Root Canal Treatment (RCT) Consent Form: - PDF Document

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  1. Root Canal Treatment (RCT) Consent Form: I have been informed that there are certain inherent and potential risks associated with root canal treatment. I understand that during and after treatment I may experience pain or discomfort, swelling, changes in my bite, loosening and loss of dental restorations. I understand that it is possible for an infection to occur, or an existing infection to worsen in the tooth being treated or in the area around the tooth, and that I may need antibiotics and or other procedures to treat the infection. I understand that sometimes root canal instruments separate (break) inside the canal. If the separated fragment cannot be retrieved, it may need to be sealed inside the root canal. It may also be necessary to have additional procedures performed on root to address the problem. To prevent this, all root canal filing instruments are used only once, which is at the expense of $128 per tooth. I understand that other risks include: perforation of the tooth, or tooth root by an instrument, injury to soft tissues adjacent to the tooth, sinus perforation, and nerve disturbances such as temporary or permanent numbness, itching, burning, or tingling of the lip, tongue, chin, teeth Root canal Therapy: The procedure requires removing the nerve and other tissues (pulp) from inside the tooth and its roots. It is done by first making an opening through the chewing surface of the tooth to gain access to the tooth’s pulp. The contents of the canals are removed and the canals are cleaned and shaped. The canals are then filled and sealed with a material called gutta percha. Following root canal therapy, the tooth will need a final restoration, usually a crown, to return it to proper function. The final restoration is not part of the procedure today. I have provided an accurate and complete medical and personal history. I will follow any and all treatment and post treatment instruction as explained and directed to me. I realize that in spite of the complications and risks, my recommended treatment is necessary. Root Canal Treatment is recommended for me for tooth number: __________. and/or mouth tissues. I understand that many factors contribute to the success of root canal treatment and not all factors can be predicted in advance. I understand that my case may be more difficult if my tooth has blocked, curved or very narrow canals. I understand that RCT may not relieve my symptoms, that treatment can fail during and after the completion of treatment and that it may fail for unexplainable reasons. If treatment and/or other procedures fail (including root canal retreatment) it may be necessary to retain the tooth or it may require extraction. I understand that when root canal therapy is concluded, I must promptly return to bleeding, begin the next step treatment. If I fail to return to have the tooth restored, I risk a failure of the RCT, infection, and tooth fracture, even loss of the tooth. in I understand that this procedure can also be performed by an endodontist (a dental specialist). I understand the risks and elect to have this procedure done by Dr. Augustyn/Dr. Singh. I understand that if any unexpected difficulties occur during treatment, I may be referred to an endodontist for further care. decay, possible I understand that I will be given a local anesthetic injection and in rare instances patients could experience temporary or permanent injury to nerves and or blood vessels from injection. I understand that injection areas may be following treatment and that my jaw may be stiff and sore from holding my mouth open during treatment. uncomfortable Signature: Witness Signature: Date: