Notification of Periodontal Disease

I have been advised on this date that I have:

• Gingivitis
• Slow Periodontitis
• Moderate Periodontitis
• Rapid Periodontitis

I have been informed that bleeding and periodontal pockets are indicators of this disease along with x-ray findings.

I have been informed that I have the following:

• Total bleeding points (sites of active infection)
• 1-3mm probing depth (normal)
• 4-5mm probing depth (indicates moderate periodontal disease)
• 6+ mm probing depth (indicates advanced periodontal disease)
• Areas of recession

I understand that periodontal disease is progressive in nature and that failure to treat the disease may result in loss of tooth eventually. I also understand the bacteria that causes periodontal disease can reach beyond the oral cavity and may be associated with other health issues such as heart disease, stroke and diabetes.

I understand my treatment recommendations and that it will not cure this disease but will attempt to control the disease process to avoid or minimize further destruction. I also understand that I must become very active in my homecare and dental clinical recommendations in order to arrest the disease process. The doctor and hygienist cannot control the disease by themselves.

I choose to accept the treatment recommendations to help in the control of the disease process.

I have been informed of my periodontal condition and choose not to accept the recommended treatment at this time.