Consent for Endodontic Treatment - PDF Document

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  1. Consent for Endodontic Treatment PATIENT’S NAME (PRINT) __________________________________________Tooth/Teeth#__________ Please be reassured that we use accepted infection control procedures and universal precautions for the protection of our patients and staff. Endodontic Root Canal Therapy, Endodontic Surgery, Anesthetic, and Medications. While serious complications associated with root canal therapy are very rare, we would like our patients to be informed about the various procedures involved in endodontic therapy and have their consent before starting treatment. Endodontic (root canal) therapy is performed in order to attempt to save a tooth which otherwise might need to be removed. This is accomplished with possible risks that may occur from endodontic treatment, and other treatment choices. Risks: Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections. These complications include swelling, sensitivity, bleeding pain, infection, numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth – which is transient but, on infrequent occasions, may be permanent, reaction to injections, changes in occlusion (biting), jaw muscle cramps and spasms, temporomandibular (jaw) joint difficulty, loosening of teeth, referred pain to ear, neck, and head, nausea, vomiting, allergic reactions, delayed healing, sinus perforations, and treatment failure. Risks more Specific to Endodontic Therapy: The risks include the possibility of instruments broken within the root canals; perforations (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns, or porcelain veneers, loss of tooth structure in gaining access to canals; and cracked teeth. During treatment, complications may be discovered which make treatment impossible or which may require dental surgery. These complications may include blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal disease (gum disease), and splits or fractures of the teeth. Medications: Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol, tranquilizers, sedatives, or drugs). It is not advisable to operate any vehicle or hazardous device until recovered from their effects. Birth Control Pills are not effective when taking antibiotics. Other Treatment Choices: These include no treatment, waiting for more definite development of symptoms, or tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection to other areas. The prognosis for this/these procedure(s) was described as: (please leave for the doctor to check) Favorable Questionable Unfavorable Consent I, the undersigned, being the patient (parent or guardian of the above minor patient), consent to the performing of procedures decided upon to be necessary or advisable in the opinion of the doctor. I also understand that, upon completion of root canal in this office, I should return to my general dentist for a permanent restoration such as a crown, cap, jacket onlay, or silver filling of the tooth involved. I understand that root canal treatment is an attempt to save a tooth, which may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Occasionally, a tooth, which has had root canal therapy, may require retreatment, surgery, or extraction. It has also been fully explained to me that if my tooth, which is treatment planned for endodontic therapy, is restored with porcelain restoration, in the event the porcelain should crack or fracture during treatment, Dr. Gosier is not responsible for replacing or repairing said porcelain. It has been explained to me and I understand that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted. UPON COMPLETION OF MY ROOT CANAL TREATMENT, I UNDERSTAND THAT I AM TO RETURN TO MY GENERAL DENTIST FOR PERMANENT RESTORATION IMMEDIATELY! Patient’s signature ____________________________________________________________ Date _______________________ Doctor’s signature ____________________________________________________________ Date _______________________

  2. Witness’s signature ___________________________________________________________ Date _______________________