Patient's Name:

E-mail Address

1. Extraction of teeth is an irreversible process and whether routine or difficult is a surgical procedure. As in any surgery, there are some risks. They include, but are not limited to:
2. Swelling and/or bruising and discomfort in the surgery area. Stretching of the corners of the mouth resulting in cracking and bruising.
   
3. Possible infection requiring further treatment. Dry socket-jaw pain beginning a few days after surgery; usually requiring additional care, it is more common with lower extractions, especially wisdom teeth.
   
4. Possible damage to adjacent teeth, especially those with large fillings or caps.
   
5. Numbness or altered sensation in the teeth, lip, tongue, and chin, due to the closeness of the tooth roots (especially wisdom teeth) to the nerves which can be bruised or injured. Sensation most often returns to normal, but in rare cases, the loss may be permanent.
   
6. 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.
   
7. Bleeding - significant bleeding is not common, but persistent oozing can be expected for several hours.
   
8. Sharp ridges or bone splinters may form later at the edge of the socket. These may require another surgery to smooth or remove them.
   
9. 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.
   
10. Sinus involvement - the roots of the 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. Bisphosphonate Drug Risks: Drugs such as Fosamax, Actonel, Bonita, or any other drug prescribed to decrease resorption of bone as in osteoporosis or for treatment of metastatic bone cancer, there is an increased risk of osteonecrosis or failure of bone to heal properly following any oral surgical procedure, including extractions.
    
13. Discomfort, swelling, numbness, and irritation of the vein (thrombophlebitis) that may result from intravenous and/or intramuscular injections.
    

I understand I will routinely be given local anesthesia (unless allergic) but may also choose supplements such as nitrous oxide, oral premedication, intramuscular, and/or intravenous anesthesia (conscious sedation that may be deepened according to a patient’s needs). My decision is based on my discussion with and the judgment of the dentist involved in my case.

Medication, drugs, anesthetic, and prescriptions cause drowsiness and lack of awareness/coordination, which is increased with alcohol and/or other drugs. I have, therefore, been advised not to drink or take drugs other than my prescription medications, not to operate any vehicle or hazardous device, and not to work or make important decisions while taking any medications and/or until fully recovered from anesthetic medication given to me for oral surgery. I agree to have a responsible adult drive me home after surgery and stay with me until fully recovered from anesthetic effects.

Most procedures are routine and serious complications are not expected. Those that do occur are most often minor and can be treated.

Proposed Treatment: