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

I am being provided this information and consent form so I may better understand the treatment recommended for me. Before beginning, I want to be provided with enough information, in a way I can understand, to make a well-informed and confident decision regarding my proposed treatment.

I understand that I may ASK ANY QUESTIONS I WISH, and that it is better to ask them before treatment begins than to wonder about it after treatment has started.

Extraction involves the complete removal of a tooth from the mouth. Some extractions may require cutting into the gums and removing supporting bone and/or cutting the tooth into sections prior to removal.

This recommendation is based on visual examination(s), on any x-rays, models, photos and other diagnostic tests taken, and on my doctor’s knowledge of my medical and dental history. My needs and wants have also been taken into consideration.

The intended benefit of extraction is to relieve my current symptoms and/or to permit me to continue with any additional treatment my dentist has proposed.

Principal Risks and Complications:  I have been informed and fully understand that there are certain inherent and potential risks associated with any type of surgical procedure, including extractions. I understand that during and following treatment, I may experience pain or discomfort, bleeding, swelling, bruising, and stiff jaws. All of which can last for several days. I understand that it is possible for an infection to occur in the extraction site and that I may need antibiotics and/or other procedures to treat the infection. I understand that less common complications include: dry socket (lost blood clot); loss or loosening of dental restorations; loss or injury to adjacent teeth and soft tissues; jaw fractures; sinus exposure (upper teeth); swallowing or aspiration of teeth and/or restorations.  

I understand that small root fragments may break off from the tooth being extracted. Depending on their size and position, they may either be left to remain in the jaw or may require additional surgery for removal.   

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 additional teeth.  

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.   

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.