Download CONSENT FOR ENDODONTIC TREATMENT

Clayton Brook Dental Practice
CONSENT FOR ENDODONTIC (ROOT CANAL) TREATMENT
PLEASE REVIEW THE FOLLOWING CONSENT FORM. YOU WILL BE REQUIRED TO SIGN THIS FORM PRIOR
TO THE INITIATION OF TREATMENT. YOUR SIGNATURE DOES NOT COMMIT YOU TO ANY TREATMENT.
NECESSARY: Root canal treatment has been recommended by your dentist as a procedure necessary to
help retain your tooth in a situation that would otherwise indicate its extraction.
ALTERNATIVES: These are 1. No treatment and Review; or 2. Extraction
If no treatment is done, there is a risk of infection, pain, swelling, and loss of the tooth. If the tooth is
extracted, then some form of an artificial replacement may be considered eg. denture, bridge, implant.
RELIABILITY: Root canal treatment can be highly successful depending on the case, availability of special
equipment, dentist expertise, and patient cooperation. However, success cannot be guaranteed,
particularly in premolar and molar teeth. Maintaining a very good standard of oral hygeine is important
to improving success.
FUTURE TREATMENT: It is possible that your tooth may require additional treatment in the future such
as repeat root canal treatment, surgery, or even extraction, normally at extra cost.
COMPLICATIONS: These are rare. While no complications may be expected, it is possible that they may
still occur. Examples include situations that may not be apparent until treatment has started, eg. cracked
parts of tooth, difficult access, fine canals, difficult anatomy.
RISKS: All reasonable measures are taken to minimise risks during treatment. Possible risks include, but
are not limited to, the following: instrument seperation within the root canals; perforations; damage to
existing restorations; missed canals or calcified canals; loss of tooth structure; fractured teeth.
In some cases there is also a small risk of loss of sensation (numbness) which could be either temporary
or permanent.
FOLLOWING ROOT CANAL TREATMENT: Some discomfort after root canal treatment is normal.
The tooth will be more brittle and more likely to fracture. Therefore a diet of softer foods is essential
following treatment. A crown or onlay, with or without a post and core, is often necessary to restore the
tooth. This is more likely for back teeth and your dentist will explain if this is required and the additional
costs involved.
CONSENT FOR TREATMENT
I have read the above and I understand that no treatment is without some measure of risk and the risks
of the proposed treatment have been explained to me. I prefer to undergo the endodontic (root canal)
procedure in order to attempt to retain my tooth.
Consequently, I hereby give my consent to Daniel Cheung to do whatever he deems necessary to
perform the endodontic procedure which has been described to me. I further request and authorize
Daniel Cheung to do whatever he deems advisable and necessary as a result of unforeseen
circumstances.
Furthermore, I give my permission for the use of any digital photos and radiographs of my procedure for
purposes of case study and/or patient education or dental education. This will be kept confidential.
Signed:
________________________________
Print Name:
________________________________
Date: _________________