The Patient: You have been diagnosed with a condition known as Periodontal Disease or "Gum Disease". You have the right as a patient to be informed about your condition and the recommended medical and/or diagnostic procedure to be used so that you may make an informed decision whether or not undergo the recommended procedures(s).
Treatment: Periodontal disease is a chronic disease requiring more frequent oral exams and maintenance procedures to be performed. Periodontal disease is defined as inflammation and degeneration of tissue that surround and support teeth, including gingival (gum), alveolar bone (bone surrounding tooth roots) and periodontal ligament (connects root with bone). Periodontitis is defined as gingival inflammation combined with some loss of the periodontal ligament and alveolar bone support. Clinical manifestations of periodontal disease range from gingival bleeding when brushing and chronically red, swollen periodontal tissues to bone loss, tooth mobility, and tooth loss. The effectiveness of periodontal therapy is partially dependent on early evaluation, diagnosis, and intervention.
SRP/LAAs: There are two parts to our non-surgical treatment of periodontal disease. Treatment involves removal of plaque and mineralized deposits above and below the gum line, scaling and smoothing of the root surfaces (root planing). These procedures allow the tissues to heal and give opportunity for re-attachment. Over the next 3 to 6 months, you will be evaluated as to the progress of the healing and extent of re-attachment. Our goal of the procedure is to reduce the depth of the pockets that have formed around the tooth to a depth manageable by good oral home care.
In addition to this mechanical process of (SRP), a local administered antibiotic (LAA) will be applied to all pocketsÂ that need additional therapy. The benefit of applying this local agent in these areas is to enhance the SRP procedure and further reduce pocket depths associated with your periodontal disease. At your recare visit (3 month follow up visit), we will locally administer antibiotics to all pocket depths 5mm or greater with bleeding on probing, that did not respond to mechanical SRP on its own merit. This will help to further reduce infection associated with periodontal disease.
I have been advised that periodontal treatment procedures are necessary, rather than simple prophylaxis (cleaning), to properly treat my gum condition. This is necessary because of conditions such as moderate to heavy stain, calculus, tarter, or bleeding from inflamed tissue, which may contribute to periodontal (gum) disease if left unattended.
I acknowledge my disease state and CONSENT to the performance of the above treatment procedures of Mechanical SRP and Locally Administered Antibiotics to pockets found in need of additional therapy at the initial SRP to help further reduce pocket depth. Also, I consent to locally administered antibiotics found at the 3 month recare visit that did not respond to mechanical SRP on its own merit. This would include 5mm pockets or greater and bleeding on probing.
The nature of the problem has been explained to me and I understand the consequences of my decision NOT to follow these above recommendations. I understand that periodontal disease (gum disease) weakens support of my teeth by separating the gum from the teeth and that the progressive loss of gum support can ultimately cause me to lose my teeth.
I release my doctor and hygienist from liability in this matter.