This form is intended to provide you with an overview of potential risks and complications. Prior to consenting to treatment, you should carefully consider the anticipated benefits, commonly known risks, and complications of the recommended procedure, alternative treatments, or the option of no treatment.
X-rays are required to complete your examination, diagnosis, and treatment plan. A periodic examination will be provided by the dentist at all routine cleanings to evaluate your teeth for decay, gum disease, oral cancer, and overall health.
A routine dental prophylaxis involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line called periodontal disease. Some bleeding after a cleaning can occur; however, should it persist and if it is severe in nature, the office should be contacted.
This treatment involves removing the bacterial substance known as plaque, which is the principal cause of periodontal disease, and calculus (tartar), which is an accumulation of hard deposits on the tooth above or below the gingival margin. A topical and/or local anesthetic may be administered depending on the sensitivity of the area to be treated. The success of the treatment depends in part on your efforts to brush and floss daily, receive regular cleaning as directed, follow a healthy diet, avoid tobacco products, and follow proper home care taught to you by this office.
I understand that because cleanings involve contact with bacteria and infected tissue in my mouth, I may also experience an infection, which would be treated with antibiotics.
I also understand that after the procedure I may experience:
Tooth Number:
Alternatives to the above treatment