Gingivectomy: A type of surgery used to remove excessive tissue or reduce pockets. It involves not
only removal of the tissue, but scaling and root planing of the affected teeth. This procedure is
performed with local anesthesia.
All dental treatments have an associated risk. Periodontal surgery of any type may result in bleeding,
swelling, bruising, pain, infection, sore jaws, recession, tooth sensitivity to hot and cold, caries
exposure,trauma to the nerve tissue or blood vessels that may lead to loss of sensation of lip tongue
check or other tissues in the mouth or altered sensation or pain. I understand that every person
responds to treatment differently. Therefore, it is impossible for the doctor to predict how long the
healing period may take or if time away from normal routines may be necessary.
I understand that smoking and poor oral hygiene may significantly interfere with healing and cause
disease reoccurrence.
I understand if no treatment is rendered or if active treatment is interrupted or discontinued, my
periodontal condition would likely continue and worsen. This may result in pain, swelling, bleeding,
infection, recession, mobility, decay, staining, bone loss, and tooth loss.
In the case of a gingivectomy, a second procedure may be required to ensure good symmetry and
esthetics, depending on how the tissue heals.
I have been advised of my alternatives to this treatment and understand what has been proposed
thoroughly.
I confirm with my signature that my dentist has discussed the above information with me. I have had
the chance to ask questions. All of my questions have been answered to my satisfaction. I do hereby
consent to the treatment described in this form.
Once fully read and reviewed, please make sure that the above document is filled out appropriately.
By signing below and submitting this document, we are assuming that it has been read in its entirety.
All patient signatures will be verified for authenticity in the office.
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