To view this, you need to install the Flash Player 8. Please go to here and download it.
Print this page for hard-copies of these forms.
1. Insurance Codes For Extraction Site Grafting
ADA Code 07955- Repair of maxillofacial soft and hard tissue defect. (This code is to be used to indicate that flap entry and closure were done to repair a defect)
ADA Code 04263- Bone replacement graft- first site in quadrant ( This code indicates a graft material was placed in the first extraction site in a quadrant. The graft material is the choice of the clinician. Another tooth in another quadrant will require re-submission of this code)
ADA Code 04264- Bone replacement graft-each additional site in quadrant ( This code is used when an additional tooth is being grafted in the same quadrant as the tooth for code 04263)
ADA Code 04266- Guided tissue regeneration- resorbable barrier, per site, per tooth (This code is to be used for a membrane that covers the extraction site graft. This is for a resorbable membrane such as the collagen membranes
2. Surgical Checklist Prior To Surgery
Patients Name:_____________________________
Procedure:_________________________________
Treatment Planning: (Date)________(Reviewed by)_____________________
____Treatment plan sheet signed
____Financial arrangement signed
____Pre Operative Prescriptions Given To Patient
____Pre Operative Medication Instruction Sheet given to patient
____Post Operative Instructions given to patient and reviewed
____Informed consent sheets given
Pre Operative: (Date)_____________(Reviewed by)______________________
____Patients blood pressure taken and recorded in chart
____Medications taken by patient and reviewed
____Informed consent forms signed and reviewed
6 Decadron 1.5 mg on the morning of appointment _____
3 Decadron 1.5 mg on the morning after appointment
1Decadron 1.5 mg on the third morning
Amoxicillan 500mg, 4 tablets one hour before appointment ______
Amoxicillan , one tablet three times a day afterwards until finished with entire bottle.
Cleocin 150mg, four tablets one hour before appointment______
Cleocin 150mg, one tablet three times a day afterwards until finished with entire bottle.
Ibuprofen 800mg 1 Tab 1 hour before appointment _______
then every 6 hours as needed
Peridex rinse three times a day gently for two weeks after appointment
Lortab 7.5 1 tab every 6 hours as needed
Post Operative: (Date)________________ (Reviewed by)_________________
____ Post Operative Instructions reviewed and any questions answered
____Conscious sedation patients have a ride home
Signature of driver____________________________ Date____________
____Ice pack given to patient
____Suture removal/observation appointment made
3. Dental Surgery Post Operative Instructions
Bleeding
Slight bleeding is expected and may last for 24 hours. The saliva may be pink during this time. The saliva should be swallowed. Continued spitting or creation of suction by drinking through a straw or smoking will cause more bleeding. Sitting upright and remaining inactive helps minimize bleeding. Cool, not very cold, liquids will help proper clotting take place -- lightly-iced tea, lemonade and water. However, do not rinse vigorously. After 24 hours you may brush gently but avoid the area of the implant. If the amount of bleeding concerns you apply pressure by biting on a tea bag soaked in cold water and call us if you have any concerns.
Swelling
Swelling may occur after any surgical procedure. It may be accompanied by some temporary discoloration of the skin. It is not unusual if you wake up with more swelling the day after an implant. Keeping the head elevated with an extra pillow helps to minimize the swelling. If you have been given an ice pack, use it the day of the surgery 20 minutes on and 20 minutes off for the remainder of the day.
Temperature
An elevated temperature is not unusual for the first 24 hours. If your temperature remains elevated longer than this please phone our office.
You should expect some discomfort but not intolerable pain. Pain medication should be taken with food and never more frequently than indicated in the instructions. Call our office if you need help.
Sensitivity to cold on the natural teeth can occur and will disappear gradually with time.
Antibiotics
All antibiotics should be taken exactly as prescribed and until the full prescription is finished. Please report any ill effects from medication to our office immediately
Antibiotics can render the birth control pill ineffective, Therefore, other methods of birth control should be used.
Activities
You have just had a surgical procedure done in your mouth and rest is very important for proper healing and prevention of ill effects. Keep physical activity down to a minimum for 24 hours. Wait at least four days before you exert yourself, participate in sporting activities, or exercise. In 7-10 days gently brush the surgical area. Otherwise rinse with Peridex 3X a day as directed.
Diet
Do not eat solid foods until the local anesthetic wears off. You may bite yourself.
A nutritious diet throughout your healing process is most important to your comfort, temperament and healing. Hungry people become less able to deal with discomfort which can follow surgery. Since you are taking medication it is important that you are aware that eating can prevent nausea sometimes associated with certain medications.
Avoid hot foods and liquids for the first two days. Eat soft foods such as eggs, prepared cereals, mashed potatoes, yogurt, cottage cheese, soups (not hot), broiled fish, Nutriment, and Ensure.
Please avoid acidic and spicy foods such as tomatoes, pepper, orange juice, and citrus fruits. Stay away from the surgical area for 3 days in general.
Smoking and Alcoholic Beverages
Both will slow healing tremendously, create a possibility of infection, additional pain and more bleeding. Alcohol will not mix well with many medications.
If you must smoke, wait at least 72 hours.
Medications
Follow all medications prescribed carefully. Rinse with Peridex 3X a day for 2 weeks as directed.
5. Surgical Supplies and Companies used by Michael Tischler ,DDS
Products are in Bold
ACE 800-441-3100 Decadron Vicryl Sutures (6-0 IS P1) (4-0 PS2)
AMERICAN RED CROSS 800-693-6272 Grafton Matrix Plug HT942308
BIOHORIZON 888-bio-teeth Implants Alloderm Autotak
CERAMED/Dentsply 800-426-7836 LD300 D300 Osteograph N 300
CRITICARE 800-458-4615 EKG Monitor Monitor Paper Sample Lines Cannulas
DENTSPLY 800-662-1202 Root Pro MTA
OSTEO HEALTH 800-874-2334 Bio-Oss Bio-Guide Collagen Membrane
PROFESSIONAL STERILE SYSTEMS 800-886-7257 Sterile Surgical Packs
REGENERATION TECHNOLOGIES 877-343-6832 Regenaform
SABLE INDUSTRIES 760-758-4553 Sable Micro blades
SALVIN 800-535-6566 Silk 4-0 sutures Cold Pks Surgical inst. Biopsy Punch
ZIMMER DENTAL 800-854-7019 Biomend Collatape Collaplug, Pure Oss
HARVEST TECHNOLOGIES 877-8HARVEST PRP Centrifuge 3I 800-343-5454 Safescraper Bone scraper, Ossix
MATERIALESE 888-327-8202 SimPlant Software
IMPLANT LOGIC SYSTEMS 516-295-1121 CT Guide Stents
6. Consent For Bone Graft Surgery (This is the form used and is shown only as a general guide)
1. I have been informed and afforded the time to fully understand the purpose and the nature of the bone graft surgery procedure. I understand what is necessary to accomplish the placement of the bone graft under the gum on/or in the bone.
2. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire a hone graft to help secure the replaced missing teeth.
3. I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are thromhophlehitis (inflammation of the vein), injury to teeth present, bone fractures. sinus penetration, delayed healing, allergic reactions to drugs or medications used, etc.
4. I understand that if nothing is done any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth followed by necessity of extraction. Also possible arc temporomandihular joint (jaw) problems, headaches, referred pains to back of the neck and facial muscles, and tired muscles when chewing. In addition, I am aware that if nothing is done an inability to place a hone graft or implants at a later date due to changes in oral or medical conditions could exist.
5. My doctor has explained that there is no method to predict accurately the gum and bone healing capabilities in each patient following the placement of a hone graft. It has been explained that bone in its healing process remodels and there is no method to predict the final volume of bone, thus additional grafting may be necessary.
6. It has been explained that in some instances hone grafts fail (mal-union, delayed union, or non-union of the donor bone graft to the recipient bone site) and must be removed. Lack of adequate bone growth into the bone graft replacement material could result in failure. I have been informed and understand that the practice of dentistry is not an exact science; no guarantees or assurances as to the outcome of the results of treatment or surgery can be made. I am aware that there is a risk that the bone graft surgery may fail, which might require further corrective surgery or the removal of the hone graft with possible corrective surgery associated with the removal. If the bone graft surgery fails I understand that alternative prosthetic measures may have to be considered.
7. I understand that excessive smoking, alcohol, or blood sugar may effect gum healing and may limit the success of the bone graft. I agree to follow my doctor’s home care instructions. I agree to report to my doctor for regular examinations as instructed.
8. I agree to the following procedures:
Autogenous graft - Which transplants bone from one region to another.
Donor Sites:
- Chin (mental symphysis) U Upper arch
- Edentulous area
- Maxillary tuberosity Site
- Ascending ramus
- Iliac crest
- Tibia
- Other___________
Recipient Site:
- Upper Arch
- Lower Arch
- Edentulous Area
- Sinus
Allograft - Which transplants bone from one individual to a genetically non-identical individual of the same species (cadaver bone). All allografts are processed from donors found to be negative by FDA approved tests for HBsAg, anti-HBc, anti-HCV, STS, antiHlV ‘/2, and anti-HTLV-I. Although efforts are made to ensure quality, most tissue banks make no claims concerning the biological or biomechanical properties of provided allograft. All allografts have been collected, processed, and distributed for use in accordance with the Standards of the American Association of Tissue Banks.
Donor:
- Demineralized freeze-dried bone Recipient(DFDB)
- Freeze-dried bone
Recipient Site:
- Upper arch
- Lower arch
- Edentulous area
- Sinus
Alloplast - Implantation of synthetic/ chemically derived bone substitutes or membranes.
Donor:
- Dense HA Recipient
- Resorbable HA Site
- Collagen membranes
- Other_____________
Recipient Site:
- Upper Arch
- Lower Arch
- Edentulous Area
- Sinus
9. 1 agree to the type of anesthesia, depending on the choice of the doctor. I agree not to operate a motor vehicle or hazardous device for at least 24 hours or more or until fully recovered from the effects of the anesthesia or drugs given for my care.
10. To my knowledge, I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health.
11. 1 consent to photography, filming, recording, x-rays, and additional professional staff observing the procedure to he performed for the advancement of implant dentistry, provided my identity is not revealed.
12. 1 agree to notify the doctor’s office of any and all changes to my address and/or telephone number within a reasonable time frame (two to four weeks).
13. With clear knowledge of all of these possible complications, I have requested that the procedure be per formed in the:
- Office environment
- Hospital environment
14. I request and authorize medical/dental services for myself, including bone grafts and other surgery. I fully understand the contemplated procedure, surgery, or treatment conditions that may become apparent which warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modifications in design, materials, or care, if it is felt this is for my best interest. If an unforeseen condition arises in the course of treatment which calls for the performance of procedures in addition to or different from that now contemplated I further authorize and direct my doctor, associate or assistant, to do whatever they deem necessary and advisable under the circumstances, including the decision not to proceed with the bone graft procedure.
Signature of Patient or Guardian______________________________
Date________________
Signature of Witness______________________________
Date ______________________
Signature of the Doctor______________________________
Date__________________________
7. Consent for Gingival Augmentation Surgery for Function and/or Aesthetics
Diagnosis: After a careful oral examination and study of my dental condition, my dentist has advised me that in order to achieve improved aesthetics and/or hygiene, I will need my gum tissue to be repositioned, augmented/grafted. I understand the importance of having healthy attached gum tissue near my teeth and/or dental implants. Gum tissue may also be grafted to protect roots of the teeth from sensitivity.
Recommended Treatment: In order to treat this condition, the doctor has recommended that gingival surgical procedures be performed in areas of my mouth with gum recession, deficient attached gingiva or for reduction of gum tissue to expose more tooth for aesthetics. Reduction of gum tissue will also involve reduction of bone structure. I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of the treatment. This surgical procedure may involve the transplanting or repositioning of gum tissue from my palatal area (upper jaw), maxillary tuberosity area (behind the upper back teeth), adjacent gum areas to be treated or from cadaver donor tissue. Donor tissue has been screened for transmissible diseases and has been determined to be safe by the FDA.
Expected Benefits: The purpose of gingival augmentation is to create an amount of attached gum tissue adequate to reduce the likelihood of further gum recession, improve gum tissue quality and/or improve aesthetics. Another purpose for this procedure may be to cover exposed root surfaces, to enhance the appearance of teeth, implants and/or to prevent or treat root sensitivity or root decay.
Principal Risks And Complications: I understand that a small number of patients do not respond successfully to gingival augmentation. If a transplant is placed so as to partially cover the tooth root surface or dental implant exposed by the recession, the gum placed over the root may shrink back during healing. In such as case, the attempt to cover the exposed root surface may not be completely successful. Indeed, in some cases, it may result in more recession with increased spacing between the teeth. A second revision surgery might be necessary at an additional cost.
I understand that complications may result from gingival augmentation or from anesthetics. These complications include, but are not limited to (1) post-surgical infection, (2) bleeding, swelling and pain, (3) facial discoloration, (4) transient or on occasion permanent tooth sensitivity to hot, cold, sweet, or acidic foods, (5) allergic reactions, (6) accidental swallowing of foreign matter. (7) transient but on occasion permanent numbness of the jaw, lip, tongue, teeth, chin or gum, jaw joint. The exact duration of any complications cannot be determined, and they may be irreversible. There is no method that will accurately predict or evaluate how my gum and bone will heal. I understand that there may be a need for a second procedure if the initial surgery is not satisfactory. In addition, the success of gingival augmentation can be affected by (1) medical conditions, (2) dietary and nutritional problems, (3) smoking, (4) alcohol consumption, (5) clenching and grinding of teeth, (6) inadequate oral hygiene, (7) medications that I may be taking. To my knowledge I have reported to the doctor any prior drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any way relate to this surgical procedure. I understand that my diligence in providing the personal daily care recommended and taking all prescribed medications are important to the ultimate success of the procedure. Alternative To Suggested Treatment. The doctor has explained alternatives treatments for my gum recession. These include no treatment, continued monitoring for progressive recession, and modification of technique for brushing my teeth. I understand the condition might worsen if suggested treatment is not performed.
Necessary Follow-up Care and Self-Care: I understand that it is important for me to continue to see the doctor for follow up care and monitoring. I recognize that natural teeth, gum tissues, and appliances should be maintained daily in a clean, hygienic manner. I will need to come for appointments following my surgery so that my healing may be monitored and so that the doctor can evaluate and report on the outcome of surgery upon completion of healing. Smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery. I know that it is important (1) to abide by specific prescriptions and instructions given by the doctor and (2) to have periodic dental examinations and preventive treatment. Maintenance also may include adjustment of dental prosthesis.
No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit in reducing my present condition and should produce healing which will help me keep my teeth and/or dental implants. Due to individual patient differences, however, a dentist cannot predict the absolute certainty of success. There is risks of failure, relapse, additional treatment, or even worsening of my present condition, including the possible loss of certain teeth and/or dental implants, despite the best of care.
PATIENT CONSENT
I have been fully informed of the nature of gingival augmentation surgery, the procedure to be utilized, the risks and benefits of such surgery, the alternative treatments available, and the necessity for follow-up and self care. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with the doctor. After thorough deliberation, I hereby consent to the performance of gingival augmentation surgery as presented to me during consultation and in the treatment plan presentation as described in this document. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of the doctor.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.
Signature Of Patient____________________ Date _________________
Signature Of Witness__________________ Date______________________
