Darren W Chaumont DDS LLC

Lake Charles Family Dental Care

Family, Cosmetic & Sedation Dentistry

Darren W. Chaumont, DDS LLC

(337) 477-8931

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Consent for Extraction of Teeth with Anesthesia and or Oral Sedation

Extraction of teeth is an irreversible process and, whether simple or difficult, it is a type of surgery. I understand that Dr. Chaumont is not a specialist in oral surgery and that I have the option to be referred to such a person for my treatment. As in any surgery, there are inherent risks. They include, but are not limited to, the following:

• If oral sedation is given (nitrous oxide or anti-anxiety medications), patients may experience nausea, fatigue, drowsiness, and amnesia while on medication. Patients understand they must have someone bring them to their appointment, stay during the procedure, and bring them home.
• If local anesthetics are used, allergic reactions, hematomas, and nerve damage may occur.
• Swelling, bruising and general discomfort in area of surgery.
• Bleeding which is normally controlled, but oozing may occur for several hours.
• Dry socket and or infection requiring additional treatment.
• Nerve damage resulting in numbness, pain, or altered sensations on the side of the face where surgery was performed. This is normally temporary, but in some cases nerve damage may be permanent.
• Damage to adjacent teeth, oral tissues, and or tongue.
• Trismus (limited jaw opening) or jaw fracture may occur in some cases.
• Sinus involvement and or infection that may require additional treatment.
• Sharp ridges or bone splinters may form later at the edge of the socket. These usually require another surgery to smooth or remove them.
• To avoid injury to vital structures such as nerves or sinuses, sometimes small root tips may be left in the socket.
• Cardiovascular, neurological and or respiratory responses to medications, anesthetics, and or stress which may lead to a heart attack, stroke, seizure, and or death.
• I understand that after removing teeth the surrounding bone and tissue will shrink to a different level than the adjacent teeth or bone. This will make it difficult to restore the space at a later time if a bone graft is not placed in the socket immediately after the tooth is removed.
• I accept bone graft treatment ______
• I deny bone graft treatment ______

I understand that further care,whether by Dr. Chaumont or a specialist, may be needed if complications arise during or after treatment, and that any additional costs incurred are my responsibility.

Patient’s or Guardian’s signature Date

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