The Health Sciences continue to make remarkable advances in technology and techniques. These efforts to develop and introduce improvements over current health care treatments are ultimately intended for the benefit of prospective patient candidates. An essential element in these efforts is to communicate all essential information to patient candidates, so that the prospective patient is able to make a knowledgeable decision. With this premise in mind, all of the pertinent facts involved in the cooperation between the surgeon, and the prospective patient are listed in detail below, so that there is a full disclosure of the procedures and complete comprehension by the patient. It is necessary that each patient read, understand, and sign the following form before proceeding with LANAP® treatment:

1. I have had a consultation with Dr. Erez Cohen pertaining to my desire to treat my periodontal disease, which has been diagnosed as needing LANAP® treatment, by participating in LANAP® treatment, which involves the use of a laser.

2. I acknowledge that Dr. Cohen has carefully examined my mouth and diagnosed me with periodontal disease. The doctor expressed his opinion that LANAP® treatment may solve the problems, stemming from my periodontal disease, from which I have been
suffering.

3. I understand that based on a clinical study performed using the LANAP® treatment, a high percentage of cases (87%) have not needed retreatment for more than five years barring any unforeseen health or accident related problems.

4. Dr. Cohen has explained other alternative periodontal surgical procedures such as Widman Flap, cut and sew and other methods. I hereby state that I have tried or considered conventional methods of periodontal surgery and regard them to be unsatisfactory for me.

5. I acknowledge that Dr. Cohen has explained that optimum results with LANAP® treatment depends on the individual body response of each person. There is no method in present knowledge to guarantee the healing capabilities of any patient following LANAP® treatment.

6. Dr. Cohen has stated that smoking and/or non-moderate use of alcohol can adversely affect gum tissue healing. I am aware that observations have shown that excesses of smoking and alcohol consumption may limit the longevity of the LANAP® treatment. I understand that calcium balance and hormones can affect the continued loss of bone.

7. Dr. Cohen has detailed the methods, stressed the importance of proper oral hygiene, and explained how critical it is for optimal healing following LANAP® treatment. I agree to comply with the methods explained to me as instructed by Dr. Cohen or his assistant/hygienist. I further agree to follow Dr. Cohen’s diet recommendations.

8. Dr. Cohen has explained that if I choose not to undergo LANAP® treatment then the following sequences of events can happen:
A. Where no treatment is undertaken, further gum and bone degeneration of the supporting tissues can continue, increasing the severity of, and/or adding to, the problems presently suffered by the patient to include:
1) Loss of teeth due to traumatic occlusion and/or loss of vertical bone support.
2) Infections in the gums and bone such as Acute Necrotizing Ulcerative Gingivitis (ANUG).
3) Tarter/calculus buildup causing loss of vertical bone support.

B. Where groups of teeth are missing;
1) Not replacing lost teeth, in areas where excessive chewing forces exist, may cause pronounced loss of bone and gum disease around the remaining teeth.
2) Replacement of teeth with conventional removable partial dentures may be necessary.

9. Dr. Cohen has explained that it is my responsibility to report for further treatment and hygiene appointments, at least once every three (3) months or at any other time the doctor requires me to. I understand these visits are for the doctor to carefully check the status of my LANAP® treatment and aid in maintaining my oral health.

10. I submit that I have given an accurate report on my health history. To my best knowledge, I have not withheld any information regarding my medical or mental health. Any previous allergic or unusual reactions to drugs, foods, insect bites, anesthetics, pollens, dust, or any material or condition have been willingly offered to the doctor for my complete health history.

11. I understand that LANAP® treatment involves one or more mouth surgeries. I have been informed of the complications of the surgery, anesthesia, and other necessary drugs used as part of the treatment. I am aware that there could be pain, swelling, infections, discoloration, numbness, spaces between the teeth, tissue shrinkage, recession of the gums, and exposure of roots surfaces - - the exact duration of which may not be determinable. I understand that after adequate healing some areas may need to be spot treated with LANAP® treatment and occlusal adjustments.

12. I understand that “severe” gum disease (Case Type III & IV) with “double digit” millimeter pocket measurements (e.g. 10mm or more) will require “double” or a subsequent re-treatment at the same fee as the first fee-for-service, typically on a tooth-by-tooth basis, but could involve the entire mouth as determined by the state of active disease.

13. “Occlusal adjustment” and “occlusal equilibration” have been fully explained to me. I have had the opportunity to ask questions, and I fully understand that occlusal adjustments and equilibration require my 100% cooperation and compliance. It has been explained to me that failure to complete all phases of occlusal adjustments and equilibration may result in oral/facial pain, temporal mandibular joint dysfunction (TMJ) sore and painful teeth. It has also been explained that until the teeth have been fully adjusted and/or equilibrated I may experience transitional TMJ pain, muscle soreness, headaches, tooth pain, tooth sensitivity, and cheek biting. I understand adjusting crowns can remove porcelain, expose metal and/or tooth structure, and can require the replacement of any and all crowns. I understand that occlusal adjustment is part of the LANAP® treatment and is an ongoing part of my regular examination appointments.

14. I am aware that I may receive an explanation of all risks and treatment (s) prior to starting, as well as any other questions during the progress of my treatment, just by asking the doctor who performed the LANAP® treatment on me.

15. If Dr. Cohen considers my case appropriate, I hereby give authorization for photos to be taken of my mouth during the course of the LANAP® treatment. It has been explained to me that these photos, videos, slides, or x-rays may be used in teaching other dentists for the advancement of LANAP® protocol in dentistry.

16. With full understanding, I authorize Dr. Cohen and the LANAP® treatment team to perform dental services for me, including LANAP® treatment and other surgery deemed necessary for the planned treatment. I will also agree to the use of local or general anesthetic, sedation, and analgesia depending on the judgment of the surgeon involved in my case. Dr. Cohen has explained that if there is a need for someone to drive me from the doctor’s office following surgery I am to arrange this myself. I agree not to operate a motor vehicle or work for 24 hours or until fully recovered from the effects of the anesthesia or drug given me for my care, if it should be necessary.

17. I understand that Dr. Cohen will do the very best according to all of the latest principles of Laser dentistry to perform the LANAP® treatment on me. I understand that progress in LANAP® dentistry is continuous and due to that fact, I authorize any modification in design, material, or care to be performed on me - if based on my doctor’s experience and professional judgment, he feels it is in my
best interest.

18. I understand that it is necessary to complete all phases of recommended treatment, and I agree to do so.

1. Do not be alarmed with any color changes or appearance of gum tissue following laser therapy.
Gum tissue can turn gray, yellow, red, blue, purple, and “stringy” and reflects a normal response to laser treatments.

2. Do not apply excessive tongue or cheek pressure to the treated area.

3. Do not be alarmed if one of the following occurs:
a. Light bleeding
b. Slightswelling
c. Some soreness, tenderness, or tooth sensitivity
d. Medicinal taste, from Peridex or Periogard

4. Swelling may possibly occur. To keep this at a minimum, gently place an ice pack on the outside of the face for 20 minutes each hour until you retire for sleep that night. Do not continue using the ice bag beyond the day of the periodontal surgery.

5. Some oozing of blood may occur and will appear to be greatly exaggerated when it dissolves in saliva. Determine the side of oozing and place pressure on this area. If you cannot locate the origin of the bleeding, rinse your mouth gently with iced water and apply a wet tea bag to the general area.

6. Please call the office so that we may render further treatment if any of the following occurs:
a. Prolonged or severe pain
b. Prolonged or excessive bleeding
c. Considerably elevated or persistent temperature (Fever)
d. Sores on the roof of your mouth (Blisters)

7. If medication has been prescribed, please take exactly as directed. Antibiotic pills are prescribed. The entire bottle or prescription should be taken for the stated number of days or weeks. If you are not allergic to Motrin – generic ibuprofen- (e.g., Advil, Nuprin), we will most likely prescribe it primarily to minimize tissue swelling and local inflammation that is a natural side effect of minor surgery. Ibuprofen is also good to reduce postoperative pain and sensitivity. Ibuprofen is non-narcotic and does not affect your ability to drive. Never place aspirin directly on the tissue of a painful area.

8. Reduce physical activity for several hours following the surgery to maximize healing.

9. Try to keep your mouth as clean as possible in order to help the healing process. Only brush and floss the untreated area of your mouth. Do not brush or floss the treated area for 7-10 days or as directed by your doctor.

10. You may spit gently, but do not rinse your mouth the day of treatment. Begin rinsing your mouth gently 3 times a day with Peridex or Periogard the day following treatment. In between Peridex/Periogard rinses, rinse your mouth gently 3 times a day with warm salt water (1/2 teaspoon of salt dissolved in an 8 oz. glass of warm water). For the next several days rinse with both Peridex/Periogard and salt water as previously mentioned but with vigor.

11. You will be on a liquid diet for 3 days, then a diet of “mushy”/soft foods for 4 days, and then a diet of smart food choices for the remainder of the month. It is very important to maintain a good food and fluid intake. Try to eat soft but nutritious food such as eggs, yogurt, cottage cheese, malts, ice cream, etc., until you can comfortably return to a normal diet.
Please refer to the Post LANAP® Treatment Diet Instructions (on the next page).

12. Avoid spicy or excessively hot foods during the initial 3-day liquid diet period.

13. When eating do not chew on the side of your mouth which has been treated.

14. Do not be alarmed that beginning with just 2 weeks after therapy and extending as long as 1 year or more, the teeth may become sore and tender as the bone and ligaments around the teeth regenerate and become more firm. This is a sign of healing, but also indicates the presence of a bite imbalance that may need to be adjusted.

15. “Spaces” between your teeth can result from reduction of inflammation, swelling, and the
removal of diseased tissue after the LANAP® treatment. These spaces usually fill in over time, and again, bite adjustment is critical to making sure the teeth and the “papilla” are not traumatized and can regrow.

16. If you have been taken off blood thinners (Coumadin, Warfarin, etc.), or if your current medications have been altered at all due to your dental surgery, you must contact your physician ASAP to determine if and when you should resume your medicines. Delaying this telephone call could have potential life-threatening or other serious consequences. I agree I must continue to take all current medications as prescribed by my doctor(s) and must continue to take all supplements and vitamins.

- The first three days following Laser Therapy, follow only a liquid-like diet to allow
healing. Anything that could be put into a blender to drink is ideal. The purpose of this is to protect the clot that is acting as a “band-aid” between the gums and the teeth. Do not drink through a straw, as this creates a vacuum in your mouth that can disturb the “band-aid”. Take daily vitamins.

- Next four days after treatment, foods with a “mushy” consistency such as those listed below are recommended. *See below.

- Starting seven to ten days after treatment, soft foods may be allowable. The time to start on soft foods is dependent upon the loss of the white material that appeared around your teeth following LANAP® treatment. You were introduced to this material by your doctor or doctor’s
assistant during your follow-up visit immediately following your initial treatment session. It was explained to you that you must leave this material alone until it naturally heals and disappears. Once the white material has disappeared, then soft foods can be introduced. Soft foods have the consistency of pasta, fish, chicken, or steamed vegetables. You may then
gradually add back your regular diet choices.

- Please remember that even after ten days, healing is not complete. The first month following treatment you should continue to make smart food choices. Softer foods are better.

*“Mushy” Diet Suggestions

DAILY VITAMINS!
Anything put through a food blender
Cream of Wheat, Oatmeal, Malt-O-Meal
Mashed Avocado, Applesauce
Mashed Potatoes or Baked Potatoes – OK with butter/sour cream
Mashed Banana or any mashed/blended fruit except berries with seeds
Broth or Creamed Soup
Mashed Steamed Vegetables
Mashed Yams, Baked Sweet Potato, or Butternut Squash
Cottage Cheese, Cream or Soft Cheese
Creamy Peanut Butter without solid pieces
Eggs any style, with or without melted cheese
Omelets can have cheese and avocado
Jell-O, Pudding, Ice Cream, Yogurt
Milk Shakes/Smoothies – DO NOT blend with berries containing seeds
Ensure, Slimfast nutritional drinks

DON’T
Chew gum, candy, cookies, chips, nuts, anything hard or crunchy, anything that has seeds or hard pieces, meat that shreds and can lodge under the gum and between teeth, raw vegetables/salad.

If you have been taken off blood thinners (Coumadin, Warfarin, etc.), or if your current medications have been altered at all due to your dental surgery, you must contact your physician ASAP to determine if and when you should
resume your medicines. Delaying this telephone call could have potential life-threatening or other serious consequences. I agree I must continue to take all current
medications as prescribed by my doctor(s) and must continue to take all supplements and vitamins.

Tobacco has a very large effect on your gums and the disease you have in them. Tobacco is associated with an increased disease rate in terms of loss of the bone and gums that are holding your teeth in, as well as an increase in the space between the gums and teeth. Tobacco is a major factor for chronic gum disease.

Any type of smoking and/or chewing tobacco will have an adverse effect on the progress of your healing and may cause the gum disease to reoccur after treatment. If you smoke or chew tobacco we highly recommend not to do so
while you are healing or anytime after that.