For Dental Implants

Patient Consent Information

You have the right and the obligation to make decisions regarding your healthcare. Your dentist can provide you with the necessary information and advice, but as a member of the healthcare team, you must participate in the decision-making process. This form will acknowledge your consent to treatment recommended by your dentist.

1. I request and authorize the doctor and his assistants to perform the surgical placement of dental implants upon me. This procedure has been recommended to me by my dentist as an option to replace my natural teeth.

Dental implants are metal anchors put inside the jawbone underneath the gum line. Small posts are attached to the implants and artificial teeth or dentures are fastened to the posts.

Most patients need two surgical procedures to install the implants. The first procedure involves drilling small holes into the jawbone and placing the anchors. A temporary denture may be worn for a few months while the anchors bond with the jawbone and the gums and bone heal. The second procedure will uncover the implants to allow for attachment of the posts. After the posts are in place, the replacement teeth, in the form of fixed or removable bridgework or a denture, are fastened to the posts. Depending on the condition of the mouth, bone grafting or guided tissue regeneration also might be necessary to install the anchors and posts. The potential benefits of this procedure include the replacement of missing natural teeth or supporting dentures.

2. I have chosen to undergo this procedure after considering the alternative forms of treatment for my condition, which include no treatment
at all, complete or partial dentures, or fixed or removable bridges. Each of these alternative forms of treatment has its own potential benefits,
risks and complications which have been explained to me.

3. I consent to the administration of anesthesia or other medications before, during or after the procedure by qualified personnel. I
understand that all anesthetics or sedation medications include the very rare potential of risks or complications, such as damage to vital
organs including the brain, heart, lungs, liver and kidneys; paralysis; cardiac arrest; and/or death from both known and unknown causes.

4. I understand that there are potential risks, complications and side effects associated with any dental procedure. Although it is impossible to list every potential risk, complication and side effect, I have been informed of some of the possible risks, complications and side effects of dental implant surgery. These could include but may not be limited to the following:

  • Postoperative pain, discomfort and swelling
  • Bleeding
  • Postoperative infection
  • Injury or damage to adjacent teeth or roots of the teeth
  • Injury or damage to nerves in the lower jaw, causing temporary or permanent numbness and tingling
    or pain of the chin, lips, cheek, gums or tongue
  • Restricted ability to open the mouth because of swelling and muscle soreness or stress on the joints in the jaw —temporomandibular joint (TMJ) syndrome
  • Fracture of the jaw
  • Bone loss of the jaw
  • Penetration into the sinus cavity
  • Mechanical failure of the anchors, posts, or attached teeth
  • Failure to implant itself
  • Allergic or adverse reaction to any medications

Most of these risks, complications or side effects are not serious and do not occur frequently.

Although these risks, complications and side effects occur only very rarely, they do sometimes occur and cannot be predicted or prevented by the dentist performing the procedure. Although most procedures have good results, I acknowledge that no guarantee has been made to me about the results of this procedure or the occurrence of any risks, complications or side effects.

These potential risks and complications could result in the need to repeat the procedures; remove the implants; or undergo additional dental, medical or surgical treatment or procedures, hospitalization or blood transfusions. Very rarely, the potential risk and complications could result in permanent numbness, disability or death. I recognize that during the course of treatment, unforeseeable conditions may require additional treatment or procedures. I request and authorize my dentist and other qualified medical personnel to perform such treatment as required.

5. I certify that I have read or had read to me the contents of this form. I have read or had read to me and will follow any patient instructions related to this procedure. I understand the potential risks, complications and side effects involved with any dental treatment or procedure and have decided to proceed with this procedure after considering the possibility of both known and unknown risks, complications, side effects and alternatives to the procedure. I declare that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

Post-Operative Instructions


Do not disturb the wound. Avoid rinsing, spitting, or touching the wound on the day of surgery. There may or may not be a metal healing abutment protruding through the gingival (gum) tissue.


Some bleeding or redness in the saliva is normal for 24 hours. Excessive bleeding (your mouth fills up rapidly with blood) can be controlled by biting on a gauze pad placed directly on the bleeding wound for 30 minutes. If bleeding continues please call for further instructions.

Swelling is a normal occurrence after surgery. To minimize swelling, apply an ice bag, or a plastic bag, or towel filled with ice on the cheek in the area of surgery. Apply the ice continuously, as much as possible, for the first 36 hours.

Drink plenty of fluids. Avoid hot liquids or food. Soft food and liquids should be eaten on the day of surgery. Return to a normal diet as soon
as possible unless otherwise directed.

You should begin taking pain medication as soon as you feel the local anesthetic wearing off. For moderate pain, 1 or 2 Tylenol or Extra Strength Tylenol may be taken every 3‐4 hours. Ibuprofen (Advil or Motrin) may be taken instead of Tylenol. Ibuprofen, bought over the counter comes in 200 mg tablets: 2‐3 tablets may be taken every 3‐4 hours as needed for pain. For severe pain, the prescribed medication should be taken as directed. Do not take any of the above medication if you are allergic, or have been instructed by your doctor not to take it.

If prescribed, be sure to take antibiotics as directed to help prevent infection.

Oral Hygiene
Good oral hygiene is essential to good healing. The night of surgery, use the prescribed Peridex Oral Rinse before bed. The day after surgery, the Peridex should be used twice daily, after breakfast and before bed. Be sure to rinse for at least 30 seconds then spit it out. Warm salt water rinses (teaspoon of salt in a cup of warm water) should be used at least 4‐5 times a day, as well, especially after meals. Brushing your teeth and the healing abutments is no problem. Be gentle initially with brushing the surgical areas.

Keep physical activities to a minimum immediately following surgery. If you are considering exercise, throbbing or bleeding may occur. If this occurs, you should discontinue exercising. Keep in mind that you are probably not taking normal nourishment. This may weaken you and further limit your ability to exercise.

Wearing your Prosthesis
Partial dentures, flippers, or full dentures should not be used immediately after implant surgery unless specified by the doctor. This should have been discussed in the preoperative consultation, and will be covered again after your surgery. Special adjustments must be made in advance to ensure that the implants are not compromised.

It is our desire that your recovery be as smooth and pleasant as possible. Following these instructions will assist you, but if you have questions about your progress, please call the office.