Informed Consent for Oral Prophylaxis


Overview of Treatment Risks and Complications

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.

During your course of treatment, the following care will be provided to you:

Examination and X-Rays

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.

Dental Prophylaxis (Cleaning)

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.

Scaling and Root Planning (SRP/Deep Cleaning)

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:

  • Post-operative discomfort.
  • Stretching of the corners of the mouth with resultant cracking and bruising.
  • Swelling, bruising, and bleeding of the gum tissue.
  • Shrinkage of the gum tissue.
  • Sensitivity of the teeth.
  • Loosening of the teeth.
  • Exposure of margins of previous crowns or caps.

Tooth Number:

Alternatives to the above treatment

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :