consent-for-periodontal-surgery-(j-suzuki).doc - TEMPLE...

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TEMPLE UNIVERSITY DEPARTMENT OF PERIODONTOLOGY PHILADELPHIA, PA Consent for Periodontal Surgery PATIENT NAME: _________________________________________________ SURGERY DATE_____/_____/_____ Diagnosis - After a careful oral examination and study of the condition of the teeth, the periodontist has advised that the above named patient has periodontal disease. Periodontal disease weakens support of the teeth by separating the gum from the teeth. If untreated, periodontal disease can cause tooth loss and other adverse consequences. Recommended Treatment - In order to treat this condition, the periodontist has recommended that treatment include periodontal surgery. I understand that a local anesthetic will be administered as a part of the treatment. I further understand that antibiotics and other substances may be applied to the roots of the teeth. During the procedure, the gum will be opened to permit better access to the roots and to the eroded bone, inflamed and infected gum tissue will be removed and the root surfaces will be thoroughly cleaned. Bone irregularities may be reshaped, and bone regenerative material may be placed around the teeth. The gum will then be sutured back into position, and a periodontal bandage or dressing may be placed. I further understand that unforeseen conditions may call for a modification for change from the anticipated surgical plan. These may include, but are not limited to, (1) extraction of hopeless teeth to enhance healing of adjacent teeth, (2) the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, or (3) termination of the procedure prior to completion of all the surgery originally outlined. Expected Benefits - The purpose of periodontal surgery is to reduce the infection and inflammation and to restore the gum and bone to the extent possible. The surgery is intended to help keep the teeth in the operated areas and to make oral hygiene more effective.

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