, Consent for Extraction

Medway Smile – Consent Form

    Consent for Extraction

    Extraction is a dental procedure during which a tooth is removed normally because it has a major problem and has not got a good long term prognosis. The intended benefits of the procedure include removal of pain and/or infection or aiming to make the mouth less prone to future problems.

    As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

    Expected complications
    • Numbness lasting a few hours.
    • Soreness, bruising and localised swelling lasting up to a week.

    Common risks and complications
    • Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue etc.
    • Prolonged post-operative pain due to poor healing or infection.
    • Fracture of the tooth during the procedure which can lead to a minor surgical procedure being required or a piece of the tooth being left because it cannot be removed.

    Rare risks and complications
    • Trauma to tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
    • A communication (hole) between the mouth and sinus.
    • Displacement of part of the tooth into the sinus.
    • Allergic reaction to something used during the procedure.

    Alternative options
    • 1. Referral to a specialist in this field who may be able treat the tooth better via the use of specialist equipment etc.
    • 2. It may be possible to save the tooth with different treatment such as a root canal treatment etc.
    • 3. Refusing treatment but this will result in a high risk of further pain and infection from this tooth.

    By signing below I acknowledge that this procedure has been explained to me and I have had time to ask questions, consider my options and am happy to proceed. I am also aware that I have the right to seek a second opinion from another dentist at any time.


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