Periodontal Treatment Consent Informed Consent to Periodontal Treatment Patient Name: I have been informed that I have periodontal (gum) disease and/or deformities that could lead to the loss of certain of my teeth. I have been advised that the proposed therapy is intended to extend the life expectancy of my teeth. This consent form outlines the treatment program, its expected consequences, and limitations. My treatment may include some or all of the following treatment procedures: I hereby authorize —Please choose an option—Dr. ZeiterDr. JacksonDr. Weitz (herein after called "Doctor"), and whomever they may designate as their assistant(s), to perform the following treatment and/or surgery upon. TREATMENT PROCEDURES Oral hygiene/disease prevention Bacterial culturing Chemical pocket irrigation and/or placement of subgingival medication Orthodontic exposure of unerupted teeth Polishing and scaling The administration of anesthetic agents topically and by injection Root planning of the teeth and/or curettage of the soft tissue Occlusal/bite adjustment Tooth straightening procedures with fixed and/or removable appliance(s) Temporary splinting Occlusal guard (Biteguard) Periodontal surgery (gingivoplasty; flap surgery with/without osseous contouring; osseous/alloplastic and/or bone bank grafts; soft tissue grafts; frenectomy; stomatoplasty; fibrotomy; placement of special membranes for guided tissue regeneration; exostosis reduction/removal; crown lengthening) Ridge augmentation Extraction of teeth or roots as determined during surgery Root desensitization therapy Oral and/or intravenous therapy Periodontal maintenance therapy (professional recall care) ALTERNATIVES Further, I have been informed that possible alternatives to the above treatment include: No treatment at all Maintenance therapy only Root planing/curettage and maintenance therapy only Pre-surgical and maintenance therapy only Extraction(s) We have discussed, however, that the procedures first recommended should be performed for the optimum prognosis. NON- TREATMENT RISKS I further understand that if no treatment is rendered, the risks to my dental health include, but are not limited to, the following: Premature loss of teeth Gum recession Halitosis Loosening of teeth Abscesses (gum boils) Tooth drifting, flaring, or other tooth movement Further deepening of periodontal pockets (puss pockets) and loss of attachment TREATMENT RISKS Risks of treatment may include, but are not limited to: Allergic or other reactions to medications Swelling Pain Thermal sensitivity Exposure of margins of crown (caps) and/or root surfaces Phonetic interferences Infection Tooth mobility Food impaction and spaces between teeth Temporary restricted mouth opening Numbness of jaw or gum Root resorption Loss of dental restorations Other (as discussed) CONSENT TO UNFORSEEN CONDITIONS DURING SURGERY If any unforeseen condition should arise in the course of the operation, I call for the Doctor’s judgment for procedures in addition to or different from those contemplated, I further request and authorize the Doctor to do whatever he may deem advisable. PHOTOGRAPHS – OBSERVERS In furtherance of my progression of dentistry and the dental health of the public, I do hereby consent to photographs being taken of my oral and facial structures, and subsequent publication solely for the educational and scientific purposes, and to having health professional observers in the examination and/or treatment room for educational purposes. My identity will not be revealed and only my mouth will be shown. NO WARRANTY No guarantee, warranty, or assurance has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. Due to the individual patient differences, a risk of failure, relapse, or worsening of my present periodontal condition may result despite treatment and may require retreatment and/or extraction of teeth. However, it is the Doctor’s opinion that therapy will be helpful, and that the further loss of supporting tissue or bone would occur sooner without the recommended treatment. It has been explained to me that the long-term success of the treatment requires my cooperation and performance of daily removal of bacterial deposits (plaque) from my teeth, as well as periodic periodontal maintenance therapy after the proposed treatment. I CERTIFY THAT I HAVE READ FULLY AND HAVE HAD ALL OF MY QUESTIONS ANSWERED SO THAT I UNDERSTAND THE ABOVE CONSENT TO TREATMENT, THE EXPLANATION THEREIN REFERRED TO OR MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND THE INAPPLICABLE SECTIONS, IF ANY, WERE STRICKEN BEFORE I SIGNED. Signature of Patient (or parent or legal guaridan): Relationship to Patient: Date: Press the button below to submit the completed consent form.