MDC- Oral Surgery Consent – onlinedentalcheckin.com

Sheffali Sheth-Nadler, DMD Sergio Nadler, DMD

CONSENT FOR EXTRACTION OF TEETH

Please select checkbox for each paragraph after reading. If you have any questions, please ask your doctor BEFORE selecting checkbox.

You have the right to be informed about your diagnosis and planned surgery so that you can decide
whether to have a procedure or not after knowing the risks and benefits.

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Your Planned Treatment is: *

Alternative Treatment methods include: *

Taking teeth out is a permanent process. Whether the procedure is easy or difficult, it is still a surgical procedure. All surgeries have some risks. They include the following and others:

1. Swelling, bruising and pain

2. Stretching of the corners of the mouth that may lead to cracking or bruising

3. Possible infection that might need more treatment

4. Dry Socket- jaw pain that begins a few days after surgery, that may need more care

5. Possible damage to other teeth close to the ones being taken out, more often those with large fillings or caps

6. Numbness, pain or changed feelings in the teeth, gums, lip, chin and/or tongue (including possible loss of taste). This is due to the closeness of tooth roots (mainly with wisdom teeth) to the nerves which can be injured or damaged. Usually the numbness or pain goes away, but in some cases, it may need more treatment or may be permanent

7. Trismus – you can only open your mouth a little. This is most common after wisdom teeth are taken out. Sometimes it happens because of jaw joint (TMJ) problems already there. Damage can occur to the ligaments of the jaw joint (TMJ) from having your mouth open wide and/or for a period of time. This is more common if you already have symptoms or signs. This may need separate additional treatment

8. Bleeding- oozing can often happen for several hours, but a lot of bleeding is not common

9. Sharp ridges or bone splinters may form later at the edge of the hole where the tooth was taken out. These may need another surgery to smooth or remove

10. Sometimes tooth roots may be left in to avoid harming important things such as nerves or a sinus (a hollow piece above your upper back teeth)

11. The roots of the upper back teeth are often close to the sinus and sometimes a piece of root can get into the sinus. An opening may occur from the sinus into the mouth that may need more treatment

12. It is very rare that the jaw will break, but it is possible in cases where the teeth are buried very deep in their sockets

13. When donated, processed, or artificial bone substitutes are placed top preserve a socket the pieces might not join together with the natural bone and could be lost

Information for Female Patients

I have told my doctor that I use birth control pills. My doctor has told me that some antibiotics and other medications may reduce the preventive effect of birth control pills, and I could conceive and become pregnant. I agree to ask with my personal doctor to begin to use other forms of birth control during my treatment, and to continue those methods until my personal doctor says that I can stop them and use only oral birth control pills

Checkbox *

I have read all the risks listed above, understand them and I agree to proceed with the procedure

I understand that my doctor can’t promise that everything will be perfect. I understand that the treatment listed above and other forms of treatment or no treatment at all are choices I have and the risks of those choices have been presented to me. I have read and understand the above and give my consent to surgery and chosen anesthesia. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form *

Doctor's Signature *

Witness Signature *

Date / Time *