Endodontic Consent and Information form

We would like our patients to be informed about the various procedures involved in endodontics therapy and have their consent before starting treatment. Conservative root canal therapy or endodontic surgery might be required for complete treatment of the tooth. The following discusses possible risks that may occur from endodontic treatment and other treatment choices.

Risks Specific to Endodontic Therapy

• The possibility of instruments breakage within the root canals: extra openings of the crown or root of the tooth.
• Damaged bridges, existing fillings, crowns or porcelain veneers.
• Loss of tooth structure in gaining access to canals.
• Cracked teeth.

During treatment, complications may occur which make treatment impossible or which may require dental surgery.

Other Treatment Choices

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

Consent

I, the undersigned, being the patient (parents or guardian of minor patient) consent to the performing of procedures decided upon to be necessary or advisable in the opinion of the doctor. I understand that root canal treatment is an attempt to save a tooth that might otherwise required extraction. Although root canal therapy has a very high degree of success, it cannot be guaranteed.

Signature:__________________________

Date:____________________________

Place:___________________