CONSENT OF GINGIVECTOMY

What is a gingivectomy and what are its benefits?

Gingivectomy is a procedure where excessive gum tissue is removed. The benefit of selective gum removal is for esthetic improvement or to gain access to a lesion on a tooth for restorative repair.

What are the risks?

There may be some soreness or sensitivity for a few days afterwards and it may appear red. With time this will improve.
The gum tissue may grow back. In the case of gaining access for a restorative procedure, regrowth of the gum tissue is of little significance. However, if the regrowth is in an esthetic area, then a more invasive procedure called crown lengthening may be needed. This procedure involves the reduction in gum and bone tissue and is performed by a periodontist.
3. Unevenness of the result in esthetic areas, we can reveal more enamel and aim for symmetry. However, as the gums heal this may not be perfect. A recontouring follow up (another gingivectomy) can be done to fine tune symmetry. After that the gums will have settled into their final position and further gingivectomies will not improve symmetry.

What are my alternatives?

For esthetic areas a crown lengthening procedure can be done as described above. For restorative access areas a cord may be placed under the gums to expose the lesion but it may be obstructive. Of course, choosing no treatment is an option, but the desired outcome will be compromised.

INFORMED CONSENT:

I can read and write English and have been given the opportunity to ask any questions regarding the nature and purpose of the proposed treatment and have received answers to my satisfaction. I do voluntarily assume any, and all possible risks, including the risk of substantial harm, which may be associated with any phase of this treatment in hopes of obtaining the desired result. The fees for these services have been explained to me and I accept them as satisfactory. By signing this form, I am freely giving my consent to authorize the doctor in rendering any services they deem necessary or advisable to treat my dental conditions, including the administration and/or prescribing of any anesthetic agents and/or medications.

Anesthetic:

The use of local anesthetic is used for pain control during dental procedures. There are inherent risks and side effects. They include, but not limited to: swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction, and altered sensation that may lead to self-injury. Partial or complete numbness may linger after the dental appointment. In rare cases it can last for an extended time and potentially it can be permanent.

Notifications: If a patient develops a problem, it is the patient’s responsibility to notify the doctors and/or staff. Through this notification we will be able to act on the patient’s behalf. Attempts to correct a problem may occur at our office or a referral to another health care practitioner may be warranted.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

Pre and post treatment instructions have been explained to me.
I had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
Must notify the clinician if my medical history changes prior to subsequent treatments.
I consent to clinical photographs being taken of my treated areas for my personal health record only.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE Clinic, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.

Patient Name & Signature :

Doctor/Therapist Name & Signature :

Witness Name & Signature :

Parent or Gaurdian Name (if patient is minor) :

Date :