Root Canal Consent Form Dr. Chris Reynolds - PDF Document

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  1. Root Canal Consent Form Dr. Chris Reynolds When you give permission to have a root canal you should fully understand what the most common risks and complications are: 1.Pain and soreness may continue for 3 to 5 days 2.Swelling- should resolve over time with healing aided by NSAIDs (Motrin) and ice 3.File fracture- occasionally the instruments used to clean and shape the root system can break and become lodged in the tooth. Attempts will be made to remove or get around the piece. If unable to remove it may be left in the tooth and complete healing can still occur. The treatment may be halted and sent to an Endodontist (specialist in root therapy). If this occurs, a medicine will be placed into the root of the tooth and a temporary filling will be placed in the interim. We will notify you if there is any evidence of a file breakage. 4.Perforation- a small hole leading to the outside of the tooth can occur. The tooth may or may not heal because of this. Some perforations are repairable. If this occurs you will be notified and sent to an Endodontist after the tooth is temporary filled. 5.Cracks or fractures- sometimes a crack in the tooth will be found or made during root canal treatment. If this occurs the tooth may need to be removed. Sometimes these cracks can go undetected and can be the cause of a non-healing tooth. 6.Numbness- the local anesthesia or any of the medicines used to clean the root can cause temporary or permanent numbness in the jaws. 7.Existing fillings, crowns, and veneers may be weakened or damaged during root canal treatment. It may require replacement of these fillings and restorations. 8.Despite our best efforts, the root canal anatomy may not lend itself to being completely disinfected or filled. Severe curvatures, blocked and impassible canals, or a longstanding dead tooth may not respond as well as most teeth respond to root canal therapy. The benefits of root canal treatment are: 1.Elimination of cavities, bacterial infections, and other abscesses 2.Retention of a broken down tooth, when the only other option is removal 3.Elimination of pain, swelling, and bad taste 4.Immune system integrity- when an infection is present the body has to work harder and subsequently acts as a drain on the bodies’ natural defenses. All complications will be handled immediately and appropriately with the patient being informed of any issues that are present. The complete process can take extended

  2. periods of time depending on the difficulty of the tooth being worked on. A second or multiple visits may be necessary for the best result. Root canal therapy success ranges varies based upon the extent of the damage that has occurred when the issue was found and diagnosed. The success rates will be discussed prior to starting the procedure. Appropriate follow-up and alternative options if the tooth does not heal appropriately will be discussed and may include referral to an endodontist, retreatment of a root canal, surgical procedures on the tooth, or removal of the tooth. The frequencies of occurrence of the above complications are different for each item listed, but as a group are relatively infrequent. Please sign and date the form below; by doing so you do not give up any rights and do not release the surgeon from responsibility. Prior to signing please ask any additional questions you may have. Thank you! I have read the above, understand my procedure, and have no further questions Patient: _______________________________ Dr. Reynolds: ____________________________ Date: _____________ Date: ______________