Endodontic Consent Form

Please be assured we use proper infection control procedures and universal precaution for the protection of our patients and staff.

Root Canal Therapy, Endodontic Surgery, Anesthetics and Medication

While serious complications with endodontic (root canal) therapies are very rare, we would like our patients to be informed about the
various procedures involved and have their consent before starting treatment. Endodontic therapy is performed to save a tooth that
otherwise might need to be extracted. This is accomplished by conservative root canal therapy or endodontic surgery. The following
discusses possible risks involved with endodontic therapy and other treatment choices.

Risks: Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines,
analgesics, anesthetics, and injections. These complications include swelling, sensitivity, bleeding, pain, infection, transient or permanent
numbness and tingling sensation in the lip, tongue, cheek, gums, and teeth (very infrequent complications from injections), changes in
occlusion (bite), jaw muscle cramps and spasms, TMJ difficulty, loosening of teeth, referred pain to ear, neck and head, nausea, vomiting,
allergic reaction, delayed healing, sinus perforation, and treatment failure.

Risks Specific to Endodontic Therapy: Possibility of instruments broken within the root canal, perforation (extra opening) of the
crown or root of the tooth, damages to bridges, crowns, existing fillings or porcelain veneers, loss of tooth structure in gaining access to
canals and cracked teeth. During treatment, complications could arise 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 root, periodontal (gum) disease and splits or fractures of the teeth.

Medications: Prescribed medications and drugs may cause drowsiness or lack of awareness and coordination that may be increase by
the use of alcohol, tranquilizers, sedatives or other drugs. It is not advisable to operate any vehicle or hazardous device until you have
recovered from the effect of any medication. Birth control pills are not effective when taking antibiotics.

Other Treatment Options: These include no treatment or waiting for more definitive development of symptoms, or tooth extraction.
Risk involved in these choices may include pain, infection, swelling, loss of teeth and infection in other areas.

Consent

I, undersigned, being the patient, parent or guardian of the patient, consent to the performance of procedures decided upon as necessary
or advisable in the opinion of the doctor. I also understand that upon completion of root canal therapy in this office I should return to my
referring general dentist.
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 extraction.