"*" indicates required fields

Patient Information

Name*

Date*

Consent for Scaling & Root Planing

What is scaling and root planing and what are its benefits?

Scaling and Root Planing (aka: Periodontal Therapy or Deep Cleaning) is used to treat the beginning stages of periodontal or gum disease. This is usually indicated by deeper pocket depths than normal, bleeding gums, tartar accumulation below the gum line and x-ray evidence of bone loss. The goal of periodontal therapy is to reduce these pocket depths, remove unhealthy tissue and to thoroughly clean the root surfaces of the teeth. These efforts are done to help a patient retain their teeth and improve periodontal health. There is not a cure for periodontal disease, only treatment.

What are the risks?

1- Response to treatment: Because of many variables within each patient’s physiological make-up, it is impossible to precisely determine whether or not the healing process, in which tissue response is a vital element, will achieve the desired results. Should the desired results not be attained, periodontal surgery or extractions may be required.

2- Postoperative patient responsibility for care: With the types of treatment required in correcting periodontal problems, it is mandatory that the patient exercise extreme diligence in performing the home care required after treatment, as instructed by the treating hygienist. Without the necessary follow-up care by the patient, the probability of unsatisfactory results is greatly increased.

3- Pain, soreness and sensitivity: There may be post-operative discomfort which may be transitory or permanent, related to hot and cold stimuli, contact with teeth, and sweet and sour foods. The gums will also be sore immediately following treatment and may bleed.

4- Recession of the gums after treatment: After healing occurs, there may be gum recession which exposes the margin or edge of crowns or fillings, increases sensitivity of teeth, creates esthetic or cosmetic changes in front teeth which results in longer teeth and wider interproximal spaces visible as a black triangle. These wider interproximal spaces are more likely to trap food.

5- Increased mobility (looseness) of the teeth during the healing period.

6- Noise and water spray: Ultrasonic instrumentation is noisy and the water used may cause cold sensitivity during treatment on unanesthetized teeth not in the treatment field.

What are my alternatives?

Improved home care alone will not treat gum disease. Having a prophy (dental cleaning) is NOT a treatment for gum disease since the roots cannot be accessed during this appointment. Choosing no treatment is always option, but it will permit the gum disease to progress which could result in tooth loss.

INFORMED CONSENT: I can read and write English and have been given the opportunity to ask any questions regarding the nature and purpose of the proposed treatment and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, which may be associated with any phase of this treatment in hopes of obtaining the desired result. The fees for these services have been explained to me and I accept them as satisfactory. By signing this form, I am freely giving my consent to authorize the doctors and staff at Cross Timbers Dental in rendering any services they deem necessary or advisable to treat my dental conditions, including the administration and/or prescribing of any anesthetic agents and/or medications.

Anesthetic: The use of local anesthetic is used for pain control during dental procedures. There are inherent risks and side effects. They include, but not limited to: swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction, and altered sensation that may lead to self-injury. Partial or complete numbness may linger after the dental appointment. In rare cases it can last for an extended time and potentially it can be permanent.

Medications: Any medications dispensed or prescribed are the patient’s responsibility to understand before taking. Medication inserts are available from our office upon request. Particular attention should be given to possible allergic reactions, drug interactions with current medications and their specific side effects.

Guarantees: The practice of dentistry is not an exact science and no procedure is 100% successful. The doctors and/or staff at Cross Timbers Dental have made no guarantees of a successful outcome.

Notifications:If a patient develops a problem it is the patient’s responsibility to notify the doctors and/or staff of Cross Timbers Dental. Through this notification we will be able to act on the patient’s behalf. Attempts to correct a problem may occur at our office or a referral to another health care practitioner may be warranted.

Patient's name (please print)*

Date*
MM slash DD slash YYYY

Signature of patient/legal guardian*