Consent for Extraction

Dental extraction is the permanent, irreversible, removal of a primary (baby) or permanent (adult) tooth/ teeth.
拔牙是對乳牙或恆牙進⾏永久性、不可逆的移除。

• Pain, loss of function, decay, infected or abscessed tooth, non-restorable tooth, fractured tooth, orthodontic reasons (crowding), failure to erupt, ankylosis, ectopic eruption, pathological resorption, associated with dental cysts, impaction
  疼痛、功能受損、蛀牙、感染或膿腫的牙⿒、無法修復的牙⿒、斷裂的牙⿒、牙⿒矯正需要、牙⿒無法正常 ⽣長、牙⾻黏連、異位⽣長、牙根吸收、與牙囊腫瘤有關、牙⿒阻⽣

• Space maintainers (for baby teeth)
  空間維持器（適⽤於乳牙拔除)
• Orthodontic treatment (for mixed dentition, permanent dentition)
  正畸治療(適⽤於混合牙⿒期和恆牙期）
• Fixed prosthodontic treatment (for adult teeth): implants, bridge (more tooth structure loss)
  修復治療（適⽤於恆牙）：植牙、牙橋（更多牙結構缺失）

• Relieve pain, eliminate source of infection, facilitate eruption of permanent teeth, enhance favorable result of orthodontic treatment, prevent dental diseases
  減輕疼痛，消除感染源，促進恆牙⽣長，增強正畸治療的良好效果，預防牙⿒疾病

• Swelling, bleeding, bruising in the treatment area 傷⼝附近區域腫脹、出⾎、瘀⻘
• Traumatic lesions (due to post-op anesthesia: lips/cheeks/tongue/gum biting) 由於⼿術後麻醉引起的嘴 唇/臉頰/⾆頭/牙齦創傷
• Stretching of the corner of the mouth 嘴⾓伸展困難
• Aspiration (swallowing of extracted tooth) 誤吞拔除牙
• Injury to adjacent teeth and fillings 損傷鄰近牙⿒和填充物
• Fractured tooth 長牙⿒斷裂
• A small piece of root may be left in the jaw when removal would require extensive surgery
  在複雜的拔除⼿術中，可能會在下顎⾻中留下牙根斷⽚

• Restricted opening for several days or weeks with possible dislocation of the temporomandibular (TMJ) joint
  數天或數週內張嘴困難，可能伴隨顳顎關節（TMJ）關節脫位
• Opening of the sinus requiring additional surgery
  需要額外⼿術治療⼝⿐竇相通
• Post-operative infection requiring additional treatment (dry-socket, cellulitis)
  ⼿術後感染，需要額外治療（乾槽症，細菌性蜂窩組織炎）
• Injury to a nerve resulting in numbness/ tingling of the chin, lip, cheeks, gums, tongue on the treatment area; this could persist for several days, weeks, months, or in rare cases, permanently
  神經損傷導致治療區域下巴、嘴唇、臉頰、牙齦、⾆頭麻⽊/刺痛，可能持續數天、數週、數⽉，或在罕⾒情 況下永久存在
• In rare circumstances, cardiac arrest or breakage of the jaw
  在罕⾒情況下，可能發⽣⼼臟停頓或顎⾻斷裂
• During the course of surgery unforeseen conditions may occur which necessitate modifying or discontinuing the planned procedure
  ⼿術過程中可能出現無法預料的情況，需要修改或中⽌計劃中的⼿術程序

• No treatment which may lead to other serious conditions
  不進⾏治療，可能導致其他嚴重情況
• Root canal treatment/ pulptomy/ pulpectomy/ stainless steel crowns/ porcelain fused metal crowns
  根管治療（杜牙根）/牙髓移除/牙髓切除/不鏽鋼牙冠/瓷貼⾦屬牙冠
• Referral to oral surgeon
  轉介⾄⼝腔外科醫⽣

I hereby authorize Dr. Katrina Liu to perform the following procedure in conjunction to dental restorative treatment: extraction of tooth/ teeth: 我特此授權張書瑜醫⽣在進⾏牙⿒修復治療時進⾏以下程序 。

I have carefully read the printed material on this form. My signature on this form affirms that I fully understand this form, have had the opportunity to have questions answered to my satisfaction and authorize the procedure listed above.
我已仔細閱讀這份表格上的內容。我對這份同意書有充分的了解，有機會問問題並得到滿意嘅答案，同意進⾏ 上述的程序。