Your dentist suggests that the following teeth be removed: For the following reason(s):
The consequences of not performing necessary extractions may include:
Continuation, growth, and/or spread of infection
Pain and swelling
Systemic infection, such as fever, sepsis, and (in rare cases) death
Aspiration (inhaling) of loose teeth or tooth fragments
Though rare, the following complications may occur during or after dental extractions:
Pain and swelling
Injury to neighboring teeth, restorations, or soft tissues
Reversible or irreversible nerve damage
Dry socket (a painful, noninfectious complication)
Infection
Adverse reactions to medications, anesthesia, or substances used for the extraction
Retained fragments of teeth in the jaw (if the risk of removal outweighs the
benefit)
Perforation of the maxillary sinus, possibly requiring further treatment
In rare cases, fracture of the jaw requiring further treatment
I understand that tooth extraction is an elective procedure, and there are often alternative
treatments, such as a root canal and restoration or performing no treatment at all. My
dentist has described other options, invited me to ask questions, and I am electing to
proceed with the extraction.
I will follow the verbal and written postoperative instructions and return for a follow-up
appointment if requested.