HEALING WITH A GENTLE TOUCH
Consent for Endodontic Treatment
I understand that root canal treatment is a procedure to retain a tooth, which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed.
I, the undersigned, have been informed that I require an Endodontic procedure (root canal treatment) on tooth number ______ and that I fully understand the following:
1) Failure to follow this recommendation will most likely result in:
a) The loss of the tooth.
b) Bone destruction due to abscess.
c) Possible systemic (affecting the whole body) infection.
2) Certain percentages (5-10%) of root canals fail, and they may require re-treatment, periapical surgery, or even extraction.
3) During instrumentation of the tooth an instrument may separate and lodge permanently in the tooth or an instrument may perforate the root wall. Although this rarely occurs, such an occurrence could cause the failure of the root canal and the loss of the tooth.
4) When making an access (opening) through an existing crown or placing a rubber dam clamp, damage could occur and a new crown would be necessary after Endodontic therapy.
5) Successful completion of the root canal procedure does not prevent future decay or fracture.
6) Temporary fillings are usually placed in the tooth immediately after root canal treatment. Teeth which have had root canal treatment will require a permanent (outside) restoration. This may involve a filling or more extensive restorative work (pins, post, crown build-up, crown) depending on the clinical status of the tooth.
I understand that more than one (1) appointment may be necessary to complete the root canal therapy, as well as other appointments for restoration. I am also aware that I may have continuing temporary symptoms throughout the treatment. Those symptoms may include:
1) Swelling 4) Drainage
2) Pain 5) Fever
3) Infection 6) Numbness
There are risks involved in administration of anesthetics, analgesics (pain medication) and antibiotics. I will inform the Doctor of any previous side effects or allergies.
NOTE: Antibiotics may decrease the effectiveness of birth control medication. Additional methods of birth control should be used while on antibiotics.
Patient or Patient’s Guardian Signature Date
Witness to Signature Date