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Dental  Surgery 

      Master, College of Conscious Sedation American Dental Society of Anesthesiology           

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Star Sedation Dentistry   

Specializing in Total Dentistry

                     With Advanced Infusion Therapy                   To Rejuvenate the Mind & Body

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Dental Implant Informed Consent

Implants are nearest to your own teeth and have great advantages over other dental treatment such as preserving a patient's jaw bone, such as being impervious to dental decay; such as no hot and cold sensitivity; such as out lasting most dental work by years; implants are designed to last for decades. But implants are NOT for everyone and there are risks in having dental implants placed.

The risks of dental implants are several and are not limited to this list.

1. It takes time to complete dental implant treatment! The  most important to understand. Even though we can sometimes place an implant after an immediate extraction there is still healing time. There may be additional time needed to reshape or add gum to the implant area, there may be the need for additional bone graft material. There may be other work that has to be done before implant crown work is completed. The point is treatment many times takes longer than the patient expects; some patients become annoyed or feel that they are being put off.
   
2. Patients most common complaint is the amount of time it takes to complete implant treatment. It can take over a year.
   
3. Implants can fail.
   
4. There are times when implants are NOT the optimum treatment because teeth move and gums recede. It can be more effective to do a bonded bridge for esthetics sometimes. It can be more reasonable to have a removable denture or a full denture in cases where there are health risks and financial issues to consider as well as if the patient is NOT going to be able to commit to  a long term prevention and maintenance plan. Which means seeing the patient for cleaning every 3 to 12 months depending on patient home care and systemic health.
   
5. Implants may not move but the teeth and bone around implants can move. One particularly disconcerting problem is that a space may form between an implant and a tooth after a year or several years or just a few months. It does not always happen but it does happen. Now that can be managed by placing a composite or a veneer to close the gap. Sometimes the crown has to be replaced. Sometimes it is of no concern to the patient and sometimes it is.
   
6. Implants can damage adjacent critical structures such as teeth and nerves and sinus.
   
7. Implant can damage the mandibular nerve or the lingual nerve, or  mental nerve in the lower jaw and cause temporary or permanent numbness in the  lip, chin and or tongue.
   
8. A patient with infected sinus has a higher risk of implant failure for upper implant.
   
9. Implants can make a hole in the sinus
   
10. damage an adjacent tooth and cause the tooth to need root canal treatment or in worse case need to be extracted
    
11. Implants can get infected.
    
12. Bone grafting for the implant may not take. It may be necessary to remove the graft and the implant.
    
13. There are risks due to extraction of teeth in order to place dental implants. Please see informed consent for dental surgery
    
14. Extraction and immediate implant placement has the advantage of reduced time of treatment, less visits, less expense. However these procedures still have a higher failure rate than waiting sufficient time for bone to form naturally.
    
15. Implants can break, implant posts and screws can break, crowns can break.
    
16. Implants can fail for no apparent cause. In fact Sometimes the implant is defective and one cannot tell by just looking at it.
    
17. A failed dental implant can cause the loss of more bone than was originally there. the lost implant can leave an unattractive and difficult to manage void in jaw bone.
18. Post purchase disappointment. Sometimes when patient is NOT fully decided or if the patient has not discussed this thoroughly with a significant other these third parties may show dismay or surprise at the choices you made. This is disconcerting for the patient and the staff. Avoid this mental pain by working out and talking to those who will have a say so in your health and how you spend your scarce finance ail resources.
19. The need for Dr. Starkey to create a thicker layer of gum tissue or to create a connective tissue that is thicker around an implant at the gum line. This may be needed for esthetics or to protect the implant. There are times when a doctor places an implant that there is not enough attached gingiva to protect the implant at the gum line. Usually Dr. Starkey can predict that problem before the start of treatment but sometimes it isn't obvious until after implant or after attempting to work with the attached gingiva that is present.
    
20. Gum grafting. Gum tissue may need to be transplanted from the palate or from the back of the jaw in order to create a thick enough gum tissue around implant. There are risks with this surgery. The transplant can fail. You can actually lose more bone and gum after the surgery than if you were not to do the surgery.
    
21. There can be gaps that form under an implant bridge that results in being a food trap or causes air to blow through the space between the gum and teeth. Bonding can be done to alleviate the problem after treatment but we do our best to not have this issue. It becomes an issue if final implant bridge is placed in the area where teeth were extracted less than a year prior.
    
22. Obtaining adequate bone for implant procedure is more often than not the issue and problem for Dr. Starkey and the patient. Bone grafting may be needed. It may be necessary to do orthodontic therapy to super erupt a tooth that we plan to remove or to move a tooth. When the doctor can super erupt a tooth the result is the body will create bone in an area of intense need. This is safer than attempting bone grafting and is a more esthetic result. The problem is it requires braces and time and is an extra expense. And if it is not done optimally the results are sub optimum.
    
23. Implants do not decay but they can get gum disease around the implants. The inflammatory by products and infected tissue and bacteria can get in the blood stream and cause problems in patient's other organs or cardio vascular system.
    

There are important instructions to follow before and after surgery and there are trauma problems and post surgery healing events that are important to understand and for the patient to help  so that healing is uneventful and as tolerable as possible.

1. Dental implant placement require patient follow certain instructions prior to and after dental surgery.
2. If you are following stress reduction protocol then it is mandatory that you have an escort and a driver to and from the office. The escort and the driver can be the same.
3. You are often required to take antibiotics at least one hour before surgery or possibly starting a day or days before.
4. You are required to get the gums and teeth as healthy as possible prior to dental implant placement. This means a complete exam and radiographs and oral cancer screening as well as making sure the teeth and gums are clean. 
5. If there is gum disease that must be managed prior to implant placement
6. You may be required to rinse with a special mouth wash starting an hour before or even days before the dental implant surgery.
7. Stitches will be placed. the most common complication is the stitches coming loose. if they do then you will have terrible pain. It could result in loss of dental implant or bone graft. It is critical to be careful and avoid chewing on the stitches. 
8. Sometimes there are two kinds of stitches placed. short acting and long acting. 
9. in addition a membrane thin like paper as well as something that looks like plaster of Paris may be required to protect the graft and or implants.
10. It is now rare but the doctor may elect to place something that looks like a giant wad of gum over the implant and sutures. This you want to avoid for about three days. It will come loose and may come out before your return visit.
11. Sometimes Dr. Starkey needs to check the implant surgery the very next day. Most times the sutures will need to stay in 10-14 days and that is when you will need to come in to have sutures removed. Sutures for soft tissue, bone grafting, and implants do not dissolve by themselves.
    
12. You need to call Dr. Starkey at home on the cell or at office if the sutures come out on their own or the wound opens. We need to have you back sooner. Such an opening may require re-suturing. This is most often a problem for patients who smoke.
13. The patient can expect pain for 24 hours
14. there will be swelling of approximate  one quarter to half an inch or more; this depends on the patient to a great deal.
15. To minimize swelling and pain Dr. Starkey advises IV sedation that includes IV steroid to prevent pain.
    
16. Sometimes there is severe bruising. Patients on blood thinners will experience bruising quite easily.
    
17. The patient will NOT be able to eat on the dental implants for a week. 
18. It may be that patient cannot wear a temporary crown or bridge for a week or more.
19. There will be sutures placed.
20. If you take medications for health issues such as diabetes and high blood pressure or emotional health then most likely you will follow the regimen you always do. BUT you are responsible for discussing these meds with the doctor.
21. If you take a medicine like warfarin that impedes coagulation (clotting) most likely the doctor will want you to continue. Dr. Starkey will manage any bleeding issues.
22. Special diets and times that you are suppose to follow need to be discussed with doctor.
23. Diabetes in control along with many other systemic diseases are NOT a contraindication to dental implants when a health protocol is followed.
24. Smoking is NOT a contra indication but needs to be reduced. that can be addressed with doctor.
25. After implants are placed they may have posts placed on them to expedite healing or to place a temporary on. But many times the implants are buried because bone is required and covering the implant will help prevent bone being lost.
26. Sometimes bone grafting requires screws or tacks to maintain. At a follow up surgery several weeks to months later these screws and tacks and possibly membrane will have to be removed.
27. This informed consent does NOT cover the problems of temporary and final crown and bridge work.
28. We do not want the patient to leave the office as long as there is a bleeding problem after surgery. 
29. The patient may be told to keep packing in his mouth with pressure against the extraction site or the implant or graft site but usually the packing is only for extractions. H
30. If you bite hard on the gauze that pushes against the bone graft you can cause the graft to move and or to fail.  so we don't want you biting on the gauze unless the area is very stable. to restate. Do NOT bite on the gauze if it pushes against the bone and implant because it can cause a failure. if this is a problem call the doctor. 
31. You may need to return to office that afternoon for follow up.
32. Your surgery with few exceptions will be done first thing in the morning. 
33. that way if there is a problem we can see you in the afternoon. Also patients are a little more relaxed in the morning.
34. It is possible that we place a temporary crown or bridge at the time of the dental implants. The individual crown will be placed so that there is no pressure on it. The provisional bridge will also be placed such that hard chewing is avoided.
35. The doctor likes complete closure of the incision line after implant and grafting. This requires making the flap extra large. But sometimes primary closure is not possible or in some instances not wanted. When the flaps cannot completely closed you can expect extra time for healing. It takes about six weeks for the completion of soft tissue.
36. If you are having numbness in the lower lip or tongue or chin after 24 hours it is important to call Dr. Starkey. It means that one of the nerves may be damaged and the implant will have to be removed or "backed off." it is critical to contact the doctor right away because the longer there is nerve trauma the longer it takes for the nerve to heal.
37. Ice packs or "cryo-therapy." This is the single best thing you can do for yourself. Keep ice packs that we give you on the wound area continuously. If you use ice from your fridge  then the cold must be on and off every 2 minutes or so otherwise you will get freezer burn.
38. You will be required to sleep elevated and rest propped up. the reason for this is when you lay flat that builds up pressure which builds up pain and swelling and bleeding.
39. Have icy drinks like milk shakes and pop on hand; NO hot food the first night and no chewing.
40. You can use straws  unless you have been told otherwise as in when there is a sinus communication.
41. You can expect to become black and blue from the surgery. This is most likely in cases where there is removal of multiple teeth and or placement of multiple dental implants. You will be black and blue along the smile line and cheeks. this will take a couple of weeks to go away.
42. While it is possible to place temporary crowns and bridges at the time of implant placement the conditions have to be optimum. Keep in mind your conditions are probably NOT optimum.
43. Not having enough bone is a problem for the implant dentist. Thus bone grafting is often required along with soft tissue grafting.
    
44. There are times when super eruption of a tooth that we plan to extract is advised. This is because when a tooth is pulled out of the jaw through braces the tooth will bring the patient's own bone with it. Now this takes weeks to months but the result are superior to attempting grafting esthetically and functionally. This most often is done in the front teeth where a healthy attractive smile is essential. This takes extra time and extra expense.
    

Not only are there risks with dental implants failing and damaging or leading to the damage  and loss of bone, loss of feeling, jaw problems dental implants will or may require or create new problems, challenges, and or needs:

1. Dental implants require extra x-rays and that means radiation; sometimes special three dimensional scans to see how much bone is available and where the critical structures are for instance.  this adds to cost and in extra radiation., x rays area required as implants are placed to make sure they have been done as good as p;ossible.Implants require regular cleaning and checkups by the hygienist and dentist.
   
2. It often is NOT possible to place a dental implant as intended due to poor quality bone, granulated old soft tissue that can be several years old or due to other infected teeth will cause a halt in the implant progress. Bpone must be rebuilt or developed; it may NOT be possible to place dental implant(s) for months to come.
3. Dental implants often require bone to improve the esthetics, to have enough bone to support the dental implant; this bone will add to the cost of treatment.
4. It may take more than one surgery before there is enough bone for dental implants.
5. Gum surgery to reduce or add to the existing gum may be required  for function as well as esthetics.
6. Implants require periodic inspection through exam and radiographs; implants require cleaning.
7. Gum tissue can and often does recede from the implant exposing the metal or threads of the dental implant.
8. Sometimes in spite of Dr. Starkey's best efforts an implant cannot be placed as plan. Additional bone grafting and or soft tissue grafting is required.
   

Dental Implants rquire "prosthetics" that is the crowns or bridge work that act as the patients teeth. Now the problems with dental implant reconstrucation of crowns and bridge work has many short and long term problems. Problems such as the implant crown or bridge coming loose, Implant post(s) coming loose, food impaction under implant bridges and crowns, complaint of speech, complaint of tongue feeling trapped because the tongues of patients without teeth for a long actually expands to fill available space. When implant bridge is placed the tongue is forced back to a smaller space.

There are patients that cannot tolerate that change very well.

Crowns and bridges can be made that are removable or fixed. The materials may be made of acrylic, composite, metal or some combination, they can also be made of porcelain.

The crowns and bridges both fixed and removable can be made provisionally, that is to last only a year or so, or made long term. That is to last for many years.

Excellent hygiene and regular maintenance visits are required. While a patient will not get any cavities a patient can get gum disease and inflammation around the implant teeth and implants.

There is the risk of bone loss around implants. It is not uncommon. Usually it does not prevent the function of the implant but not always.

Perfection while a worthwhile goal is not possible.

There will be several visits to complete implant and restoration treatment. It can be as few as 2 but realistically it will be about ten visits for most cases if not more.

Again there are alternatives to dental implants and sometimes the alternatives are more appropriate.

Ask the doctor any questions you want. Do not proceed with any procedure until you are clear on finances and risks and benefits and disadvantages.

I have asked Dr. Starkey the questions I wanted and he has answered them to my satisfaction.  I understand the risks regarding the implant surgery and have decided that I would like Dr. Starkey and his dental staff to provide the following services:

__________________________________________________________________________________________

Patient signature _____________________________________________Date__________________

Witness_____________________________________________________

Informed Consent

It is critical that patients understand Risks as well as benefits of various dental treatment Options.

The patient has an obligation to understand as much as possible what can improve her dental health as well as what can go wrong with certain procedures.

In addition to the options below there is always the option to obtain a second or to do nothing at all. Doing nothing at all. There are risks with just about everything in life. The more you know the more proactive you can be about your decisions.

The informed consents below are for

1. HIPPAA- this gov regulation entitles you to certain privacy.
   
2. I (you) allow Dr. Starkey or one of his dental team or representatives to text or email me from time to time to confirm appointments, to make appointments, to update me (you) on what might be of interest to me regarding health care both oral and general.
3. Informed consent for Your permission to void HIPPAA regs in certain instances, theft by private parties, accidental transfer of information to private individuals or groups. The government by open demand as well as the surreptitious theft of your personal information by laws that allow the federal or state government to do such as well as taking information illegally.  /quasi government organizations, as well as businesses such as Google and insurance companies. We are obligated to inform you of your rights. HOWEVER. We also require your informed consent to contact you by email, cell phone, land line, requesting to speak to you when we talk to fellow workers or relatives, we request the ability to leave messages on your cell phone  or work phone or text  or email or write you letters with our return address and name of our practice. You are also informed and we need you to accept that there may be instances when your information is sent to the wrong address such as the wrong email or even residence or work. You are informed of this possble error or other possible inadvertent errors such as using pictures of you on our web site or pictures sent to others by accident. you are informed that the government may demand your records from us; we do not know which agency whether it is a state agency or a federal agency. It is possible that government agencies may just take your information and identity without anyone's permission; there point is the information you give us is suppose to be confidential and we do our best to keep the information private but in today's new ways to communicate and to interdict and for the possibility for errors to be multiplied this may happen to you as it relates to our practice. This is inadvertent and not on purpose we just do not have the ability to completely make your information confidential. Unless you agree that we all do our best but understand that information transfer to parties that were not on your permission list  can happen then we will not be ab le to have you as dental patient.
   
4. Photography, radiographs, and other data and notes for sharing information with other dental practitioners, to use for insurance purposes, the use of your dental work but NOT face to show in professional meetings or on the internet. Your name will not be used your face will not be used without your written permission. If by some rare event there is a photo of you that you did not permit us to use then we will remove this photo. If there are X-rays you do not want us using we will remove. The issue is complicated by the possibility that another entity has acquired your property and is using it in a way you do not like we have no control over that.
   
5. Your permission to call your office your home or text or email you concerning your treatment. Your permission to ask for you and tell the other party who we are.
   
6. Dental Anesthesia/analgesia
   
7. Dental Implants
   
8. Dental Implant prosthetics meaning the teeth, crowns, dentures bridge work temporary, provisional, and long term.
   
9. Bone grafting
   
10. Extractions
    
11. Fillings, posts, pins and complex chair side restorations (fillings)
    
12. Crowns and partial crowns and bridge work
    
13. Bonding veneering bleaching
    
14. hygiene visits
    
15. Gum Surgery
    
16. Root canal treatment
    
17. Orthodontics
    

1. HIPPA Regulations require that we respect your privacy; though the government does not respect or regard you as an individual. We must have your signature regarding your privacy rights and that is done in the office. Dr. Starkey does request from you the ability to take photographs and  radiographs to share with other dental medical professionals as well as insurance companies. Dr. Starkey would like permission to use photographs of your dental work and teeth and mouth for before and after photographs and radiographs as well as models on his web site and in the office to show other patients or interested parties, for dental focused magazines, and for marketing purposes in other ways such as the internet, brochures, fliers, and what ever methods that are available in our ever changing communication world.

In our modern world it is possible to contact the wrong person on internet and on telephone and very rarely the U S Mail or private  carriers. I (understand) that is a risk and it may happen that the wrong person is called or contacted inadvertently and I (you) except that risk and that possibility. Such contacts are very rare and unintentional but they can and do occur.

Dr. Starkey will NOT use and does NOT use photographs of your face and does NOT use your name on the internet/web unless he has your permission.  This does allow him to use photographs of your smile and teeth and oral cavity, let's say the lower third of your mouth or photographs of other areas that do NOT include your face or name unless we have your oral or written permission.

By signing below you acknowledge that Dr. Starkey can take x-rays, 3D scans, photos, impressions and share with colleagues, other practitioners, insurance companies, dental laboratories, other medical and health care professionals. I give Dr. Starkey permission to use this information on the internet, in particular his web site as before and or after. I understand this agreement does NOT allow Dr. Starkey to use photographs of your face to show on the internet. It does NOT allow Dr. Starkey to use your full name on this web site unless we have your oral permission. In which case we will use only your first name and Initial of your last name.

Signature___________________________________

Witness_____________________________________Date_______________