Download English

PATIENT INFORMED CONSENT FOR ENDODONTIC TREATMENT
I hereby authorize a _______ DENTIST / DENTAL RESIDENT / DENTAL STUDENT to perform a
ROOT CANAL TREATMENT on tooth number: _______________________________________
I understand that a root canal treatment is a procedure to retain a tooth, which may otherwise require extraction.
Although root canal treatment has a very high degree of clinical success, it is still a biological procedure, so its
success cannot be guaranteed.
I (or my child/ward), __________________________________, have been informed that I (or my child/ward)
require an endodontic procedure (root canal treatment) to retain this tooth 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 an abscess
c) Possible systemic (affecting the whole body) infection
2) 5 to 10% of root canal treatments fail and may require re-treatment, periapical surgery, or even
extraction.
3) During cleaning of the tooth, tools may break and lodge permanently in the tooth. Also, an instrument
may perforate the root wall. Although this occurs rarely, broken tools or perforation can cause root canal
treatments to fail. This may lead to the need of further more complex treatment or referral to Root Canal
Specialists (Endodontist) or loss of the tooth.
4) Possible complications associated with root canal treatments are cracked teeth, blocked canals, curved
roots, and gum disease. These are rare complications that can make the treatment impossible.
5) During or after the root canal treatment, there are some complications that could arise. These possible
complications include: swelling, bleeding, pain, infection, permanent or temporary numbness / tingling
of the lip and or tongue.
6) On occasion, while performing the root canal treatment, the cleaning solution used can cause sudden
pain followed by rapid swelling that can last for a while. This pain and swelling will go away with time.
Treatment involves waiting and taking pain medications if needed.
7) When making an access (opening) through an existing crown or placing a rubber dam clamp, damage
could occur to the existing crown and a new crown may be necessary following endodontic therapy.
8) Successful completion of the root canal treatment does not prevent future decay or fracture of the tooth.
9) Temporary fillings are usually placed in the tooth following root canal treatment. These endodontically
treated teeth usually need a buildup and a crown will be required in order to restore the tooth to proper
function and appearance. Failure to place the recommended final restoration, such as a crown, on a
completed root canal treated tooth can result in tooth fracture or recurrent decay which in turn can result
in failure of the root canal and eventual need for retreatment or extraction.
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.
____________________
Date
______________________________________________________
Patient or Patient’s Parent/Guardian
____________________
Date
______________________________________________________
Witness to signature