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INFORMED CONSENT FOR ENDODONTIC (ROOT CANAL) TREATMENT

Please initial each item. Let Dr. Homa Azargoon know if you have questions
BEFORE initialing.

The goal of root canal treatment is to save a tooth that might otherwise require
extraction. Success rates for root canal treatment are 85-98% based on the scientific
literature. Root canal therapy is a dental-biological procedure and success is not
guaranteed. It is important that you understand and accept potential complications that
may occur during treatment and may affect the outcome of the treatment. Such
complications include, but are not limited to the following:
______Post-operative discomfort or sensitivity lasting a few hours to several days that
may require pain-relieving medications as deemed necessary by the dentist. ______Post-operative swelling of the surrounding gum tissues or face that may require antibiotics as deemed necessary by the dentist. ______Exacerbation or creation of restrictive mouth opening (TMJ, TMD, jaw muscle spasms, jaw muscle cramps) due to the length of time required to maintain an open mouth during root canal treatment procedures. ______Complications associated with anesthetics, chemicals or medications such as allergic reaction, fainting, heart palpitations, overdose, bruising, numbness and hematoma, which may last for days/weeks/months/permanently. ______Separation (breakage) of instruments in the canal that may, at the judgment of the dentist be left in the canal or require surgery. ______Perforation of the tooth/root, which may require additional surgical treatment by a specialist or result in the loss of the tooth. ______Damage to sinuses or nerves resulting in temporary or possibly permanent numbness or tingling of the lip, chin, tongue, or other areas. ______Irreversible damage of the tooth/restoration (especially porcelain restorations) during treatment that may require a new restoration and/or possibly loss of the tooth. Permanent crowns may come off during treatment and require replacement. ______Complications associated with past or current use of bisphosphonate therapies (i.e. Fosamax, Boniva), which may impact surgical or non-surgical endodontic treatment. ______I understand that an alternative treatment might be (but not limited to) extraction of the involved tooth or teeth. ______I understand that the consequences of doing nothing might be worsening of the condition, further infection, cystic formation, swelling, pain, loss of tooth, and/or other systemic disease problems. ______I understand the recommended treatment, the risks of such treatment, any alternatives and the risks of these alternatives including the consequences of doing nothing. Fee(s) involved have also been explained to me. ______Following the completion of root canal therapy, it is crucial that you return to your dentist for definitive restoration of the treated tooth. A temporary
restoration is included in the root canal therapy fee. It may be possible have a
permanent restoration placed in our office for an additional fee. The placement
of a permanent restoration should be done no later than 4 weeks, unless you
continue to have symptoms. If this occurs, please contact our office for further
evaluation. Failure to complete this important phase of treatment may result in
recontamination of the root canal system. This may lead to the need for
retreatment, surgery, or result in loss of the treated tooth.
______I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs, and that I have had sufficient opportunity for discussion and to have all of my questions answered. A follow up evaluation in 12 months is needed. This is considered a part of the therapy and there is no fee for this service. ______________________________________ ______________ Signature of patient, parent or guardian ______________________________________ ______________ Witness Signature

Source: http://www.booneendo.com/editor/assets/D5738D9B-526A-4335-A7B1-D1E880E7C02C.pdf

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