Discussion and Informed Consent for Nonsurgical Periodontal Treatment

Discussion and Informed Consent for Nonsurgical Periodontal Treatment
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Treatment:
Facts for Consideration

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An examination of your oral cavity includes measuring the pockets under the gums surrounding your teeth to determine if your gum condition requires treatment. Dental X-rays will be taken to check the condition of the bone that supports your teeth.
Initial
In general, as bone is lost from the periodontium (the bone that is directly attached to the teeth), pocket depths increase and "deep pockets" generally form. This is significant because the bacteria can easily be harbored beneath the gums attached to the root of the teeth and cause continued bone loss. For this reason, the paramount therapy in periodontal treatment is to decrease the pocket depths. The shallower the pocket depths, the healthier the periodontium.
Initial
Periodontal (gum) treatment is intended to remove the bacterial substance known as plaque, which is the principal cause of gum disease, and hard mineral deposits called calculus from above and below the gum line.
Initial
The treatment involves scaling, which uses hand instruments to remove plaque and calculus from the tooth and root surfaces are then smoothed. Medications or a special mouth rinse can be used to help control the growth of bacteria and may be part of treatment.
Initial
The long-term success of the treatment depends in part on your efforts to brush and floss daily, receive regular cleanings as directed, follow a healthy diet, avoid tobacco products and follow proper homecare taught to you by our office.
Initial
A topical or local anesthetic (numbing medication) may be administered just before treatment depending on the sensitivity of the area to be treated.
Initial
Benefits of Nonsurgical Periodontal Treatment, Not Limited to the Following:

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Regular,professional dental cleanings create a clean environment in which your gums can heal, reduce the chances of further irritation and infection, make it easier for you to keep your teeth clean and decrease the cost of replacing teeth lost due to gum disease.
Initial
Risks of Nonsurgical Periodontal Treatment, Not Limited to the Following:

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I understand that one of the effects of treatment is that my gums may bleed or swell and I may experience moderate discomfort after the anesthesia wears off. There may be soreness for a few days, which may be treated with pain medication. I will notify the office if conditions persist beyond a few days.
Initial
I understand that because cleanings involve contact with bacteria and infected tissue in my mouth, I may also experience an infection that may require treatment with antibiotics or other therapies.
Initial
I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it difficult for me to open wide for several days, sometimes referred to as trismus. However, this can occasionally be an indication of a more significant condition or problem. Inthe event this occurs, I must notify this office if I experience persistent trismus or other similar concerns arise.
Initial
I understand that after treatment, as my gum tissues heal they may shrink somewhat, exposing some of the root surface. This could make my teeth more sensitive to hot or cold. I understand that additional surgical procedures may be needed to treat the exposed areas.
Initial
I understand that depending on my current dental condition, existing medical problems or medications I may be taking, these periodontal treatment methods alone may not completely reverse the effects of gum disease or prevent further problems.
Initial
I understand that I may receive a topical or local anesthetic and/or other medication as part of my treatment. In rare instances,patients may have a reaction to the anesthetic, which could require emergency medical attention. Because of the anesthesia, I may need a designated driver to take me home. Rarely, temporary or permanent nerve injury causing numbness or pain of the lip, chin, cheek, teeth or tongue may result from an injection.
Initial
I understand that ALL medications have the potential for accompanying risks, side effects and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking, which are:
I understand that smoking can adversely affect the outcome of the periodontal therapy suggested and that final results of periodontal therapy may be minimal or negated because of my history or lack of smoking cessation.
Initial
I understand that every reasonable effort will be made to ensure that my condition is treated properly, although it is not possible to guarantee results. By signing below, I acknowledge that I have received adequate information about the proposed treatment, that I understand this information and that all of my questions have been answered to my satisfaction.
Initial
Consequences if No Treatment Is Administered Are Not Limited to the Following:

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I understand that if no treatment is administered or ongoing treatment isinterrupted or discontinued, my current periodontal condition may continue andis likely to get worse. This could lead to further inflammation and infection of gum tissues, tooth decay above and below the gum line, deterioration of bone surrounding the teeth and eventually the loss of teeth
Initial
Alternativesto Nonsurgical Periodontal Treatment, Not Limited to the Following:

Patient's initials required
I understand that surgical methods may also be necessary to help control my gum disease. I have discussed with my dentist the alternatives and associated expenses. My questions have been answered to my satisfaction regarding the procedures and their risks, benefits and costs.
Initial
Discussion and Informed Consent for Anesthesia

Local Anesthesia
Anesthetizing agents, (medications) are injected into a small area with the intent of numbing the area to receive dental treatment. They also can be injected near a nerve to act as a nerve block causing numbness to a larger area of the mouth beyond just the site of injection.
Initial
Risks include but are not limited to: It is normal for the numbness to take time to wear off after treatment, usually two or three hours. This can vary depending on the type of medication used. However, in some cases, it can take longer, and in some rare cases, the numbness can be permanent if the nerve is injured. Infection, swelling, allergic reactions, discoloration, headache, tenderness at the needle site, dizziness, nausea, vomiting, and cheek, tongue, or lip biting can occur.
Initial
Potential benefits: The patient remains awake and can respond to directions and questions. Pain is lessened or eliminated during the dental treatment.
Initial
For All Female Patients
Because anesthetics, medications and drugs may be harmful to the unborn child and may cause birth defects or spontaneous abortion, every female must inform the provider of anesthesia if she could be or is pregnant. Anesthetics, medications and drugs may affect the behavior of a nursing baby. In either of these situations, the anesthesia and treatment may be postponed.
Initial
For All Patients
I have been given the opportunity to ask questions about the recommended method of anesthesia and believe that I have sufficient information to give my consent as noted below.
Initial
Check the boxes below that apply to you:
Consent
Refuse
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No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above.
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Discussion and Informed Consent for Nonsurgical Periodontal Treatment

Facts for Consideration

Benefits of Nonsurgical Periodontal Treatment, Not Limited to the Following:

Risks of Nonsurgical Periodontal Treatment, Not Limited to the Following:

Consequences if No Treatment Is Administered Are Not Limited to the Following:

Alternativesto Nonsurgical Periodontal Treatment, Not Limited to the Following:

Discussion and Informed Consent for Anesthesia

For All Female Patients

For All Patients

Check the boxes below that apply to you: