Download consent to scaling and root planing

CONSENT TO SCALING AND ROOT PLANING
I,
, (name of patient) hereby authorize Dr. Rick H. Heard/Lisha Edwards,
RDH to perform scaling and root planing of_______________________________________________________
To address the following condition being treated:
With the use of local anesthesia, and possibly with intravenous / oral sedation.
____ I understand that I have (had) a form of periodontal disease that has caused damage to the soft tissues
and/or bone around my teeth and is endangering the health of my oral tissues. This disease, if left untreated, is
generally non-reversible and progressive - leading to further damage and possible loss of teeth.
____ I also understand that a non-surgical procedure, scaling and root planing, is the most conservative
method used to treat periodontal disease. While this non-surgical procedure is generally successful, I
understand that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be
curative and/or successful to complete satisfaction. Due to the possibility of unforeseeable changes in my
health, habits, and compliance with routine care, a risk of failure, relapse, or worsening of my present condition
may result despite the treatment.
Scaling and Root Planing Procedure: Following the administration of local anesthesia, small scaling
devices (either manual or ultrasonic) are placed into the gum pockets and systematic smoothing of the root
surfaces will be accomplished. Debris that has collected on the tooth surfaces will be removed along with
diseased soft tissue. Deep tooth and root scaling requires significant time and expertise. Usually only one or
two segments of your mouth will be treated at one appointment. Other appointments will be needed to complete
the therapy.
Major Risks of Scaling and Root Planing: Although significant complications from scaling and root
planing are rare, they can occur. The most common complications are as follows: discomfort, bleeding, swelling,
tooth sensitivity, infection, gum recession (shrinkage), space development between teeth, increased tooth
looseness, and food impacting between teeth after eating. Other risks include: damage to adjacent teeth or
underlying adjacent structures such as soft tissue. Although dental work is designed to withstand routine
cleaning procedures, this procedure may find that some restorations/fillings are loose, broken or faulty. This
may result in the need for you to see your restorative dentist to repair or even replace these restorations.
Risks of Anesthetics and Sedation: I understand that certain anesthetic risks, which could involve
serious bodily injury, brain damage, or death, are inherent in any procedure that requires general anesthetic or
intravenous sedation. If I am to have a general anesthetic or intravenous sedation, I certify that I have not had
anything to eat or drink for at least 6 (six) hours prior to the time of surgery and have complied with all special
preoperative instructions.
I understand that certain medications, drugs, anesthetics, and prescriptions may cause drowsiness and lack of
awareness and coordination, which can be increased with the use of alcohol or other drugs. These medications
can have residual effects for up to 12-18 hours that can still cause a lack of awareness and coordination. Thus, I
have been advised not to operate any vehicle, automobile, or hazardous devices, or work, while taking such
medications, and/or drugs; or until fully recovered from the effects of same. I agree not to drive myself home
after surgery and I will have a responsible adult drive me and accompany me home after my discharge from
surgery, if I have been sedated or have received nitrous oxide. I understand that a responsible adult will need to
remain with me until I have recovered fully from the effects of any sedation.
Need for Follow-up Care: It has been explained to me that long term success of treatment requires my
cooperation and performance of effective plaque control (home care) on a daily basis and periodic periodontal
maintenance visits at a dental office after the proposed treatment is performed. This is because most
periodontal disease is chronic in nature requiring continuing treatment to keep it under control. Scaling and root
planing is meant to be as definitive as possible, however in order to determine your response, a reevaluation will
be performed six to eight weeks afterward to determine any remaining periodontal needs. These remaining
needs could include localized application of antibiotics, removal of teeth, or periodontal surgery.
____ Alternative Treatments Discussions: I have been informed of other possible alternative treatment
methods.
____ Probable Results if No Treatment: I further understand that if no treatment is rendered, my present
periodontal condition will probably worsen in time, which may result in premature tooth loss.
I certify that I have fully read and understand the above consent to scaling and root planing.
Signature of Patient/Parent/Guardian:
Date:
Signature of a Witness:
Date:
Signature of Hygienist / Surgeon:
Date: