Extraction Consent Form

Date:*
Patient name:*
Parent /legal guardian name:*
Extractions of primary or permanent teeth may be necessary due to extensive caries (decay), infection or orthodontic treatment recommendations. Extractions will be performed using a topical anesthetic (20% benzocaine) and an injectable local anesthetic (2% lidocaine with 1:100,000 epinephrine which contains sulfites) to minimize pain, but the patient will still feel pressure. The pressure sensation is often uncomfortable to some children. Nitrous oxide (see additional consent) is typically used to help with patient comfort during an extraction procedure.

Local anesthetics result in loss of sensation for oral tissues and teeth (typically for 45 minutes up to 3 hours) depending on the type of injection used. I understand that I must watch my child carefully for the full duration of the local anesthetic to ensure they do not bite, pinch, scratch, or otherwise injure themselves where they are anesthetized. This can include lips, cheeks, gums, and tongue adjacent to where a dental procedure is performed.

Space maintainers (see additional consent) are sometimes recommended after extraction of primary (baby) teeth that are extracted (removed) far in advance of normal exfoliation (tooth loss).

Potential benefits of an extraction (tooth being taken out):
1. Prevention or resolution of pain due to caries (decay), trauma, or fracture resulting in a non-restorable tooth or one with poor prognosis for nerve treatment or other restorations
2. Treatment of current abscess/infection which may also require antibiotics if advised
3. Possible prevention of future abscess/infection
Risks include but are not limited to:
1. Post extraction pain, discomfort, minimal swelling
2. Prolonged bleeding (especially likely if post-extraction instructions are not followed)
3. Bruising or infection
4. Damage to adjacent teeth
5. Damage to adjacent tissues
6. Damage to nerves in the area of anesthetic administration which can be temporary or permanent
7. Damage to nerves in the area of tooth extraction which can be temporary or permanent
8. Changes in occlusion (bite) or difficulty opening the mouth due to stress on the temporomandibular joint (TMJ) from pressure used during an extraction procedure
9. Breakage of tooth roots that may or may not be left intact in order to prevent damage to developing permanent teeth or adjacent structures
10. Further treatment by an oral surgeon may be needed which may require sedation
11. Loss of space/tooth movement which may necessitate orthodontic treatment in future
Contraindications:
1. Bleeding disorder
2. Immunological or cardiovascular disorder that would necessitate medical clearance/treatment such as premedication prior to extraction
3. Sulfite allergy (component of local anesthetic)
Alternatives:
1. No treatment
2. Extraction and possibly space maintenance
I understand that I must follow all post-extraction home-care instructions, or healing may be delayed and bleeding may be prolonged.
Signature of parent/legal guardian:*

Extraction Consent Form

Patient Forms

Consent Forms

Socialize with Us!

Our Office Hours

A Little About Bean