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.