CONSENT FOR SUBPERIOSTEAL IMPLANT
Patient’s NameDate
Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing.
You have the right to be informed about your diagnosis and planned surgery so that you can decide whether to have a procedure or not after knowing the risks and benefits.
My condition has been explained to me as a Missing Tooth orMissing Teeth described as: ______
______
The procedure necessary to treat the condition has been explained to me and I understand the nature of the procedure to be:
I have been informed of possible alternate methods of treatment (if any) including: ______
No guarantee has been given that the implant will last for a specific time period. It has also been explained to me that, once the implant is inserted, the entire treatment plan must be followed and completed on schedule. If this schedule is not carried out, the implant may fail.
I understand that the bone loss in my jaw is so severe that other types of implants are not ideal and that the subperiosteal implant is being recommended to reconstruct my upper and/or lower jaw in an effort to provide greater stability of dentures and possibly improve chewing efficiency.
There is more than one way to put in a subperiosteal implant. The first involves making a surgical cut in my gums to uncover as much of the jawbone as possible. Then an impression of my jaw will be taken and a model will be made from the impression. A metal framework (subperiosteal implant) is made on that model. It will be put in my gum later by re-opening the original cut. A second wayis to take a special x-ray study of the jaw. A three-dimensional model of my jawwill be made based on the x-ray and the implant framework is made on that model. The implant will then be put in through a surgical cut in my gums. This wayneedone less surgical procedure. However, the framework might not fit as well. A synthetic graft material might be used to try to correct anydifference.
CONSENT FOR SUBPERIOSTEAL IMPLANT
I may not be able to wear my old dentures for some time after surgery. Even when I can, the fit may not beperfect. As soon as good healing has taken place, new dentures must be made to match the implant.
All surgeries have some risks. They include the following and others:
Post-operative discomfort, swelling, bleeding, bruising and a fairly long recovery period. I might be limited in what I can chew and eat during recovery.
Bleeding that is heavy or lasts for a long time that might need more treatment.
An infection after the procedure that might need more treatment or cause loss of the implant.
Implants placed in lower jaw might injure the nerve that gives feeling to the face. After the surgery, there might be pain or a numb feeling in my chin, lip, cheek, gums, teeth or tongue. It is possible that I might lose my sense of taste. This might last for weeks or months. It can be permanent, but this rarely happens.
A stress fracture of the metal framework can occur, but this is rare. If it happens, I might need to have part or all of the implant removed.
Allergic reactions (not known before) to any medications or materials used in treatment.
This treatment might not be successful and a situation might come up during surgery where the surgeon can’t finish the implant procedure. If the implant fails and is removed, it might be possible to put in another oneafter a good healing period.
Poor oral hygiene might result in the loss of the implant.
Smoking is extremely harmful to the success of implant surgery. I agree to stop all use of tobacco for 2-3 weeks before and after surgery, including thelater uncovering procedure. I also agree to make strong efforts to give up smoking entirely.
_____ Initial here if you have read and acknowledged the above.
INFORMATION FOR FEMALE PATIENTS
I have informed my doctor about my use of birth control pills. I have been advised that certain antibiotics and other medicines might make the birth control pills not work as well. This might result in conception and pregnancy. I agree to talk with my own doctor to start additional forms of birth control during the period of my treatment. I will continue those methods until my doctortells me that I can return to the use of oral birth control pills.
_____ Initialhere if you have read and acknowledged the above.
CONSENT FOR SUBPERIOSTEAL IMPLANT
ANESTHESIA
I have had the opportunity to speak with Dr. ______about my options for anesthesia. These options include Local Anesthesia, Nitrous Oxide/Oxygen Analgesia with Local Anesthesia, Oral Medication with Local Anesthesia, Intravenous Sedation, or Deep Sedation/General Anesthesia. After this discussion, I have chosen to have ______as my anesthesia. I understand the risks and potential complications of anesthesia to include:
Discomfort, swelling or bruising where the drugs are placed into a vein.
Vein irritation, called phlebitis, where the drugs are placed into a vein. Sometimes this may grow to a level of discomfort or disability where it may be difficult to move my arm or hand. Sometimes medication or other treatment may be needed.
Nerves travel next to the blood vessels where the drugs are placed into a vein. If the needle hits a nerve or if drugs or fluidleaks out of the vessel around a nerve, I may have numbness or pain in the nerve where it runs along the arm. Usuallythe numbnessor pain goes away, but in some cases, it may be permanent.
Allergic reactions (previously unknown) to any of the medications used.
Nausea and vomiting, although not common, are possible unfortunate side effects. Bed rest, and sometimes medications, may be needed for relief.
Conscious sedation and deep sedation/general anesthesia are serious medical procedures and, whether given in a hospital or office, carry the risk of brain damage, stroke, heart attack or death.
In situations where a breathing tube is used, I may have a sore throat, hoarseness or voice change.
_____ Initial here if you have read and acknowledged the above.
MY OBLIGATIONS:
Because anesthetic or sedative medications (including oral premedication) cause drowsiness that lasts for some time, I MUST be accompanied by a responsible adult to drive me to and from surgery, and stay with me for several hours until I am recovered sufficiently to care for myself. Sometimes the effects of the drugs do not wear off for 24 hours.
During recovery time (normally 24 hours), I should not drive, operate complicated machinery or devices or make important decisions such as signing documents, etc.
I must have a completely empty stomach. It is vital that I have NOTHING TO EAT OR DRINK for six (6) hours prior to my treatment. TO DO OTHERWISE MAY BE LIFE-THREATENING.
_____ Initial here if you have read and acknowledged the above.
CONSENT FOR SUBPERIOSTEAL IMPLANT
Unless instructed otherwise, it is important that I take any regular medications (high blood pressure, antibiotics, etc.) or any medicinesgiven to me by my surgeon using only small sips of water.
_____ Initial here if you have read and acknowledged the above.
CONSENT
I understand that my doctor can’t promise that everything will be perfect. I understand that the treatment listed above and other forms of treatment or no treatment at all are choices I have.I have read and understand the above and give my consent to surgery and chosen anesthesia. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form.
Patient’s (or Legal Guardian’s) Signature Date
Doctor’s Signature Date
Witness’ Signature Date
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