Consent for Tooth Removal

DESCRIPTION OF THE PROCEDURE: After anesthetics have numbed the area to be operated, extraction will be accomplished by either the removal of the tooth/teeth or by surgical reflection of gum, possible removal of some bone around the tooth/teeth, and possible sectioning of tooth roots to facilitate removal of the tooth/teeth. After the extraction, tooth socket(s) (hole in jawbone left by tooth removal) will be inspected, possibly cleansed of debris or infected soft tissue, and when indicated, this soft tissue may be submitted for histological examination to determine if pathology was present. Finally, the gum and socket or gum tissue may be sutured, and measures will be taken to reduce bleeding from the extracted area(s) after this procedure.

RISKS RELATED TO THE SUGGESTED TREATMENT: Risks related to tooth removal surgery might include, but are not limited to, post-surgical infection, bleeding, swelling, pain, infection, facial discoloration, transient but on occasion permanent numbness of the lip, teeth, chin, or gum, jaw joint injuries or associated muscle spasms, fracture of the tooth/teeth during surgery, retention of part of a root or roots, dislodging of a tooth or part of a tooth into the upper jaw sinus, swallowing of a tooth or fragments of a tooth, sensitivity to hot or cold or sweets or acidic foods, or shrinkage of the gum upon healing. Risks related to the anesthetics might include, but are not limited to, allergic reactions, accidental swallowing/aspiration of foreign matter, facial swelling or bruising, pain, soreness, or discoloration at the site of injection of the anesthetics.

ALTERNATIVES TO THE SUGGESTED TREATMENT MAY INCLUDE:

1. No treatment, with the expectation of the advancement of my condition resulting in greater risk or complications including, but not limited to, bone loss, pain, infection, and possible damage to the support of adjacent teeth.

2. Root canal treatment, with the expectation that this may not eliminate infection in the area, or that I may still lose the tooth soon.

3. Restoration (filling or cap) of this tooth/ these teeth with the expectation that it/they may be lost soon.

NO WARRANTY OR GUARANTEE: I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed surgery will be completely successful in eradicating all pre-existing symptoms or complaints. It is anticipated that the surgery will provide benefit in reducing the cause of this condition and produce healing which will enhance the possibility of longer retention of my teeth by reducing the problems associated with this tooth/ these teeth. However, due to individual patient differences, one cannot predict the absolute certainty of success. Therefore, there exists the risk of failure, relapse, selective retreatment, or worsening of my present condition including the possible loss of certain teeth with advanced involvement, despite the best of care.

CONSENT TO UNFORSEEN CONDITIONS: During surgery, unforeseen conditions could be discovered which would call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, extraction of hopeless teeth to enhance healing of adjacent teeth, the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, or termination of the procedure prior to completion of all of the surgery originally scheduled. I therefore consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of the treating doctor.