(416) 538-8883
415 Bloor Street West Suite 300
Toronto, Ontario M5S 1X6

Grafting of Gum Tissue Consent Form

I hereby understand the recommended treatment for mycurrent dental needs is to have a gum graft. I understand the cost per graft and it is my responsibility topay the balance per tooth upon the work being completed as Bloor Dental Health Centre is a nonassigned office. I understand that I will need to receive an anesthetic. I also understand that I will begiven specific post-operative instructions to take home with me on the day of surgery and that I mustfollow them to maximize the success of the graft.

After your surgery, if you experience any of the following but not limited to please contact our office for an appointment:

  1. Parathesia
  2. Prolonged bleeding
  3. Discomfort

I am aware that any of the following may compromise my gum graft:

  1. Smoking
  2. Carbonated drinks
  3. Seeds and crusty foods

I understand that I may experience any of the side effects mentioned above, or all, but not limited to and still wish to go ahead with the grafting of the gum tissue that was recommended by and will be done by Dr. Lawrence Freedman at Bloor Dental Health Centre.

Please be advised that parathesia may occur in either jaw from the administration of the anesthetic. I understand that this is a possible outcome when having my gum graft done. I also understand that at the end of the surgery if I fail to follow the specific postoperative instructions that are given to me the day of surgery that is at my own risk and Dr. Lawrence Freedman will not be held responsible.


Patient Name:
Patient Initials:

Gum Graft Aftercare


  • Discomfort is normal and to be expected. The level and duration varies between patients.
  • Take the prescribed or recommended pain medications as directed.


  • Rest quietly with your head elevated for the remainder of the day.
  • Always get up slowly from a reclining position to prevent dizziness.
  • Limit physical activity
  • To encourage rapid healing, please rest!


  • Rest quietly with your head elevated for the remainder of the day.
  • Always get up slowly from a reclining position to prevent dizziness.
  • Limit physical activity
  • To encourage rapid healing, please rest!


  • Ideally, pain medication should be taken BEFORE numbness wears off.
  • If an antibiotic was prescribed take it as directed until it is ALL GONE.
  • Some pain medications may cause light-headedness. Lying down will help this.
  • Some medications may cause an upset stomach. Taking these with food will lessen the side-effect.


  • Slight bleeding from the surgery area is normal, however, extensive bleeding should not occur. If such bleeding should occur, apply firm pressure with moist gauze or a moistened tea bag to the area for 20 minutes. If bleeding does not subside, please call!

Mouth Care

  • Do not brush, floss, rinse or spit the day of your surgery.
  • Avoid rinsing, spitting, or sucking through a straw for 24 hours after surgery. Blood clotting will occur and this will disturb the healing process.
  • You may begin to brush the NON-SURGICAL area the day following surgery.
  • Start to gently brush (with ultra-soft brush) the surgical area after your post-operative appointment.
  • Chlorhexidine mouth wash can be used daily but be aware staining may occur.
  • Do not touch the surgical sites for the first week; you could dislodge the healing tissue and compromise the success of the graft.
  • Do not pull your lip away to view the graft site.


  • Eat softer foods such as pasta, eggs, yogurt, baked potato or hot cereal.
  • Chew in the non-surgical areas as much as possible.
  • Avoid extremes: very hot, very cold, acidic food, also hard or crunchy foods.
  • Avoid the use of alcohol for 2 days after the surgery or until you are no longer taking medication.


  • Fluids should be consumed as soon as possible. It is recommended that you drink 6 ? 8 glasses of water over the remainder of the day following surgery.
  • Avoid using a straw as it may cause suction, which may loosen the blood clot and cause bleeding and loss of graft.

Swelling and Bruising

  • Some swelling often occurs and this is normal in the healing process.
  • Bruising may occur in surgical areas.
  • If swelling seems excessive and is accompanies by fever or pain, please call immediately.


  • We strongly advise NOT SMOKING after surgery. Smoking delays the healing process, increases discomfort, and may encourage bleeding and infection in the surgical site.


  • A periodontal dressing or sutures may have been placed to protect the healing wound. It should remain in place as long as possible.
  • If part of all of the dressing or sutures comes off, do not be alarmed. This is normal (expected) and will not affect the results.

Bloor Dental Health Centre Toronto - Office
© Bloor Dental Health Centre - All Rights Reserved