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Extraction Consent

Smile Pro Studio

1701 E. Woodfield RD # 510,
Schaumburg, IL 60173
(847) 850-0254

Patient Details( * mandatory to fill )
( * mandatory to fill )

An explanation of the proposed surgery, its purpose and benefits, the procedure used and the possible complications of its use, as well as alternative procedures and likely treatment outcomes, were discussed with you at your consultation.  We obtained your verbal consent to undergo this procedure. Please read this document, which restates the issues we discussed and provide the appropriate signature at the end of the document. Please ask for clarification of anything you do not understand.

Consent for Tooth Removal

After a thorough examination of my mouth, head and neck and a study of my dental and medical conditions, my doctor has advised me that I need a tooth extraction.  The reasons for this extraction have been explained to me in a way that I fully understand.

To the best of my knowledge, I have stopped my blood thinner medication or supplement as directed by my physician or dental office, OR I do not take any blood thinner medication or supplement.  Examples include Warfarin/Coumadin, Efficient, aspirin, Motrin, Plavix, Pradaxa, Sintrom, Ecotrin, fish oil, Co-Q10, or similar medications or supplements.

  •  Agree
  •  Disagree
  •  Not Sure

 

To the best of my knowledge, I have not used or taken any bisphosphonates (bone density medications) in the past 10 years OR I have discussed my recent usage with my dentist and physician to reduce the risk of osteonecrosis. Examples of bisphosphonates include Fosamax, Boniva, Reclast, Aredia, Actonel, Didronel, Zometa, Skelid and others.

  •  Agree
  •  Disagree
  •  Not Sure

 

Patients taking bisphosphonates may experience complications including, but not limited to, compromised wound healing, infection, osteonecrosis of the jaw, bone exposure, severe pain, etc.

  •  Agree
  •  Disagree
  •  Not Sure
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To the best of my knowledge, I have not had radiation treatment within the last 10 years OR I have discussed my recent usage with my dentist and physician.

  •  Agree
  •  Disagree
  •  Not Sure

 

I understand that a local anesthetic will be administered to me as part of the treatment. Additionally, I have the option of oral sedation and/or nitrous oxide.

I understand that unforeseen conditions may call for a modification or change from the anticipated surgical plan. These conditions may include, but are not limited to 1) surgical recontouring of gum and bone tissue around the tooth based upon new evidence that may allow the tooth to be saved, 2) the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, 3) placement of a bone replacement graft in deep bony defects to rebuild lost tooth structures, or 4) termination of the procedure prior to the completion of all of the surgery originally outlined.

After anesthetics are used to numb the area(s) to be treated, removal of the tooth will be performed.  Removal of the tooth may involve: surgically moving the gum tissues to gain better access to tooth structures, removal of small amounts of gum and/or bone tissue adjacent or attached to the tooth to be extracted, and/or sectioning of the tooth to facilitate removal.  After extraction, the tooth sockets (holes left in the jaw after tooth removal) will be inspected and cleaned so that they are as free as possible of soft tissue and debris. Soft tissue from the socket or around the tooth may be sent to be further inspected by an oral pathologist for microscopic analysis to determine if pathology is present.  Resorbable material may be placed in the extraction socket to aid in blood clotting at the extraction site. In addition, if recommended and accepted, bone grafting may be done. Sutures may be used to reposition gum tissues and other measures may be taken to decrease bleeding at the extraction site.

I understand that complications may result from my tooth extraction surgery, drugs, or anesthetics.  These complications include, but are not limited to: post-surgical infection, bleeding, swelling, and pain, facial discoloration, transient and/or permanent numbness of the jaw, lip, tongue, chin, or gum, jaw joint injuries or associated muscle spasm, transient and/or permanent increased tooth looseness, tooth sensitivity to heat, cold, sweet, or acidic foods, shrinkage of the gums upon healing resulting in elongation and/or larger spaces between some teeth, cracking and bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, changes in speech, allergic reactions, and accidental swallowing of foreign material.  The exact duration of any complications cannot be determined and they may be irreversible.  

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There is no method that will accurately predict or evaluate how my gum and bone tissues will heal.  I understand that there may be a need for additional therapies or procedures if the initial results are not satisfactory to maintain health.  In addition, the success of any periodontal procedure can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and/or grinding of teeth, inadequate oral hygiene, and medications that I may be taking. To my knowledge, I have reported to my doctor any prior drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any way relate to this surgical procedure. I understand that failure to do so may compromise surgical results.

I understand that alternatives to oral surgery include: 1) no treatment, 2) root canal therapy of the tooth/teeth in question with the knowledge that this may not fully eliminate the infection and the tooth may still be lost, 3) placement of a filling or crown (cap) on the tooth/teeth in question with the knowledge that the tooth may still be lost, 4) performance of periodontal surgery on the tooth/teeth in question with the knowledge that the tooth in question may still be lost.  I understand that failure to receive the care recommended by my doctor may result in a worsening of my dental condition, additional bone loss at the tooth/teeth in question and/or adjacent teeth, increased health risks due to the spread of infection, increased treatment time and expense, and destruction of underlying oral structures to yield fewer treatment options should I decide on surgical treatment at some point in the future.

I understand that it is important for me to continue to be seen for regular dental care.  In most cases, replacement of extracted teeth should be completed as soon as possible to minimize movement of adjacent teeth and to maintain as much dental function as possible.  I understand that the failure to follow such recommendations could lead to ill effects, which would be my sole responsibility.

I recognize that natural teeth and appliances should be maintained daily in a clean, hygienic manner.  I will need to comply with appointments following the surgery so that my healing may be monitored and so that my doctor can evaluate and document the outcome of surgery upon completion of surgical post-operative healing.  Smoking, alcohol intake, and/or poor nutrition may adversely affect the gum and bone healing and may limit the success of my surgery. I know that it is important 1) to abide by the specific prescriptions and instructions given to me by my doctor and 2) to see my doctor for periodic examination and preventative treatment.  Maintenance also may include adjustment of prosthetic appliances.

I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment would be successful.  Due to individual patient differences, the certainty of success cannot be predicted. There is a risk of failure, relapse, need for additional treatment, or even worsening of my present condition, including the loss of teeth, despite the best care.

I authorize photos, slides, x-ray films, or any other viewing of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes.

I have been fully informed of the nature of the dental extraction(s) to be performed, the specific procedure to be utilized, the risks and benefits of the surgery, the alternative treatments available, and the necessity for follow-up and self-care.  I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with my doctor. After thorough deliberation, I hereby consent to the performance of oral surgery as presented to me during consultation and in the treatment plan presentation as described in the document.  I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my doctor.

 

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.

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