LEHIGH VALLEY ENDODONTICS - Allentown, - PDF Document

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  1. Before we begin your treatment, we’d like you to know as much as possible about the risks which endodontic (root canal) therapy may pose and possible alternatives to endodontic treatment. You will be required to sign this consent prior to the initiation of the treatment however; it does not commit you to treatment. This consent serves to acknowledge that you have been informed and understand the following: Root Canal treatment is an attempt to retain a tooth, which may otherwise require extraction. I understand that it is a process involving removal of tissues in the center of the tooth (root canal) and the sealing of the space that is created during the process of removal and cleansing of the root canal system. I further understand that the root canal treatment may fail if proper restoration of the tooth is not completed after the root canal treatment is done, and that such restoration is a separate and distinct procedure with an additional fee. Although root canal therapy has a high degree of success, it cannot be guaranteed. The doctor will do everything in his power to achieve success, and avoid or minimize complications listed below. Initial root canal treatment success can be as high as 90%. Occasionally, a tooth which has had root canal therapy may need retreatment, microsurgery, or extraction. Retreatment and surgical success rates are approximately 70%. Risks of endodontic treatment are of two kinds: those risks associated with general dental procedures (in any office) and those risks specific to endodontic treatment (in our office). Risks of General Dental Procedures: Include (but are not limited to) complications resulting from the use of dental instruments, drugs sedation, medicines, analgesics (pain killers), anesthetics, and injections. These complications may include pain, infection, swelling, bleeding, sensitivity, numbness and tingling sensations in the lip, tongue, chin, gums, cheeks and teeth; thrombophlebitis (inflammation to a vein), reaction to injections, change in occlusion (biting), muscle cramps and spasms, temporomandibular (jaw) joint difficulty, loosening of teeth or restorations in teeth, injury to other tissues, referred pain to the ear, neck, head, nausea, vomiting, allergic reactions, itching, bruises, delayed healing, sinus complications, and further need for surgery. Initials _______ Medications: Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol and other drugs) thus, it is not advisable to operate any vehicle or hazardous device until recovered from the effects of the medication and drugs. Antibiotics may interfere with oral contraceptives and caution should be used during antibiotic use. Initials ______ Risks More Specific to Endodontic Therapy: Include the possibility of instruments broken within the root canals; perforations (extra openings) of the crown or the root of the tooth; damage to bridges, crowns, existing fillings, or porcelain veneers, loss of tooth structure in gaining access to the canals and fracture of tooth structure, and change in tooth color (becoming darker than adjacent teeth). During treatment, complications may be discovered which make endodontic treatment impossible, or which may require microsurgery or extraction. These complications may include blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal (gum) disease, and split or fractures of the teeth. Root canal treatment is an attempt to retain a tooth that may otherwise require extraction. Although the endodontic treatment performed will be performed in a manner which will minimize and avoid risks and has a very high degree of clinical success, it is still a biological procedure and cannot be guaranteed. Occasionally a tooth that has had root canal therapy may require retreatment, surgery, or even extraction. Initials ______ Alternatives to endodontic treatment: Include no treatment; waiting for more definitive development of symptoms; and extraction of the tooth. I understand the risks of no treatment include, but are not limited to infection, swelling, cyst formation, pain, and loss of tooth/teeth/and/or systemic disease. Initials ______ Consent: I have carefully read and understand the above statements about root canal therapy; my questions have been answered to my satisfaction, and I give my consent to the treatment described in this paper. _________________________________________________________________________________________________ Signature of Patient or Guardian (if patient is a minor) Consent form reviewed by: (Pennsylvania State law now requires a consent form prior to any endodontic procedure) LEHIGH VALLEY ENDODONTICS - Allentown, PC Informed Consent for Endodontic Treatment (root canal therapy) Date Doctor or Assistant