Download Endodontic Treatment Information and Consent

Endodontic Treatment Information and Consent
We would like our patients to be informed about the various treatment options and risks
involved in endodontic therapy and have their consent before starting any treatment. Basic
endodontic (root canal) therapy is performed in an attempt to save a tooth which otherwise
might need to be extracted. Other procedures, such as endodontic surgery, may sometimes be
indicated. Please discuss your treatment options and risks with your endodontist today.
RISKS OF ENDODONTIC TREATMENT: Although not common, the risks include
the possibility of instruments broken within the root canal; perforations (extra openings)
of the crown or root of the tooth; damage to bridges, existing fillings, crowns, or porcelain
veneers; loss of tooth structure in gaining access to canals; and cracked teeth. During
treatment, complications may be discovered which make treatment impossible or which may
require dental surgery. These complications may include canals blocked by fillings or prior
treatment, natural calcifications, broken instruments, curved roots, periodontal disease
(gum disease), or tooth fractures.
OTHER TREATMENT CHOICES: These include no treatment at the present time (monitoring
symptoms and waiting for them to become more definite before treatment) and tooth extraction.
RISKS of these choices include pain, infection, swelling, loss of teeth, and spread of infection to
other areas .
MEDICATIONS: Medications prescribed for pain (such as oxycodone, hydrocodone
Norco, Percocet, and others) may cause drowsiness and lack of awareness and
coordination which may be increased or complicated by the use of alcohol, tranquilizers,
sedatives or other drugs. It is not advisable to operate any vehicle or hazardous device until the
effects of such medications have subsided. Any antibiotics (such as penicillin, Keflex,
erythromycin, clindamycin, and others) that may be prescribed for you can reduce the
effectiveness of oral birth control for up to two weeks after the last dose. Antibiotics can also
react with sinus and other medications. Your endodontist or pharmacist can answer any
medication questions you may have. If you are taking medications, check with your pharmacist
about interactions.
CONSENT: I, the undersigned patient (or parent/guardian of minor patient), consent
to receive procedures deemed necessary or advisable in the opinion of the doctor. I also
understand that upon completion of root canal therapy in this office I shall return to my general
dentist for a permanent restoration (such as a crown or filling) of the tooth or teeth involved. I
understand that it is my responsibility to see my general dentist for this purpose and that if I do
not return to my dentist in a timely fashion, the root canal may fail or require retreatment at my
expense.
I understand that root canal treatment is an attempt to save a tooth which may otherwise require
extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed.
Occasionally a tooth which has had root canal therapy may require retreatment, surgery, or
even extraction.
Patient/Guardian signature_______________________________ Date__/___/______