Periodontal Scaling and Root Planing Informed Consent

I understand that I have periodontal disease, a condition resulting in the destruction of the gum and bone supporting my teeth.  The disease process has been explained to me and I understand that it is caused by several factors: poor home care and neglect, bacterial toxins found in plaque, and my body's immune response to these toxins.

Periodontal disease is a progressive disorder.  If untreated, it leads to the loss of teeth.  Early detection and aggressive treatment are critical to stopping or slowing the progression of the disease to the point of tooth loss.

Treatment of periodontal disease includes scaling and root planing, effective home care, possible referral to a periodontist (gum specialist), and possible surgery.  Scaling and root planing can be a corrective procedure, or it may be a preliminary step to more invasive treatment by a specialist, ie. surgery.

Scaling and root planning is the removal of calculus (tarter), bacterial plaque and toxins, diseased cementum (the outer covering of the root surface) and diseased tissue from the inner lining of the crevice surrounding the teeth (the gingival sulcus).  The purpose of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by the immune system.

We can help, but the greater responsibility lies with you and your conscientious commitment to the recommended treatment.  Excellent home care and continual professional maintenance will be essential for long term success.  Optimum results are achieved only when appointments are kept.  Deferring your appointments can lead to prolonged treatment, additional appointments, poor results, and possibly additional charges.

The consequences of no treatment may include, but are not limited to the following:

1. Worsening of the disease with increased bone loss and eventual tooth loss
2. Possible systemic (general health) problems: there is an established link between periodontal disease, cardiovascular disease, premature birth, and low birth weight babies
3. Worsening of gum bleeding, pain, and soreness

The prescribed treatment for periodontal disease varies according to severity, but generally includes the following:

1. An initial comprehensive examination, including all necessary x-rays.
2. Periodontal charting - record probing depths, gum recession, tooth mobility, etc.
3. Home care instructions - brushing, flossing, rinsing
4. Initial debridement - removal of superficial calculus deposits to begin the healing
5.  ___________ appointments for root planing and scaling
6. Irrigation
7. Re-evaluation of periodontal condition - repeat step # 2

Treatment risks include, but are not limited to the following:

1. Increased gum recession with increased root surface exposure
2. Increased tooth sensitivity to hot, cold, or sweet foods/liquids.  This may require further treatment, may fade with time, or may persist no matter what is done.
3. Exposed roots may acquire stain more readily without diligent home care.
4. Food may collect between teeth.  Proper cleaning techniques will be necessary.
5. If teeth were loose before treatment, they will be loser immediately after.   After healing the looseness may decrease but it may persist long term, and splinting may be necessary to reduce mobility.
6. Some pain, swelling or bruising may be experienced initially after treatment.

Periodontal therapy and periodontal maintenance help to create a healthy foundation for future treatments that may be necessary to restore your teeth to good function and health.

My diagnosis, recommended treatment(s), the risks and benefits of such treatment(s), the risks of no treatment, my role in treatment success, and any alternative treatment(s) have been explained to me.  All of my questions have been answered.