Oral Surgery and Dental Extraction Consent Form

This field is for validation purposes and should be left unchanged.

Tooth/Teeth to be removed*

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

2. Inherent Risks. Oral surgery risks include but are not limited to:
a. Bleeding:
Bleeding usually subsides within a few minutes to a few hours. However, if it continues beyond that, it should receive immediate attention.

b. Bruising and/or swelling:
May occur and can last for a few weeks. This is especially true if impacted wisdom teeth are involved or if you bruise easily.

c. Nerve Injury:
This includes nerves in the lips, the tongue, the cheeks, 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. In extremely rare instances it could be permanent.

d. Dry Socket:
This occasionally 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. Please contact our office if you think this has happened.

e. Infection:
While proper sterilization and cleanliness are carefully adhered to, the human mouth and oral cavity are inherently non-sterile environments, so infection can occur. Occasionally infection can result in swelling, fever, malaise, etc. Attention should be received as soon as possible, especially if fever is present.

f. Sinus Involvement:
The roots of the upper teeth are very close to the sinus cavity in some patients. During extractions or other surgical procedures, the sinus can be perforated, and it may be necessary to surgically repair it.

g. Injury to adjacent teeth or fillings:
No matter how carefully surgical and extraction procedures are performed, adjacent teeth and fillings (especially very large fillings) can sustain injury.

h. 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. Other times, the decision may be made to refer the patient to a specialist for evaluation and/or treatment.

i. Bacterial Endocarditis:
Otherwise known as infection of the heart. Bacteria are present in the oral cavity. The tissues of the heart (for reasons known or unknown, i.e. rheumatic fever) may be susceptible to bacterial infection that is transmitted via the blood vessels. If any heart problems are known or suspected the patient should inform the doctor before any treatment has begun.

j. Reactions to medication:
Reaction to the medication, anesthetic, or analgesia may occur. Reaction may also occur in response to any other medications that were administered or prescribed.

I have been advised that the following medications listed below can lead to osteonecrosis of the jaw (breakdown of jaw bone) after dental surgical procedures when taking/undergoing bisphosphonates and chemotherapy.

Have you taken any of these medications?
Bisphosphonates:

Etdronate (Dodronel)*

Yes
No

Tiludronate (Skelid)*

Yes
No

Alendronate (Fosamax)*

Yes
No

Ridedronate (Actonel)*

Yes
No

Ibandronate (Boniva)*

Yes
No

Pamidronate (Aredia)*

Yes
No

Zoledronate (Zometa)*

Yes
No

Have you ever received chemotherapy treatment (Intravenous or oral medication)?*

Yes
No

Please explain:

Month/Year (start of therapy)

Month/Year (end of therapy)

Condition ex breast cancer

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 instructions.

The nature and purpose of the oral surgery and/or extraction has been explained to me, and I have had an opportunity to have my questions answered. I consent to the tooth/teeth numbers listed above are to be extracted. I understand that dentistry is not an exact science and success with oral surgery and/ or extractions cannot be guaranteed. I voluntarily assume the risks, including the risk of substantial harm which may be associated with any part of this treatment. In view of the above information, I authorize the doctor and/or such associates and assistants as necessary to render any treatment necessary and/or advisable to my dental condition including any and all anesthetics and/or medications.

Patient Name*

First Last

Patient Signature*

Date*

Doctor's Name*

Prefix First Last

Doctor's Signature*

Date_3*

Oral Surgery and Dental Extraction Consent Form

Oral Surgery and Dental Extraction Consent Form

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