APICOECTOMIES AND APICAL SURGERY

I UNDERSTAND that APICOECTOMIES include possible inherent risks such as, but not limited to the following:

1. Injury to the nerves: This would include injuries causing numbness of the lips; the tongue; any tissues of the mouth;

and/or cheeks or face. Th is numbness could occur and may be of a temporary nature, lasting a few days, a few weeks; a few

months; or could possibly be permanent, and could be the result of surgical procedures or anesthetic administration.

2. Bleeding, bruising, swelling: Bleeding may last several hours. If bleeding is profuse, you must contact us as soon as

possible. Some swelling is normal, but if severe, you should notify us. Bruises or hematomas may persist for some time.

3. Infection: No matter how carefully surgical sterility is maintained, it is possible, due to existing non-sterile or infected oral

environment, infections may occur postoperatively. At times, infections may be of a serious nature. Should severe swelling

occur, particularly accompanied with fever or malaise, attention as soon possible should be received.

4. Sinus or Mandibular Canal Involvement: In some cases, the roots of the teeth that are going to be apically treated lie in

closer apposition to the Maxillary Sinuses or to the Mandibular Canal, including the Mental Foramen than they appear to

be radiographically. Even though a rare occurrence, there is a slight possibility that the Maxillary Sinus or the Mandibular

Canal may be perforated, or the nerves emanating from the Mental Foramen may be traumatized during the surgical

procedure involved with removing the apices of the infected teeth.

5. Injury to adjacent teeth or adjacent roots: There is a possibility of injury to an adjacent tooth or to roots of teeth during

the procedure. If an adjacent tooth or roots of teeth are inadvertently nicked or otherwise damaged during the surgical

procedures, conventional endodontic treatment, endodontic surgery, or extraction may be required.

6. Bacterial Endocarditis: Because of normal existence of bacteria in the oral cavity, the tissues of the h eart, as a result of

reasons known or unknown, may be susceptible to bacterial infection transmitted through blood vessels, and Bacterial

Endocarditis (an infection of the hear t) could occur. Pre-existing conditions causing valvular dysfunction are the most

likely cause of this complication. It is my responsibility to inform the dentist of any heart problems known or suspected.

7. Failure: Even though the surgical pr ocedure is properly perform ed, th ere exists th e possibility th at th e attempt to preser ve

the tooth will fail due to the tooth and tissues not responding as they should, thereby necessitating extraction of the tooth.

8. Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from

anesthetics or other medications administered or prescribed. All prescription drugs must be taken according to instructions.

Women using oral contraceptives must be aware that antibiotics that m ay be necessary to control infection can render these

contraceptives ineffective. Other methods of contraception must be utilized during the treatmen t period.

9. 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 known as Apicoectomy an d have received answers to my satisfaction. I h ave been given the option of seeking care from

any oral-maxillofacial surgeon; a periodontist; and/or endodontist. I do voluntarily assume any and all possible risks, including the

risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results,

which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of

treatment to be rendered to me. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I

am freely giving my consent to allow and authorized Dr.Skinner_ and his/her associates to render any treatment

necessary or advisable to my dental conditions, in cluding any and all anesthetics and/or medications.

__________________________________ ________________________________ _________________

Patient’s name (please print) Signature of patient, legal guardian Date

or aut horized representative

Tooth No.(s) _______________________

__________________________________ ________________________________ _________________

__________________________________ Witness to Signature Date