Dental Tooth Extraction Consent Form

I understand that there are certain risks associated with dental tooth extraction, including but not limited to:

1- Pain or discomfort

2- Bleeding 

3- Swelling

4- Infection: An infection after a tooth extraction can be a serious complication

5- Nerve damage resulting in temporary or permanent numbness or tingling

6- Damage to adjacent teeth, artificial crown/bridge, or fillings

7- Dry socket: Severe pain at the extraction site, often radiating to the ear, eye, temple, or neck, with Bad breath or a foul taste in the mouth

8- Sinus involvement (for upper teeth)

A-Sinus Perforation: During extraction, the sinus membrane can be punctured or torn, leading to a perforation, which can cause discomfort and complications such as sinus infections.

B-Sinus Infection: If the extraction site communicates with the sinus cavity, bacteria can enter and cause an infection

9- Jaw fractures (rare)

10- Restricted mouth opening after a tooth extraction, also known as trismus, can be quite uncomfortable.

I understand that at any stage of the treatment, the treatment’s provider may consider it appropriate to refer the patient to a surgeon for a reevaluation or further treatment

I understand that surgical flaps may be used during the extraction procedure to improve access to the site and facilitate a smoother extraction process.

I consent to the use of topical and local anesthesia (injection) during the procedure.

I have read and understood the information provided above. I have discussed any questions or concerns with my dentist and have received satisfactory answers. I acknowledge that no guarantees have been made regarding the outcome of the procedure.

At any stage of treatment, the provider may refer the patient to an endodontist for further evaluation or treatment.