Surgery: Informed Consent

4. Principal Risks and Complications: A small number of patients do not have the graft “take.” The usual causes are Smoking, excessive alcohol intake or inadequate may adversely affect gum healing and may limit the Patient name: Date: excessive shrinking of the graft tissue during initial healing, smoking, or trauma caused by the patient during successful outcome of my surgery. I know that is important to: normal function (i.e. eating, talking etc.) or hygiene practise. Such events can cause the original defect to return or, 1) Abide by the speci c prescriptions and instructions given. Site: Periodontist: Dr. Jacob Swiderski in rare instances, become worse. Therefore, it might be necessary to perform additional grafting procedures, 2) See my periodontist for post-operative check-ups as needed. usually after about 3 months (to allow the surgical sites to heal up rst). Usually, but not always the second graft will 3) Quit smoking. “take.” There is no extra surgical fee charged for this, if the graft did not take and is redone within 6-9 months. 4) Perform excellent oral hygiene once instructed to, usually starting 2 weeks after the surgery is done. Complications that may result from surgery could involve the surgery procedure, gum or bone regenerative 5) I know I should only use soft bristle or soft electric toothbrushes. Good oral hygiene is essential

1. Diagnosis: After a careful oral examination and study of my dental conditions, I have been advised that I have materials, drugs or anesthetics. These complications include, but are not limited to: to good dental health. gingival (gum) recession (root exposure) or areas with insuf cient amounts of attached gingiva ( rm gum tissue). In • Post-surgical infection Supplemental Records and Their Use: health, two types of tissue super cially surround teeth: gingiva and mucosa. Mucosa is like cheek tissue, and does 7. I consent to photography, video recording, and x-rays of my oral structures • Bleeding, swelling, pain, facial bruising not adhere to the roots of the teeth or underlying jawbone very well, as compared to gingiva, which is a more as related to these procedures, and for their educational use in lectures or publications, provided my identity is not • Jaw joint pain or muscle spasm brous tissue. Mucosa at the gum line of teeth or as the only gum tissue that is adhering to the roots of the teeth is revealed. • Cracking or bruising of the corners of the mouth much more likely to recede, causing more root of the tooth to show and causing a loss of the underlying jawbone 8. No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me • Restricted ability to open the mouth for several days to weeks around the tooth. Having a good amount of jawbone around the teeth is essential, as it is the jawbone that holds that the proposed gum graft will be successful. Due to individual patient differences, no one can predict certainty • Impact on speech the teeth in. of success. There is a remote possibility of worsening of my present condition, including the possible loss of • Allergic reactions After an examination and study of my dental condition, I have been advised that I have an insuf cient amount of certain teeth, despite the best of care. This is extremely rare. • Accidental swallowing or aspiration of foreign matter attached gingival ( rm gum tissue) around some teeth. With this condition, recession of the gum may occur. In • Transient or permanent increase in tooth looseness addition, for llings or crowns with edges under the gum line, it is important to have suf cient width of rm, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTOOD THIS DOCUMENT. I AM AWARE AND UNDERSTAND • Tooth sensitivity to hot, cold, sweet or acidic foods adhered gingival to the roots of the teeth to withstand the irritation they may cause. Gingiva ( rm gum tissue) also THE RISKS AND BENEFITS INVOLVED WITH THE PROPOSED PROCEDURE, AS WELL AS ALTERNATIVES TO THE • Transient (on rare occasions permanent) numbness of the jaw, lip, tongue, chin or improves the appearance and protects the roots of the teeth by reducing risk of future gum recession. PROPOSED PROCEDURE. THE PERIODONTIST HAS ANSWERED ALL MY QUESTIONS. *The exact duration of any complication cannot be determined, and they may be irreversible. 2. Recommended Treatment: I have been recommended that gingival grafting (gum grafting) be performed in some I HEREBY AUTHORIZE DR. SWIDERSKI TO PERFORM PERIODONTAL SURGERY ON MYSELF. areas of my mouth. Local anesthetic will be administered as part of doing the gum graft surgery. Gum grafting 5. Alternatives to Suggested Treatment: In order to treat my condition, a gum grafting procedure was suggested. involves the transplanting of a thin strip of gingiva from the (the roof of the mouth) and sutures will be Alternatives has also been discussed with me, including: no treatment, which may entail regular professional placed on the palate. The existing gum tissue around the teeth to be grafted will either be excised back to provide hygiene and monitoring. I understand that not grafting the affected site could result in an increased likelihood of room for the graft, or temporarily pushed back to allow for the graft to be placed in the desired location, followed further gum recession and subsequent jawbone loss around the effected teeth is higher with no gum graft than with by re-positioning of the existing gum tissue over the graft. Both the donor site (e.g. the palate) and the grafted site, a successful gum graft. In extreme cases, the affected tooth might be lost. will have sutures placed to maintain the position, stabilize the surgerized tissue, and to control potential bleeding. Patient/Guardian name Signature 6. Necessary Follow-up Care and Self-Care: It is important for me to continue to see my regular for routine Two types of sutures (stitches) might be used: dissolvable (“resorbable”) and/or non-resorbable. Any dissolvable dental care. sutures will dissolve in about 1-2 weeks. The surgeon will remove any non-dissolvable sutures around the grafted tooth at a later visit (in about 2-4 weeks after the grafting). Smoking may adversely affect gum healing and may limit the successful outcome of my surgery. Studies show smokers have more grafts that fail to “take” than non-smokers. 3. Expected Bene ts: The purpose of gingival grafting is to create an amount of attached gum tissue adequate to Witness Name Signature reduce the likelihood of further gum recession. It is also hoped to cover back up some of the exposed root(s) of I have told my doctor about any pertinent medical conditions I have, allergies (especially to medications or sul tes the tooth/teeth. I understand that grafting surgery is dif cult to predict, as such, I do not expect all of the exposed (many local anesthetics have sul te preservatives)) or medications I am taking, including over the counter tooth/root caused by existing gum recession to be totally recovered with this gum graft surgery. In some cases, medication such as aspirin or any other blood thinners. coverage is not possible at all, and in other cases additional procedures might need to be undertaken to further I also need to inform my surgeon as soon as possible of any complications or symptoms that may relate to the correct the condition. procedure.

I need to come back for post-operative check-ups so that healing may be monitored and so the doctor can evaluate and report on the outcome of the surgery to my dentist.

1325 Clarence St S, Unit 1, Brantford, ON N3S 0C7 Email: [email protected] | Phone: 519.756.8080 Gingival Grafting Surgery: Informed Consent

4. Principal Risks and Complications: A small number of patients do not have the graft “take.” The usual causes are Smoking, excessive alcohol intake or inadequate oral hygiene may adversely affect gum healing and may limit the excessive shrinking of the graft tissue during initial healing, smoking, or trauma caused by the patient during successful outcome of my surgery. I know that is important to: normal function (i.e. eating, talking etc.) or hygiene practise. Such events can cause the original defect to return or, 1) Abide by the speci c prescriptions and instructions given. in rare instances, become worse. Therefore, it might be necessary to perform additional grafting procedures, 2) See my periodontist for post-operative check-ups as needed. usually after about 3 months (to allow the surgical sites to heal up rst). Usually, but not always the second graft will 3) Quit smoking. “take.” There is no extra surgical fee charged for this, if the graft did not take and is redone within 6-9 months. 4) Perform excellent oral hygiene once instructed to, usually starting 2 weeks after the surgery is done. Complications that may result from surgery could involve the surgery procedure, gum or bone regenerative 5) I know I should only use soft bristle toothbrushes or soft electric toothbrushes. Good oral hygiene is essential

1. Diagnosis: After a careful oral examination and study of my dental conditions, I have been advised that I have materials, drugs or anesthetics. These complications include, but are not limited to: to good dental health. gingival (gum) recession (root exposure) or areas with insuf cient amounts of attached gingiva ( rm gum tissue). In • Post-surgical infection Supplemental Records and Their Use: health, two types of tissue super cially surround teeth: gingiva and mucosa. Mucosa is like cheek tissue, and does 7. I consent to photography, video recording, and x-rays of my oral structures • Bleeding, swelling, pain, facial bruising not adhere to the roots of the teeth or underlying jawbone very well, as compared to gingiva, which is a more as related to these procedures, and for their educational use in lectures or publications, provided my identity is not • Jaw joint pain or muscle spasm brous tissue. Mucosa at the gum line of teeth or as the only gum tissue that is adhering to the roots of the teeth is revealed. • Cracking or bruising of the corners of the mouth much more likely to recede, causing more root of the tooth to show and causing a loss of the underlying jawbone 8. No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me • Restricted ability to open the mouth for several days to weeks around the tooth. Having a good amount of jawbone around the teeth is essential, as it is the jawbone that holds that the proposed gum graft will be successful. Due to individual patient differences, no one can predict certainty • Impact on speech the teeth in. of success. There is a remote possibility of worsening of my present condition, including the possible loss of • Allergic reactions After an examination and study of my dental condition, I have been advised that I have an insuf cient amount of certain teeth, despite the best of care. This is extremely rare. • Accidental swallowing or aspiration of foreign matter attached gingival ( rm gum tissue) around some teeth. With this condition, recession of the gum may occur. In • Transient or permanent increase in tooth looseness addition, for llings or crowns with edges under the gum line, it is important to have suf cient width of rm, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTOOD THIS DOCUMENT. I AM AWARE AND UNDERSTAND • Tooth sensitivity to hot, cold, sweet or acidic foods adhered gingival to the roots of the teeth to withstand the irritation they may cause. Gingiva ( rm gum tissue) also THE RISKS AND BENEFITS INVOLVED WITH THE PROPOSED PROCEDURE, AS WELL AS ALTERNATIVES TO THE • Transient (on rare occasions permanent) numbness of the jaw, lip, tongue, chin or gums improves the appearance and protects the roots of the teeth by reducing risk of future gum recession. PROPOSED PROCEDURE. THE PERIODONTIST HAS ANSWERED ALL MY QUESTIONS. *The exact duration of any complication cannot be determined, and they may be irreversible. 2. Recommended Treatment: I have been recommended that gingival grafting (gum grafting) be performed in some I HEREBY AUTHORIZE DR. SWIDERSKI TO PERFORM PERIODONTAL SURGERY ON MYSELF. areas of my mouth. Local anesthetic will be administered as part of doing the gum graft surgery. Gum grafting 5. Alternatives to Suggested Treatment: In order to treat my condition, a gum grafting procedure was suggested. involves the transplanting of a thin strip of gingiva from the palate (the roof of the mouth) and sutures will be Alternatives has also been discussed with me, including: no treatment, which may entail regular professional placed on the palate. The existing gum tissue around the teeth to be grafted will either be excised back to provide hygiene and monitoring. I understand that not grafting the affected site could result in an increased likelihood of room for the graft, or temporarily pushed back to allow for the graft to be placed in the desired location, followed further gum recession and subsequent jawbone loss around the effected teeth is higher with no gum graft than with by re-positioning of the existing gum tissue over the graft. Both the donor site (e.g. the palate) and the grafted site, a successful gum graft. In extreme cases, the affected tooth might be lost. will have sutures placed to maintain the position, stabilize the surgerized tissue, and to control potential bleeding. Patient/Guardian name Signature 6. Necessary Follow-up Care and Self-Care: It is important for me to continue to see my regular dentist for routine Two types of sutures (stitches) might be used: dissolvable (“resorbable”) and/or non-resorbable. Any dissolvable dental care. sutures will dissolve in about 1-2 weeks. The surgeon will remove any non-dissolvable sutures around the grafted tooth at a later visit (in about 2-4 weeks after the grafting). Smoking may adversely affect gum healing and may limit the successful outcome of my surgery. Studies show smokers have more grafts that fail to “take” than non-smokers. 3. Expected Bene ts: The purpose of gingival grafting is to create an amount of attached gum tissue adequate to Witness Name Signature reduce the likelihood of further gum recession. It is also hoped to cover back up some of the exposed root(s) of I have told my doctor about any pertinent medical conditions I have, allergies (especially to medications or sul tes the tooth/teeth. I understand that grafting surgery is dif cult to predict, as such, I do not expect all of the exposed (many local anesthetics have sul te preservatives)) or medications I am taking, including over the counter tooth/root caused by existing gum recession to be totally recovered with this gum graft surgery. In some cases, medication such as aspirin or any other blood thinners. coverage is not possible at all, and in other cases additional procedures might need to be undertaken to further I also need to inform my surgeon as soon as possible of any complications or symptoms that may relate to the correct the condition. procedure.

I need to come back for post-operative check-ups so that healing may be monitored and so the doctor can evaluate and report on the outcome of the surgery to my dentist.

1325 Clarence St S, Unit 1, Brantford, ON N3S 0C7 Email: [email protected] | Phone: 519.756.8080 Gingival Grafting Surgery: Informed Consent

Smoking, excessive alcohol intake or inadequate oral hygiene may adversely affect gum healing and may limit the successful outcome of my surgery. I know that is important to: 1) Abide by the speci c prescriptions and instructions given. 2) See my periodontist for post-operative check-ups as needed. 3) Quit smoking. 4) Perform excellent oral hygiene once instructed to, usually starting 2 weeks after the surgery is done. 5) I know I should only use soft bristle toothbrushes or soft electric toothbrushes. Good oral hygiene is essential to good dental health.

7. Supplemental Records and Their Use: I consent to photography, video recording, and x-rays of my oral structures as related to these procedures, and for their educational use in lectures or publications, provided my identity is not revealed.

8. No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed gum graft will be successful. Due to individual patient differences, no one can predict certainty of success. There is a remote possibility of worsening of my present condition, including the possible loss of certain teeth, despite the best of care. This is extremely rare.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTOOD THIS DOCUMENT. I AM AWARE AND UNDERSTAND THE RISKS AND BENEFITS INVOLVED WITH THE PROPOSED PROCEDURE, AS WELL AS ALTERNATIVES TO THE PROPOSED PROCEDURE. THE PERIODONTIST HAS ANSWERED ALL MY QUESTIONS.

I HEREBY AUTHORIZE DR. SWIDERSKI TO PERFORM PERIODONTAL SURGERY ON MYSELF.

Patient/Guardian name Signature

Witness Name Signature

1325 Clarence St S, Unit 1, Brantford, ON N3S 0C7 Email: [email protected] | Phone: 519.756.8080