Informed Consent for Dental Surgery and Dental Extractions

Complications from dental procedures very rarely occur, but it is important to understand the possibilities both with and without treatment.

Oral Surgery (which does include dental extractions) has a certain inherent risk. These risks include but are not limited to:

Bleeding. Usually bleeding subsides in a few minutes to a few hours. However, if it continues beyond that, it should receive immediate attention.
Bruising and/or swelling may occur and can last for a day or even a few weeks. This is especially true if you have a tendency to bruise easily.
Nerve injury. This includes nerves in the lips, the tongue, the cheeks and the floor of the mouth, etc. The numbness, which could occur, may be temporary, lasting just a few days, a few weeks, a few months. It could possibly be permanent.
Dry Socket. Occasionally this occurs after a tooth extraction and results from the blood clot not forming properly during the healing time. Dry socket refers to the blood clot being lost from the tooth socket. A dry socket can be painful, and if it occur, should be treated by a dentist as soon as possible.
Infection. While proper sterilization and cleanliness are carefully adhered to, the human mouth and oral cavity are inherently non-sterile environments. Infection can occur. Occasionally infection can result in swelling, fever, and malaise, etc. Attention should be received as soon as possible.
Sinus involvement. The roots of upper teeth are very close to the sinus cavity in some patients. During extraction or other surgical procedure, the sinus can be perforated, and it may be necessary to surgically repair it.
Injury to adjacent teeth or fillings. No matter how carefully surgical extraction procedures are performed, adjacent teeth and fillings (especially very large fillings) can sustain injury.
Fractured jaw, root fragments. While rare, it is possible that jaw, teeth roots or bone may be fractured. Sometimes a decision is made to leave a root fragment especially when removing it would necessitate further surgery and/or complications. There are times the decision may be made to refer the patient to a specialist for evaluation and/or treatment.
Bacterial endocarditis. Bacteria are present in the mouth. This is a normal condition. The tissues of the heart (for reasons known or unknown) may be susceptible to a bacterial infection that is transmitted via the blood vessels. Bacterial endocarditis (otherwise known as infection of the heart) is a very serious condition. If any heart problems are known or suspected, the patient agrees to inform the doctor before the treatment is begun.
Reactions to medication. Reactions to medication, anesthetic or analgesic may occur. Reaction may occur over a period of time which may result in how teeth fit, pain, jaw problems, interference with normal eruption of permanent teeth, wear of teeth and/or loss of teeth. In many cases, this can be prevented by timely placement of temporary or permanent prosthesis such as a bridge, flipper, partial denture, implants or space maintainer.

It is the patient’s responsibility to seek attention should any problem arise after the treatment. In addition, the patient’s responsibility is to diligently follow any and all pre-operative and post-operative instruction. The nature and purpose of the oral surgery and/or extraction has been explained to me, and I have had the opportunity to have my questions answered. I understand that dentistry is not an exact science and success with oral surgery or extractions cannot be guaranteed. I voluntarily assume the risks, including the risk of substation harm, which may be associated with any part of this treatment.

Condition(Required)

In view of the above information, I authorize the doctor and/or such associate’s and assistants as necessary to treat my condition which has been explained as:

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Is patent under 18?(Required)

No

Yes

Parent's Name (if patient is under 18)

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Relationship to Patient

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