Informed Consent for Treatment

You will be asked to sign this document if a root canal is needed. 

  • Endodontic therapy (root canal treatment) is a dental procedure that is done to save a tooth that may otherwise be lost (extracted), and allows you to preserve your natural teeth. It involves the removal of the diseased pulp tissue from the inside of the tooth (the canal/s), cleaning, shaping and disinfecting the canals, and then the sealing of the canals to prevent further infection.
  • Endodontic therapy has a high degree of success; however, it is a biological procedure, and as with any medical or dental procedure not all teeth respond favorably to treatment. As a result there cannot be any guarantee of success, nor can success be predicted for any length of time. Teeth with previous root canal treatment will have a lower success rate.
  • Treatment may require multiple visits. It is important to keep scheduled appointments or infection, swelling and/or pain, can recur, or the tooth may become unable to be saved and therefore require extraction.
  • After the Endodontic therapy is completed the final restoration in the tooth is placed by your regular dentist. If the tooth has a crown, then your dentist will repair the crown with a permanent filling. If the tooth does not have a crown your dentist will determine the best way to restore the tooth, which usually requires the placement of a crown. Failure to return to your regular dentist to restore the tooth can result in decay, failure of the endodontic procedure, infection, tooth fracture, or premature loss of the tooth.
  • Alternatives to Endodontic therapy include extraction or having no treatment. In the event no treatment is done, there is the risk of infection, bone loss due to infection, systemic infection (affecting the whole body), swelling, pain, and/or loss of the tooth.
  • Risks or complications of treatment are rare but may occur. Some of the inherent risks and complications may include, but are not limited to: swelling and/or persistent infection; the possible necessity of antibiotics; pain; the need for pain medication; delayed healing; tooth fracture; loosening of teeth, crowns, bridges; fracture of veneers and/or porcelain crowns; numbness and/or tingling sensation in the lip, tongue, chin, gums, cheeks and teeth which is usually temporary but could be permanent; perforations of the tooth, root, sinus; separated (broken) instruments within the tooth; overfilling of root canal filling material; reaction to medications including but not limited to anesthetics, irrigating solutions, intracanal medications, antibiotics, analgesics (for pain); jaw muscle cramps, spasms, temporomandibular joint (jaw joint) difficulty; missed, calcified, blocked, or non-negotiable (non-treatable) canals.
  • Women: If birth control pills are being used, and antibiotics are prescribed, an alternate form of contraception is appropriate, since antibiotics may interfere with the effectiveness of oral contraceptives.
  • Pregnant Women: Medical clearance for dental treatment may be needed from the physician who is overseeing your pregnancy.
  • Pain medication can cause drowsiness, dizziness, or nausea. You should not drive an automobile or operate equipment that may be hazardous to yourself or others.

I have read the above and I understand that no treatment is without some measure of risk and the risks of the proposed treatment have been explained to me. I hereby authorize the doctors and their assistants to perform the necessary endodontic therapy which has been explained to me. I further request and authorize them to do whatever they deem advisable and necessary as a result of unforeseen circumstances.   It has been explained to me and I understand that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted. I have been given the opportunity to question the doctor concerning the nature of treatment, the inherent risks of the treatment, and the alternatives to this treatment.