Consent For Endodontic (Root Canal) Treatment printable pdf download

BROADWAY DENTAL CARE

2606 NE Broadway, Suite A

Portland, Oregon 97232

(503)595-KIND (5463)

CONSENT FOR ENDODONTIC (ROOT CANAL) TREATMENT

At Broadway Dental Care, we strongly believe that you should be informed about the

treatment and its risks and that you should give your consent before starting that

treatment. The purpose of this form is to outline the risks that may occur in the root

canal treatment.

RISKS of ENDODONTIC THERAPY: These risks include instruments broken within the

root canals, perforations (extra opening) of the crown or root of the tooth, damage to

bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining

access to canals, and cracked teeth. During treatment, complications may be discovered

which make treatment impossible or which may require dental surgery. These

complications may include: blocked canals due to fillings, prior treatment, natural

calcification; broken instruments; curved roots; periodontal disease; and splits or

fractures of the teeth.

TREATMENT ALTERNATIVES: no treatment OR extraction (having the tooth removed).

Risks involved in these choices might include pain, swelling, infection, loss of tooth, and

infection to other areas. Treatment will be done in a manner to minimize or avoid risks.

Root canal treatment is an attempt to retain a tooth which may otherwise require

extraction. Although root canal therapy has an average success rate of 92%, it cannot be

guaranteed. Occasionally a tooth which has had root canal therapy may require re-

treatment, surgery, or even extraction. If the root canal treatment of a tooth is more

complicated than anticipated, the root canal may not be finished by our office and be

referred to root canal specialist for completion.

I understand that during treatment, complications may arise which complicate or make

treatment more difficult, or which may require additional dental surgery.

I understand that root canal treatment weakens the crown of the tooth. The dentist has

explained to

me the need for a restoration which adequately protects the tooth after root canal

treatment has been

completed. I understand that no guarantee of success has been or can be given. All of my

questions

have been answered by the dentist and I fully understand all the above statements

contained in

this consent form.

Treatment tooth : ______________________________________________

Patient’s Signature: ________________________ Date:________________________

Doctor’s Signature: _________________________________

Witness’s signature: ________________________________

Consent For Endodontic (Root Canal) Treatment