Soft Tissue Grafting Consent Consent for Soft Tissue Grafting Patient Name: Diagnosis. After a careful oral examination and a study of my dental condition, my periodontist has advised me that I have significant gum recession. I understand that with this condition, further recession may occur and the condition will worsen. In addition, for fillings at the gum line or crowns with edges under the gum line, it is important to have sufficient width of attached gum to withstand the irritation caused by the fillings or edges. Gum tissue may also be placed to improve the appearance and to protect the roots of the teeth. Recommended Treatment. In order to treat this condition, my periodontist has recommended that soft tissue augmentation (gum grafting) procedures may be performed in areas of my mouth with significant gum recession. I understand that a local anesthetic will be administered to me as part of the treatment. This surgical procedure involves the transplanting of a thin strip of tissue from elsewhere in my mouth or use of donated human tissue “Alloderm”. The transplanted strip of tissue can be placed at the base of the remaining gum, or it can be placed to partially cover the root surface exposed by the recession. Expected Benefits. The purpose of soft tissue grafting is to create an amount of attached gum tissue adequate to reduce the likelihood of further gum recession. Another purpose for this procedure may be to cover exposed root surfaces, to enhance the appearance of the teeth and gum line, or to prevent or treat root sensitivity or root decay. Principal Risks and Complications. I understand that complications may result from soft tissue grafting or from anesthetics. These complications include, but are not limited to (1) post surgical infection, (2) bleeding, swelling, and pain (3) facial discoloration, (4) transient or on occasion permanent tooth sensitivity to hot, cold, sweet, or acidic foods, (5) allergic reactions, and (6) accidental swallowing 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 my gum and bone will heal. I understand that there may be a need for a second procedure if the initial surgery is not satisfactory. In addition, the success of tissue grafting can be affected by (1) medical conditions, (2) dietary and nutritional problems, (3) smoking, (4) alcohol consumption, (5) clenching and grinding of teeth, (6) inadequate oral hygiene, and (7) medications that I may be taking. To my knowledge I have reported to the periodontist any prior drug medication reactions, allergies, diseases, symptoms, habits, or conditions, which might in any way relate to this surgical procedure. I understand that my diligence in providing the personal daily care recommended by my periodontist and taking all prescribed medications are important to the ultimate success of the procedure. Alternatives to Suggested Treatment. My periodontist has explained the alternative treatments for my gum recession, and modification of technique for brushing my teeth. Necessary Follow-up Care and Self-Care. I understand that it is important for me to continue to see my regular dentist. Existing restorative dentistry can be an important factor in the success or failure of any treatment. I recognize that I will need to come for appointments following my surgery so that healing may be monitored and so that my periodontist can evaluate and report on the outcome of my surgery. I know that it is important (1) to abide by the specific prescriptions and instructions given by the periodontist and (2) to see my periodontist and dentist for periodic examination and preventive treatment. Maintenance also may include adjustment of prosthetic appliances. No Warranty or Guarantee. I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide the benefit in reducing the cause of my condition and should produce healing, which will help me keep my teeth. Due to individual patient differences, however, a periodontist cannot predict the certainty of success. There is a risk of failure, relapse, additional treatment, or even worsening of my present condition, including the possible loss of certain teeth, despite the best of care. 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.