Endodontic Treatment Consent Form printable pdf download

Endodontic Treatment Consent Form

Tooth #: _______

Risks of Endodontic Treatment

 I understand that many factors contribute to the success of root canal treatment and not all factors can be determined in

advance. Some of the factors are: my resistance to infection; the bacteria causing the infection; the size, shape, and location of

the canals. My case may be more difficult if my tooth has blocked, curved, or narrow canals.

 I understand that root canal treatment may not relieve my symptoms and treatment can sometimes fail for unexplained

reasons. If treatment fails, other procedures (including re-treatment or surgery) may be necessary to retain the tooth, or it may

have to be extracted.

 I understand that during and after treatment, I may experience some pain or discomfort, swelling, bleeding and loosening of

dental restorations. I may also need antibiotics to treat any associated infections.

 I understand that root canal instruments sometimes separate (break) inside the canal, which may or may not affect the

prognosis. If the separated fragment cannot be retrieved, it may be sealed inside the root canal, or require additional treatment

in the future.

 I understand that other risks include perforation by an instrument, sinus perforation and/or nerve disturbances.

 I understand local anesthetic will be given. Some discomfort following treatment may develop from the injection area and

from opening my mouth during treatment. On rare occasions, paresthesia of the nerve may occur.

 I understand that once root canal treatment is completed, I must have a permanent restoration placed by my regular

dentist within the next few weeks. If I fail to have the tooth restored, I risk a failure of the root canal treatment, decay,

infection, tooth fracture and/or loss of the tooth.

Alternatives to Endodontic Treatment

Depending on my diagnosis, there may be alternatives to root canal treatment that involve other types of dental care. I

understand the most common alternatives to root canal treatment are:

Extraction: I may choose to have this tooth removed. The extracted tooth usually requires replacement by an artificial tooth

by means of a fixed bridge, dental implant, or removable partial denture.

No treatment: I may choose to not have any treatment performed at all. If I choose no treatment, my condition may worsen

and I may risk serious personal injury, including severe pain, localized severe pain, localized infection, loss of this tooth and

possible other teeth, severe swelling, and/or severe infection that may spread to other areas and could be potentially fatal.

I acknowledge that I have provided an accurate medical history, will follow treatment recommendations, and have had the

opportunity to ask questions about these risks in continuing with root canal treatment.

Patient’s Signature ________________________________________________________ Date: __________________

Patient’s Printed Name ______________________________________________________ Date: __________________

Provider’s Signature: _______________________________________________________ Date: __________________

Endodontic Treatment Consent Form