Consent For Oral Surgery & Anesthesia

All surgeries have some risks. They include the following, but are not limited to:

1. Swelling, bruising and pain.
2. Possible infection that may need additional treatment.
3. Changes in your bite, or difficulty opening your mouth because of stress on the jaw joint (TMJ).
4. Possible damage to other teeth near the surgical site (more often those with large fillings or caps), or other tissues of the face or mouth.
5. It is very rare that the bones of the jaw break, but it is possible in cases where the teeth are buried deeply in their sockets.
6. Dry socket is a condition in which the surgical site cannot heal due to loss of the blood clot. If this occurs, you would experience a sudden increase in pain 2-3 days after surgery.
7. Reactions to medicines are possible, but uncommon.
8. Sharp ridges or bone splinters may form later at or near where the tooth was taken out. These may need another surgery to smooth or remove.
9. The hole where the tooth had been might need more care, or small pieces of the tooth root might be left there to prevent damage to very important things like nerves or a sinus (a hollow place above your upper back teeth).
10. Upper back teeth are often close to the sinus and sometimes the tooth or a piece of root can get into the sinus and need more treatment. An opening may occur from the sinus into the mouth that may need more treatment.
11. The roots of the lower teeth might be very close to the sensory nerve, and after the surgery there might be pain or a numb feeling in the chin, lip, cheek, gums, teeth or tongue. Loss of the sense of taste is possible. This might last for weeks or months, or could be permanent, although extremely rare.
12. Healing time and course can vary between patients.

Information For People With Internal Reproductive Organs/Menstruation Organs

1. Birth control pills can interact with certain medications, making them ineffective.
2. Please alert the doctor if you are pregnant or actively chest-feeding/breastfeeding.

Anesthesia

I have had the opportunity to speak with Dr. Epstein about my options for anesthesia. These options include local anesthesia, nitrous oxide/oxygen analgesia with local anesthesia, intravenous sedation, or deep sedation/general anesthesia. I understand the risks and potential complications of anesthesia include:

1. Discomfort, swelling or bruising where the drugs are placed into a vein.
2. Vein irritation, called phlebitis, where the drugs are placed into a vein. Sometimes this may grow to a level of discomfort or disability where it may be difficult to move your hand or arm. Sometimes medication or other treatment may be needed.
3. Nerves travel next to the blood vessels where the drugs are placed into a vein. If the needle hits a nerve or if drugs or fluid leaks out of the vessel around a nerve, numbness or pain in the nerve where it runs along the arm may develop. Usually the numbness/pain goes away, but in some cases it may be permanent.
4. Allergic reactions (previously unknown) to any of the medications used.
5. Nausea and vomiting, although uncommon, are possible side effects. Bed rest, and sometimes medications, may be needed for relief.
6. Conscious sedation and deep sedation/general anesthesia are serious medical procedures and, whether given in a hospital or office, carry the risk of brain damage, stroke, heart attack or death.

My Obligations

1. Anesthetic or sedative medications (including oral premedication) cause drowsiness that lasts for some time. I MUST be accompanied by a responsible adult to drive me to and from surgery, and stay with me for several hours until I am recovered sufficiently to care for myself. Sometimes the effects of the drugs do not wear off for 24 hours.
2. During recovery time (normally 24 hours), I should not drive, operate complicated machinery or devices, or make important decisions such as signing documents, etc.
3. I must have a completely empty stomach. It is vital that I have NOTHING TO EAT OR DRINK for eight (8) hours prior to my treatment unless otherwise directed.
4. Unless instructed otherwise, it is important that I take any regular medications (high blood pressure, antibiotics, etc.) or any medicines given to me by my surgeon using only small sips of water.

Consent

I understand that my doctor can’t promise that everything will be perfect. I understand that the treatment listed above, other forms of treatment, or no treatment at all, are all choices I have. I have read and understand the above and give my consent to surgery and chosen anesthesia. I have been given an informative handout that goes over opioid risks, safe and secure storage, and proper disposal of unused medication. 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 and all my questions have been answered before signing this form.