Consent for anesthesia and extraction of teeth

Please initial each paragraph after reading.  If you have any questions, please ask your doctor BEFORE initialing.

You have the right to be informed about your diagnosis and planned surgery so that you can decide whether to have a procedure or not after knowing the risks and benefits.

Your diagnosis is: _______________________________________________________
Your Planned Treatment is:                                                                                                             
Alternative treatment: methods include:                                                                                        

Taking teeth out is a permanent process.  Whether the procedure is easy or difficult, it is still a surgical procedure.  All surgeries have some risks.  They include the following and others:

          1.     Swelling, bruising and pain.

          2.     Stretching of the corners of the mouth that may lead to cracking or bruising.

          3.     Possible infection that might need more treatment.

          4.     Dry socket - jaw pain beginning a few days after surgery, usually needing additional care.

          5.     Possible damage to other teeth close to the ones being taken out, more often those with large fillings or caps.

          6.     Numbness, pain, or changed feelings in the teeth, gums, lip, chin and/or tongue (including possible loss of taste).  This is due to the closeness of tooth roots (mainly with wisdom teeth) to the nerves which can be injured or damaged.  Usually the numbness or pain goes away, but in some cases, it may be permanent.

          7.     Trismus – you can only open your mouth a little.  This is most common after wisdom teeth are taken out.  Sometimes it happens because of jaw joint problems (TMJ), mainly when TMJ disease is already there.

          8.     Bleeding – oozing can often happen for several hours, but a lot of bleeding is not common.

          9.     Sharp ridges or bone splinters may form later at the edge of the hole where the tooth was taken out.  These may need another surgery to smooth or remove.
          10.   Sometimes tooth roots may be left in to avoid harming important things such as nerves or a sinus (a hollow place above your upper back teeth).

          11.   The roots of the upper back teeth are often close to the sinus and sometimes a piece of root can get into the sinus.  An opening may occur from the sinus into the mouth that may need more treatment.

          12.   It is very rare that the jaw will break, but it is possible in cases where the teeth are buried very deep in their sockets.

ANESTHESIA:

LOCAL ANESTHESIA: (Novocaine, Lidocaine, etc.) A shot is given to block pain in the area to be worked on.

NITROUS OXIDE WITH LOCAL ANESTHESIA:  Nitrous Oxide (or Laughing Gas) helps to lessen uncomfortable sensations and offers some relaxation.

ORAL PREMEDICATION WITH LOCAL ANESTHESIA: A pill is taken for relaxation prior to giving local anesthesia.

INTRAVENOUS SEDATION WITH LOCAL ANESTHESIA: makes you less aware of the procedure by making you calmer, sleepy, and less able to remember the procedure.

INTRAVENOUS GENERAL ANESTHESIA WITH LOCAL ANESTHESIA:  You will be completely asleep for the procedure.

Whichever technique you choose, giving any medication involves certain risks.  These include:

1.   Nausea and vomiting.
2.   An allergic or unexpected reaction.  If an allergic reaction is severe, it might cause more serious breathing or heart problems which may need treatment.

In addition, there may be:

1.   Pain, swelling, or infection of the vein area where the anesthesia or sedation was given.
2.   Injury to nerves or blood vessels in the vein area.
3.   Confusion, or a long period of sleepiness after surgery
4.   Heart or breathing responses which may lead to heart attack, stroke, or death.

Fortunately, these complications and side effects are not common.  All forms of Anesthesia are generally very safe, comfortable, and easy to deal with.  If you have any questions, PLEASE ASK.

I have read and understand the above and give my consent for:

1. ¨   Local Anesthesia
2. ¨   Nitrous Oxide/Oxygen Analgesia with Local Anesthesia
3. ¨   Oral Premedication with Local Anesthesia
4. ¨   Intravenous Sedation with Local Anesthesia
5. ¨   General Anesthesia with Local Anesthesia

CONSENT

1. If I have IV Sedation or General Anesthesia, I confirm that I HAVE NOT HAD ANYTHING TO EAT OR DRINK (INCLUDING WATER) FOR SIX (6) HOURS PRIOR TO SURGERY.  I HAVE AN EMPTY STOMACH.  TO DO OTHERWISE MAY BE LIFE-THREATENING!  I agree not to drive myself home and to have a responsible adult stay with me until I am recovered from my medications.  I understand that during this time I should not drive, operate machinery or devices, or make important decisions such as signing documents, etc.

I understand that my doctor can’t promise that everything will be perfect.  I have read and understand the above and give my consent to surgery.  I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc.  I certify that I speak, read and write English.  All of my questions have been answered before signing this form.