Form

Scaling & Root Planning Services Consent

The purpose of this document is to provide written information regarding the risks, benefits and alternatives of the
procedures named above. This material serves as a supplement to the discussion you have with Dr. Mallory . It is
important that you fully understand this information, so please read this document thoroughly. If you have any
questions regarding the procedure, ask Dr. Mallory prior to signing the consent form.
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PROCEDURE:
Scaling and Root Planing, also known as SRP is the removal of calculus (tarter), bacterial plaque and toxins,
diseased cementum (the outer covering of the root surface) and diseased tissue from the inner lining of the crevice
surrounding the teeth (the gingival sulcus). This procedure is performed by a Registered Dental Hygienist (RDH)
under the supervision of Dr. Mallory . The dental hygienist will use an ultrasonic scaler, which sprays water between
the teeth and vibrates at a high frequency and various hand instruments to loosen and remove the bacterial debris.
You have the option to use a local anesthesia during your appointment. Local anesthesia is an injection of a numbing
agent to relieve pain in your gum tissue and make your procedure more comfortable. You may feel pressure
throughout your procedure which can be mildly uncomfortable. At the conclusion of your visit you will be given a
prescription mouth rinse called Chlorhexidine. This is an extremely vital part of your post-operative care and should
be used as directed by Dr. Mallory and your hygienist.
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RISKS:
I have been informed of and understand the potential risks related to this procedure include but are not limited to:
Varying lengths and degrees of sensitivity.
Swelling, sensitivity and/or bleeding of the gum tissue.
Infection of the teeth, gum tissues or bone.
Increased spacing between teeth due to removal of hard deposits.
Revealing recessed gums which can cause prolonged sensitivity.
Cracking or stretching of the lips or corners of the mouth
Increased mobility of teeth, if deemed severe enough - a tooth may need to be extracted.
Allergic and/or adverse reaction to anesthetic, medication and/or materials.

BENEFITS:
It has been explained to me that the purpose of this therapy is to reduce some of the causes and symptoms of active
periodontal disease. I understand that although there is no cure for periodontal disease, it can be treated. I
understand my condition requires additional treatment that may include additional SRP's, periodontal
maintenance, periodontal surgery, and/or antibiotics.

ALTERNATIVES:
Declining periodontal scaling and root planing and allowing diagnosed periodontal disease to remain untreated, which
could be detrimental to my health.

POST-TREATMENT
I agree to follow all instructions provided to me by this office before and after the procedure including:
Taking medication(s) as prescribed, practicing proper oral hygiene as recommended by my dental team, keep
all appointments, make return appointments if complications arise, and complete care.
Informing Dr. Mallory of any post-operative problems as they arise.
My failure to comply could result in complications or less than optimal results.
I understand if my condition does not improve, I may be referred to a gum specialist called a Periodontist, to
discuss further treatment options.
I understand that scaling and root planing is only the first step to treating my periodontal disease. I must follow
the instructions given by Dr. Mallory and hygienist to maintain my oral hygiene at home to the best of my
ability.

CONSENT
By signing below, I attest to the following: Dr. Mallory and/or Dental Hygienist has explained this treatment/procedure and what it is for. Dr.
Mallory has explained how this procedure could the help me, and also reviewed the associated risks and
complications. Dr. Mallory has explained to me the alternative treatments that might be done instead, and what
would happen if I decline this procedure. I understand that the doctor nor hygienist cannot guarantee the results of
the procedure. Dr. Mallory has answered all my questions. I know that I may refuse or change my mind about having
this treatment/procedure. I have been offered the opportunity to read the consent form. I hereby give my consent to
have this treatment/procedure.

First Name

Last Name

Date Of Birth

Area of the mouth which the treatment/procedure will be performed:

I have elected to proceed with the anesthesia(s) indicated below:

I consent to Scaling & Root Planning Services:

Patient/Legal Guardian Signature

Date