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Include the particular date and place your e-signature. 2016-03-23T10:38:23-07:00 This consent form outlines the treatment program, its expected consequences, and limitations. 3752338809 Periodontal scaling and root planning is the removal of calculus, bacterial plaque, bacterial toxins, diseased cementum, and diseased tissue from the inner lining crevice surrounding the teeth. Scaling and Root Planing (aka: Periodontal Therapy or Deep Cleaning) is used to treat the beginning stages of periodontal or gum disease. 0 According to the American Dental Association, roughly 47% of adults over 30 have a serious gum disease known as chronic periodontitis. PostScript adobe:docid:indd:a9e3cc9d-14a5-11db-b366-c21f6f9a2bb8 Adobe PDF Library 15.0 • Glasscoe Watterson D. Documentation and Insurance Reporting of Periodontal Care. 2615198724 Treatment of periodontal disease may include periodontal scaling and root planning, either as a therapeutic procedure or preliminary to more extensive treatment. 1.31 %PDF-1.4
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Scaling is performed to remove plaque and tartar deposits and planning under the gum is done to smooth the root surface, allowing the gum tissue to heal and reattach to the tooth. PERIODONTAL PROCEDURES: SCALING AND ROOT PLANING I consent to Dr. _____ and/or their chosen assistants doing periodontal procedures such as scaling and root planing, including anesthetics and/or medicines. Informed Consent – Periodontal Treatment Patient Name * First ... either as a therapeutic procedure or preliminary to more extensive treatment. TrueType Informed Consent and Authorization for Periodontal Treatment Utilizing Scaling & Root Planning (SRP) 1. Simply click Done following twice-examining all the data. adobe:docid:indd:a9e3cc9d-14a5-11db-b366-c21f6f9a2bb8 I understand: The purpose and benefit of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by my own individual immune system. �%=)�����`tӭ0���D̖�4K��L"�
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�(Yb�JX�,0U��$�i@�Z�I��J������A��t�1]�)��b�a��3���lE���g��Nĕ��H���\?hM�~1[��h. Periodontal disease involves the soft tissue surrounding the teeth (gum tissue). The purpose of this procedure is to reduce some of the causes of periodontal Even though the 2825406603 2016-03-23T10:38:23-07:00 This form will be provided by the doctor for your signature, after receiving a full explanation. CenturySchoolbookBT-BoldItalic I have been informed that the purpose of this procedure is to treat and possibly correct my diseased gum tissues, teeth, implant, and/or supporting jawbones. 0 Times 2 0 obj <> TrueType Periodontal Scaling and Root Planning Informed Consent I understand that negligence on my part could result in the failure of periodontal treatment. 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 This disease has resulted in the loss the bone which normally supports the teeth. 66263 07/14 Root Planing Consent Form CPG064 ROOT PLANING INFORMED CONSENT: PERIODONTAL SCALING AND ROOT PLANING Scaling and Root Planing: Periodontal disease involves the soft tissue surrounding the teeth (gum tissue). from application/x-indesign to application/pdf Periodontal scaling and root planning is the removal of calculus, bacterial plaque, bacterial toxins, diseased cementum, and diseased tissue from the inner lining crevice surrounding the teeth. … The purpose of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by the immune system. 001.007 Root. Linotype AG The disease process has been explained to me and I understand that it is caused by bacterial toxins (poisons) and my host response to these toxins. 0 PERIODONTAL TREATMENT REFUSAL FORM. She no longer thinks that way. I, _____ have been informed by the treating dentist and hygienist that I have periodontal disease. application/pdf 2016-03-23T10:38:23-07:00 Open it up using the cloud-based editor and begin altering. I understand that I have periodontal (gum and bone) disease. Optima I have been informed that I have periodontal (gum) disease and/or deformities that could lead to the loss of certain of my teeth. This is usually indicated by deeper pocket depths than normal, bleeding gums, tartar accumulation below the gum line and x-ray evidence of bone loss. Foundations of Periodontics for the... • Pollack B. proof:pdf If left untreated, periodontal disease Periodontal scaling and root planing are procedures used to remove plaque in the treatment of gum disease. CentSchbook BT Periodontal Scaling and Root Planning . )5�xyP+�%Ґ*~x�l��Ҵd�@�f�4�b��s�@w|�m�b�5�uiZ�dP�KB�(�y�&&�S�m.x.#p3~|N�dNpF�h@QW�M#U� �Y�W�H��:��@f�4FIZ��P�