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CONSENT FOR EXTRACTION OF TEETH/ORAL SURGERY
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:
1. Swelling and/or bruising and discomfort in the surgery area.
2. Stretching of the corners of the mouth resulting in cracking and bruising.
3. Possible infection requiring further treatment.
4. Dry socket – jaw pain beginning a few days after surgery, usually requiring additional care. It is more common from lower extractions, especially wisdom teeth.
5. Possible damage to adjacent teeth, especially those with large fillings.
6. Numbness or altered sensation in the teeth, lip tongue and chin, due to the closeness of 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.
7. 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.
8. Bleeding – significant bleeding is not common, but persistent oozing can be expected for several hours.
9. Sharp ridges or bone splinters may form later at the edge of the socket. These may require another surgery to smooth or remove them.
10. 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. Sinus involvement: the roots of 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.
Most procedures are routine and serious complications are not expected. Those which do occur are most often minor and can be treated.
Teeth to be removed: ______
I understand the doctor may discover other or different conditions that may require additional or different procedures from those planned. I authorize such other procedures as are deemed necessary in my doctor’s professional judgment to complete my surgery.
I have read and understand the above, and have had my questions answered. I recognize there can be no warranty as to the outcome of treatment, and I give my consent to surgery.
Patient’s (or Legal Guardian’s) Signature Date
Doctor’s Signature Date
Witness’ Signature Date
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PATIENT INFORMATION AND CONSENT FOR ROOT CANAL TREATMENT
(ENDODONTICS)
Patient’s Name: ______Date: ______
Planned treatment: ______
What is root canal treatment and what are its benefits?
Root canal treatment is the procedure of cleaning disease or infected tissue from inside the tooth, followed by placement of a seal in the root canal. Using a local anesthetic, there is little or no discomfort during the procedure. Root canal therapy allows the tooth to remain in the mouth and contributes to sound, healthy and functional dentition for many years, if not a lifetime. The practice of endodontics also includes such procedures as bleaching, inducing closure of immature diseased roots, treatment of traumatic injures and the fabrication of posts and buildups under crowns.
What are the complications of treatment?
With a success rate of approximately 95%, endodontic therapy is one of the most reliable dental or medical procedures, and complications are not expected. However, there can be no absolute guarantee regarding treatment success. Some very infrequent complications include, but are not limited to: the possibility of perforations of the tooth or root, damage to existing restorations (fillings), the possibility of a split or fractured tooth, the possibility of separation of a portion of the instrument that cannot be removed from within the tooth, and the possibility of pain, swelling and infection. The use of prescription drugs during treatment may also result in unexpected drug reactions. Any of these complications could result in failure of the procedure requiring possible re-treatment or extraction of the tooth.
What alternatives are there?
Removal of the tooth is the alternative. If the tooth is removed and not replaced, the empty space will create problems in tooth alignment because of shifting of adjacent teeth. This may result in periodontal (gum) disease and you could lose more teeth as a consequence. The missing tooth may be replaced by a bridge or partial denture, but the cost for this is more expensive than root canal treatment and involves dental work on adjacent teeth. The option of no treatment often results in persistent or recurrent pain and infection in the affected tooth. If any doubt exists in your mind about treatment, we encourage you to seek a second opinion.
What are your responsibilities?
It is important to complete an accurate medical history. Please understand that after root canal treatment, it is wise to have the tooth properly restored within a reasonably short time. Depending on your situation, certain other post-treatment precautions or special instructions must be followed (such instructions will be given to you separately by the doctor or team).
I have read the above form and have been given the opportunity to ask questions. I authorize my doctor to perform the diagnostic procedures and root canal treatment outlined above.
Patient’s (or Legal Guardian’s) Signature Date
Doctor’s Signature Date
Witness’ Signature Date
dr smile, DMD
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Consent for Insertion of Dental Implants
Patient’s Name: ______Date: ______
Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initializing.
You have the right to be informed about your condition and the recommended treatment so that you may make an informed decision whether to undergo the procedure after you know the risks and complications possible. This disclosure is not meant to alarm you; but is an effort to properly inform you so that you may give or withhold your consent.
____ 1. I hereby authorize Dr. Schumacher and team to treat the condition described as: ______
______
____ 2. The procedure recommended to treat the condition has been explained to me and I understand
the nature of the procedure to be: ______
______
____ 3. I have been informed of possible alternative methods of treatment (if any) including: ______
______
____ 4. I understand incisions will be made inside of my mouth for the purpose of placing a metal implant
in my jaw to serve as an anchor to stabilize teeth and/or a denture.
____ 5. No assurances have been given that this implant will last for a specific time or that a perfect
result can be guaranteed. It has been explained that once the implant is inserted, the entire
treatment plan must be followed and completed on schedule. If not, the implant may fail.
____ 6. My doctor has explained to me that there are certain inherent and potential risks and side
effects in any surgical procedure and in this treatment such risks include (but are not limited to):
____ A. Post-operative discomfort and swelling that may require several days of
at home recuperation, as well as chewing and diet restrictions.
____ B. Prolonged or heavy bleeding, formation of a hematoma (blood clot) at the
surgery site or in the floor of the mouth, and possible bruising of the chin and
lips, any of which may require additional treatment.
____ C. Post-operative infection that may require additional treatment.
____ D. Stretching of the corners of the mouth that may cause cracking and bruising,
and may heal slowly.
____ E. Restricted mouth opening for several days or longer, sometimes related to
swelling and muscle soreness and sometimes related to stress on the jawjoints
(TMJ). Pre-existing TMJ symptoms may be worsened.
____ F. Fracture of the jaw, especially when an implant is placed in a very thin jaw.
____ G. Injury to nerve branches serving the lower lip and gums which may result in
numbness, pain or tingling of the chin, lip, gums, tongue, or floor of the mouth
which may persist for several weeks or months and may, in rare instances, be
permanent.
____ 7. I have been told that this treatment may not prove successful, that problems may arise during
the surgery that will prevent the placement of the implant and that rejection of the implant is
possible which will necessitate its removal. Should the implant require removal, I understand that
it may be possible to insert another implant following a suitable period of bone healing.
____ 8. I understand that my doctor is not a seller of the implant device itself and makes no warranty
or guarantee regarding success or failure of the implant or its attachments used in the
procedure.
____ 9. It has been explained to me that during the course of the surgery, unforeseen conditions may
be revealed which will necessitate extension of the original procedure or a different procedure
from those above. I authorize my doctor to perform such other procedure(s) as are necessary
and desirable in the exercise of professional judgment.
____ 10. I understand smoking is extremely detrimental to the success of implant surgery. I agree to
cease all use of tobacco for 2-3 weeks prior to and after surgery, including the later uncovering
procedure, and to make strong efforts to give up smoking entirely.
____ 11. ANESTHESIA
The anesthetic I have chose for my surgery is:
q Local anesthesia
q Local anesthesia with nitrous oxide/oxygen analgesia
q Local anesthesia with oral premedication
____ 12. ANESTHESIA RISKS include: discomfort, swelling, bruising, infection, prolonged numbness,
and allergic reactions. There may be inflammation at the site of an intravenous injection (phlebitis) which may cause prolonged discomfort and/or disability and may require special care.
____ 13. YOUR OBLIGATIONS IF ORAL PREMEDICATION IS USED
A. Because anesthetic medications cause prolonged drowsiness, you MUST be accompanied
by a responsible adult to drive you home and stay with you until you are sufficiently
recovered to care for yourself. This may be up to 24 hours.
B. During recovery time (24 hrs) you should not drive, operate complicated machinery or
devices, or make important decisions such as signing documents, etc.
C. It is important that you take any regular medications or any medications provide by this
office, using only a small sip of water. YOU SHOULD NOT HAVE ANYTHING TO EAT
OR DRINK FOR EIGHT (8) HOURS PRIOR TO YOUR ANESTHETIC.
____ 14. No guaranteed or warranted results have been offered or promised. I realize my doctor may
discover conditions, which may require different surgery from that which was planned, and I
give my permission and authorization for those other procedures that are advisable in the
exercise of professional judgement to complete my surgery.
CONSENT
I have had the opportunity to have all my questions answered by my doctor and I certify that I speak
read and write English. My signature below signifies that I understand the surgery and anesthetic that
is proposed for me, together with the known risks and complications associated. I hereby give my
consent for such surgery and the anesthesia I have chosen.
______
Patient’s or Legal Guardian’s Signature Date
______
Doctor’s Signature Date
______
Witness’ Signature Date
Dr’s Name
CONSENT FOR PERIODONTAL SURGERY WITH BONE GRAFTING
Diagnosis: You have been diagnosed with a condition known as Periodontitis (Periodontal Disease). This is a bacterial infection of the gums, which compromises the bone surrounding the teeth leading to premature bone loss.
Recommended Treatment: The Periodontist has recommended treatment to include bone regenerative periodontal (gum) surgery. Local anesthetic will be administered to you as part of the treatment. Antibiotics and other substances may be applied to the roots of the teeth. During the procedure, the gum will be opened to permit better access to the roots and the eroded bone. Bacterial plaque, inflamed and infected tissue will be removed, and the root surfaces will be thoroughly cleaned. Bone irregularities will be reshaped. Bone graft material will be placed in areas of bone loss around the teeth. Various types of graft materials may be used. These materials may include your own bone, synthetic bone substitutes or human bone material from tissue banks (allografts). Membranes may be used with our without graft material, depending on the type of bone defect present. The gum will be sutured back into position and a periodontal dressing may be placed. There exists the possibility of a modification or change from the anticipated surgical plan. This may include, but is not limited to, (1) extraction of hopeless teeth to enhance healing of adjacent teeth, (2) the removal of a hopeless root of a multirooted tooth so as to preserve the tooth, or (3) termination of the procedure prior to completion of all originally outlined surgery.
Expected Benefits: The goal of this treatment is to eliminate the periodontal pockets, stop the progression of the periodontal disease and restore the gum tissue health of the surrounding bone to the greatest extent possible. The use of bone, bone grafting material or membranes is intended to enhance bone and gum healing. The surgery is intended to help keep the teeth in the treated areas and to make oral hygiene more effective. This procedure is effective in the treatment of moderate to severe Periodontitis, but may not be a definitive treatment, especially in deep pocketing sites or around teeth with a questionable or poor prognosis. The long-term success of this treatment largely depends upon your practice of good oral hygiene techniques at home, in conjunction with supportive periodontal maintenance every three (3) months by a dental professional. This will require a commitment on your part to a 3-month preventive periodontal maintenance program with your periodontist/dentist for the rest of your life. The Periodontist and/or Hygienist will periodically reexamine the periodontal pocket site(s) at future appointments to monitor the activity of this disease and help you prevent further breakdown.
As in any oral surgery procedure, there are some risks of post-operative complications.