Periodontal Scaling and Root Planning Form

WORK TO BE DONE: I understand that I am having the following work done

1. DRUGS AND MEDICATIONS: I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction)
2. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being Root Canal Therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.

I understand that I have a serious condition causing gum and bone infection or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.

It has been recommended by your dentist and hygienist that you receive a deep cleaning in all or parts of your mouth in order to manage active periodontal (gum) disease with the use of anesthetic and possible antibiotic placement. If left untreated, periodontal disease can cause tooth loss and other adverse consequences to your general health.

The purpose of this therapy is to reduce some of the causes of periodontal disease and promote healing. Additional treatment may be necessary to control gum disease and prevent tooth loss (ie- referral to a gum specialist (periodontist), gum surgery, tooth extraction, etc).

As with all procedures, there are risks associated with scaling and root planing. These risks include, but are not limited to the following:

1. Swelling, pain, and bleeding after treatment
2. Gum recession, root exposure, and/or sensitivity
3. Infection
4. Increased spacing and food impaction between teeth
5. Increased tooth mobility
6. Numbness in tissues
7. Broken instruments during cleaning which may require surgical retrieval.

OUTCOMES AND PATIENT RESPONSIBILITY

Because of variables within each patient’s physiological makeup, it is impossible to predict exactly how the gums and supporting structures will respond to any periodontal procedure. Therefore, additional treatment may be necessary. It is mandatory that the patient exercise extreme diligence in performing homecare and maintaining the recommended recall as there is no cure for periodontal disease. It must be maintained at home and with regular recare appointments. Without this, the probability of unsatisfactory results and reoccurrence is greatly increased.

CONSENT

I have been given the opportunity to ask questions regarding the nature and purpose of my periodontal treatment and have received satisfactory answers. I voluntarily assume any risks that may be associated with any phase of this treatment in the hopes of obtaining the desired results. No promises have been made to me concerning my recovery and/or results of this treatment. The fees for these services have been explained to me and are acceptable. By signing this form, I am freely giving my consent to allow Dr. Amy Mathew and her staff to render any treatment necessary or advisable for my dental conditions, including all anesthetics and/or medications.