Portfolio.upistruzak.com

dental iMplantS • WiSdoM teeth reMoval • trauMa • reConStruCtion pediatriC oral Surgery • Bone grafting • I-Cat 3d x-ray iMaging Board Certified oral and MaxillofaCial SurgeonS Obtaining Informed Consent Relating to Risks
Associated with Oral Bisphosphonate Use
Informed Consent for Patient: _______________________________________________________________________
The following provides you with some additional information about dental/oral surgery treatment for patients taking oral bisphosphonates. Because you are taking a type of drug called a bisphosphonate, you may be at risk for developing osteonecrosis of the jaw and certain dental treatments may increase that risk. You should understand that the risk for developing this condition is very small.
By signing this consent to treatment form, you are indicating that you and your dentist have thoroughly discussed the risks, benefits and alternatives for the treatment you will be given and that you have understood that discussion.
What is osteonecrosis of the jaw?
Bone is a living tissue with living cells and a blood supply. Osteonecrosis means ‘death of bone’ which
can occur from the loss of the blood supply or by a problem with the bone’s ability to heal from
surgery/procedures. Very rarely, osteonecrosis of the jawbone has occurred in individuals taking oral
bisphosphonates for treatment of osteoporosis or Paget’s disease of bone. Dental treatments that involve
the bone can make the condition worse.
What is the risk for developing osteonecrosis of the jaw?
Your risk for developing osteonecrosis of the jaw, from using oral bisphosphonates, is very small (estimated
at less than one person per 100,000 person-years of exposure to the drugs Fosamax, Actonel, Didronel
or Boniva and the like); but, if it does occur, it may be a serious condition with no known treatment so
you should be aware of this complication. At this time, there is no way to determine who will develop
the disease. However, the condition is rare and has just recently been associated RARELY with the use
of oral bisphosphonates. It is important for you to understand that other factors may play a role in the
development of osteonecrosis, such as other medications you are taking and health problems that you
may have.
Intravenous forms of bisphosphonates (Aredia, Bonefos, Zometa etc.) are associated with much higher risks for osteonecrosis and their benefits for cancer treatment must be weighed against these increased risks for jaw problems.
Should I stop taking the oral bisphosphonate?
The benefits of reducing hip fractures and other complications associated with osteoporosis can be very
important. We cannot advise you about these benefits. You should talk with your physician if you have
questions on that topic. Also, it has not been shown that stopping use of the drug will decrease your risk
for developing osteonecrosis.
1174 MontgoMery drive • Santa roSa, Ca 95405 • 707-545-4625 • 707-545-4940 fax 1350 MediCal Center drive • rohnert park, Ca 94928 • 707-584-1630 • 707-584-2394 fax dental iMplantS • WiSdoM teeth reMoval • trauMa • reConStruCtion pediatriC oral Surgery • Bone grafting • I-Cat 3d x-ray iMaging Board Certified oral and MaxillofaCial SurgeonS What are the risks associated with dental procedures?
Although the risk is low with any procedure, it is higher with procedures involving the bone and associated
tissues, such as tooth extractions. Your dentist will be able to tell you if the procedure will involve these
tissues.
How can I decrease my risk of developing osteonecrosis of the jaw?
Talk to your dentist about oral hygiene, because maintaining good oral hygiene is the best way to prevent
oral diseases that may require dental surgery.
What are the signs and symptoms of osteonecrosis of the jaw?
You should tell your dentist immediately if you have any of the following symptoms, now or in the months
following treatment:
 feeling of numbness, heaviness or other sensations in your jaw What other choices do I have if I do not have the procedure?
Your treatment options depend on the oral health condition that you have. Your dentist will be able to
discuss treatment options with you.
Risks associated with not having the procedure.
Your risk for developing osteonecrosis of the jaw is very small, unless you are on an intravenous form of
bisphosphonate. You may be at increased risk for developing other health problems if a dental disease is
not treated. Your dentist will be able to discuss alternative treatments, other risks associated with various
treatment options, and the risk of no treatment, even temporarily. You should also consult with your treating
physician about any health risks.
 I have reviewed the above information, and have had the opportunity to have any questions/concerns addressed. Based on the information presented by my doctor(s) regarding my diagnosis, the proposed treatment, the treatment alternatives, and the associated risks and complications of such treatment, I request that you perform the planned surgical treatment. 1174 MontgoMery drive • Santa roSa, Ca 95405 • 707-545-4625 • 707-545-4940 fax 1350 MediCal Center drive • rohnert park, Ca 94928 • 707-584-1630 • 707-584-2394 fax

Source: http://portfolio.upistruzak.com/sros/forms/104%20Oral%20bisphosphonate%20consent.pdf