ALTERNATIVE TREATMENT OPTIONS

• Retaining tooth/teeth as is.
• Retaining tooth/teeth with the use of fillings, crowns, bridges and if necessary, root canal therapy.
• Retaining tooth/teeth with the use of gum surgery.

SURGICAL PROCEDURES MAY INVOLVE SOME OR ALL OF THE FOLLOWING

• Use of local anesthetic, oral or intravenous sedation, antibiotics, analgesics and sutures (stitches).
• Use of a bone graft to preserve bone on neighboring teeth or to provide sufficient bone volume for a future implant. The bone may be my own bone, human donor bone or cow bone. A membrane may also be utilized, which may require an additional procedure to remove the membrane.

RISKS AND COMPLICATIONS OF EXTRACTION AND BONE GRAFT (IF APPLICABLE)

• Allergic reactions to dental materials/medications
• Bleeding, swelling, infection
• Pain and/or tooth sensitivity
• Bruising
• Perforation of upper jaw sinus or nasal cavity
• Bone fracture
• Scarring
• Damage to other teeth/roots which may need repair or removal
• Damage to dental appliances
• Cracking/stretching corners of mouth
• Cuts inside mouth or on lips
• Slow healing
• Temporary restriction of mouth opening
• Stress or damage to jaw joints (TMJ)
• Increased mobility of neighboring teeth
• Possible altered or loss of sensation due to dental nerve damage including loss of taste
• Dry socket
• Bony ridges or splinters that may require further treatment
• Part of tooth and/or roots may be left to prevent damage to nerves or other structures
• Nerve injury in the place the graft was taken from or where it is placed if applicable
• Rare chance of disease spread from processed bone
• Failure/infection of the bone graft

RISKS AND COMPLICATIONS OF LOCAL ANESTHETIC USE

I understand that the risks and complications associated with local anesthetic include, but are not limited to: nerve injury, altered or loss of sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve, but in some cases may be permanent.

NO WARRANTY OR GUARANTEE

I understand that the doctor cannot guarantee the results of the procedure.

CONSENT TO UNFORESEEN CONDITIONS

During treatment, unknown conditions may modify or change the original treatment plan. I authorize the treating dentist to perform additional or alternative procedures if, in their professional judgment, it is in my best interest.

COMPLIANCE WITH SELF-CARE INSTRUCTIONS

I have provided an accurate and complete medical history, including all past and present dental and medical conditions, prescription and non-prescription medications, allergies, recreational drug use, and pregnancy (if applicable).

I understand that excessive smoking and/or alcohol intake may affect healing and may limit the successful outcome of my surgery.

I agree to follow all instructions provided before and after the procedure, take medication(s) as prescribed, practice good oral hygiene, keep all appointments, make return appointments if complications arise and complete care.

SUPPLEMENTAL RECORDS AND THEIR USE

I consent to photography, filming, recording, and x-rays of my oral structures related to these procedures for educational use in lectures or publications, provided my identity is not revealed.

PATIENT ENDORSEMENT

My endorsement (signature) to this form indicates that I have read and fully understood the terms and explanations contained in this document and consent to the performance of any and all procedures related to extraction and bone grafting.