Downtown Whitby Dentistry

Periodontal Treatment Consent Form

130 Byron Street North, Whitby, ON, L1N 4M9      905-430-7045

Patient's Name:
E-mail Address
I have been informed that I have periodontal disease. Periodontal disease stems from accumulation of plaque - sticky, colorless bacteria that form on teeth. Toxins produced by bacteria irritate the gums and harden into calculus (tartar), destroying the supporting tissue around the teeth. As the plaque and calculus build up between the teeth and the gums, gum tissue recedes from the teeth and pockets form. Due to the destruction of bone holding in our teeth, Tooth loss is inevitable.

The bacteria that cause periodontal disease re-establishes within 3 months after treatment. A 3- or 4-month periodontal maintenance appointment is critically timed to disable the destructive process at its critical stage. This critical stage is when the bacteria and their poisons do the most harm to the supporting structures, namely the periodontal attachment.

While there is no cure for Periodontal disease, it can be managed and controlled. A 3- or 4-month Periodontal Maintenance Therapy Appointment, is a soft tissue Management program. This program is a non-surgical approach to Control Periodontal disease. It is the most Conservative approach to prevent more extensive aggressive treatment.

Periodontal disease has also been implicated as having an effect on general health and an increased incidence of stroke, heart disease, diabetes, low birthweight babies, and some types of cancer. Additional scaling has been recommended to clear away the toxins causing inflammation and follow-up periodontal care has been recommended at three- or four-month intervals. I have been told that my periodontal disease is progressive and that I may experience consequences that include but are not limited to future loss of teeth or other serious health problems if I wish to decline recommended treatment.
All of my questions and concerns have been answered.


Patient Consent

Signature