Westside Family Dentistry - PDF Document

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  1. Westside Family Dentistry 2330 Buffalo Rd. Bldg 800A ROCHESTER, NY 14624 Phone (585) 247-1530 Emergency phone (585) 889-9539 Email: wfdentistry14624@gmail.com PATIENT INFORMATION AND CONSENT FOR ROOT CANAL TREATMENT (ENDODONTICS) Patient Name______________________________ Date ________________ Planned Diagnostic Procedure______________________________________________________ ________________________________________________________________________________ Planned Treatment _______________________________________________________________ What is root canal treatment and what are its benefits? Root canal treatment is the procedure of cleaning diseased or infected tissue from inside the tooth followed by placement of a seal in the root canal. Using a local anesthetic, there is little or no discomfort during the procedure. Root canal therapy allows the tooth to remain in the mouth and contribute to sound, healthy and functional dentition for many years, if not a lifetime. The practice of Endodontics also includes such procedures as bleaching, inducing closure of immature diseased roots, treatment of traumatic injuries and the fabrication of posts and buildups under crowns. What are the complications of treatment? With a success rate of approximately 95%, Endodontic therapy is one of the most reliable dental or medical procedures, and complications are not expected. However, there can be no absolute guarantee regarding treatment success. Some very infrequent complications include, but are not limited to: the possibility of perforation of the tooth or root, damage to existing restorations (fillings), the possibility of a split or fractured tooth, the possibility of separation of a portion of an instrument that cannot be removed from within the tooth, unexpected or unanticipated reactions to materials used during the procedure, and the possibility of pain, swelling and infection. The use of prescription drugs during treatment may also result in unexpected drug reactions. Any of these complications could result in failure of the procedure requiring possible retreatment or extraction of the tooth. What alternatives do you have? Extraction of the tooth is an alternative. If the tooth is removed and not replaced, the empty space will create problems in tooth alignment because of shifting and opposing teeth. This may result in periodontal (gum) disease and you could lose more teeth as a consequence. The missing tooth may be replaced by a bridge, partial denture or dental implant and crown. The cost for these alternative procedures is usually more expensive than root canal treatment, and may involve dental work on adjacent teeth. The option of no treatment often results in persistent or recurrent pain and infection in the affected tooth. If any doubt exists in your mind about treatment, we encourage you to seek a second opinion. What are your responsibilities? It is important to provide a complete and accurate medical history. Please understand that after root canal treatment, it is usually wise to have the tooth properly restored within a reasonably short time. Depending on your situation, certain other post-treatment precautions or special instructions must be followed (such instructions will be given to you separately by the doctor or staff). I have read the above form and have been given the opportunity to ask questions. I authorize my doctor to perform the diagnostic procedures and root canal treatment outlined above. PRINT _________________________________________________________________________________ Patient’s (or Legal Guardian’s) Signature Date _________________________________________________________________________________ Doctor’s Signature Date _________________________________________________________________________________ Witness’ Signature Date REV 9-23-2015