This is what I brought in to my dentist and it is tailored for my needs/level of sensitivity. You will need to modify it, but it’s a good place to start. 

Dental Cleaning Instructions for ________________

Products Okay To Use:

• powder-free nitrile gloves

• white cosmetic (kaolin) clay (provided by patient)

• cup for rinsing provided by patient

• Desert Essence Tea Tree Dental Tape

Avoid:

• No paper/disposable cups.

• No q-tips

• No mouth rinses/mouth wash.

• When I rinse, I need to use my own water from home. 

• Topical anesthetics, disinfectants, or any other products in the mouth or on lips that were not discussed ahead of time.

X rays: I react to the plastic sheath you use for the digital receiver. I need to use my own sandwich bags for this.

Safety

-My first point of reaction is always my mouth:  tongue swelling, difficulty swallowing, sometimes lip swelling. In extreme cases I will have an asthma attack.  I may need your help to watch out for swelling if we’ve missed anything about the ingredients or products used.

– If there is a swelling reaction, I have a benadryl pill that I can take.

– If my airway  begins close off, I will need to use my epi-pen and then go to the emergency room.

• Dental Health
• Health