Informed Consent Form Root Canal Therapy printable pdf download

Informed Consent Form

Root Canal Therapy

1. Root Canal Therapy is about 95% successful. Many factors influence the treatment

outcome: the patient’s general health, bone support around the tooth, strength of the

tooth including possible fracture lines, shape and conditions of the root and nerve canal

(s), etc.

2. Teeth treated with root canals must be protected during treatment. Between

appointments, your tooth will have a temporary cement filling. If this should come out,

please call the office and arrange to have it replaced

3. The tooth may normally be sensitive following appointments and even remain

tender for a time after treatment is completed. If sensitivity persists, and does not

seem to be getting better, even several weeks after the root canal is finished, please let

the Doctor know.

4. Fractures are one of the main reasons why root canals fail. Unfortunately, some

cracks that extend from the crown down to the root are invisible and hard to detect. They

can occur on uncrowned teeth from traumatic injury, biting on hard objects, habitual

clenching or grinding, even just normal wear and tear. Whether the fracture occurs

before or after the root canal, it may require extraction of the tooth.

5. Since teeth with root canals are more brittle than other teeth, the Dentist will

probably recommend a crown to prevent future damage. This is especially important

with molar and bicuspid teeth.

6. Teeth treated with root canals can still decay, but since the nerve is gone, there will

be no pain. As with other teeth, the proper care of these teeth consists of good home

care, a sensible diet, and periodic dental checkups.

7. With some teeth, conventional root canal therapy alone may not be sufficient. For

examples, if the canal(s) are severely bent or calcified, if there is substantial or

longstanding infection in the bone around the roots, or if a metal file becomes separated

within a canal, the tooth may remain sensitive and a surgical procedure may be necessary

to resolve the problem.

8. 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 of Root Canal Therapy has been explained to me and I have had a chance to have my

questions answered. I understand that dentistry is not an exact science and success with root

canals cannot be guaranteed. In light of the above information, I authorize the doctor to proceed

with the treatment.

Patient’s

Signature_________________________________Date_________________________

Informed Consent Form Root Canal Therapy