Tooth Extraction Consent Form

RISKS: There are some risks / complications, which include:

(a) Patients should assume that there will always be a possibility of pain and/or discomfort and/or swelling, and/or bruising. The duration can be for up to 2 weeks, or sometimes longer.
(b) Infection of the extraction socket (dry socket). This may cause some pain and discomfort, but is usually easily managed by the oral surgeon/dentist.
(c) Biting of the numb lip which may cause damage after the teeth have been removed. Children should be watched closely by a parent/guardian until the numbness wears off.
(d) In the case of lower teeth: Damage to the Inferior Dental Nerve on each side of the Mandible (lower jaw). This nerve passes very close to the root of the lower tooth (often in contact with it) and gives feeling to the lower teeth, lower lip and chin on that side. This nerve is very close to the area of surgery, with a slight risk of some damage to the nerve. This may cause numbness of the lower teeth, lower lip and chin. This may be temporary (6–12 months) or permanent.
(e) In the case of lower teeth: Damage to the Lingual Nerve on each side of the Mandible (lower jaw). This nerve passes very close to the tongue side of the lower wisdom tooth and posterior mandibular teeth and gives feeling and taste to that side of the tongue. When this nerve is very close to the area of surgery, there is a slight risk of some damage to the nerve. This may cause numbness and loss of taste to that side of the tongue. This may be temporary (6–12 months) or permanent.
(f) The tooth root tip may break off in small pieces when the tooth is taken out. The oral surgeon/ dentist may not remove those pieces if there is a chance that the nerves or other structures may be damaged during removal. When roots are left behind we will either keep them under observation and/or refer them to a specialist.
(g) Damage to teeth growing tightly against the wisdom teeth during removal of the wisdom teeth.
(h) Weakness of the jaw due to removal of the teeth. The jaw may break during the procedure or the healing period.
(i) If the upper teeth are close to the sinuses, removal may cause a hole between the mouth and the sinus.

PATIENT CONSENT: by my signature below, I expressly acknowledge that:

The dentist has explained the likely outcomes and possible complications of extraction and each alternative option. The dentist has made leaflets and other relevant information available to me to help with my decision making. The dentist has given me an opportunity to ask questions about any matters related to my treatment, raise any other concerns and given me the opportunity to postpone the treatment or seek a second opinion. The dentist has also explained to me the options and complications related to restoring the gaps created by the extraction of teeth and the complications related each. The dentist has also explained to me the options and complications related to leaving the gaps created by the extraction of teeth unrestored and the complications related to this option. The dentist has discussed the option of a dental implant and the importance of preserving the socket bone, and of not delaying implant treatment after an extraction.

The Dentist has explained to me that the procedure can be stopped at any time. The patient only needs to say stop, put up a hand, shout or make another signal etc. We say again, the patient can decide to stop the procedure at any time and for whatever reason they wish. We will always respect the patient's decision. The dentist has explained the importance of following the post extraction leaflet instructions including returning for a review appointment after the extraction, when the socket can be checked and future treatment option discussed.

The dentist has explained the options for referral to a specialist Oral Surgeon for treatment or simply for a second opinion. The dentist has explained the options for waiting before I make my decision. You have given us an up to date account of your medical and dental history, especially about and recent changes. You understand that no guarantee has been made that the procedure will improve the condition, and may even make your condition worse.

I confirm that I am not taking, nor have ever taken any medication that includes Bisphosphates. This is very important as this particular medicine can cause complications after extractions that can involve hospital admissions

On the basis of the above statements, I REQUEST TO HAVE THE PROCEDURE LISTED HEREIN (Extraction) I realise that signing this does not oblige me to have all or any part of the treatment proposed, but is simply an acknowledgement of the fact that I am giving my informed consent if I decide to go ahead. .



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