Reasons for Treatment

Endodontic (root canal) therapy is accomplished in an effort to save a tooth which otherwise would require extraction. Treatment is done by standard root canal therapy, or when necessary, endodontic surgery.

Other Treatment Choices

These include no treatment at all, waiting for more definitive symptoms to develop, and tooth extraction. The risks involved in these choices may include pain, infection, swelling, loss of teeth and spread of infection to other areas.

Risks Specific to Endodontic Therapy

Those risks include the possibility of instruments broken within the root canals, perforation(s) (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns, fracture of porcelain, loss of tooth structure in obtaining access to the canals, and cracked teeth. During treatment complications may be discovered which make treatment impossible, or which may require endodontic surgery. These complications may include: blocked canals due to previous fillings or prior root canal treatment, natural calcification(s), broken instruments, curved roots, periodontal disease (gum disease), splits or fractures of the root and resorption. Broken instrument removal, retreatment or post removal may cause damage to the root/tooth structure.

Other Risks of Treatment including Local Anesthetics

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, reaction to injections, changes in occlusion (bite), jaw muscle cramps and spasms, temporomandibular joint (TMJ) difficulty or injury to the jaw and supporting structures. Pre-existing problems with TMJ jaw joint maybe aggravated or worsened as a result of treatment, loosening of teeth, referred pain to the ear, neck and head, nausea, vomiting, allergic reactions, delayed healing, sinus perforations and treatment failure. Certain medical conditions such as diabetes, autoimmune or connective tissue disorders may cause non-healing or continuation of symptoms after root canal therapy.

Medications

Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be worsened by the use of alcohol, tranquilizers, sedatives or other drugs). It is not advisable to operate any vehicle or hazardous device until recovered from their effects.

Consent

I, the undersigned, being the patient (parent or guardian of minor patient) consent to the performing of procedures deemed advisable in the opinion of the doctor.

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 I am responsible for treatment failure if my tooth is not permanently restored in a timely manner (typically one month).

I understand, and it has been explained to me, that there are some risks in the administration of local anesthetics. Most risks are related to the position of the nerves under the tissue at the site of the injection which cannot be determined prior to the administration of the anesthetic agent. Although the risks seldom occur they might include loss of, or disturbed sensation of the tongue and lip on the side of the injection. If this occurs, it is often temporary, and normal sensation usually returns in several days. However, in very rare cases the loss of sensation may extend for a longer period and may become permanent. In addition, injecting a foreign substance into the body such as an anesthetic agent may result in an allergic reaction. Allergic reactions to these agents are rare, but may take place.

I further understand that individual reactions to treatment cannot be predicted, and that if I experience any unanticipated reactions following the injection(s), I agree to report them to the office as soon as possible.

I have been told that the success of my dental treatment depends upon my cooperation in keeping scheduled appointments, following home care instruction, including oral hygiene and dietary instructions, taking prescribed medication and reporting to the office any change in my health status.

I acknowledge that no guarantees or assurances have been given by anyone as to the results that may be obtained.

Form Completion

I have read and understand the above information. By my signature below, I acknowledge my financial responsibility for all fees incurred regardless of my insurance reimbursement.

If Patient is a Minor