Happy Dental Treatment Consent Page 3
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3H. ______ Extractions
Procedure: Removal of a primary (baby) or permanent (adult) tooth. When an adult tooth is
removed, a new tooth will not replace it. When baby teeth are removed, a permanent tooth should
erupt in its place eventually. This can take months or years. When baby front teeth are removed,
new front teeth won’t erupt until the child turns 7 or 8 years old.
Goals: To remove an infected tooth, one that cannot be restored or one that is retained (not lost
naturally). At times, a healthy tooth is extracted if blocking a more important tooth.
Alternatives: If a tooth has an infection, or insufficient tooth structure to be restored, it will need
to be extracted. If a tooth is blocking another healthy tooth, not removing it will cause crowding or
deviations.
Risk: Leaving infected teeth in the mouth can damage surrounding structures and tissues.
Severe infections can cause pain and even be life threatening.
I.
______ Space Maintainers
Procedure: An impression is taken so that a space maintainer can be made. Once this appliance
is fabricated, it is cemented into place.
Goals: To prevent movement and shifting of the remaining teeth after extractions and to
preserve the space of the lost tooth or teeth.
Alternatives: Not placing a space maintainer can cause tipping and movement of adjacent teeth,
leading to space loss and teeth blockage.
Risk: These can fall out. They require adequate hygiene to keep area clean and healthy around
the space maintainer. They can bend and be uncomfortable until adjusted. If left in too long, they
can prevent the permanent tooth from erupting in the mouth.
J. ______ Use of Nitrous Oxide (laughing gas) to reduce anxiety
Procedure: Nitrous oxide is administered to the child at the time of a procedure through a nasal
mask. The benefit of nitrous oxide sedation is that no premedication is required and the child
recovers very quickly from the effects once the nitrous oxide is turned off. Local anesthetics are
still used, but are much easier to give when the child is under nitrous oxide. In some instances,
nitrous oxide is used in conjunction with other means of sedation.
Goals: To reduce anxiety related to the dental visit and to provide some pain relief.
Alternatives: Not to use any nitrous oxide or to use more advanced forms of sedation in order to
reduce anxiety and to promote cooperative behavior.
Risk: Very minimal. Occasionally, some children will get nauseous while under nitrous oxide.
A. ______ Frenectomy/ Lip or tongue release
Procedure: Surgical release of unnecessarily tight ligaments or muscle of the tongue or lips to
the jaw.
Goals: To release tension of the lips or tongue, which can prevent proper movement of the
tongue or lips. If they are tight, they can cause pain, speech problems, difficulty feeding and/or
excessive pull on the gums around the teeth, causing gum recession and, with time, loss of dental
stability.
Alternatives: Not performing this procedure can have all of the consequences listed above,
which in turn will affect the patient’s social ability to interact with others.
Risks: At Happy Pediatric Dentistry, this procedure is performed with a Laser; which allows for
very little or no bleeding, minimal discomfort or risk of infection. Some inflammation is expected.
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Parent or Guardian’s Signature
Date
Witness
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