INFORMED CONSENT

I consent to Dr. Monique Fitch performing laser therapy on me.

I. BENEFITS OF LASER THERAPY

Laser therapy is designed to eliminate or substantially reduce periodontally diseased gums and/or pockets to help control or prevent future periodontal disease progression.

Laser therapy reduces periodontal gum pocket depth by facilitating:

A) Dr. Monique Fitch's improved visualization of the laser-detached gum pocket soft tissue linings to aid scaling and root planing for removal of tartar (calculus).

B) Re-attachment of the Laser-treated gum tissues to the roots by promoting growth of new bone and/or root surfaces. Laser treatment is generally less painful than flap surgical procedures. Laser therapy peer reviewed research proves predictable re-attachment of gum tissue and bone growth to promote long term periodontal health and to preserve teeth. 

II. ALTERNATIVE THERAPIES

Dr. Monique Fitch has explained to me alternatives, benefits, and potential complications of treatments for my periodontal disease as follows.

A) Non-surgical root planing

After local anesthetic injections of my gums, root surfaces are scaled and deep cleaned (planed) to the bottom of any gum pockets by hand or ultrasonic instruments to remove bacterial plaque on teeth and root tartar (calculus) deposits.

B) Periodontal flap surgery

After local anesthesia injections, flap surgery involves surgically incising my gum tissues. After the gums are flapped and surgically lifted away from the teeth, underlying diseased gum tissue is curetted out, roots planed, diseased bone trimmed and/or grafted. Finally the flap of gum tissue is closed with sutures.

C) Complications

Non-surgical scaling and root planing alone may not eliminate or substantially reduce deep pockets. Laser therapy may be done for further periodontal pocket depth reduction if root planing does not shrink deep pocket gum pockets. Periodontal surgery treatment risks include post-operative bleeding, infection, swelling, sinusitis, and in surgeries close to facial nerves on rare occasions persistent numbness and/or pain of the lip, chin and gums.

III. LASER THERAPY COMPLICATIONS

Laser therapy post-surgical complications, if any, are usually milder, less severe and not as long lasting as conventional periodontal flap surgery complications.

IV. LASER THERAPY - NO GUARANTEE

Laser therapy, as with all periodontal procedures, may not be entirely successful in gum pocket reduction or new attachment. Success is not guaranteed. Nonetheless, other laser therapy performing dentists report that almost 90% of laser therapy treated patients required not laser therapy re-treatment during the first 5 years after laser therapy.

V. NON-TREATMENT RISKS

Doing nothing can worsen my periodontal disease including increased gum pocket depth which predisposes to early (premature) teeth loss, infections, abscesses. Lost teeth require replacement with costly implants, crowns, bridges, or partial/complete dentures.

VI. PATIENT COMPLIANCE

I agree to follow Dr. Monique Fitch's written and oral post-operative instructions including post-surgical oral hygiene and take medications given or prescribed. I also agree to schedule regular periodontal maintenance visits quarterly or as Dr. Monique Fitch may recommend to aid in maintaining my periodontal health.

__________________ Patient or Guardian

Witness _________________________

Date ___________________________