All On Four Consent Form

All-on-4 Consent Forms

Your All-on-4 Procedure will involve the following (with the exception of extractions for edentulous);

Extractions

The proposed treatment should help to relieve your symptoms and may also enable you to proceed with the All-on-4 procedure.

I understand that following treatment I may experience bleeding, pain, swelling, and discomfort for several days, which may be treated with pain medication. It is possible infection can follow extraction and must be treated with antibiotics or other procedures. I will contact the office immediately if symptoms persist or worsen.

I understand that all medications have the potential for accompanying risks, side effects, and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking.

I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it difficult for me to open wide for several days. However, this can occasionally be an indication of a further problem. I must notify your office if this or other concerns arise.

Implant Placement

Dental implants are titanium anchors placed into the jawbone, underneath the gum tissue, to support artificial teeth where natural teeth are missing. When the bone attaches itself to the implant, these implants act as tooth root substitutes and form a strong foundation to stabilize the customized, artificial teeth.

Short term effects after surgery: There may be normal side effects that my surgeon will instruct me how to handle at home, such as: swelling, stiffness of the jaw muscles, bruising, and occasional oozing of blood for 24 to 48 hours or moderate pain for 24-48 hours.

Consequences of implants and prostheses in the mouth: I understand that smoking, excessive alcohol consumption, chewing hard foods such as ice or hard candy, may result in damage to my implants and can cause them to fail completely.

I understand that a medical condition, such as uncontrolled diabetes can compromise the Osseo integration and longevity of an implant.

I understand that I must keep my implants and prosthesis clean by daily maintenance as well as regular checkups and cleanings at my dentist’s office. I understand that in addition to the risks and complications associated with implants and prosthetics, certain complications may result from the use of anesthetics or sedatives. The risks, benefits, and alternatives regarding anesthesia will be explained to me, and I will disclose any allergies I have and/or any substances or medications I am taking because they may affect my response to the anesthetic.

Sedation

Nitrous Oxide/Oxygen Inhalation Sedation

Nitrous oxide/oxygen inhalation is a mild form of conscious sedation used to calm an anxious patient. A colorless, odorless gas that has no explosive or flammable properties, it can act as a pain buffer as well. Oxygen is given simultaneously with the nitrous oxide through a small mask placed over the nose. Pure oxygen, given at the end of treatment, is intended to flush the nitrous oxide out of the patient’s system and minimize the effects of the gas. The patient is observed while nitrous oxide is administered and until the patient is fully recovered from its effects.

Risks, include but are not limited to: An early effect is an inability to perceive one’s spatial orientation and temporary numbness and tingling. Nausea and vomiting may occur. If the patient will not accept the mask, nitrous oxide/oxygen cannot be used.

Potential benefits: The patient remains awake and can respond to directions and questions. Nitrous oxide helps overcome apprehension, anxiety, or fear.

Conscious Sedation

Conscious sedation is a controlled, drug induced, minimally depressed level of consciousness that allows the patient to breathe independently and continuously respond appropriately to physical stimulation and/or verbal command, e.g., “open your eyes.” This type of anesthesia may be administered orally (a drink) or through a tube to a needle in the vein.

Risks, include but are not limited to: Infection, swelling, discoloration, bruising, headache, tenderness at the needle site and vein, dizziness, nausea, and vomiting can occur. Adverse reactions to medication including allergic and life-threatening reactions are possible though rare. Complications may require hospitalization or even result in brain damage or death. With any patient, reflexes are delayed. Patients should not drive a car or operate machinery for 24 hours because the effects of sedation remain in the system even after the patient is awake and mobile.

Potential benefits: Pain is lessened or eliminated during the dental treatment. Stress and anxiety are greatly reduced and often there is no memory of the treatment.

The All-on-4 Bridge

I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it difficult for me to open wide for several days. This can occasionally be an indication of a further problem. I must notify my dentist if this or other concerns arise.

I understand there may be gum soreness or discomfort under the bridge(s). This can be relieved by Dr. Golpa with adjustments and tissue treatment.

I understand the new bridges(s) may feel awkward for a few weeks until I become accustomed to them, and the bridges(s).

I understand Dr. Golpa will make every attempt to create a natural appearance for the bridges(s); however, it may not be possible for the bridges(s) to support my lip and facial contours perfectly.

I understand eating with the bridges(s) will require practice. I understand I may need to be cautious when eating chewy, hot, or hard foods (for example: popcorn, raisins, candy). I understand that pronouncing certain words may take practice. I can do this by reading aloud and repeating troublesome words. If a speaking problem persists, I will call my dentist for consultation.

Photographs

I hereby give my consent for Dr. Golpa to take photographs, slides and/or videotape of jaw, and teeth. I also grant permission to reproduce, print and/or publish these images for use in articles, lectures, or advertisements to promote cosmetic dentistry. I understand that some of these images may be used by laboratories for fabrication of bridges and these images will become part of my dental record.

I do not expect compensation, financial or otherwise, for the use of these images.

Smokers

The most common complication associated with dental implants is problems with implant integration; that is failure to fuse with the bone and this often leads to implant failure. This complication becomes even worse if the person undergoing implant surgery is a smoker. Dental implants need oxygen to fuse correctly with the bone. If there is not a good blood flow to the tissues and the bone, the implant may not be able to stay in proper place. Remember that nicotine found in tobacco has a negative effect on blood flow that makes bone healing after implant surgery even more difficult. That is why smokers are more vulnerable to developing various implant complications.

It is recommended to QUIT smoking or consuming tobacco products 3 weeks prior to an implant surgery. We offer Chantix to aid in this process. Improper healing not only causes the implant to fail but also forms other complications that may even take you to the hospital.

I agree and understand that the degree of success of any dental treatment is directly related to my cooperation and that, if I fail to cooperate as requested and instructed, I may suffer temporary or permanent injury to my dental and general health and to the dental work performed by Dr. Golpa. I understand that smoking, alcohol and improper dietary practices may affect gum and bone healing and will limit the success of the implants.

I hereby state that I have read and I fully understand this consent form, that I have been given an opportunity to ask any questions I might have had, that those questions have been answered in a satisfactory manner. I further agree that Dr. Golpa will not be liable for any failures or complications that may arise from my failure to comply with these instructions. Failure to adhere with these recommendations voids guarantee on implant placement.

I understand that alternatives to the All-on-4 Procedure may exist, including the use of individual dental implants, crowns, veneers, bridges, conventional dentures, and no treatment. I understand that the alternatives may allow me to preserve my remaining teeth. Dr. Golpa has satisfactorily explained these alternatives and their respective expenses. My questions have been answered to my satisfaction regarding the procedures and their risks, benefits, and costs. If applicable, I have elected to extract my existing teeth and move forward with the All-on-4 Procedure.

Dated this day of , 20