Dr Ted's new website is:
As of January 1, 2017, Dr. Rothstein has limited his practice to providing Orthodontic Jaw Wiring for Weight-Control: OJW®: Weight-control. He provides this service in Brooklyn, NY and will soon announce a new office location in Portland,OR where the Oregon Board of Dentistry on June 23 created history by ruling that Dental Professionals are at liberty to Provide Weight-control services. See www.ojwforweightcontrol.com
Contact: 718 808 2656; drted35@gmail.com

Informed Consent for Procedures in Which the Soft Tissue Laser is Used

*Informed Consent for Procedures in Which the Soft Tissue Laser is Used

 The Laser procedure that will be undertaken is called: _____________________________

Dr. Rothstein has strongly advised me to visit his web page at: http://drted.com/LaserGumTrimmingGingivectomy.htm  to obtain a thorough understanding of the use of the Laser in the management of soft-tissue problems where laser is an appropriate/approved form of treatment.  He has encouraged me to look at the videos present on that page in order to acquaint me with the procedure which is planned for me/my child.

 The patient undergoing the laser soft tissue procedure is allergic to–List allergies here:

 The fee for the particular Laser service being provided are in addition to the fee for the Orthodontic treatment and are rarely covered by insurance.  I understand this office does not operate on the assumption that insurance will reimburse me for the treatment rendered.

 Laser procedures as a general rule offer positive results that can be achieved by informed and cooperative patients. Thus, the following information is routinely supplied to all who are considering a laser procedure. While recognizing the benefits of healthy teeth and tissues, you should also be aware that laser treatment has limitations and potential risks. These are seldom serious enough to indicate that treatment should be avoided, but they should be considered in making the decision whether or not to undergo laser surgery. Laser treatment usually proceeds as planned; however, as in all areas of medicine, results cannot be guaranteed, nor can all consequences be anticipated. Some unexpected consequences/side effects include: post-procedure swelling, infection and tooth sensitivity.

Laser surgery strives to improve either the overall appearance of the smile by reducing and recontouring the gingival tissues, or by removing the excess gum tissue that is preventing the timely eruption of permanent teeth, which slows the progression of orthodontic treatment.

Laser surgery is performed in our office utilizing a strong topical anesthetic which is painted onto the gums that are being treated. The surgery cauterizes the tissue, therefore bleeding is minimal. The recovery period is brief, lasting for as little as three days, but for some patients may last up to two weeks. The area being treated will be a “caramel” color after the procedure is completed and the patient will experience bleeding during brushing for the first few days, but brushing should not be discontinued. Oral antiseptic rinses are recommended to promote healing in the days following the procedure.

In addition, I have been advised to gently cleanse the areas that have been treated with a 3% peroxide solution three times each day for three day and to avoid traumatizing those areas while tooth brushing as well to avoid hard crunchy food. Normal oral hygiene can be resumed in 3-7 days.

All forms of medical and dental treatment have risks and limitations. Fortunately, complications are infrequent with laser procedures. Nevertheless, they should be taken into account in deciding whether to undergo laser surgery. Some of the primary concerns may include:

1. Prolonged healing at the surgical site.

2. Possible gingival recession that may require intervention by a periodontist

3. The topical anesthetic may leave the area numb for a minimum of ten-twenty minutes. Some younger patients may find this feeling awkward and may make swallowing difficult. Younger patients are cautioned to avoid chewing or biting their lip or cheek while numb.

4. Although the strong topical anesthesia is usually effective in controlling/eliminating pain and discomfort resulting from reshaping the gum tissue, sometimes a local injection of anesthetic will be required to entirely eliminate all sensations of discomfort during the procedure.

5. Gum tissue that has been removed can/will sometimes regrow especially when good oral hygiene/home care is not carefully observed.

As with any elective procedure, there are alternatives that patients/parents may consider. You may choose to accept your present oral condition, or chose one of the following alternatives:

1. Have the procedure performed by an oral surgeon under a local anesthetic

2. Have the procedure performed by a periodontist, also under a local anesthetic

3. Decline the surgery, understanding that orthodontic treatment may be delayed.


I hereby acknowledge that the major treatment considerations and potential risks of laser surgery have been presented to me, I have read and understand this form and also understand that there may be other problems that occur less frequently or are less severe, and that the actual results may be different from the anticipated results.

Dr. Rothstein has discussed the planned treatment with me to my satisfaction and has answered all the questions I presented to him. I have consented to have him proceed doing the procedure.

I  understand that photographs and or video clips may be produced for educational/demonstrational/comparative purposes and may be appropriately placed on the web site showing before and after images of the areas treated.

Signature/Patient, Parent or Guardian_____________________________ Date ___________

Witness_________________________  Date ________

"Experience and reputation really count when it comes to providing quality patient care."