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I consent to Dr. __Rupa Hamal DMD_ performing on me the LANAP procedure.  


Doctor and staff have provided me with access to literature describing the LANAP procedure which I have read.  I understand I may ask the Doctor any questions I may have before I consent to LANAP treatment (Laser Assisted New Attachment Procedure). 



Doctor has explained to me the following alternatives to the LANAP procedure:

·         No treatment

·         Extraction of the affected teeth

·         Non-surgical scaling and root planing (Deep Cleaning):  After local anesthetic injections of my gums, root surfaces are scraped and deep cleaned (planed) to the bottom of any gum pockets by hand or ultrasonic instruments to remove bacterial plaque containing tartar (calculus) deposits on my teeth roots.

·         Periodontal Flap / Osseous Surgery: After local anesthesia injections, flap surgery involves surgically cutting my gum tissues.  After the gums are flapped and surgically lifted away from my teeth, the underlying diseased gum tissue is scooped out, teeth roots scraped, diseased bone trimmed and/or grafted and the flap of gum tissue sutured closed.


Periodontal treatments are designed to eliminate or substantially reduce periodontally diseased gum pockets to help control or prevent future periodontal disease progression. 



•                     No cutting and no stitches – a minimally invasive procedure.

•                     Laser energy will selectively target only the diseased tissues, while leaving the adjacent healthy tissues alone.

•                     Promotes regeneration of tissues surrounding both natural teeth and implants.

•                     Faster healing

•                     Decreased pain after the procedure when compared to traditional surgery

•                     Patients are less likely to develop hypersensitivity when compared to traditional surgery

•                     Patients are less likely to develop gum recession.



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 and chin.  LANAP post-surgical complications, if any, are usually milder, and not as long lasting as potential conventional periodontal flap surgery complications. 


LANAP treatment, as with all periodontal procedures, may not be entirely successful in gum pocket reduction or new attachment.  Success is not guaranteed.  Nonetheless, LANAP research has shown that in almost 90% of LANAP treatment cases, patients did not require any retreatment within 5 years after the initial treatment.



 Doing nothing can make my periodontal disease worse, including increased gum pocket depth which risks early (premature) teeth loss, infections, and abscesses.  Lost teeth may require replacement with costly implants, crowns, bridges, or partial or complete dentures. 


I understand that there is no method currently available to predict how the tissue and bone will heal following any periodontal procedure. The success of any periodontal procedure can be affected by other factors such as pre-existing medical conditions, medications, dietary and nutritional problems, genetics, clenching and grinding of teeth, and home care.



Occlusal Adjustment - Adjustment of your bite to reduce force on teeth may be done. This facilitates regeneration and healing. Occlusal adjustments can be performed at subsequent post-op visits and wearing an occlusal guard may also be recommended. Patient compliance in wearing the recommended occlusal guard is extremely important.


Risks of Occlusal Adjustment:  Occlusal adjustments may cause roughness on teeth and crowns or may remove porcelain, expose metal and/or tooth structure.


 I agree to follow Doctor’s written post-operative instructions, perform post-surgical oral hygiene, take the medications prescribed by my doctor.  I also agree to schedule regular periodontal maintenance visits, as often as my dentist and /or hygienist may recommend, to aid in maintaining my periodontal health.  Failure to comply with follow-up visits may result in treatment failure and relapse to the present condition


I understand that smoking and/or excessive use of alcohol can adversely affect gum tissue healing. Studies have shown that smoking may limit the longevity of the LANAP treatment.


I understand that some aggressive and/or more persistent forms of gum disease may require a second procedure if the initial results are not satisfactory. Provided that I have attended for prescribed follow-up appointments and strictly followed the home care instructions given to me following LANAP treatment, any re-treatment which is considered appropriate by Dr. Hamal will be handled as follows:

Depending on the complexity of your case, the time that has elapsed from initial treatment, and your individual risk factors, Dr. Hamal will determine whether retreatment will be done at no additional cost, partial cost, or full cost. Each patient’s condition is unique, and we will try to be fair when determining the fees for retreatment.



Date _________          Patient or Guardian _______________       



As part of this consent agreement, Dr Hamal gives her personal pledge, as a healthcare

Professional dedicated to the well-being of her patients, to make every reasonable effort to assure that they receive the best possible care with the least possible risk.

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