Dentistry On 66

Dr. Azawi INFORMED CONSENT FORM FOR PERIODONTAL SURGERY

I understand that I have a form of periodontal disease that has caused damage to the soft tissue and/or bone around my teeth
and is endangering the health of my oral tissues. This disease, if left untreated is generally non-reversible and can be
progressive, leading to further damage and possible loss of my teeth.


I also understand that a variety of non surgical/surgical procedures are used to treat periodontal disease. While these surgical procedures are generally successful, I understand that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be curative and/or successful to my present condition may result despite the treatment.

It has been explained to me that long-term success of treatment requires my cooperation and performance of effective plaque
control (home care) on a daily basis. Equally important are periodic periodontal maintenance visits at a dental office after
the proposed surgical treatment is performed. This is because most periodontal disease is chronic in nature and requires
continuing treatment to keep it under control. Periodontal disease is rarely curable even with the most effective treatment.

I further understand that the rate of the progression of the disease is variable and unpredictable, but if no treatment is
rendered, my present periodontal condition will probably worsen in time, which may result in premature tooth loss. I am
aware that smoking caused delay healing and may interfere with the success of the treatment.

I have been informed that other possible alternative methods of treatment include: no treatment, non-surgical treatment
which may or may not include local drug delivery agents (root planning followed by periodic maintenance), other surgical
treatment procedures, or extraction.

Although complications from periodontal surgery are rate, they can occur. The most common complications are as follows:
post surgical discomfort, bleeding, swelling, tooth sensitivity, infection, gum recession (shrinkage) with tooth elongation,
increased tooth looseness, food impaction between teeth after eating, unaesthetic exposure of crown margins, and/or
(SPECIFY) _______________________________________________

By signing, I or the patient for whom I act as guardian/POA, understand and agree with the following statements:

  • The above risks, benefits and alternative treatments have been discussed clearly
  • Although success rates are very high there no guarantees are regarding the longevity or anticipated result of the procedure.
  • I understand the information discussed and have had the opportunity to ask questions.

I hereby authorize Dr. JOSHUA SHIEH to perform the following surgical treatment(s) as indicated below.  

do66 dr azawi perio consent surgery
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PERIODONTAL FLAP THERAPY
Under local anaesthesia, the gum tissue is surgically detached from the teeth and gently retracted to expose the roots. After thoroughly cleaning the root surfaces, tissue is secured back in place with sutures. Sometimes smoothing or re-contouring the underlying bone is necessary.

REGENERATIVE THERAPY
This is a variable of the procedure. In addition to thoroughly cleaning the root surfaces, various materials may be placed under the tissue in an attempt to regenerate the connective tissue and/or bone previously destroyed by the disease process. These materials do not guarantee the regeneration of the lost support, but have been demonstrated to be more effective than replaced flap therapy. The following materials are commonly employed: Bone particles obtained by the re-contouring process above are placed into the bony defect to stimulate growth.
Inert, man-made “ bonecrystals”, composed of the same minerals as in natural bone, are used to fill the bony defects. Membranes of Teflon or other substances are placed between the gum tissue and the bone and secured in place with sutures. These aid the repair process by preventing the soft gum tissue and the bone and secured in place with sutures. These aid the repair process by preventing the soft gum tissue from interfering with new bone formation during the early stages of the healing period. A second surgical phase may be required to remove the membrane after a suitable healing period.
One of the most common tissues used today in regenerative techniques is decalcified freeze-dried bone. This material is taken under sterile conditions from donors with no known systemic disease, and the blood test are negative for any infection. The tissue is also tested (cultured), then decalcified and processed under strict laboratory conditions known to kill all bacteria and viruses under experimental conditions. It is then cultured again for any contamination, and stored in a vacuum-sealed sterile container until it is ready to be opened during
the surgical procedure.

SURGICAL CROWN LENGTHENING
The gingival margin (gumline) is altered to expose more of the tooth. This may be desirable to decrease the pocket depth around the teeth, to improve aesthetics or to allow the restoration of a badly broken down tooth.

TMUCOGINGIVAL SURGERY
Gum tissue may be moved or transplanted from one are of the mouth to another in an attempt to reinforce the gumline or to cover an area of exposed root surface. If the roof of the mouth is used as the donor site, a protective plastic liner may be placed to protect that area while it is healinghis procedure often requires removal of some of the bone around the necks of the teeth.