ENDODONTIC CONSENT AND INFORMATION FORM We want to inform our patients about the various procedures involved in Endodontic Therapy and have their consent before starting treatment. Endodontic (root - PDF Document

Presentation Transcript

  1. ENDODONTIC CONSENT AND INFORMATION FORM We want to inform our patients about the various procedures involved in Endodontic Therapy and have their consent before starting treatment. Endodontic (root canal) Therapy is performed to save a tooth which otherwise might need to be removed. The alternatives to Endodontic Therapy include no treatment, waiting for more symptoms, or extraction of the tooth. Risks involved in these choices might include pain, infection, swelling and tooth loss. Endodontics or root canal therapy is the cleaning, shaping, disinfecting, and filling of the root canal(s) of the diseased tooth. A minimal number of x-rays will be taken as indicated by the needs of treatment. We use state-of- the-art computer enhanced x-rays requiring half of the radiation of conventional x-rays. (1) As a rule, 90-95% of routine cases are successful. Endodontics, as with any branch of medicine or dentistry, is not an exact science. Thus, no guarantee of treatment success can be given or implied. If the original treatment is not successful, it may be retreated, a surgical procedure may be required, or the tooth may need to be extracted. (2) Endodontic treatment started in other offices or retreatment cases may have a different outcome than expected under optimal conditions. (3) Proper post-treatment restoration of the treated tooth is a necessity. Please contact your general dentist after the completion of your endodontic therapy for the proper restoration of your tooth. Most teeth will require a crown. Do not chew hard foods on your tooth until your dentist has a chance to restore the tooth and gives you the OK to chew hard foods again. Otherwise the tooth may break or even split, requiring more extensive treatment or even extraction. (4) Treatment will include a local anesthetic to numb your tooth. In rare instances numbing with local anesthetic can bruise or injure a nerve leaving a paresthesia. This means when the numbness wears off, there still is some numb sensation. This paresthesia is rarely permanent but can take weeks or months to resolve. (5) Possible unavoidable complications of Endodontic Therapy include: swelling, soreness, or muscle spasms (trismus), fracture of the crown or root; separation of endodontic instruments during treatment; blocked canals due to fillings or prior treatment, natural calcifications, severely curved roots, root resorptions; damage to bridges, existing fillings, crowns, or porcelain veneers. ** Medications: If you are prescribed pain medications, they cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol, tranquilizers, or other drugs). It is not advisable to operate any vehicle or hazardous device until fully recovered from their effects. ** Other treatment choices: These include no treatment, waiting for more definite development of symptoms, and 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 (or parent/guardian of a 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 therapy in this office, I shall return to my general family dentist for a permanent restoration of the tooth, such as a crown, cap, jacket, onlay or filling. 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 even extraction. I understand that if complications should arise, I should contact Dr. Vargo, Dr. Southern or my referring dentist. ____________________________________ _____________________ PATIENT SIGNATURE DATE ____________________________________ ______________________ PARENT/GUARDIAN (IF PATIENT IS A MINOR) WITNESS