1. Purpose of Dental Implant(s)
The purpose of dental implant(s) is to provide stability, support, and/or retention for a crown, fixed bridge, fixed denture, or removable denture in the absence of natural teeth. Based upon thorough examination and discussion, I request the fabrication of an implant prosthesis. I approve any future modification in prosthetic design, materials, or treatment if, in the doctor’s professional judgment, it is in my best interest.
- Fixed – Similar to natural teeth in color and size
- Fixed – Longer and/or larger than natural teeth, and of similar color
- Fixed – Longer and/or larger than teeth, with tooth color and pink to replace the missing gum
- Removable – Supported by Implants
- Removable – Supported by implants and gums
2. Understanding of the Procedure
I have been informed and afforded the time to fully understand the purpose and the nature of the implant restorative procedure. I understand what is necessary to accomplish the restoration of the implant previously inserted into or onto the bone and under the gum.
3. Alternative Treatments
Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire an implant prosthesis to help secure the replacement of my missing teeth. The entire procedure has been fully explained, including the benefits and possible risks. I have not asked for, nor have I received, a guarantee of the outcome of this procedure.
4. Possible Risks and Complications
The possible risks and complications for fixed prostheses include:
- Compromised appearance and/or lack of support of the lip(s) and cheek(s) due to inadequate bone
- Air escaping underneath the prosthesis while talking, which may adversely affect speech
- Food entrapment underneath the prosthesis since space is necessary for homecare of the implants
The possible risks for removable prostheses include:
- Sore gums
- Food entrapment
- Wearing of attachments
- Replacement of attachment components
- Initial problems with speech
5. Risks of Excessive Forces
Excessive forces such as grinding or clenching my teeth on the implant(s) may lead to:
- Loosening and/or fracture of the retaining screws or cement
- Fracture of the porcelain, metal, or acrylic on the prosthesis
- Loosening and/or fracture of the implant(s)
- Loss of bone around the implant(s), potentially causing implant failure
Additional treatment and associated costs will be involved should this occur, including, but not limited to, occlusal guards.
6. Consequences of No Treatment
I understand that if nothing is done, any of the following could occur:
- Loss of bone
- Gum tissue inflammation
- Infection
- Sensitivity
- Loosening of teeth followed by the necessity of extraction
- Temporomandibular joint problems
- Headaches
- Referred pains to the back of the neck and facial muscles
- Fatigued muscles when chewing
Additionally, I am aware that if nothing is done at the present time, future bone loss may prevent the placement of implant(s) at a later date due to changes in oral or medical condition(s).
7. Possibility of Implant Failure
It has been explained that in some instances, implant(s) fail and must be removed. I have been informed and understand that the practice of dentistry is not an exact science; therefore, there are no guarantees or assurances as to the outcome of treatment results.
8. Follow-Up Care
Follow-up care for the implants and prosthesis is extremely important to success. It will be necessary to return to the office at regular intervals for examination and service. I understand that failure to maintain oral hygiene may jeopardize the success of my implant(s).
I realize that unforeseen long-term factors may necessitate additional surgery, modification of the implant(s), or even surgical removal of the implant(s). I also understand that I will be financially responsible for long-term maintenance and/or any modifications required, including but not limited to:
- Cleaning
- Attachment replacements
- X-rays
- Examinations
9. Health History
To my knowledge, I have given an accurate report of my physical and mental health history. I understand that excessive smoking, alcohol use, or uncontrolled blood sugar may affect gum healing and limit the success of the implant(s) and restoration. I will report any significant change in my health should it occur.
10. Consent for Documentation
I consent to photography, filming, recording, x-rays, and additional professional staff observing the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed.
11. Contact Information Updates
I agree to notify the doctor’s office of any changes to my address and/or telephone number within a reasonable time frame (two to four weeks), so future follow-up care may be established.
12. Authorization for Additional Procedures
If an unforeseen condition arises in the course of treatment which calls for additional or different procedures than initially planned, I further authorize and direct my doctor, associate, or assistant to do whatever they deem necessary and advisable under the circumstances, including the decision not to proceed with the implant restoration.
