Consent:
After a careful oral examination and study of my dental condition, Dr. Mathur has
recommended dental implants as the best method to reconstruct my dentition. I have
been fully informed of the nature of dental implants, the procedures involved, the
associated benefits and risks of implant supported artificial teeth, and the alternative
treatments available. I agree not to drive or operate heavy machinery for 24 hours after
my surgery. I hereby declare it my wish to have the benefits of dental implants and I
consent to their surgical placement in my jaw (s).
Surgical Phase Of Procedure:
I understand that sedation may be utilized and that a local anesthetic will be administered
to me as part of the treatment. My gum tissue will be opened to expose the bone.
Implants will be placed by pushing or threading them into holes that have been drilled in
my jawbone. The implants will have to be snugly fitted and held tightly in place during
the healing phase.
The soft tissue will be stitched closed over or around the implants. A periodontal
bandage or dressing may be place. Healing will be allowed to proceed for a period of
four to six months. I understand that dentures usually cannot be worn during the first one
to two weeks of the healing phase.
I further understand that if during surgery, clinical conditions turn out to be unfavorable
for the use of this implant system or prevent the placement of implants, my periodontist
will make a professional judgment on the management of the situation. The procedure
may need to be cancelled or may involve supplemental bone grafts or other types of
grafts to build up the ridge of my jaw to allow placement, gum closure, and security of
my implants. I understand that additional charges may be incurred.
For implants requiring a second surgical procedure, the overlying tissues will be opened
at the appropriate time, and the stability of the implant will be verified. If the implant
appears satisfactory, an attachment will be connected to the implant. Plans and
procedures to create an implant prosthetic appliance or artificial crown can then begin.
Restorative Phase of Treatment:
I understand that I will be referred back to my dentist or to a prosthodontist. This phase
is just as important as the surgical phase for the long-term success of the oral
reconstruction. During this phase, an implant prosthetic device will be attached to the
implant. This procedure should be preformed by a person trained in the prosthetic
protocol for the root form implant system. The restorative dentistry (“the teeth”) is to be
done by another dentist who has no affiliation with Dental Specialists Of Texas P.A./Dr.
Mathur. There will be a substantial fee for the prosthesis (teeth). I understand that fees for the restorative treatment done by another dentist are IN ADDITION TO the surgical
fees.
Risks and complications:
I have been informed and understand that complications may result from the implant
surgery, drugs, and anesthetics. These complications include pain, infection, swelling,
and /or discoloration. Numbness of the lip, tongue, chin, cheeks, or teeth may also occur.
The exact duration of these complications cannot be determined and they may be
irreversible. Also possible are injury to the teeth, bone fractures, nasal and sinus
penetrations, delayed healing and allergic reactions to drugs or medications used.
Benefits:
The purpose of dental implants is to allow me to have more functional artificial teeth or
improved appearance. I understand that the purpose of dental implants is to provide
support, anchorage, and/or retention for artificial teeth. The artificial teeth attached to the
implants will be essentially stationary and, depending upon design, will be removable by
either me or my dentist.
Alternative Treatments:
Alternative treatments for my edentulous (missing teeth) have been explained to me.
These include no treatment, or new fixed or removable appliances. I also understand that
continued wearing of ill fitting removable appliances can result in the further damage to
the bone and soft tissue of my mouth.
Healing Capacity and Predictability:
I have been informed there is no method of accurately predict or evaluate how much my
gum and bone will heal. I do understand that the success of the implant can be affected
by: systemic disease, dietary and nutrition problems, smoking, alcohol consumption, drug
abuse, clenching and grinding of the teeth, and inadequate oral hygiene.
To my knowledge, I have reported to my dentist any prior drug reactions, allergies,
diseases, symptoms, habits, or conditions which might in any way relate to this surgical
venture. I agree to follow the personal daily care as recommended by my dentist and my
physician.
Further Complications:
It has been explained to me that the connection between the implant and the bone may
fail and it may become necessary to remove the implant. I understand that this can
happen in the preliminary healing phase, or at any time thereafter. I further understand
that there is no guarantee or assurance that the implant system and/or the artificial
appliances will be completely successful in function or appearance (to my complete
satisfaction). Because of the uniqueness of each patient and since the practice of
dentistry is not an exact science, long term success cannot be guaranteed and the
function, comfort, and appearance of the prosthesis may be less than what I hoped for.
The Proposed Implant System:
I do agree that if clinical conditions are found to be unfavorable for the use of this
implant system, and alternative system or method selected by my dentist can be
substituted. If clinical conditions prevent the placement of implants, I defer to my dentist
judgement on the surgical management of that situation.
Tampering With The Implant System or Prosthetic Appliance:
I have been informed that the prosthetic appliance can be a big factor in the success or
failure of the implant. I understand that alterations made on the artificial appliance or the
implant by an uniformed person, (including myself), could possibly lead to ill effects,
which would become the sole responsibility of said individual doing the alterations.
Necessary Follow-up Care and Self-Care:
I understand that it is important for me to continue to see my general dentist or
prosthodontist. Implants, natural teeth and appliances must be maintained daily in a
clean, hygienic manner. Implants and appliances must also be examined periodically and
may need to be adjusted. I understand that it is important for me to abide by the specific
prescriptions and instructions given by my periodontist.
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. Due to individual patient differences, a
therapist cannot predict certainty of success. There exists the risk of failure, relapse,
additional treatment, or worsening of my present condition, including the possible loss of
certain teeth or implants, despite the best care.
Publication Of Records:
I authorize photos, slides, x-rays or any other viewings of my care and treatment during
or after its completion to be used for the advancement of dentistry and for reimbursement
purposes. My identity will not be revealed to the general public however, without my
permission.