Bay Dental Group, LLC Cheryl S. Budd, DMD, Member Diplomate, American Board of Endodontics Information and Consent for Endodontic Treatment - PDF Document

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  1. Bay Dental Group, LLC Cheryl S. Budd, DMD, Member Diplomate, American Board of Endodontics Information and Consent for Endodontic Treatment We would like our patients to be informed about the procedures involved in root canal therapy and have their consent before starting treatment. Root canal treatment is performed in order to save a tooth which otherwise might need to be removed (extracted). Root canal therapy: Root canal therapy is performed when the pulp of the tooth has been damaged, usually by decay or physical trauma. Treatment consists of removing the pulp( the soft tissue inside the tooth), and cleaning, disinfection, filling, and sealing the canals inside the root of the tooth. In most cases the tooth will be numbed for root canal in the same way a tooth is numbed for a filling. Following the completed root canal procedure, the tooth will have some type of temporary filling on it. After a period of initial healing you will be asked to see your general dentist to place a permanent filling and/or a crown on the tooth, or whichever type of permanent restoration your dentist deems appropriate. Although root canal treatment is most often successful, its success cannot be guaranteed. Its success is determined primarily by the biologic makeup of each individual person. Success is also determined by how well the person’s body heals, how well the individual takes care of the tooth, the anatomy of the roots, how well the canals can be sealed, the relationship of this tooth to opposing teeth, how well the tooth is restored after the root canal, and other factors. Sometimes a tooth which has had root canal treatment may require re-treatment, an endodontic surgical procedure on the roots, or even extraction. Complications and Risks: Complications that may occur from Endodontic treatment include, but are not limited to, the following: the possibility of instruments broken within the root canal; perforations (extra openings) of the crown or root of the tooth; damage to existing bridges, filling, crowns (porcelain crowns, metal crowns or other types of crowns), veneers; loss of tooth structure in gaining access to canals; cracked teeth. In rare cases, muscle trismus (soreness and limitation to opening the jaw), long-term numbness, tingling of the face, or nerve damage, may occur. During treatment, complications may be discovered which make treatment impossible, or which may require dental surgery. These complications may include, but are not limited to, the following: blocked canals due to fillings or prior dental treatment, natural calcification, broken instruments, curved roots, periodontal disease (gum disease), splits, cracks, or fractures of the teeth. If a porcelain crown or other type of crown, veneer, or bridge already exists on the tooth, a new crown or bridge may be needed after the root canal is completed. Medications: Some types of medications prescribed either before or after root canal therapy may cause drowsiness and lack of awareness. These medications and their affects may be influenced by the use of alcohol, tranquilizers, sedatives, or other drugs. For some medicines, it is not advisable to operate any vehicle or hazardous device until recovered from the effects of the medicines. Initial_________________ Date_________________

  2. Other Treatment Choices: Other treatment choices include: no treatment, waiting for more definitive development of symptoms, or tooth extraction. Consent: I, the undersigned, being the patient (or parent or guardian of a minor patient, special needs patient, or elderly patient) consent to the performing of procedures decided to be necessary or advisable in the opinion of Dr. Budd. I also understand that upon completion of root canal therapy in this office, I shall return to my general family dentist in a timely manner for a permanent restoration (filling, crown, or other) of the tooth involved. I also understand that periodic follow-up exams, x-rays are needed to monitor the healing progress of the treated tooth. These follow-up visits may occur at my general dentist’s office or Dr. Budd’s office and are in addition to the root canal fee. I consent to administration of local anesthesia by Dr. Budd and to the use of such anesthetics, as she may deem advisable. I also consent to the administration of pretreatment or post treatment medication as deemed necessary. I consent to the disposal by Dr. Budd or whomever she may designate of any tissue or parts that may be removed. I understand that root canal treatment is an attempt to save a tooth that may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Sometimes a tooth that has had a root canal treatment may require retreatment, endodontic surgery, or even extraction. I also understand that if a fine file severs inside a root it may lead to future failure, future endodontic surgery, or extraction of the tooth. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained. I certify that I have read and fully understand the above consent to treatment, that the explanation therein referred to were made, and that all blanks or statements requiring insertion or completion were filled in, and inapplicable paragraphs, in any, were stricken before I signed. I understand that I may request a copy of this form and acknowledge receipt of this copy. ______________ ______________________________________________ _____________ Date Patients Signature ______________________________________________ Printed Name of Patient Witnessed by