Root Canal Treatment Patient Information and Consent Form Dr. Karla Macias-Diaz Endodontic Treatment Consent Form • I understand that many factors contribute to the success of root canal treatment and not all factors can be determined in advance. Some of the factors are: my resistance to infection; the bacteria causing the infection; the size, shape, and location of the canals. My case may be more difficult if my tooth has blocked, curved, or narrow canals. • I understand that root canal treatment may not relieve my symptoms and treatment can sometimes fail for unexplained reasons. If treatment fails, other procedures (including re-treatment or surgery) may be necessary to retain the tooth, or it may have to be extracted. • I understand that during and after treatment, I may experience some pain or discomfort, swelling, bleeding and loosening of dental restorations. I may also need antibiotics to treat any associated infections. This medication may have side effects, to include but nor limited to, nausea, dizziness, drowsiness, diarrhea, or allergy, (itching, rash, hives or difficulty breathing). It is my responsibility to call immediately if the above side effects occur. • I understand that root canal instruments sometimes separate (break) inside the canal which may or may not effect the prognosis. If the separated fragment cannot be retrieved, it may be sealed inside the root canal, or require additional treatment in the future. • I understand that other risks include perforation by an instrument, sinus perforation and/or nerve disturbances. • I understand local anesthetic will be given. Some discomfort following treatment may develop from the injection area and from opening my mouth during treatment. On rare occasions, paresthesia of the nerve may occur. • I understand that access to the root canal trough a crown, bridge, any type filling (existing restoration), etc. Will result in necessary repair or replacement of the restoration. This necessary repair is a consequence of root canal treatment and not a fault by my dentist. • I understand that once root canal treatment is completed, I must have a permanent restoration placed by my dentist within the next few weeks. If I fail to have the tooth restored, I risk a failure of the root canal treatment, decay, infection, tooth fracture and/or loss of the tooth. Alternatives to Endodontic Treatment Depending on my diagnosis, there may be alternatives to root canal treatment that involve other types of dental care. I understand the most common alternatives to root canal treatment are: • Extraction. I may choose to have this tooth removed. The extracted tooth usually requires replacement by an artificial tooth by means of a fixed bridge, dental implant, or removable partial denture. • No treatment. I may choose to not have any treatment performed at all. If I choose no treatment, my condition may worsen and I may risk serious personal injury, including severe pain, localized severe pain, localized infection, loss of this tooth and possible other teeth, severe swelling, and/or severe infection that may spread to other areas and could be potentially fatal. Local Anesthesia: I agree to the type of anesthesia, depending on the choice of the doctor. I understand the risk of the anesthesia, including but not limited to, allergy to the anesthetic and broken needle. I understand that pain, bruising and occasional temporary or sometimes permanent numbness in lips, cheeks, tongue or associated facial structures can occur with “Shots” (local anesthesia). About 90% of these cases resolve themselves in less than 8 weeks. Although very rarely needed, a referral to specialist for evaluation and possible treatment may be needed if the symptoms do not resolve. I consent my dentist to give me anesthesia anytime it is needed. I acknowledge that I have provided an accurate medical history, will follow treatment recommendations, and have had the opportunity to ask questions about these risks in continuing with root canal ____________________________________________________________________________________________ Signature of Patient or legal guardian If the patient is unable to sign or is a minor.