Information & Informed Consent for Dental Implant Placement(s)
CONSENT FOR DENTAL IMPLANT(S)
I hereby authorize and direct the provider whose name appears above with associates and/or assistants of his or her choice to perform the proposed surgery upon me, or on my dependent (of whom I have legal guardianship of and/or are legally empowered to give consent for) to insert dental implant(s) in my upper and/or lower jaw and/or placement of bone graft as necessary.
SURGICAL PHASE OF PROCEDURE
I understand that a local anesthetic will be administered to me as part of the treatment. My gum tissue will be opened to expose the bone, implants will be placed and the gum sutured during the healing phase.
HEALING PHASE
I understand that the healing phase of surgery (that is, until the implants bare integrated with the bone and ready for loading) varies from patient to patient and case to case, but typically lasts between3-6 months (or more when bone grafts or sinus elevation are concerned). I understand that dentures or partial dentures that place pressure on the surgical site are to be avoided for 1-2 weeks following surgery unless instructed otherwise. If an immediate restoration is placed over the implant(s), it is important that touch and pressure on the region is minimized during the healing phase.
I further understand that if dental implant placement is planned for the initial surgery and during surgery the clinical situations turn out to be unfavourable for the implant, the dentist will make a professional judgement to manage the situation. This includes cancelling the procedure, supplemental bone grafting/modification and supplemental soft tissue grafting to allow placement, gum closure and security of the dental implants. These procedures may be done in conjunction with or separately from the implant placement. I understand that some implants require second stage surgeries to uncover the implant. Overlying tissues will be opened at the appropriate time and the stability of the implant will be verified.
PRINCIPAL RISKS AND COMPLICATIONS
I understand that a small number of patients do not respond successfully to implant placement. In such cases, implants may have to be removed and replaced. Because each patients conditions are unique, long term success may not occur for every case.
I understand that complications may result from the implant surgery, drugs or anesthetics. These complications include but are not limited to:
- Post-surgical infection, bleeding, swelling, pain and facial discoloration.
- Cracking or bruising of the corners of the mouth.
- Transient but rarely permanent numbness of the jaw, lip, tongue, teeth, chin or gum. This can be due to the proximity of nerves to the surgical site, though this risk is low.
- Restricted ability to open the mouth for several days.
- Jaw joint injuries or associated muscle spasm.
- Transient but rarely permanent increased tooth looseness.
- Inflammation or infection of the sinuses (where grafts or implants to the upper jaw are concerned).
- 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.
- Impact on speech.
- Allergic reactions.
- 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 the gum and bone will heal. I understand that there may be a need for a revision procedure if the initial result is not satisfactory.
In addition, the success of dental implants 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 any prior drug reactions, allergies, diseases, symptoms, habits and conditions which might in any way relate to this surgical procedure. I understand that my diligence in providing the personal daily care recommended and taking all medications as prescribed are important to the ultimate success of the procedure.
NECESSARY FOLLOW UP CARE AND SELF CARE
I understand that it is important for me to continue to see my regular dentist. Implants, natural teeth and appliances must be maintained daily in a clean and hygienic manner. Implants and appliances should be examined by the dentist periodically. I understand that failure to follow such recommendations could lead to ill effects, which would become my sole responsibility. I understand that smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery.
NO WARANTY OR GUARANTEE
Although the likelihood of success is extremely high, 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, dental implant surgery cannot be predicted with a certainty of success. There is a risk of failure, relapse, additional treatment or even worsening of my dental implants and surrounding teeth, including the possible loss of certain teeth or implants, despite the best care.
In the event of a failed implant a review will be conducted by the dentist in an attempt to ascertain the root cause of the failure. Following review and a healing period of approximately 3 months (to be confirmed by the dentist) re-placement of the implant can be considered. If re-placement surgery is elected by the patient there is a non-refundable payment of $750 required.
SMOKING
It is advised that smoking be ceased for as long as possible in the weeks surrounding the surgery- preferably 3 weeks before and 4 weeks after. Smoking can seriously impede healing and integration of dental implants and bone/sinus grafts.
PATIENT CONSENT
I have been fully informed of the nature of implant surgery, the procedure to be utilized, the risks and benefits of implant surgery and the selected anesthesia, the alternative treatments available and the necessity of follow up and self-care. After thorough deliberation, I hereby consent to the performance of dental implant surgery as presented to me during consultation and in the treatment plan presentation as described in this document. I also consent to the performance of such additional and alternative procedures as may be deemed necessary.
ACKNOWLEDGEMENT
I have provided as accurate and complete a medical and personal history as possible including antibiotics, drugs, or other medications I am currently taking as well as those to which I am allergic. I will follow any and all treatment and post-treatment instructions as explained and directed to me and will permit the recommended diagnostic procedures, including X-rays.
I realize that in spite of the possible complications and risks, I do not have to proceed with the treatment should I choose not too. I am aware that the practice of dentistry is not an exact science, and I acknowledge that no guarantees, warrantees, or representations have been made to me concerning the results of the procedure.
I have read this form and have been provided with ample time to ask any and all questions I had in relation to the treatment that has been proposed. I understand and accept the potential risks and complications associated with the treatment.
I wish to proceed with implant placement.
