Periodontal Scaling and Root Planing Consent Form

I understand that I have periodontal (gum) disease. The disease process has been explained to me and all of my questions have been answered.

Periodontal scaling and root planing involves the removal of calculus, bacterial plaque, and diseased tissue from the inner lining of the gum tissue surrounding the teeth. Local anesthetic is recommended for this procedure. A “regular” cleaning will NOT treat gum disease, since the roots are not accessed in that procedure. I understand that my own efforts with home care are just as important as my professional treatment. A later referral to a periodontist may be necessary and there are no guarantees involved with this treatment.

Risks of treatment include the following:

• Increased gum recession
• Increased sensitivity to hot, cold, and sweets
• Exposed roots may stain more easily
• Loose teeth
• Pain, soreness, swelling, bruising, infection, bleeding
• Food collecting between teeth, proper cleaning techniques will be explained
• Reaction to anesthetic, temporary or permanent numbness due to anesthetic

Consequences of doing nothing to treat my periodontal disease may result in:

• Increased gum recession
• Increased sensitivity to hot, cold, and sweets
• Increasingly loose teeth
• Tooth Loss
• Continued infection of the gums and supporting structures
• Spread of Infection

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

I understand that I have periodontal disease, for which a routine cleaning will not benefit my health. In fact, failure to treat the disease may result in the eventual loss of my teeth and in some instance, acute illnesses such as heart attack and stroke. But I decline treatment for now.