ROOT CANAL TREATMENT CONSENT FORM - PDF Document

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  1. Richard J. Gray, DDS 1149 Jefferson Green Circle Midlothian, VA 23113 ROOT CANAL TREATMENT CONSENT FORM 1)I have been advised that I require root canal treatment. I understand the purpose of endodontic or root canal treatment is an attempt to save a tooth rather than remove it. I understand the desirability of root canal treatment compared to extraction and the consequences of not having root canal treatment. 2)I understand root canal therapy removes the source of the infection from the tooth. Once the source of the infection has been removed, the body will usually heal the infected tissue directly adjacent to the tooth. If the body does not heal the infected tissue, the infection may persist. Root-end surgery may be required, or the tooth may have to be removed. 3)Treatment may require multiple visits. It is important that scheduled appointments be maintained or the infection can reoccur. After root canal treatment, I understand that I will need to return to my general dentist for a permanent restoration of the tooth. 4)Endodontic treatment has a high degree of success. As any medical or dental treatment, however, this treatment has no guarantee of success for any length of time. Occasionally, the tooth that has had root canal treatment may require retreatment, root-end surgery, or even extraction. Teeth with previous root canal treatment that have to be re-treated will have a lower success rate. 5)The most common complications with root canal therapy include, but are not limited to: a)Chipping or breakage of the porcelain covering the surface of a crown or bridge. b)Although rare, breakage of root canal instruments or perforations (going outside the confines of the tooth or root) of the root canal with instruments happens. Usually correctable, these situations may require additional surgical corrective treatment, result in premature tooth loss, or require extraction of the tooth. Rarely, during the filling of the root canal, a root may split, requiring extraction of the tooth. c)Postoperative discomfort lasting a few hours to a few days for which medication will be prescribed, by the doctor, if deemed necessary. d)Postoperative swelling of the gum in the vicinity of the treated tooth or facial swelling either of which may persist for a few days longer. If the swelling remains persistent and healing does not occur, endodontic (root canal) surgery or extraction of the tooth may be required. e)Overflow of the gutta percha or cement which is used to permanently seal the root canal(s) of the tooth. In the majority of cases, this overfill is gradually reabsorbed or stays inactive. If this occurs, the healing process of the tooth will be monitored. 6)Nerve damage from dental injections, prior to root canal therapy, can happen, but is rare. This may cause a “tingling” or “numbness”, usually temporary; however, in some cases it can be permanent. 7)Other treatment choices include no treatment, waiting for more definitive development of symptoms, or tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, or infection to other areas. 8)No warranty or guarantee of success has been or can be given in root canal treatment. 9)I fully understand the statements in this consent form. In light of this information, I hereby authorize Dr. Gray to proceed with treatment. _________________________________________________ _____________________________________ Signature of patient/guardian Date _________________________________________________ _____________________________________ Signature of witness Date