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Endodontic Consent and Information Form

We would like to inform you of the various procedures involved in endodontic therapy and have your 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. The following discusses possible risks, that may occur from endodontic treatment .

Endodontic Therapy, Risks, Anesthetics and Medications

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; bleeding; pain; infection; numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth, which is transient but, on rare occasions, may be permanent; reactions to injections; changes to occlusion (biting); jaw muscle spasms and cramps; tempromandibular (jaw) joint difficulty; loosening of teeth; referred pain to ear, neck and head; nausea; vomiting; allergic reactions; delayed healing; and treatment failure.

Risks more specific to endodontic therapy:

The risks include the possibility of broken instruments within the root canals; perforations (extra openings) of the crown or the 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, complications 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.

Other treatment choices:

These include no treatment, waiting for more definite symptoms, and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth and infection to other areas.


I, the undersigned, being the patient, parent or guardian 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 involved, such as a crown, cap, jacket, onlay or silver/composite filling. I realize that a check up x-ray should be taken in 6 months by my own dentist or by the treating endodontist. I understand that root canal therapy has a very high degree of clinical success; it is still a biological procedure and cannot be guaranteed. Occasionally a tooth which has had root canal therapy may require retreatment, surgery, or even extraction. I am aware of alternate forms of treatment and the risks and benefits of each, including no treatment. I certify that I have read and fully understand the authorization that I am about to sign for the proposed treatment, medication, or surgery, described above. I accept the risks of substantial harms, if any, in hopes of obtaining the desired beneficial results of this treatment or procedure. I ask that Dr. Lindemann provide the recommended treatment.

Parent or Guardian if patient is a minor

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