Endodontic Consent and Information Form
Root Canal Therapy, Apexification, Endodontic Surgery, Anesthetics, and Medications
We would like to inform you about 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 that otherwise might need to be removed. This is accomplished by conservative root canal therapy, or when needed, endodontic surgery. The following discusses possible risks that may occur from endodontic treatment and other treatment choices.
- 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 infrequent occasions may be permanent; reaction to injections; changes in occlusion (biting); jaw muscle cramps and spasms; temporomandibular (jaw) joint difficulty; loosening of teeth; referred pain to ear, neck, and head; nausea; vomiting; allergic reactions; delayed healing; sinus perforations and treatment failure.
Risks More Specific to Endodontic Therapy
- The risks include the possibility of instruments broken within the root canals; extrusion of endodontic irrigating solution causing facial swelling; extrusion of filling materials necessitating further treatment; perforations (extra openings) of the crown or 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 include blocked canals due to fillings or prior treatment; natural calcifications; broken instruments; curved roots; periodontal disease (gum disease); and splits or fractures of the teeth.
- Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol, tranquilizers, sedatives, or other drugs). It is not advisable to operate any vehicle or hazardous device until recovered from its effects.
- If you have been treated with Bisphosphonate drugs, you should know that there is a small but real risk of a future complication called Bisphosphonate Related Osteo Necrosis of the Jaws (BRONJ). An infection may occur in the soft tissue and/or inside the bone. This is a long-term process that deteriorates the jawbone and is very often hard or even impossible to cure. We must know the medications and drugs that you have received or taken in the past along with your current medications.
Other Treatment Choices
- These include no treatment, waiting for more definite development of symptoms, and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection in other areas.
- Many procedures in our office include the use of sharp instruments which may come in contact with your blood and saliva, which may contain bloodborne pathogens. In the unlikely event that an employee of our practice is stuck by a needle or sharp instrument, during or following a procedure, you will be asked to submit to a blood test. This protocol is mandated by OSHA, and is meant to protect you and our staff.
- We are following all guidelines to minimize the risk of COVID-19 transmission. Unfortunately, even after following protocols set by the CDC, American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office.
- I have been advised to my satisfaction of the available alternatives and I have been given the opportunity to ask questions about the endodontic procedure. By signing this form, I am fully consenting to the suggested procedure.
Consent and Permission for Endodontic Procedure
- I, the undersigned, consent to the performing of an examination and/or endodontic procedure that has been decided upon to be necessary or advisable in the opinion of the doctors. I HAVE BEEN EXAMINED AND UNDERSTAND THE GIVEN EXPLANATION OF TREATMENT. I CONSENT TO PROCEED WITH THIS PROCEDURE. The doctors DO NOT guarantee the results of any root canal procedure. I also understand that I am to return to my dentist for permanent restorations of the treated teeth.
Should treatment be necessary,
you will be asked to sign this form in our office.