Information & Consent for Root Canal Therapy Form

Information & Consent for Root Canal Therapy

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Patient Information

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Information & Consent for Root Canal Therapy

Name:*

Tooth #*

1. Root Canal therapy is about 95 percent successful. Many factors influence the treatment outcome, the patient's general health bone support around the tooth, strength of the tooth including possible fracture, line, shape, and condition of the root and the nerve canal (s), fill separation, etc.
2. The treated tooth many normally be sensitive following appointments and remain tender for a time after treatment is completed. If sensitivity persists, and does not seem to be getting, even several weeks after the root therapy is finished, call the office immediately.
3. Teeth treated for root canal therapy must be protected during treatment. Between appointments, your tooth will have a temporary filing. If this should come out, please call the office Immediately and arrange to have It replaced.
4. Fractures are one of the main reasons why root canal treatment falls .DO NOT EAT ON THE TREATED TOOTH UNTIL PERMANENT CROWN IS PLACED . Unfortunately , some cracks that extend from the crown down into the root are Invisible and are virtually Impossible to detect. They can occur on uncrowned teeth from traumatic Injury, biting on hard objects, habitual clenching or grinding or even normal wear. Whether the fracture occurs before or after the root canal treatment, the many have to be extracted.
5. You could experience possible lip numbness when treating lower premolar and molars.
6. Since tooth with Root Canal Treatment is more brittle than other teeth. It is highly recommended that a post / core and permanent crown be made to finally restore the tooth. Because the tooth is not hollow, or will fracture easily. It is the tooth is not crowned, it may break, rendering It unrestorable and consequently require extraction.
THE POST / CORE & PERMANENT CROWN / RESTORATION ARE SEPARATE PROCEDURES AND ARE NOT INCLUDED IN THE ROOT CANAL TREATMENT FEE ***

Patient Initials*

7. With some teeth , conventional root canal treatment alone may not be sufficient . If the canal ( s ) are several bent or calcified , if there is substantial or long standing Infection in the bone , or if a metal file or Instrument becomes separated within a canal , the tooth may remain sensitive and surgical procedure may be necessary to resolve the problem.
8. When removing your existing crown the porcelain or tooth may chip or fracture . If the doctor must remove your existing crown to achieve proper access to the canals , the removal procedure may cause the crown porcelain or the tooth to fracture . Therefore , the crown may have to be remade or the tooth extracted.
9. There are alternatives to root canal therapy . They include no treatment at all , extraction with nothing to fill the space , and extraction followed by a bridge , partial denture , or implant to fill the space.
The nature and cost of root canal therapy and crown repair has been explained to me . I have all of me question answered related to root canal therapy and post / core crown repair . I understand that success with root canal treatment cannot be guaranteed and understand that root canal therapy is necessary .

I authorized Dr.

Doctor Name*

to proceed with root canal treatment.

SIGNATURE OF PATIENT (or Legal Guardian)*

SIGNATURE OF DENTIST*

SIGNATURE OF DENTAL ASSISTANT

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