Richard A. Miller DDS, FAGD
CONSENT TO PERFORM PERIODONTAL CLEANING
I _____________________, the undersigned, have been informed that I have periodontal disease, and that this disease process has been explained to me and that I fully understand the following:
1. This disease can cause the loss the bone which normally supports the teeth.
2. To help prevent the loss of bone around my teeth, I must prevent buildup of live bacteria called “bacterial plaque” on a daily basis and it is my responsibility to schedule the regular dental checkups and cleansing after treatment is complete.
3. The proposed treatment plan to arrest the effects of periodontal disease that has been explained to me and I understand that additional treatment may be needed later if further problems develop.
4. As a result of periodontal root planing and curettage:
a. The gums maybe more receded where cleaned, and portions of the roots my be exposed post- cleaning.
b. The exposed roots may be more sensitive to hot, color and/or sweets. This problem usually
corrects itself in about six months time. Occasionally, further treatment may be needed. On rare occasions, this condition persists no matter what is done.
c. The exposed roots, being more porous, may stain more easily than the crowns of teeth.
d. Food may collect more easily between the teeth after meals.
e. The teeth may feel loose immediately after cleaning. This occasionally persists indefinitely on isolated teeth where more bone loss has taken place. Normally, the teeth will eventually be about as loose as they were pre-operatively.
5. Failure to follow these recommended actions will most likely result in continued bone loss with probably periodontal abscesses and eventually, tooth loss.
6. After an appropriate healing period, the status of periodontal disease will be evaluated. At that time, referral to a periodontist for periodontal surgery may be indicated.
7. I am aware that the practice of dentistry is not an exact science and I acknowledge that no guarantees have been made to me. The risks involved in the administration of anesthetics, have been fully explained to me and I do give my free voluntary informed consent to the same.
Date Signature of Patient