I(we) understand that IV conscious sedation (“twilight sleep”) and other forms of supplemental sedation involve additional risks and hazards, but I(we) request the use of IV conscious sedation and/or other forms of supplemental anesthesia to assist in the relief and protection from pain during the planned and additional procedures. I(we) realize the IV conscious sedation and/or other forms of supplemental anesthesia may have to be changed possibly without explanation to me(us). I(we) understand this is not general anesthesia (being completely asleep), and that it is unlikely, but I may have unpleasant memories of the procedure.
I(we) understand that certain complications may result from the use of any IV sedative or other form of anesthesia, including respiratory problems, drug reactions, paralysis, brain damage, or even death. Other risks and hazards which may result from the use of IV sedation or other sedatives or anesthetics range from minor discomfort to injury of the vocal cords, teeth, and/or eyes.
I(we) have been given an opportunity to ask questions about my(our) condition, alternative forms of anesthesia and treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I(we) believe that I(we) have sufficient information to give this consent.
I(we) certify this form has been fully explained to me(us), that I(we) have read it or have had it read to me(us), that the blank spaces have been filled in, and that I(we) understand its contents.
INFORMATION FOR PATIENTS REGARDING POSSIBLE CHANGES
IN SENSATIONS OF THE LIP, CHIN, OR TONGUE
FOLLOWING DENTAL SURGERY
Dental surgery, like any other surgery, has certain inherent risks and limitations that may occur despite the experience and skill of the doctor. Following your surgery, it is possible that you may experience either temporary or permanent changes in the sensation or feelings of your lip, chin, or tongue. Permanent changes in sensation of the affected areas are extremely rare.
WHAT CAN CAUSE IT?
Because the nerves that supply these regions are close to the area where the surgery is performed, the nerves may not function normally for a while afterwards. These nerves affect sensation only and not movement.
The most common cause of this type of injury is from the pressure that can occur during either the removal of a tooth root or by the placement of an implant in the lower jaw. Occasionally, hooks or curves on the root may tear some of the nerve fibers. Another possible cause of injury is during the administration of the local anesthesia (numbing medicine). X-rays are helpful but cannot tell us the exact location of the important structures. When the nerve is especially close to the site of the surgery, it could be nicked or cut. Additionally, the incidence and severity of nerve injuries increases with age. This is particularly true for lower wisdom teeth. Further, sometimes sensation is affected without knowing exactly what caused it.
HOW LONG WILL IT LAST?
The likelihood that a change in sensation will occur and how long it will last can depend on many factors, including position of the tooth, the nerve, or the difficulty of the procedure. The duration of the condition is unpredictable and different in each case. It may last a few days, weeks, or months, and in very rare instances, may be permanent. In the majority of cases, the sensory loss gradually returns to normal although you may not be aware of any immediate improvement. Nerve tissue is the slowest tissue in the body to heal, and it can be weeks or months before you notice significant improvements. Nonetheless, it is important for you to stay in touch with us, so we may advise you of your specific circumstances.
HOW CAN I TELL IF I AM GETTING BETTER?
During nerve recovery, you may notice changes such as tingling, as if a local anesthetic is wearing off. Other sensations may also be present. Do not be alarmed; this is often a positive sign. It is important for you to help us in recording any changes in your symptoms so that we may better answer your questions and advise you as to your prognosis.
WHAT IF IT DOESN’T GET BETTER? CAN ANYTHING BE DONE?
If there has been absolutely no improvement in six weeks, then depending on your case, microsurgical repair could be considered. We can further council you on this possibility, and you will be referred to a specialist who is experienced and knowledgeable in this area.
Remember, in the overwhelming number of instances of altered sensation, all or most of the normal sensation will return. If residual symptoms do remain, the risks involved with surgical repair may not be warranted, in that spontaneous, post-operative recovery may take up to two years to occur. By keeping in close contact with us, we are better able to advise you throughout your recovery process to insure optimum results.
DENTAL IMPLANT CONSENT
(if applicable)
I have been fully informed of the nature of implants and implant surgery, therapeutic risks, and treatment alternatives to dental implants, and I hereby consent to their surgical placement in my jaws (mouth). I agree to maintain these implants as prescribed by my dentist.
The initial surgical phase consists of the surgical reflection of the gum tissue followed by precision drilling of holes into the underlying jawbone which depth and width are somewhat smaller than the roots of your natural teeth. These holes are immediately filled with metal cylindrical posts (implants), which are designed to remain in the jawbone indefinitely. In some situations, where inadequate bone is present, a regenerative procedure might be utilized in which a freeze-dried bone graft is placed and the site is then covered with a regenerative membrane. All surgery is performed under local anesthesia and may be supplemented with sedative drugs or IV conscious sedation (if requested by the patient or if deemed necessary). If a tooth is being extracted, there is no guarantee that an implant can be immediately placed. In that case, a graft will be placed, and the site will be re-evaluated after healing. In some cases, a temporary tooth can be immediately placed but only when quality bone is present. This temporary placement is for cosmetic purposes only and is not for chewing.
During the first two (2) weeks following the initial surgery, no dentures or partial dentures should be worn over the surgical sites without consent of the surgeon.
The second surgical procedure usually occurs three-to-eight months after the initial surgery. At this time the implant is evaluated for proper healing and a post is placed into the implant, which extends through the gum tissue into your mouth. Additionally, a minor surgical correction of tissue may later be necessary to modify any tissue overgrowths or discrepancies.
In the final prosthetic phase, a metal sleeve is threaded into the previously surgically imbedded implant, which is then attached (anchored) to the overlying denture, crown, or bridge. The fee for the prosthetic phase is separate and not part of the surgical fee.
Alternative Treatments to Implants
1. If no treatment is elected to replace existing dentures or missing teeth, the non-treatment risk includes maintenance of the existing full or partial denture with relines or remakes every three-to-five years for shifting of teeth, or as otherwise may be necessary due to the slow but progressive resorption (dissolution) of the underlying (supporting) jawbone.
2. Construction of new full or partial dentures or bridges, which may provide better fit and function than your present situation.
3. Surgical treatment to provide a better base or foundation for a new denture. Associated risk and benefits of alternative surgical procedures may be explained in greater detail by consulting an oral surgeon.
Risks
1. Surgical risks include, but are not limited to: post-surgical infection; bleeding; swelling; pain; facial discoloration; sinus or nasal perforation during surgery; TMJ (jaw joint) injuries or spasms; bone fractures; slow healing; and, transient, but on occasion, permanent numbness of the lip, chin, and tongue; damage to adjacent teeth or root(s); bone loss; and, post-operative infection requiring additional treatment.
2. Prosthetic implant risks include, but are not limited to: unsuccessful union of the implant to the jawbone and/or stress metal fractures of the implant. After one (1) year of stable implant retention, it is probable that the implant is permanently joined to the underlying jawbone. A separate surgical procedure for removal of the implant is necessary if implant failure or fracture occurs or requires replacement for changed prosthetic needs. If the implant fails, there will be fees charged for their removal and/or replacement.
No Warranty or Guarantee
I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed implant will be completely successful in function or appearance (to my complete satisfaction). It is anticipated that the implant will be permanently retained, but because of the uniqueness of every case, and since the practice of dentistry is not an exact science, long-term success cannot be promised.
Consent to Unforeseen Surgical Conditions
During treatment, unknown oral conditions may modify or change the original treatment plan such as discovery of changed prognosis for adjacent teeth or insufficient bone support for the implant. I therefore consent to the performance of such additional or alternative procedures as may be required by proper dental care in the best judgment of the treating doctor.
Patient Agreement to Daily Home Care
In order to improve chances for success, I have been informed that the implant and adjacent teeth must be maintained daily in a clean and hygienic manner, and I agree to perform the home care in accordance with instructions provided, as well as keep periodic professional maintenance visits. I understand that once the implant is inserted, the entire treatment plan must be followed and completed on schedule. If the planned schedule is not carried out, the risk of implant failure increases.
I understand Dr. Duong is a general dentist, and that he will be responsible to assist me during the post-operative phase. It is my responsibility to inform Dr. Duong of any problems that occur following the surgery. I understand how to get in touch with Dr. Duong. In rare cases, it may be necessary to refer some post-operative patients to another doctor. The costs associated with any consultation or treatment with other doctors will be the patient’s responsibility.
I certify that I have read and fully understand the above authorization and information consent to implant insertion and surgery and that all of my questions, if any, have been answered.
CONSENT FOR ALLOGRAFT TISSUE/BONE GRAFTING/
MEMBRANE PROCEDURES
(if applicable)
I(we) further understand that a separate procedure to obtain bone for grafting is intended and that portions of bone will be removed from my ________________________________________ and placed in the area to be treated.
I(we) understand that Dr. Duong may discover other or different conditions which require additional or different procedures than those planned. I(we) authorize Dr. Duong and such associates, technical assistants, and other healthcare providers to perform such other procedures which are advisable in their professional judgment.
I(we) understand that no warranty or guarantee has been made to me as to result or cure. I(we) have been given both oral and written pre- and post-operative instructions, and I(we) agree to personally contact Dr. Duong in the event I(we) have a problem. I(we) will follow his instructions until that problem has been satisfactorily resolved. I(we) realize that in the event I(we) develop certain complications, I(we) may miss school or work schedules or I(we) may incur additional, unexpected expenses, including, but not limited to, expenses for other dentists, doctors, or medical facilities.
In addition to the risks of the primary surgical procedure, which have been explained to me(us) separately, I(we) understand that bone grafting itself involves specific risks. Dr. Duong has explained to me(us) that such risks include, but are not limited to the following.
I. GENERAL RISKS AND COMPLICATIONS OF BONE GRAFTING:
A. Bleeding, swelling, infection, scarring, pain, nerve injury, sinus involvement, and numbness or altered sensation (possibly permanent) at the donor site, which may require further treatment
B. Allergic or other adverse reaction to the drugs used during or after the procedure
C. The need for additional or more extensive procedures in order to obtain sufficient bone
D. Rejection of bone particles from donor or recipient sites for some time after surgery
E. Rejection of the bone graft
II. RISKS AND COMPLICATIONS OF BONE GRAFTING FROM WITHIN THE MOUTH AREA:
A. Damage to adjacent teeth, which may require future root canal procedures or which may cause loss of those teeth
B. Removal of adult teeth in order to obtain sufficient bone material
C. Temporary or permanent numbness or pain in the area of the donor or recipient site or in more extensive areas
D. Penetration of the sinus or nasal cavities in the upper jaw, which could result in infection or in other complications, requiring additional drug or surgical treatment
III. RISKS AND COMPLICATIONS OF BONE GRAFTING FROM BANKED BONE (freeze-dried, lyophilized, demineralized, xenografts) OR BONE SUBSTITUTES:
On occasion, additional donated bone, processed bone, or artificial bone substitutes are used to supplement the patient’s bone or to spare patient an extensive graft harvesting procedure. If used, such materials may have separate risks, including, but not limited to:
A. Rejection of the donated or artificial graft material
B. The remote chance of viral or bacterial disease transmission from processed bone
IV. TYPES OF GRAFT MATERIAL: Some bone graft and membrane materials commonly used are derived from human or other mammalian sources. These grafts are thoroughly purified to be free of contaminants. Signing this consent signifies my approval for the doctor to use materials according to his or her knowledge and clinical judgment of my situation.
I(we) certify that: a) this form has been fully explained to me(us) and that its contents are understood; b) I(we) have read it or have had it read to me(us); c) the blank spaces were filled-in prior to initialing/signing; d) I(we) speak, read, and write English; and, e) I(we) have had my(our) questions answered. I have also been advised of the possible risks of non-treatment and understand that I have the option of seeking additional opinions from other providers, if desired.
I understand that I am to follow the oral and written instructions given to me, realizing failure to do so may result in less-than-optimal results of the procedure, and that I am to present myself for post-operative appointments, as scheduled.
I understand unforeseen circumstances may necessitate a change in the procedure, or, in rare cases, prevent completion of the planned procedure.
I authorize photographs, slides, X-rays, or any other visual records of my care and treatment during of after its completion to be used for the advancement of dentistry and reimbursement purposes. However, my identity will not be revealed to the general public without my permission.
I(we) have been given an opportunity to ask questions about: a) my condition; b) alternative forms of anesthesia and treatment; c) risks of non-treatment; d) the procedures to be used; and, e) the risks and hazards involved, and I(we) believe that I(we) have sufficient information to give this consent.