Discussion and Refusal of Periodontal Charting

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Periodontal Refusal Form

At Blue Heron Dental Group we care deeply about your oral health and its connection to your overall wellbeing. We understand and respect your decision to not have a periodontal examination done today. We would like this opportunity to explain to you why it is recommended. Periodontal disease is a progression in disease status from gingivitis in which you begin to experience bone loss around teeth due to the accumulation of bacteria that is not properly removed on a regular basis. If periodontal disease progresses unchecked it can result in greater and greater recession and bone loss surrounding the teeth, and in the end can result in tooth loss.

Periodontal disease is a progression in disease status from gingivitis in which you begin to experience bone loss around teeth due to the accumulation of bacteria that is not properly removed on a regular basis. If periodontal disease progresses unchecked it can result in greater and greater recession and bone loss surrounding the teeth, and in the end can result in tooth loss. We cannot diagnose gingivitis or periodontal disease without completing a full periodontal exam. Much like one must take a blood pressure to determine their risk for a heart attack or stroke, we must take measurements surrounding the teeth at regular intervals to determine the status of periodontal disease.

Periodontal disease has been linked to overall systemic health. Evidence suggests that periodontal disease can be a risk factor in both cardiovascular and respiratory disease. Patients with periodontal disease have twice the risk of having a fatal heart attack than people without periodontal disease, have a 7 times greater risk for having a premature or low birthweight baby, and periodontal disease may also be an early indicator of Type II Diabetes. (Please refer to the Canadian Academy of Periodontology for further information & research.) Periodontal examinations provide a baseline for the long-term monitoring of periodontal disease, and they help us to measure and evaluate the success of periodontal treatment and the need for and frequency of maintenance visits. I have read the above information and my questions have been answered by my hygienist or dentist. After reading the information provided above, I continue to refuse to consent to a periodontal examination at this time.

I have read the above information and my questions have been answered by my hygienist or dentist. After reading the information provided above, I continue to refuse to consent to a periodontal examination at this time.

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Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

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Contact Us

102-1500 Bank street Ottawa, Ontario K1H 7Z2

613-706-4101

Info@blueherondentalgroup.ca

Clinic Hours

Mon: 7:30am - 3:30pm
Tue: 7:30am - 3:30pm
Wed: 7:30am - 3:30pm
Thu: 7:30am - 7:30pm
Fri: 7:30am - 3:00pm

Sat: Closed
Sun: Closed