Informed Consent for Periodontal Treatment

I understand that I have periodontal (gum and bone) disease. The disease process has been explained to me and I understand it is caused by bacterial toxins.

I understand that the disease may be painless, but symptoms such as bleeding, swelling or recession of gum tissue, loosened teeth, bad breath, sensitivity and soreness may be noticed.

Treatment of periodontal disease may include periodontal scaling and root planning, either as a therapeutic procedure or prior to more extensive treatment. Periodontal scaling and root planning is the removal of calculus, bacterial plaque, bacterial toxins and diseased tissue surrounding the teeth.

I understand
• The purpose and benefit of this procedure is to reduce some causes of periodontal disease to a level more manageable by my own immune system.
• My own efforts with home care are just as important as my professional treatment.
• Some of the conditions caused by periodontal disease are irreversible.
• Attending regular Hygiene appointments are essential to maintain future oral health.
• Future re-­‐treatment of scaling and root planning may be necessary.
• Referral to a specialist may be required depending on my response to treatment.

The treatment risks may be, but are not limited to:
• Increased recession of the gum tissue and exposure of root surfaces as the tissue heals, and inflammation or swelling decreases (teeth will look longer).
• Some pain and/or swelling may be experienced
• Increased sensitivity to hot, cold or sweets
• Increased tooth mobility

The possible consequences of doing nothing or discontinuing treatment include:
• Worsening of the disease causing increased bone loss which may lead to the need for teeth to be extracted in the future.
• Increased infection, bleeding, discomfort and food impaction between teeth
• Research shows a clear link between periodontal disease and the following medical conditions; Heart Disease, Strokes, uncontrolled Diabetes, Respiratory disease, premature births and low birth weight in babies.

I understand the recommended treatment for my periodontal condition and I have no further questions.

Informed consent for Periodontal Treatment

Patient declines Specialist Referral

I understand that I have periodontal (gum and bone) disease. The disease process has been explained to me and I understand it is caused by bacterial toxins and my body’s response to these.

I understand that the disease may be painless, but symptoms such as bleeding, swelling or recession of gum tissue, loosened teeth, bad breath, sensitivity and soreness may be noticed.

Treatment of periodontal disease may include periodontal scaling and root planning, either as a therapeutic procedure or prior to more extensive treatment. Periodontal scaling and root planning is the removal of calculus, bacterial plaque, bacterial toxins and diseased tissue surrounding the teeth.

I understand:
• The purpose and benefit of this procedure is to reduce some causes of periodontal disease to a level more manageable by my own immune system.
• My own efforts with home care are just as important as my professional treatment.
• Some of the conditions caused by periodontal disease are irreversible.
• Attending regular Hygiene appointments are essential to maintain future oral health.
• Future re-­‐treatment of scaling and root planning may be necessary.

The treatment risks may be, but are not limited to:
• Increased recession of the gum tissue and exposure of root surfaces as the tissue heals, and inflammation or swelling decreases (teeth will look longer).
• Some pain and/or swelling may be experienced
• Increased sensitivity to hot, cold or sweets
• Increased tooth mobility

The possible consequences of doing nothing or discontinuing treatment include:
• Worsening of the disease causing increased bone loss, which may lead to the need for teeth to be extracted in the future.
• Increased infection, bleeding, discomfort and food impaction between teeth
• Research shows a clear link between periodontal disease and the following medical conditions; Heart Disease, Strokes, uncontrolled Diabetes, Respiratory disease, premature births and low birth weight in babies.

I understand the recommended treatment for my periodontal condition would be to seek specialist treatment.

I am aware, that given the severity of my periodontal disease, the Hygienist is unable to provide the same level of care as a specialist and this may mean my oral health continues to worsen however I choose to remain under my Hygienist’s care.