Informed consent oral surgery

I UNDERSTAND that ORAL SURGERY and/or DENTAL EXTRACTIONS include possible inherent risks such as, but are not limited to the
following, including the understanding that no promises or guarantees of results have been made nor are expected:
Injury to the nerves: This would include those of the lips; the tongue; the tissues in the floor of the mouth; and/or the
cheek. This numbness which could occur may be of a temporary nature lasting a few days, a few weeks, a few months,
or may possibly be permanent.
Bleeding and/or bruising: Bleeding could last for several hours. Should it persist, particularly being severe in nature,
you should receive attention. Bruising may possibly be prolonged.
Dry socket: This occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during
the healing process. Dry sockets can be extremely painful.
Sinus involvement: In some cases, the root tips of upper teeth lie in close apposition to the tissues of the sinuses.
During extraction or surgical procedures, this sinus membrane may be perforated. Should this occur, it may be necessary
to have the sinus surgically repaired.
Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile or
infected oral environment, infections may occur postoperatively. At times these may be of a serious nature. Should
severe swelling occur, particularly accompanied with fever or malaise, attention as soon as possible should be received.
Fractured jaw, roots or bone fragments: There is a possibility, even though extreme care is exerted, the jaw, teeth,
roots or bone spicules may be fractured which may require referral to a specialist. A decision may be made to leave a
small piece of root or bone fragment in the jaw when its removal would require extensive surgery and/or risk of
Injury to adjacent teeth or fillings: This may occur at times no matter how carefully surgical and/or extraction
procedures are performed.
Bacterial endocarditis: Because of the normal existence of bacteria in the oral cavity, should the issues of the heart,
because of reasons unknown, be susceptible to bacterial infection transmitted through blood vessels, bacterial
endocarditis (an infection of the heart) may occur. If any heart problems are known or suspected, I must inform the
Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from
anesthetic or other medications administered or prescribed. It is important to take all prescription drugs according to
instructions. Women on oral contraceptives must be aware that antibiotics can render these contraceptives ineffective.
Caution must be exercised to utilize other methods of contraception during the treatment period.
It is my responsibility to seek attention should any undue circumstances occur postoperatively and I shall
diligently follow any preoperative and postoperative instructions given me

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of surgical
treatment and/or extraction of teeth and have received answers to my satisfaction. I have been given the option of seeking care from
an oral and maxillofacial surgeon. I do voluntarily assume any and all possible risks including, but not limited to, those listed above,
including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired
potential results, which may or may not be achieved. No promises or guarantees have been made to me concerning the results. The
fee(s) for this service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to
allow and authorize Dr. Brickey and/or his associates or agents to render any treatment necessary and/or advisable to my dental
condition(s), including prescribing and administering any and all anesthetics and/or medications.
**Have you ever taken Fosamax, Actonel, Boniva, or any other drug prescribed to decrease the resorption of
bone as in osteoporosis?
Bisphosphonate drug risks: For patients who have taken drugs such as Fosamax, Actonel, Boniva, or any other drug prescribed to decrease the resorption of bone as in osteoporosis, or for treatment of metastatic bone cancer, there is an increased risk of osteonecrosis or failure of bone to heal properly following any oral surgical procedure involving bone.


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