Dental Extraction Information and Consent Form

While we expect no complications, there are some risks involved with this procedure. The more common complications are:

• Post operative pain, infection, swelling and bruising may occur. In some cases, a dry socket may develop.

• Adjacent teeth may be chipped or damaged during the extraction, including existing fillings or crowns, which may need to be replaced or repaired.

• Nerves that run near the area of extraction may be bruised or damaged. You may experience some temporary numbness and tingling of the lip and chin, or in rare cases, the tongue. In some extremely rare instances, the lack of sensation could be permanent.

• Teeth with curved roots may fracture at the root tips. We will inform you of this if it occurs and either attempt to remove the remnants or leave them be if there is a risk to other surrounding structures such as nerves or sinuses. If teeth fragments are left behind, healing will usually occur over these tooth fragments however, if the fragment becomes infected these may need to be removed later.

• The root tip may be pushed into the sinus or other space, in which case, you may need to be referred to an oral maxillofacial surgeon for further treatment.

• In the upper arch, sinus complications can occur because the roots of some upper teeth extend near or into the sinuses. After extraction, a hole may be present between the sinus and the mouth. If this happens, you will be informed, and the area may need to be repaired.

• The extracted tooth will leave a space which may need to be restored in the future. If the space is not treated, there is a risk of movement and drifting of the opposing and adjacent teeth.

I certify that I have read or had read to me the contents of this form. I have read or had read to me and will follow any patient instructions related to this procedure. I understand the potential risks, complications and side effects involved with any dental treatment or procedure and have decided to proceed with this procedure after considering the possibility of both known and unknown risks, complications, side effects and alternatives to the procedure. I declare that I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.