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GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH

WHAT IS AN IMPACTED TOOTH?

An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.

Some people have enough room in the backs of their mouths for their third molars to grow out straight and healthy, and they may function well for a lifetime. However, many others do not have enough room, and the wisdom teeth are crowded and tilted.

WHAT HARM CAN IMPACTED TEETH DO?

1. Impacted teeth may grow in any direction; however they often grow forward and push against the adjacent second molar. This can result in pain in the second molar and possibly damage to the roots or crown. The second molar may also be pushed out of position. 2. All teeth develop in sacs deep in the bone. If the tooth erupts normally, the sac generally disappears. If the tooth is impacted, the sac can fill with fluid and enlarge to form a cyst. The cyst can cause destruction of surrounding bone and damage to other teeth in the area. 3. Whenever saliva can reach the tooth, decay may occur, and since such cavities cannot be filled severe pain may result. This may be followed by the formation of an abscess. 4. Bacteria in the saliva may cause an infection around the crown of the wisdom tooth and under the flap of gum tissue which may be covering part of the tooth. This infection may spread to the cheek, throat or neck and result in severe pain, stiffness of the jaws, fever, and severe generalized illness. 5. Pressure from the wisdom teeth may cause crowding of the front teeth. This is why some orthodontists do not consider orthodontic treatment complete until impacted third molars have been removed.

WHEN IS IT BEST TO HAVE WISDOM TEETH REMOVED?

The dentist can study x-rays of the teeth and jaws, and can frequently tell by the teen years if the wisdom teeth are going to be impacted. At this stage the roots are usually not fully formed in most people and the bone is less dense. Therefore, the wisdom teeth are less complicated to remove and the healing is generally faster.

WHAT IS IT LIKE TO HAVE AN IMPACTED TOOTH REMOVED?

Because the impacted tooth is usually completely beneath the surface of the gum and often encased in bone, we consider its removal an operation in every sense of the word. This is said not to frighten the prospective patient, but rather to give a better understanding about certain features regarding cost, careful preparations and the need for good aftercare. Either local and general anaesthesia or local and sedation may be used. The dentist chooses the method of treatment based on each individual situation. Having a comfortable patient helps to control bleeding, allows the dentist to work without haste and causes less physiological disturbance to the patient. The actual removal of the tooth is done in keeping with recognized surgical principles, with meticulously sterile instruments, good light, a dry operative field, gentle handling of the soft tissue and bone and the advantages of a well trained team. Depending on the degree of difficulty of the individual case, the procedure may last from fifteen to sixty minutes. If sedation or general anaesthesia is used there will be a recovery period from thirty to ninety minutes. The surgical wound may be sutured with a material of the dentist’s choice. Most often dissolving sutures are used.

WHAT SHOULD I EXPECT AFTER SURGERY?

After any surgical procedure a certain amount of discomfort is anticipated. For this reason you will be provided with pain relieving medication before you leave the office. You are to take your pain medication as directed by the dentist; instructions will be on the bottle. Your dentist will decide if antibiotic medication is necessary and if this medication has been prescribed then it should be taken until all tablets are gone. Swelling after surgery is normal. You should expect to be most swollen forty eight to seventy two hours after surgery. The swelling then begins to resolve. Certain individuals have bruising after wisdom teeth surgery. The bruising may extend into the neck and chest. This should not alarm you as in some individuals this is the normal sequence of events.

Stiffness of the jaws is also normal after wisdom teeth surgery and is usually at its worst two or three days after surgery. One should start to exercise the jaws on the second or third post operative day to return the jaws to normal.

Although it will probably be difficult to eat after surgery in the mouth one must remember that the body heals itself by drawing upon its reserves of protein, vitamins, minerals, calcium and iron. Failure to replenish the body’s supplies of the above mentioned nutrients can result in fatigue, infections and even delayed healing. For the first twenty-four hours following surgery your food and beverages should be warm or cold NOT HOT. Eggs, custards, yogurt, milkshakes, baby food, etc., are both nutritious and manageable. Fluid intake should be approximately two litres or eight juice glasses per day for the average adult.

Detailed post operative instructions will be provided before you leave the office.

ARE THERE ANY COMPLICATIONS OR RISKS?

Any operation carries some degree of risk. This risk is minimized by careful preoperative assessment of your physical condition, by careful examination of all of the diagnostic materials, by careful preparation of instruments and all facilities, and by the skill of your dental team. The most commonly encountered complications will be discussed below.

Post-operative bleeding is usually encountered when the patient has not placed the gauze pack DIRECTLY over the surgical site. Pressure over the site for forty-five to sixty minutes will control most post-operative bleeding. If you are still concerned call the office and the problem will be dealt with promptly.

A condition known as dry socket occurs in approximately five percent of patients. It is more common in smokers and in female patients on the pill. It is manifest by a dull throbbing pain which starts five or seven days after the operation and is accompanied by a foul odour from the mouth. The treatment for this problem is simple and consists of two or three dressing changes. Healing is slightly slower than normal.

The roots of lower impacted teeth very often rest on and around the main nerve of the lower jaw. Very rarely, in spite of all precautions, during the removal of lower third molars this nerve is bruised, slightly lacerated or even severed. The result will be numbness of the lower lip, chin, and all of the teeth on that side. This effect does not last longer than a few weeks in most cases. It improves as the nerve repairs itself and regenerates. Occasionally the numbness may last as long as two or five years and even more rarely it may be permanent .Also in the region of the lower third molar is the nerve which supplies sensation to the lateral part of the tongue. It may on occasion be stretched with a resultant numb tongue. This problem usually resolves within several weeks or months. Upper impacted third molars lie against the wall of the sinus. Great care is taken to insure that no injury occurs to this structure but occasionally the thin wall of bone cracks and blood seeps into the sinus. Occasionally there may be formed a communication between the sinus and the mouth. If your dentist suspects this to be the case you will be informed and additional medication will be prescribed. Infections after the removal of wisdom teeth are rare. Redness, increasing swelling after an initial decrease, foul tasting discharge into the mouth, fever and chills are all signs if infection. If these should appear call the office and you will be attended to promptly.

Occasionally large fillings in the second molar teeth may be loosened or cracked during the removal of the wisdom teeth in spite of immaculate care and skill. If the possibility of this exists prior to surgery, you will be informed.

Another very rare complication is a cracked or fractured lower jaw. This occurs when the wisdom tooth is very severely impacted. If your dentist is concerned about this possibility, you will be informed.

Dr. Brian Kumer

416 605-0008

ORAL SURGERY CONSENT FORM

SWELLING, BRUISING AND PAIN

These can occur with any surgery and vary between patients and from one surgery to another. You may require several days at home for recovery. You may also have stretching of the corners of the mouth that may cause bruising and may heal slowly.

TRISMUS

This is the limited opening of the jaws due to inflammation in the muscles. This is more common with impacted tooth removal but is possible with almost any surgery. There is a higher likelihood if TMJ (see below) problem already exists.

INFECTION

This is possible with any surgical procedure and may require further surgery and/or medications if it does occur.

BLEEDING

Although significant bleeding can occur during or after surgery, it is not common. Some bleeding is, however, expected with most surgeries and is normally controlled by following the post-op instruction sheet. Prolonged or heavy bleeding may require additional treatment.

TMJ DYSFUNCTION

This means the jaw joint (Tempromandibular Joint) may not function properly and, although rare, may require treatment ranging from use of hot/cold compress and rest to further surgery.

LOCAL ANAESTHESIA

Certain possible risks exist that, although uncommon or rare, could include pain, swelling, bruising, infection, nerve damage, idiosyncratic or allergic reactions.

ALLERGIC REACTION

Allergic reaction, such as itching, rash, swelling, difficulty in breathing, is possible to any medication used it treatment.

DRY SOCKET

This is significant pain in the jaw and ear due to the loss of the blood clot and most commonly occurs after the removal of lower wisdom teeth, but it is possible with any extractions. Incidence increases with poor oral hygiene, smoking, birth control pill use. This may require additional office visits to treat.

DAMAGE TO OTHER TEETH AND FILLINGS

Due to the close proximity of teeth, it is possible to damage other teeth and/or fillings when a tooth is removed

SHARP RIDGES AND BONE SPLINTERS

Occasionally, after an extraction, the edge of the socket will be sharp or a bone splinter will come out through the gum. This may require another surgery to smooth or remove the bone splinter.

INCOMPLETE REMOVAL OF TOOTH FRAGMENTS

There are times when the dentist may decide to leave in a fragment or root of a tooth in order to avoid doing damage to adjacent structures such as nerves, sinuses, etc. or if an extensive risk of other complications is present with its removal.

NUMBNESS

Due to the proximity of roots to the nerve (especially wisdom teeth), it is possible to bruise or damage the nerve with removal of a tooth. This could remain for days, weeks, or very rarely, permanently. The lip, chin, cheek, gums and/or tongue could feel numb, tingling or have burning sensation.

SINUS INVOLVEMENT

Due to the location of the roots (especially the upper back teeth) to the sinus, it is possible for an opening to develop from the sinus to the mouth. Or a tooth/fragment may be displaced into the sinus. A possible infection and/or permanent opening from the mouth into the sinus could develop and may require medication and/ or later surgery.

JAW FRACTURE

Fracture of the jaw, usually in more complicated extractions.

QUALIFICATION

I understand that Dr. Brian Kumer is not an oral surgeon but a general dentist who has had several years experience in the extraction of wisdom teeth and always uses his best efforts to provide the appropriate treatment for his patients.

APPENDIX TO SURGICAL INFORMED CONSENT

I understand that Dr. Brian Kumer is not an oral surgeon but a general dentist who has had several years experience in the extraction of wisdom teeth and always uses his best efforts to provide the appropriate treatment for his patients.

Ontario’s Narcotics Strategy

List Of Approved Forms Of Identification

• Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.
• Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.

The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.

Below is a list of forms of identification that a person can present to a prescriber or dispenser:

• Ontario Health Card or other health card issued by a Province or Territory in Canada
• Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)
• Ontario Photo Card
• Birth Certificate from a Canadian province or territory
• Government-issued Employee Identification Card
• Ontario Outdoors Card
• BYID (age of majority card)
• Certificate of Indian Status
• Valid Passport – Canadian or other country
• Certificate of Canadian Citizenship
• Canadian Immigration Identification Card
• Permanent Resident Card
• Old Age Security Identification Card
• Canadian Armed Forces Identification Card
• Royal Canadian Mounted Police/Provincial/Municipal Police Identification
• Firearms Possession and Acquisition Licence

POST-OPERATIVE INSTRUCTIONS

DR. BRIAN KUMER

416 605 0008

PLEASE READ THESE INSTRUCTIONS CAREFULLY. Sometimes the after effects of oral surgery are quite minimal, so not all of these instructions may apply to you. Common sense will dictate what you should do. However, when in doubt, follow these guidelines or call us for advice.

DAY OF SURGERY (FIRST 24 HRS)

AND DAYS 2-7

FIRST HOUR

Bite down gently but firmly on the gauze packs that have been placed on the surgical sites, making sure they remain in place. Do not change them for the first 30 minutes unless the bleeding is not being controlled. If active bleeding persists after 30 minutes, place enough new gauze to obtain pressure over the surgical site for another 30 minutes. The gauze may be changed as necessary and may be dampened for more comfortable positioning. Do not disturb the surgical area today.NO RINSING, WHATSOEVER, DURING THIS PHASE. DO NOT SMOKE. Smoking increases the risk of dry socket dramatically.

OOZING/BLEEDING

It’s normal to have your saliva stained with blood for a few days. There may also be some slight oozing. If this persists, place fresh gauze over the area and bite down for 30-60 minutes. Bleeding should never be severe. If it is, it usually means the gauze packs are placed between your teeth and not over the surgical sites. Try to reposition them. If this doesn’t work substitute a moistened tea bag wrapped in moist gauze for 30-60 minutes. Do not sleep with gauze in your mouth.When sleeping use an old pillow and place some towels around your head to protect your bedding. If bleeding remains uncontrolled please call us.

SWELLING

Often there is swelling/bruising associated with oral surgery. Swelling is a normal response to trauma. It is not the same as infection. If you are swollen this does not mean you are infected. You can minimize this by using an ice pack applied to the face adjacent to the surgical site. The ice should be applied for a 10 minutes per side every hour over a 24-48 hour period. After the first 24-48 hours, stop icing the area. Do not use ice packs while sleeping. Despite icing the area, swelling will still occur. After 48 hours, apply a warm moist compress for 10-15 min of several times a day for balance of the week. Swelling usually increases over a 72 hour period. Therefore you will appear more swollen on the 3^rd day than the 2^nd day. After 72 hours, swelling starts to slowly subside and is mostly gone by the 7^th day.

RINSING

After the first 48 hours have elapsed you may stop icing the area. At this time start with warm salt water rinse. Place a teaspoon of salt in a glass of warm water. Gently swish it around your mouth 2-3 times a day for the next 7-10 days. Do not spit out the rinse. Let it fall out of your mouth. Spitting exerts a force on the healing clot and can slow down healing and promote bleeding. Do not use mouthwash for the first 7 days unless prescribed by the dentist. Also you may brush in the area unaffected by the surgery butleave the surgical areas alone for 7 days. After that you may gently clean around the area although swelling and soreness may not permit you to do so. In time, you will be able to return to proper oral hygiene care.

PAIN

Unfortunately oral surgery is usually accompanied by some degree of discomfort. You may have been given some pain medication prior to the start of your procedure. It is important to follow the instructions with pain medication as it is easier to “stay ahead of the pain rather than trying to catch up to it.” If you take the first pain pill before the local anesthetic has worn off you will be able to manage the discomfort better.

INFECTION

Unless you present with infection you usually don’t develop an infection in the first few days. Antibiotics are prescribed to either help prevent infections from developing or to treat an infection that is present. Not all procedures require an antibiotic. There is a decrease in effectiveness of birth control medication when taking antibiotics. Consult your physician for advice on additional birth control measures. Slightly elevated temperature may occur for reasons other than infection. Be sure to drink lots of fluids: 1.5-2 liters /day.

DIET

Soft food is the dietary choice for the first few days. Ice cream, Jell-O, pudding, mashed potatoes, soups, pasta, or baby food are good choices. Avoid foods like nuts, popcorn, and rice as they tend to get stuck in the socket areas. Drinks like ENSURE or BOOST are good supplements as well. DO NOT USE A STRAW OR DRINK FROM A BOTTLE for the first 2-3 days. This can exert a force on the blood clot and slow down healing and promote bleeding. Use a spoon or a cup. After the fourth day you can progress to solid foods at you own pace. It is important to eat as you will feel better and heal faster. If you are diabetic, maintain you normal eating habits as much as possible and consult your physician regarding your insulin schedule.

STITCHES

You may have had some stitches placed. They will dissolve on their own in 5-7 days.Not all surgical sites require stitches.If a stitch comes out it is of no concern provided there is no excessive bleeding.

SMOKING

Do not smoke!It is advisable not to smoke for at least 7days.

SYRINGE

You will be given an irrigating syringe at your appointment. Fill a cup with salt water and then fill the syringe. Gently place it in the LOWER SOCKET ONLY and irrigate it 2-3 times. Do this after each meal over the next three to four weeks until the sockets close up. DO NOT USE THE SYRINGE UNTIL 5 DAYS AFTER YOUR SURGERY!

REST

You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved.

It is our desire that your recovery be as smooth as possible. Following these instructions will assist you, but if you have any questions please call our phone number.

SHOULD YOU BE UNABLE TO REACH ME IN AN EMERGENCY, GO TO THE NEAREST EMERGENCY ROOM

DR. BRIAN KUMER 416 605-0008

I authorize Dr. Stephen Ing and associates/assistants of his choice to perform intravenous sedation/anesthesia, as a part of my dental procedure. Additionally, I authorize the performance of any other procedure that in the judgment of Dr. Ing may be necessary for my well-being, including such interventions that are considered medically advisable to remedy conditions encountered during the proposed procedure.

I am satisfied with my understanding of the nature of the anesthesia plan of care and the more common drawbacks and complications associated with it. These may include, but are not limited to: swelling, bleeding or discomfort at the site of intravenous insertion; allergic reactions to the anesthetic agents used; nausea and/or vomiting; prolonged recovery from anesthesia; post-operative disorientation/delirium (temporary); aspiration of stomach contents (rare); sore throat; fractured teeth; sore/bleeding nose. There is also a very rare potential for serious harm, including respiratory and cardiac arrest which can result in brain damage or death. I understand the risks, complications, and potential benefits of anesthesia. I have been given ample opportunity to discuss alternative methods of treatment, if any, along with their risks and benefits. No warranty or guarantee has been made as to the outcome of the anesthesia plan of care.

I understand that in some instances where a general anesthetic (ie, completely asleep/unconscious) has been specifically requested, Dr. Ing may use a breathing tube to ensure that the patient's airway remains unobstructed during the procedure. In these instances, there is an increased chance of a temporary sore throat or in much rarer circumstances, physical trauma to the airway.

I understand that anesthetics and other medicines may be harmful to an unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing Dr. Ing of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation/anesthetic. For similar reasons, I understand that I must inform Dr. Ing if I am a nursing mother.

I understand and agree to the following post-anesthetic instructions:

1. I will not drive a car or operate machinery for at least 24 hours, longer if drowsiness or dizziness persists.
2. I will not drink alcoholic beverages for a minimum of 24 hours after the procedure.
3. I will be in the care of a responsible adult until I am fully alert.

PRE-OPERATIVE INSTRUCTIONS FOR PATIENTS WHO WILL BE RECEIVING SEDATION OR ANESTHESIA

1. Nothing to eat or drink (including water) for 8 hours before the procedure.
2. The only exception to the above instruction applies if you take medications on a regular basis. Take your usual medications at (approximately) the regularly scheduled times at least two hours before the appointment, with a few sips of water (and water only).
3. Arrangements must be made to have a responsible adult take you home, by car or taxi (a taxi driver alone is not allowed to take you home). You may NOT go home by public transit.
4. Please wear something short-sleeved (eg, t-shirt). Do not wear facial makeup or nail polish.
5. Contact us prior to the appointment if has there been a change in your general health (egs, severe cold, fever, etc.)

INSTRUCTIONS FOLLOWING YOUR SEDATION/ANESTHESIA APPOINTMENT

1. You may be drowsy for the remainder of the day and should be relaxing at home in the care of a responsible adult until you are fully alert.
2. You must not drive a car or operate machinery for at least 18 hours, longer if drowsiness or dizziness persists.
3. Replenish your energy by having something to eat or drink as soon as possible.
4. Do not drink alcoholic beverages for a minimum of 18 hours after the procedure.
5. Do not sign any important or legal documents for 24 hours.
6. If there are any questions or concerns, contact the dental office. In case of an emergency, you should go to the nearest emergency room.