Clinic name
Dentist name, qualifications
Consent for tooth extraction
The treatment
Removal of the tooth or teeth named above under local anaesthesia. The dentist may need to cut the gum, remove bone around the tooth or divide the tooth into pieces to take it out.
Possible risks and complications
- Pain, swelling and bruising for a few days after the extraction.
- Dry socket: jaw pain starting a few days after the extraction that needs further care. It is more common after lower extractions, especially wisdom teeth.
- Bleeding, and infection that may need further treatment.
- Damage to nearby teeth, fillings or crowns.
- Numbness, pain or altered feeling in the lip, chin, tongue or gums, sometimes with a change in taste. It usually recovers; in rare cases it may be permanent.
- For upper back teeth: the roots lie close to the sinus. A fragment of root may move into the sinus, or an opening into the sinus may form, which may need further treatment.
- A small fragment of root may be left in place when removing it would risk more harm than leaving it.
- Stiffness of the jaw and difficulty opening the mouth, and cracking at the corners of the mouth.
- Fracture of the jaw, which is rare.
Other options
- Saving the tooth with a filling, root canal treatment or gum treatment, where the tooth can be saved.
- Leaving the tooth for now and reviewing it.
If no treatment is done: Pain and infection may continue or spread, and the tooth may need to be removed later in a more difficult state.
Consent
The dentist has explained the treatment, its risks and the other options to me in a language I understand, and I have been able to ask questions. I understand that no result can be guaranteed. I agree to this treatment, and to any further treatment the dentist finds necessary during the procedure for my safety.