THIS IS A SAMPLE FORM THAT COULD BE USED IN THE DENTAL OFFICE FOR ENDODONTIC CONSENT AND INFORMATION - PDF Document

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  1. THIS IS A SAMPLE FORM THAT COULD BE USED IN THE DENTAL OFFICE FOR ENDODONTIC CONSENT AND INFORMATION 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 save a tooth which otherwise might need to be removed. This is accomplished by conservative root canal therapy, or when needed, endodontic surgery. The following discusses possible risks that can 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, bleed- ing, pain, infection, numbness and a tingling sensation on the lip, tongue, chin, gums, cheeks and teeth. These complica- tions are transitory, but on infrequent occasions can be permanent. Other risks include: 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, com- plications 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), splits or fractures of teeth. MEDICATIONS: Prescribed medications and drugs can cause drowsiness and lack of awareness and coordination (which can be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). It is not advisable to operate any vehicle or hazardous device until recovered from their effects. OTHER TREATMENT CHOICES: These include no treatment, waiting for more definite development of symptoms, tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth and infection to other areas. CONSENT: I, the undersigned, being the patient (parent or guardian of below minor patient) consent to 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 therapy in this office, I shall return for a permanent restoration 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 treatment, surgery or even extraction. __________________________________________________________________________________________________ DATE WITNESSED BY PATIENT OR PARENT SIGNATURE