Consent for Extraction


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. Dry Socket - jaw pain beginning a few days after surgery, usually requiring additional care. It is more common from lower extractions, especially wisdom teeth.
  4. Possible damage to adjacent teeth especially those with large fillings or caps.
  5. 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 some cases the loss can be permanent.
  6. Possible infection requiring further treatment.
  7. Trismus - limited jaw opening due to inflammation or swelling, most common after wisdom teeth 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 bones 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.
  11. 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 further treatment.
  12. 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 extracted: ______________________________________________________

I have read and understand the above, and had my questions answered. I recognize there can be no warranty as to the outcome of the treatment, and I give my consent to surgery.


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Patient's Signature (or Legal Guardian) Date
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Doctor's Signature Date
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Witness' Signature Date