DENTAL TREATMENT CONSENT
I hereby authorize Dr.
and such assistants as may be selected by any of them, to treat the condition(s)
described below :
The procedure(s) necessary to treat the condition(s) have been explained to me and I understand the nature of the procedure to be:
I have been Informed of possible alternative methods of treatment (if any).
I have further understood that this is an elective procedure and other forms of treatment or no treatment at all are all choices that I
have and that this treatment (in my doctor’s opinion) will provide the optimum relationship between teeth, jaws, muscles, and the
temporomandibular (jaw) joint that is possible at this time.
The doctor has explained to me that there are certain inherent and potential risks in any treatment plan or procedure, and some of the
operative and anesthesia risks include, but are not limited to the following:
A. Post-Operative/treatment discomfort and swelling that
may necessitate several days of home recuperation.
B. Heavy bleeding that may be prolonged.
C. Injury to the adjacent teeth and fillings, causing loss
of a tooth or teeth or need for restorations or root
canal therapy.
D. Development of dry socket – localized alveolitis –
requiring extended treatment.
E. Post-operative
treatment.
F. Delayed healing requiring additional treatment.
G. Stretching of the corners of the mouth with resultant
cracking and bruising.
H. Restricted mouth opening for several days or weeks.
I. Decision to leave a small piece of root in the jaw
when its removal would require extensive surgery or
nerve damage.
infection
requiring
additional
J. Breakage of the jaw.
K. Swallowing of tooth; swallowing of tooth with tooth
being lodged in the lung, requiring a chest x-ray and
subsequent surgical removal.
L. Injury to the nerve underlying the teeth resulting in
numbness, tingling, painful or altered sensation in the
lip, chin, cheek, gum, teeth, and/or tongue on the
oper-ated side; this may persist for several weeks,
months, or in remote instances, permanently.
M. Opening of the sinus (a normal cavity situated above
the upper teeth) requiring additional surgery. A sinus
infection may develop, or loss of a piece of tooth or
whole tooth in the sinus requiring recovery.
N. Stiff neck or facial muscles.
O. Changes in the bite or pain of the Temporomandibular
joint (ear/jaw joint).
P. If intravenous medication is used, soreness at the
injection site or along the vein may develop as well as
some
discoloration
of
the
injection
site
(thrombophlebitis). This may require further surgical
treatment.
Q. Allergy to drugs used may cause an anaphylactic
reaction resulting in paralysis, brain damage, or death.
R. Cardiac arrest or stroke.
S. Other:
JAN UARY/FEBRUARY 2018 | P EN N SYLVAN IA DEN TAL JOURNAL
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