INFORMED CONSENT DISCUSSION FOR CROWN LENGTHENING PROCEDURE
PATIENT NAME: ______DATE: ______
Diagnosis: After a careful oral examination, my doctor has advised me that I have insufficient exposure of my teeth and /or overgrowth of gum tissue
Description of Proposed Procedure In order to treat this condition, my doctor has recommended that treatment include crown lengthening/exposure surgery. I understand that sedation may be utilized and that a local anesthetic will be administered to me as a part of the treatment.
During this procedure, my gum will be reduced to expose the proper amount of tooth. Bone around the teeth may be reduced and reshaped to a proper level and my gum will then be sutured back around the teeth where required.
I further understand that unforeseen conditions may call for modification or change from the anticipated treatment or surgical plan.
Benefits The purpose of crown lengthening/exposure surgery is to expose the proper length of tooth for improvement of the function of my teeth and to make oral hygiene more effective
Risk Related to Procedure (INITIALS REQUIRED) ______Bleeding, swelling, discomfort and infection: Following treatment, you may experience bleeding, pain, swelling and moderate discomfort for several days, which may be treated with pain mediation(s). You may also experience an infection following treatment, which would be treated with antibiotics.
______Reaction to anesthesia and/or sedation: You will receive a local anesthetic and possibly a sedative to keep you comfortable during treatment. In rare instances patients may have an allergic reaction to anesthetic, which may require emergency attention, or find that it reduces their ability to control swallowing, which increases the chances of swallowing foreign objects during treatment. Sedatives may temporarily make you drowsy or reduce your coordination.
______Tissue remodeling: Gum tissue heals after treatment or surgery, it may shrink somewhat, exposing some of the root surface. This could make teeth more sensitive to hot or cold. I also understand that following treatment, I may have spaces between my teeth at the gum line, which could trap food particles and require special maintenance.
______Stiff or sore jaw joint: Holding your mouth open during treatment may temporarily leave your jaw feeling stiff and sore and may make it difficult for you to open your mouth for several days afterwards. Treatment may also leave the corners of your mouth red or cracked for several days.
______Changes to nerve sensations: The nerves control sensations in your teeth, gums, tongue, lip, and chin run through your jaw. Depending on the tooth or teeth to be extracted (particularly lower teeth or third molars). In rare instances it may be impossible to avoid to avoid touching, moving, stretching, bruising, or severing the nerve. This could change the normal sensations in any of these areas, causing itching, tingling, burning, or burning (called paresthesia) or the loss of all sensation (called anesthesia). These changes could last from severe weeks to severe months or in some cases, indefinitely.
______Smoking: Smoking and/or chewing tobacco and/or alcohol intake may affect my ability to have normal gum and/or bone healing and may limit the potential for a successful outcome of my surgery.
______Medications: All medications have the potential for accompanying risks, side effects, and drug interactions. Therefore, it is critical that I tell my dentist of all medications, and supplements that I am currently taking, which are: ______
Alternatives to Proposed Treatment ______I understand that alternative to crown exposure surgery includes no treatment
Publication of Records ______I authorize photos, slides, radiographs (x-rays) or any other views of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes. My identity will not be revealed to the general public, however, without my permission.
No Warranty of Guarantee ______I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. Every reasonable effort will be made to ensure that your condition is treatment properly, although it is not possible to guarantee perfect results. There is a risk of failure, relapse, additional treatment, or even worsening of my present condition.
By signing below, I acknowledge that I have received adequate information about the proposed treatment, that I understand this information and that all my questions have been answered fully. I have been given the opportunity to ask questions and I give consent for the proposed treatment as described above.
______PRINT PATIENT NAME
______PATIENT or LEGAL GUARDIAN SIGNATURE DATE
______DOCTOR/STAFF SIGNATURE DATE