Root Canal Information
Root Canal Consent
Please review the following consent. You will be required to sign it prior to the initiation of your examination; however, it does not commit you to treatment.
I understand endodontic therapy is a procedure to retain a tooth that may otherwise require extraction. Although endodontic therapy has a very high degree of clinical success, it is a biological procedure, so it cannot be guaranteed. Occasionally, a tooth that has had endodontic therapy may require retreatment, surgery or even extraction.
Complications of endodontic therapy and anesthesia may include swelling, discomfort, trismus (restrained jaw opening), infection, bleeding, sinus involvement, and numbing or tingling of the lip, gum or tongue which rarely is protracted and even more rarely is permanent. I understand that it is my responsibility to report any symptoms to the Endodontist immediately. During treatment there is the possibility of an instrument separating within a root canal, fractures or perforations (extra openings) occurring, or damage to an existing crown, filling or bridge. During treatment, situations may be discovered which can make treatment impossible or, which may require dental surgery.
Endodontic treatment most often requires local anesthesia and I agree to the use of any appropriate local anesthetics. I understand that only the endodontic therapy is to be performed at this office. The permanent crown restoration will be done by my regular dentist. I also understand that medications for pain and sedation my cause drowsiness, which can be increased by the use of alcohol or other drugs. I will avoid operating any vehicle or hazardous devices while taking medications. I further understand that certain medications may cause hives and intestinal problems and if any of these reactions occur, I am to call the office immediately.
Other treatment choices include no treatment, waiting for more definitive symptoms to develop or tooth extractions. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection to other areas.
I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment and that occasionally the canal filling material may extend through the tooth root tip, which does not necessarily affect the success of the treatment.
PLEASE NOTE: As some issues can arise with root canal therapy, Mid-Cities Endodontics allows a patient with a completed root canal procedure 90 days to follow up with the practice. Retreatment or treatment may require an additional surgical procedure. If this is needed, we will recommend an oral surgeon to do an apicoecomy (or a root amputation).
Patient Initial or Guardian (if minor) Date
This acknowledges that I have read the above and consent to any appropriate endodontic procedures deemed necessary or advisable to be performed by Mid-Cities Endodontics and was given the opportunity to question the Doctor regarding treatment, its alternatives and prognosis. This consent does not encompass the entire discussion I had with the doctor regarding the proposed treatment.
(ALL SIGNATURES MUST BE BY PARENT OR GUARDIAN IF PATIENT IS 18 YEARS OLD OR YOUNGER)
CONSENT TO DENTAL TREATMENT