Treatment Plan and Patient Informed Consent

Surgical Tooth Extraction, Bone Grafting, Implant Placement, and Temporary and Definitive Prosthetic Restoration

This document records the discussion of the diagnosis, treatment plan, reasonable alternatives, expected benefits, and material risks. The patient's signature confirms a voluntary decision made after discussion with the treating dentist and does not replace that discussion.

1 Patient Clinic and Treatment Location

2 Patient Medical Information

The patient must provide the dentist with complete and accurate information about medical conditions, allergies, medications, and any circumstances that may affect treatment.

☐ No known allergies

☐ Allergies _________________________________________________________________

☐ Anticoagulants or medications that affect blood clotting

☐ Bisphosphonates, denosumab, or other medications that affect bone metabolism

☐ Diabetes mellitus

☐ Heart or vascular disease

☐ Immune system disorders

☐ Radiation therapy to the head or neck

☐ Pregnancy or possible pregnancy

☐ Smoking, vaping, or other nicotine use

☐ Other relevant medical conditions or medications _____________________________

Patient initials __________________

3 Diagnosis and Indications for Treatment

Tooth or treatment area ____________________________________________________________

Diagnosis ________________________________________________________________________

Clinical and radiographic findings ____________________________________________________

The recommended extraction is based on the following indications:

☐ the tooth cannot be predictably restored

☐ tooth or root fracture

☐ extensive tooth destruction

☐ infection, cyst, or other inflammatory condition

☐ periodontal disease and loss of bony support

☐ impacted or improperly positioned tooth

☐ prosthodontic or implant-related indications

☐ other _________________________________________________________________________

The final scope of treatment may be refined after examination, review of radiographs or CBCT imaging, digital scanning, specialist consultation, and evaluation of the tissues during surgery.

Patient initials __________________

4 Proposed Treatment Plan

Only the stages that are planned or clinically appropriate should be selected. Each surgical stage will be reconfirmed on the day of the procedure.

4.1 Preparation

☐ clinical examination and updated medical history

☐ radiographic examination

☐ cone-beam computed tomography (CBCT)

☐ digital scan or impressions

☐ professional dental cleaning and treatment of gingival inflammation

☐ medical consultation or laboratory testing

☐ other _________________________________________________________________________

4.2 Surgical Extraction

Tooth number or numbers ___________________________________________________________

☐ simple extraction

☐ surgical extraction with a gingival incision

☐ sectioning or removal of the tooth in pieces

☐ removal of a portion of the surrounding bone

☐ treatment of an area of infection or a cyst

☐ placement of sutures

☐ other _________________________________________________________________________

4.3 Bone Preservation and Reconstruction

☐ not planned

☐ the need will be determined during surgery

☐ socket preservation and placement of bone graft material

☐ guided bone regeneration

☐ use of a resorbable or nonresorbable membrane

☐ autogenous bone grafting

☐ sinus lift

☐ soft tissue grafting

☐ other _________________________________________________________________________

Planned graft material ______________________________________________________________

Bone graft material may be human donor, animal-derived, synthetic, or obtained from the patient. The dentist must inform the patient about the planned material, its purpose, and available alternatives.

4.4 Dental Implant Placement

Implant site ______________________________________________________________________

Number of implants ______________________ System or manufacturer ______________________

☐ immediate implant placement after extraction

☐ delayed implant placement after tissue healing

☐ the decision regarding placement will be made during surgery

☐ placement of a healing abutment

☐ submerged healing with subsequent surgical exposure of the implant

Immediate placement may not be possible if there is inadequate bony support, active infection, a bone defect, insufficient primary stability, or another unfavorable clinical condition. In that event, the dentist may perform the extraction, debride the site, and complete bone grafting if needed, while postponing implant placement.

Patient initials __________________

4.5 Temporary Prosthetic Restoration

After tooth extraction and/or implant placement, a temporary restoration may be fabricated:

☐ temporary implant-supported crown

☐ temporary crown supported by adjacent teeth

☐ temporary removable prosthesis

☐ temporary fixed bridge

☐ temporary prosthesis supported by multiple implants

☐ adjustment or reline of an existing temporary prosthesis

☐ temporary prosthetic restoration is not planned

☐ other _________________________________________________________________________

Anticipated temporary prosthesis ______________________________________________________

Anticipated period of use _____________________________________________________________

The ability to place a temporary restoration immediately after surgery depends on implant primary stability, the condition of the bone and soft tissues, the bite, and other factors. If immediate placement is unsafe, the dentist may postpone it or recommend a different temporary option.

A temporary prosthesis is used during healing and may differ from the definitive prosthesis in shape, color, strength, comfort, appearance, and chewing efficiency. Adjustment, relining, repair, or replacement may be required.

The patient agrees to follow all loading restrictions. Excessive force may damage the temporary restoration, interfere with healing, or result in implant loss.

4.6 Definitive Prosthetic Restoration

☐ single implant-supported crown

☐ implant-supported fixed bridge

☐ fixed full-arch implant-supported prosthesis

☐ clinician-removable implant-supported prosthesis

☐ removable implant-retained prosthesis

☐ custom abutment

☐ stock abutment

☐ other _________________________________________________________________________

Planned material:

☐ zirconia

☐ ceramic

☐ porcelain fused to metal

☐ acrylic or composite

☐ metal

☐ material will be selected later

☐ other _________________________________________________________________________

Definitive prosthetic treatment may include scanning or impressions, bite registration, shade selection, try-in, abutment placement, delivery of the prosthesis, and adjustment. It is performed after adequate tissue healing and implant stability have been confirmed.

Estimated healing period _____________________________________________________________

Estimated date of definitive prosthetic treatment ________________________________________

All time frames are estimates. After delivery of the definitive prosthesis, the patient may require occlusal adjustment, tightening or replacement of a screw, repair or replacement of a crown, abutment, or prosthesis, professional cleaning, follow-up examinations, and a protective night guard for bruxism.

Temporary and definitive prosthetic restorations are separate treatment stages and may have separate fees. No unlimited service life is guaranteed for either the temporary or definitive restoration.

Patient initials __________________

5 Purpose and Expected Benefits

• removal of a diseased or nonrestorable tooth

• elimination or reduction of infection and inflammation

• preservation or restoration of bone and soft tissue volume

• replacement of a missing tooth with a dental implant

• restoration of chewing function, appearance, and stability of the dentition

The outcome depends on overall health, anatomy, the condition of the bone and gums, healing, the bite, oral hygiene, compliance with recommendations, and other individual factors. A specific result and the service life of the implant or prosthesis cannot be guaranteed.

6 Reasonable Alternatives

Depending on the clinical situation, the dentist discussed the following alternatives:

☐ observation or postponement of treatment when clinically appropriate

☐ root canal treatment or retreatment

☐ endodontic surgery

☐ restoration of the tooth with a filling, inlay, crown, or another method

☐ periodontal treatment

☐ extraction without subsequent implant placement

☐ fixed bridge

☐ removable prosthesis

☐ delayed implant placement

☐ consultation with another dentist or specialist

☐ no treatment

Declining or delaying treatment may result in pain, spread of infection, an abscess or cyst, bone loss, movement of adjacent teeth, bite changes, impaired chewing, and the need for more complex treatment.

Option selected by the patient ________________________________________________________

Patient initials __________________

7 Risks and Possible Complications

The following complications may occur even when accepted professional standards are followed. This list includes the principal foreseeable risks but cannot include every rare or individual reaction.

7.1 General Surgical Risks

• pain, swelling, bleeding, bruising, and limited mouth opening

• infection, inflammation, fever, and delayed healing

• allergic or other adverse reaction to medications or materials

• scarring, change in gingival contour, or soft tissue loss

• need for additional treatment, repeat surgery, specialist consultation, or hospitalization

7.2 Risks of Tooth Extraction

• dry socket

• damage to an adjacent tooth, filling, crown, bridge, or implant

• fracture of a tooth, root, instrument, or segment of bone

• displacement of a tooth fragment into an adjacent anatomic space

• communication with the maxillary sinus or sinus inflammation

• nerve injury causing temporary or permanent numbness, tingling, pain, or altered sensation of the lip, chin, tongue, teeth, or gums

• altered taste sensation

• injury to the temporomandibular joint

7.3 Risks of Bone Grafting and Membrane Use

• infection, inflammation, or adverse reaction to the material

• wound dehiscence or membrane exposure

• partial or complete loss of the bone graft material

• inadequate formation of new bone

• need to remove the membrane or graft material

• repeat bone grafting and an extended treatment period

• additional risks at the donor site when autogenous bone is used

Bone grafting does not guarantee formation of adequate bone volume or the ability to place an implant later.

7.4 Risks of Implant Placement

• failure to integrate, loss of stability, or loss of the implant

• infection, peri-implant mucositis, peri-implantitis, and bone loss

• gingival recession or exposure of implant components

• injury to a nerve, maxillary sinus, nasal cavity, or adjacent teeth

• improper implant position or angulation

• fracture of the implant, screw, abutment, or prosthesis

• need for implant removal, repeat surgery, bone grafting, or soft tissue grafting

• inability to immediately load the implant or place a temporary tooth

7.5 Risks of Temporary and Definitive Prosthetic Treatment

• change in or dissatisfaction with the color, shape, size, or position of the teeth or the gingival contour

• discomfort or changes in speech, bite, or chewing sensation

• chipping, cracking, fracture, wear, or discoloration of the restoration

• screw loosening or fracture, loss of cement retention, or need for refixation

• food trapping, gingival irritation, and need for special oral hygiene aids

• repair, relining, remaking, or replacement of the prosthesis

• need to modify the original prosthetic treatment plan

Patient initials __________________

8 Factors That Increase Risk

The risk of complications and implant loss may be increased by the following:

• smoking, vaping, or other nicotine use

• inadequate oral hygiene and irregular follow-up visits

• current or previous periodontal disease

• uncontrolled diabetes

• bruxism, clenching, or excessive chewing forces

• inadequate bone volume or quality

• medications that affect healing or bone metabolism

• immune system disorders or radiation therapy to the head and neck

• failure to follow instructions and postoperative restrictions

Patient-specific risk factors __________________________________________________________

Patient initials __________________

9 Anesthesia and Medications

Planned type of anesthesia:

☐ local anesthesia

☐ nitrous oxide

☐ oral sedation

☐ intravenous sedation

☐ general anesthesia

☐ other _________________________________________________________________________

Possible complications include soreness or bruising at the injection site, temporary limitation of mouth opening, rapid heartbeat, dizziness, nausea, allergic reaction, altered sensation, and rare serious complications.

If sedation or general anesthesia is planned, the patient will sign a separate consent form and follow all instructions regarding food, beverages, medications, an escort, and driving.

10 Changes to the Treatment Plan During Treatment

Conditions that could not be fully identified in advance may be discovered during the procedure. The patient authorizes the dentist to perform only those actions directly related to the agreed treatment and necessary to safely complete the procedure or prevent immediate harm, provided that such actions were explained as a possible part of treatment.

If a substantially different stage of treatment can be safely postponed, the dentist must discuss it with the patient and obtain separate consent.

11 Patient Postoperative Responsibilities

☐ follow the dentist's written and verbal instructions

☐ take prescribed medications only as directed

☐ refrain from smoking and nicotine use for the recommended period

☐ follow restrictions regarding diet, loading, and oral hygiene

☐ attend follow-up visits and professional dental cleanings

☐ inform the dentist of changes in health or medications

☐ contact the clinic immediately in the event of severe or prolonged bleeding, increasing swelling, high fever, difficulty breathing or swallowing, severe pain, purulent drainage, or a sudden change in sensation

Failure to follow instructions may adversely affect the outcome and increase the risk of complications.

Patient initials __________________

12 Financial Terms

Any estimate of insurance coverage is preliminary and does not guarantee payment by the insurance carrier. Unanticipated additional procedures will be discussed and documented separately, except for emergency measures necessary to prevent immediate harm. The financial agreement does not guarantee a clinical outcome.

Signatures

By signing this document, the patient confirms voluntary consent after personally discussing the treatment with the dentist.

Dentist Confirmation

I confirm that I personally discussed the diagnosis, treatment plan, expected benefits, material risks, possible complications, reasonable alternatives, and consequences of declining treatment with the patient. The patient was given an opportunity to ask questions.