Consent for Implant Restorations
I have been provided with this information and consent form so I may better understand the treatment recommended for me. I was provided with enough information, and I understand, and have made a well-informed decision regarding my proposed treatment.
I understand that I may ask any questions I wish, and that it is better to ask them before treatment begins than to wonder about it after treatment has started.
Nature of Implant Restorations
Implant restorations replace missing teeth. They differ from conventional restorations in that they are supported by dental implants, rather than by natural teeth. The use of dental implants permits missing teeth to be replaced through the use of crowns, fixed bridges, and dentures that are supported or retained by their attachment to the implant(s).
Implant restorations usually require a number of visits to complete treatment. An impression, or mold, of the top part of the implant, associated restorative components, and surrounding gum tissue is made using a rubbery material. The implant restoration is then made by a dental laboratory. It is important to return for the insertion of your implant restoration as soon as it is ready.
This recommendation is based on visual examination(s), on any X-rays, models, photos and other diagnostic tests taken, and on my doctor's knowledge of my medical and dental history. My needs and wishes have also been taken into consideration.
I understand that no guarantee, warranty, or assurance has been given to me that this treatment will be successful, or for how long. I have had an opportunity to ask questions about any alternatives all my questions have been answered.
Risks of Implant Restorations
I have been informed and fully understand that there are certain inherent and potential risks associated with implant restorations. I understand that I may experience pain or discomfort during and/or after treatment. I understand that an implant restoration may not relieve my symptoms or meet my expectations for comfort, function, or esthetics. I understand that I may notice slight changes in my bite. I understand that during and for several days following treatment, I may experience stiff and sore jaws from keeping my mouth open.
I understand that it is possible for an infection or other problems to occur in or around an implant site and/or the surrounding gums, and that I may need antibiotics and/or other procedures, such as periodontal (gum) surgery around the implant, to treat the infection. I understand this may occur during or after treatment. I understand that my gums may recede after the completion of my implant restoration. This condition may also require periodontal (gum) surgery. I understand that poor eating habits, poor oral habits (smoking, tobacco chewing, fingernail biting, etc.), poor oral hygiene, and certain medical conditions, such as diabetes, will negatively affect how long my implant restoration lasts.
I understand that I may be given a local anesthetic injection and that in rare situations; patients have had an allergic reaction to the anesthetic, an adverse medication reaction to the anesthetic, or temporary or permanent injury to nerves and/or blood vessels from the injection. I understand that the injection area(s) may be uncomfortable following treatment, and that my jaw may be stiff and sore from holding my mouth open during treatment.
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, my recommended treatment is necessary. I am aware that the practice of dentistry is not an exact science, and I acknowledge that no guarantees, warranties, or representations have been made to me concerning the results of the procedure.
I have received information about the proposed treatment. I have discussed my treatment with the Doctor and have been given an opportunity to ask questions and have them fully answered. I understand the nature of the recommended treatment, alternate treatment options, the risks of the recommended treatment, and the risks of refusing treatment.
I wish to proceed with the recommended treatment.