[ ] maxilla
[ ] left
[ ] right
[ ] inside
[ ] outside
[ ] mandible
[ ] left
[ j right
[ ] inside
[ ] outside
[ ] Clenching/grinding. Your chewing system is overloaded because your teeth are excessively active.
[ ] Smoking. Unfavourable consequences are visible on the teeth and gums.
[ ] Your chewing pattern is uneven, i.e. you have preferably used one side for chewing.
[ ] In today‘s routine examination, you were informed that the following treatment and diagnostic requirements are present. The necessary steps should be taken by your family dentist or by us. They should be performed
[ ] as soon as possible
[ ] There are not enough chewing units available. There is a risk that this may damage your dentition as a whole. You have been informed of the following treatment options:
[ ] One or several implants have to be treated/replaced. Please make an appointment immediately.
[ ]_______________________________
[ ] in due course and occasionally
[ ]_______________________________
In today‘s routine examination, you were informed about what you should be doing to actively support the treatment and to maintain its successful outcome.
[ ] It is recommended that you quit smoking.
[ ] Please make an effort to find out which tooth areas and cusps interfere with your chewing while you are eating. Get back to us immediately to have the corresponding occlusal adjustments made.
[ ] Follow the cleaning instructions given in the enclosed fact sheet, and use the following additional tools:
[ ] Interdental brush
[ ] Dental floss with/without threader end
[ ] Soft toothbrush (designed for children)
[ ] It is recommended that you periodically undergo professional dental hygiene.
[ ] Please always inform the treating dentist specifically, and on your own initiative, of any diseases, allergological problems or any other changes in your fundamental health status and personal data.
[ ] Please schedule the next routine checkup appointment for… If you experience any pain or symptoms before that date, contact us immediately.
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Date:
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Patient signature
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Dentist signature
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Once the initial treatment has been completed successfully or the first recall session has been completed, the patient can be motivated for more long-term cooperation. The treatment provider could offer a warranty for the durability of the treatment result achieved, a warranty, however, that could be invoked only if the patient him- or herself does everything to perpetuate the favourable status quo:
Dear Patient,
Now that the initial treatment has been completed successfully and a stable state has been achieved, you might ask yourself what you need to observe while living with dental implants. First of all, it may be useful to re-read the section entitled “Life with Implants” of the Informed Consent form you signed before treatment. You thus already know about the importance of regular check-ups, recall sessions and possibly corrections performed by qualified dentists. We would like to invite you to appear for these regular appointments, and we would also like to give you an idea of the cost of these appointments. At the same time, we would like to offer you a warranty, based on regular and positive patient cooperation, which will help you ensure the preservation of the treatment result achieved so far.
24.5 Dentist’s Warranty Offer
The dentist offers the patient a seven-year/unlimited comprehensive warranty of the durability of the treatment result obtained with regard to the implants and prosthodontic work in the region of tooth …………………. (work covered by the warranty), provided the patient shows, in the event that he or she makes any claims under this warranty, that he or she has appeared for at least two annual recall appointments (more if required and if so ordered by the dentist) with a BOI-certified dentist.
I hereby give my dentist’s office permission to remind me of impending recall appointments. The extent of the examination and any diagnostic or therapeutic measures will be determined by the dentist at the recall session. The seal of any certified BOI dentist (see sample overleaf) serves as proof that the respective recall session was completed.
I agree to be invoiced according to the following staggered price list published by the European Academic Society for Implantology (EASI e.V.) (valid as per 4 February 2004):
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