Dental Implant Consent

I have had a detailed dental consultation with {select-1}

 about the procedures involved in the replacement of my missing tooth {text-1}

I have had a full discussion and given opportunity to ask questions and concerns about the risks and benefits involved in the treatment plan and have been given alternate options for the replacement of my teeth and understand in my own language that I choose dental implants as an option that would benefit my daily oral health activities. I am fully aware the procedure will be performed under local anesthesia knowing the other alternatives such as nitrous or sedation.

I am also completely aware of the following:

1- (Medical history)I have disclosed all of my past and current medical / physical health status, history of past and current medications and am completely aware that the success of the dental implants are directly and indirectly related to it. {name-9}

2- (Applicable if diabetic)I am aware that my current and future diabetic status relates directly to the long term success of the dental implant and agree to see my physician and dentist periodically to evaluate my diabetic status and oral health.

3- (Applicable if smoker / chronic alcoholic)I have disclosed that I am an current active smoker and or a chronic alcoholic and understand that there is a higher risk for infections and failure of dental implants. I agree to follow the recommended protocol(Moy and Bains Protocol of smoking cessation 2 months before and 2 months after surgery which may reduce the risk of infection during the healing phase and understand smoking and/or chronic alcoholism may affect the long term health of the dental implant

4- (Applicable if under bisphosphonate therapy)I am aware that if dental implants placed in bone that is currently under medical care for osteoporosis or any malignant changes of the bone may not heal adequately and fail or cause further complications to the bone.

5- (Applicable if under cardiac care /blood thinners / anticoagulants) I am aware that surgery cannot be conducted without prior written consent from my MD / physician about my current cardiac status and understand that I may require to stop and start my anticoagulant medication as advised specifically by the MD

6- (Applicable if under psychiatric supervision)I am aware that dental implants are contraindicated for patients under special psychiatric medical supervision and will need further dental evaluation with other treatment options.

7- (Applicable if clenching / grinding of teeth)I am aware that clenching or grinding of teeth is not mechanically healthy for the long term health of dental implants. In the situation that I am a current or future clencher/bruxer, I will require to fabricate a semi soft bite guard to protect my existing teeth and the implant supported restorations.

8- (Pre-surgical preparation)I am aware of my current dental health status and agree to undergo the prescribed phase 1 therapy which may include scaling/root planning, removal of teeth with hopeless prognosis, treatment of any existing periodontal disease and adjust / contour the neighbouring teeth for the ideal space required for the implant supported full arch prosthesis.

9- (May abort surgery on day of appointment) The surgery may be aborted due to biological reasons on the day of surgery if deemed necessary for my safety and success of the procedure.

10- (Bone / gum grafting)I have been informed that I may require bone or gum grafting (origin and source of bone/gum graft/membrane/sutures material and risks and benefits explained) prior to /during or after the implant surgery if necessary to contribute to the long term health of the dental implant. I am also aware that in the future if the grafted tissue recedes that I may require additional grafting to provide support and health to the dental implant. {name-9}

11- (PRF) I have been informed about the benefits and risks involved with the PRF procedure and consent to {select-1} from performing a venipuncture for the benefit of the surgical procedure. {name-9}

12- (Treatment time)The entire process may take about 4 - 6 months or may be longer for adequate healing of the bone and gums before my final restoration (crown / bridge or denture) is completed.

13- (Prescription medications)I am aware that I have been instructed to strictly follow the medication protocol prescribed to avoid infections or post operative discomfort and any intentional discontinuity of the medication can relate to failure of the dental implants and may cause infections and prolonged discomfort.

14- (Documentation/Observership)I consent to Photographs, videos and necessary documentation that will be conducted by additional professionals and consent to share the data on/off the web or at dental schools for the advancement of the science, research and training of other healthcare professionals provided my identity is not revealed.

15- (Post op care and maintenance) I agree to avoid any excessive talking, singing, stretching of my lips or cheeks, exercise, strenuous physical activity, disturbance to the surgical site during the 2 week post surgical healing phase.

16- The best long term results are achieved by proper home care(use of Water Irrigation devices, powered tooth brushes, un-waxed floss) keeping scheduled appointments on time, and reporting to the office immediately when unexpected mishaps occur to the implant restoration. Failure to co-operate with proper post prosthetic home care may lead to a compromise and a failure in the treatment conducted.

I also consent to such additional or alternative procedures that may be found immediately necessary during such procedures or treatment.

The nature of and purpose of the treatment, possible alternatives methods of treatment, the risks involved and the possible complications have been explained to me by {select-1} as follows:

ALTERNATIVES TO DENTAL IMPLANTS:

Include, but are not limited to:

1. No treatment,
2. A removable cast or acrylic partial denture,
3. A fixed partial denture like a bridge, and
4. or other types of implant designs and devices.

POSSIBLE COMPLICATIONS:

Which have been discussed with me include, but are not limited to:

1. pain and swelling,
2. bleeding,
3. infection,
4. failure of the implants to osseointegrate
5. injury to adjacent teeth or fillings,
6. unusual reactions to medications given or prescribed,
7. fracture of the jaw, and
8. trismus – limited jaw opening.

I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained.

I consent to the administration of such anesthetics and pain medications as may be considered necessary or advisable by {select-1} or his team.

I agree to co-operate completely with {select-1} and his team and will follow postoperative instructions to the best of my ability for my own comfort and safety.

I will be available for any follow-up appointments and will attend regular recall appointments.

I have had the opportunity to ask questions concerning these procedures.

Treatment recommendations: 

• 4, 6 or 12 monthly recall visits (for evaluation of general oral hygiene and implants) - X-rays around the dental implants annually
• continuous wearing of a night guard (to prevent fractures of the implant crown or the implant body)

Informed Consent:

I have read and understood the above-mentioned information clearly. I am aware that I have been given the option of consulting a specialist for dental implants but choose voluntarily to undergo treatment with {select-1} and give consent to conducting all necessary procedures that have been explained to me for the replacement of my missing teeth.