Oral bisphosphonate drugs consent

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Please initial each paragraph after reading. If you have any questions, please ask your
doctor BEFORE initialing.
Bisphosphonates are a type of drug which are designed to prevent bone loss and/or decrease high
blood calcium. The Oral Bisphosphonates include: Didronel (Etidronate), Actonel
(risendronate), Skelid (tiludronate), Fosamax (alendronate), and Boniva (ibandronate). Having
been treated previously with oral Bisphosphonate drugs you should know that there is a very
small, but real risk of future complications associated with dental treatment. This risk is
currently estimated to be less than 7.9%.
Bisphosphonate drugs appear to adversely affect the health of jaw bones, thereby reducing or
eliminating the jaw bones’ ordinary excellent healing capacity. This risk is increased after oral
surgery, especially from extractions; implant placement, root canal treatment, jaw abscesses,
trauma during eating causing injury to mandibular tori, or other “invasive” procedures that might
cause even mild trauma to the bone. Spontaneous exposure of the jaw bone (Osteonecrosis) may
result. This is a smoldering, long-term, destructive process in the jawbone that is often very
difficult or impossible to eliminate and for which there is no validated treatment.
Your medical/dental history is very important. We must know the medications and drugs that
you have received or taken or are currently receiving or taking. An accurate medical history,
including names of physicians is important.
The decision to discontinue oral Bisphosphonate drug therapy before dental treatment should be
made by you in consultation with your medical doctor.
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If a complication occurs, antibiotic therapy may be used to help control infection. For some patients, such therapy may cause allergic responses or have undesirable side effects such as gastric discomfort, diarrhea, colitis, etc. Despite all precautions, there may be delayed healing, osteonecrosis, loss of bone and soft tissues, pathologic fracture of the jaw, oral-cutaneous fistula (open draining wound), or other significant complications. If osteonecrosis should occur, treatment may be prolonged and difficult, involving ongoing intensive therapy including hospitalization, long-term antibiotics, and debridement to remove non-vital bone. Reconstructive surgery may be required, including bone grafting, metal plates and screws, and/or skin flaps and grafts. CONSENT FOR ORAL SURGICAL TREATMENT IN PATIENTS WHO HAVE
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Even if there are no immediate complications from the proposed dental treatment, the area is always subject to spontaneous breakdown and infection due to the condition of the bone. Even minimal trauma from a toothbrush, chewing hard food, or denture sores may trigger a complication. Long-term post-operative monitoring may be required and cooperation in keeping scheduled appointments is important. Regular and frequent dental check-ups with your dentist are important to monitor and attempt to prevent breakdown in your oral health. I have read the above paragraphs and understand the possible risks of undergoing my planned treatment. I understand and agree to the following treatment plan: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ I understand the importance of my health history and affirm that I have given any and all information that may impact my care. I understand that failure to give true health information may adversely affect my care and lead to unwanted complications. I realize that, despite all precautions that may be taken to avoid complications; there can be no guarantee as to the result of the proposed treatment.

I certify that I speak, read and write English and have read and fully understand this consent for
surgery, have had my questions answered and that all blanks were filled in prior to my initials or
Patient’s (or Legal Guardian’s) Signature

Source: http://www.drjohnschmitz.com/downloads/Bisphosphonate_Consent.pdf

Patient registration associates in family dentistry, llc

PATIENT REGISTRATION Last Name: _________________________ First Name: _______________________ Preferred Name: __________________________ Address: _________________________________________________________________________________________________________ Cell Phone: _______________________________ Marital Status:  Married  Single  Divorced  Separated  Widowed Employment


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