition(s).

                    ***I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT***