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Consent form for Extraction of Teeth
I, _______________________________________________, willingly give consent to have my tooth (teeth) #___________________________ extracted today at Alpine Dental Inc./Wollaston Dental Care Inc. under local anesthesia. Any possible alternative methods of treatment (if any exists such as root canal treatment, periodontics/gum surgery. crown, or filling) were explained to me today, and I will not hold Alpine Dental Inc./Wollaston Dental Care Inc. responsible for my willingness to have the above tooth (teeth) extracted. I fully understand that extraction of a tooth (teeth) is an irreversible process and other teeth within the dentition may shift and/or change the the bite. I also understand that replacement of missing tooth (teeth) by prosthetic procedures are recommended and are available upon request at variable costs. I have been informed that there are certain possible risks involved in any dental treatments such as: 1. Postoperative swelling, soreness, and discomfort around the treatment site may last for more than two weeks.
2. Stretching and pulling of cheek(s) muscles and lips may cause soreness or bruising on these tissues. 3. Bleeding on surgical site is expected, sometimes lasting for more than 24 hours. Meticulous adherence to postoperative instructions such as biting on gauze with pressure would assist to control bleeding and minimize discomfort. 4. Following extraction of a tooth, restorations on neighboring teeth, such as filling or crown may become cracked or otherwise damaged. Furthermore, neighboring teeth may also become chipped, shift, or loosen after extraction. 5. Due to prolonged opening of mouth under some operations, discomfort, soreness, or pain of temporomandibular joint (TMJ) may occur. 6. Injury to nerve within the jaw lying under the lower dentition may cause tingling, numbness, and loss of sensation of chin, lips, cheep, gums, teeth, and/or tongue. Sensation most often returns to normal, but in rare cases, the loss may be permanent.
7. Trismus - limited jaw opening due to inflammation or swelling, most common after wisdom tooth removal. Sometimes it is the result of jaw joint discomfort (TMJ), especially when TMJ disease and symptoms already exist.
8. During the removal of upper teeth, opening into sinus (a normal air space lying above teeth) or other sinus problems may occur which may necessitate soft tissue closure.
9. Small sharp bone fragments may work up through the gums during healing. These are not roots. If annoying, return to this office for their simple removal. These may require another surgery to smooth or remove them. 10. Incomplete removal of tooth fragments - to avoid injury to vital structures such as nerves or sinuses, sometimes small root tips may be left in place. Sinus involvement: The roots of upper back teeth are often close to the sinus and sometimes a piece of root can be displaced into the sinus, or an opening may occur into the mouth which may require additional care.
11. Jaw fracture - while quite rare, it is possible in difficult or deeply impacted teeth.
12. A certain amount of pain and discomfort is expected with any dental surgery and should be controlled with medications. Over the counter medications such as acetaminophen or ibuprofen may be sufficient for postoperative management of simple extractions.
13. With any dental treatment there is always a possibility of postoperative infection. Use of antibiotics and/or additional surgery may be required.
14. The doctors do not want to see anyone in any unnecessary pain. If one does not get numbed sufficiently to undergo dental surgery comfortably, the doctor reserves the right to stop the surgery and refer the patient out to an oral surgeon. Both prescribed and non-prescribed medications and anesthesia may cause drowsiness, lack of awareness and coordination, which may be escalated with the concomitant intake of alcohol or other hazardous equipment until fully recovered from the medication. I have read and understand the above, and had my questions answered. I recognize that there can be no warranty as to the outcome of treatment, and I give my consent to surgery. Signature:__________________________________________________________________________ Date:______________________________________ Witness:____________________________________________________________________________ Date:______________________________________

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