My dentist has informed me that root canal treatment is needed to maintain my tooth. It has been explained that root canals are needed because of tooth pain (pulpitis), or infection, or to aid restoration of a tooth. The goal of root canal treatment is to save a tooth that might otherwise require extraction. Although root canal treatment has a very high success rate, its is a procedure whose results cannot be guaranteed. Success can vary depending on the severity of infection, bacteria causing the infection and size and shape of the canals.
I understand that root canal treatment may not relieve my symptoms and treatment may sometimes fail
for unexplained reasons. Unresolved infection, recurrent infection, or continued discomfort may require
referral to a specialist for additional treatment. In some cases, treatment may not be successful and my
tooth may need to be extracted.
I understand there are alternatives to root canal treatment which include but are not limited to
- extraction or
- no treatment at all
These options have been discussed with me.
- Postoperative discomfort or sensitivity lasting a few hours to several days, which may last longer and radiate to other areas, with intensity from slight to extreme. Most commonly the tooth is temporarily sensitive to biting following each appointment along with mild to moderate localized discomfort in the area. Sometimes healing is delayed.
- Postoperative swelling, infection in the vicinity of the treated tooth, facial swelling, and/or discoloration
of tissues which may persist for several days or longer. Occasionally a small incision to drain the swelling is required.
- Restrictive mouth opening (trismus), jaw muscle spasm, jaw muscle cramps, temporomandibular joint
difficulty, or change in bite, which occurs infrequently and usually lasts for several days but may last longer.
- Failure rate of 5-10% under optimal conditions. If failure occurs, additional treatment will be required
such as: retreatment, endodontic surgery or extraction of the affected tooth. Retreatment (of previous
unsuccessful endodontic therapy) failure rates are higher, but vary due to suspected reason for failure.
- With some teeth, conventional endodontic (root canal) therapy alone may not be sufficient and
additional treatment may be required.
- Significant overfills or underfills of the filling
- If the canal(s) are severely bent, calcified/blocked, split or other condition which prevents complete
- If an endodontic instrument separates (breaks) in the tooth during treatment.
- Periodontal (gum) disease or problem in which periodontal treatment may be needed.
- Pre-existing fractures/cracks, Substantial infection in the bone, or Perforation of the root, tooth or sinus.
In some cases, follow-up visits may be recommended while in others an endodontic surgical procedure,
extraction, or other treatment may be required to resolve the problem. The doctor will explain the options
- Restoration Damage such as Porcelain Fracture while preparing an opening in the restoration or
removing restoration for access to the root canals. If damage occurs or another problem found such as a cavity, many can be "patched" while others may require replacement of the restoration. Rarely, a
restoration may be loosened.
- Premature tooth loss due to progressive periodontal (gum) disease and/or loosening of the tooth.
- Complications resulting from use of instruments, materials, medications, anesthetics, and injections,
including altered sensation (tingling or numbness) of the tongue, lip, chin, cheek, gums, which is very rare and usually temporary, but may be permanent.
I understand that after root canal therapy, my tooth will require an additional restoration (filling, onlay,
crown, or bridge). I realize that should I neglect to have the proper restoration within one month that there
is an increased risk of 1) failure of the endodontic therapy, 2) fracture of tooth and/or, 3) premature loss of
No guarantee of success or perfect result has been given to me. I understand the proposed treatment
may not be curative and/or successful to my complete satisfaction. The diagnosis, method and manner of
the proposed procedure(s), the nature and purpose, prognosis, risks of treatment and feasible
alternatives have been explained to me. I consent to endodontic (root canal) therapy and the
administration of local anesthetic. I may request oral sedation, nitrous oxide analgesia, or IV sedation. I
fully understand this consent form and it does not encompass the entire discussion regarding the
proposed treatment I had with the doctor. I have had the opportunity to question the doctor concerning the
nature of treatment, the inherent risks of treatment, and the alternatives to this treatment.
Patient (or Legal Guardian)
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