Extraction Consent Form

The procedure

I authorize the dentist named above and the staff of Next Generation Dental to remove the tooth or teeth listed above, to give local anesthetic, and to provide any other treatment that becomes necessary during the procedure.

The dentist has explained why the extraction is recommended. Reasons can include decay, infection, gum disease, a fracture, crowding or orthodontic treatment.

Risks and possible complications

An extraction is a surgical procedure. Complications are uncommon, but I understand they can include:

• Pain, swelling, bruising and jaw stiffness for several days.
• Bleeding that continues for some hours and occasionally needs further treatment.
• Infection, which may need antibiotics or further treatment.
• Dry socket: delayed healing of the socket, with pain a few days after the extraction, which needs another visit.
• Numbness, tingling or altered feeling in the lip, chin, tongue, cheek or gums if a nearby nerve is bruised. This is usually temporary but can, rarely, be permanent.
• For upper back teeth, an opening between the mouth and the sinus, which may need further treatment.
• Damage to neighboring teeth, fillings or crowns.
• A root tip breaking during removal. The dentist may leave a small fragment in place if removing it would do more harm than leaving it.
• Cracking or stretching at the corners of the mouth, and soreness of the jaw joint.
• In rare cases, a fracture of the jaw.
• A reaction to the anesthetic or to medication prescribed after treatment.

Patients who take, or have taken, medicines that affect the bone, such as bisphosphonates or denosumab for osteoporosis or cancer, have a higher risk of poor healing of the jawbone. I have told the dentist about every medication I take, including blood thinners.

Alternatives

The dentist has explained the alternatives that apply to me, which may include root canal treatment, a filling or crown, gum treatment, referral to a specialist, or no treatment. I understand that leaving a problem tooth untreated can lead to pain and to infection that may spread.

I understand that a gap left by a missing tooth can let neighboring teeth shift, and that it can be replaced with a dental implant, a bridge or a partial denture.

Anesthesia and sedation

Local anesthetic numbs the area for a few hours. If I receive sedation, I will not drive, operate machinery or make important decisions for the rest of the day, and a responsible adult will take me home.

After the extraction

I agree to follow the aftercare instructions I am given, to take medication only as directed, and to call the office if I have heavy bleeding, increasing pain or swelling, a fever, or any other concern.

Consent

• I have read this form, or had it read to me, and I understand it.
• I have had the chance to ask questions, and my questions have been answered.
• I understand that no guarantee has been made about the result of treatment.
• I consent to the extraction of the tooth or teeth listed above.