Patient's Name:

E-mail Address

Tooth (Teeth) Involved:

Treatment overview:

Root canal therapy is indicated when the pulp chamber of a tooth is contaminated with bacteria causing the canals to become infected. The procedure is accomplished when the dentist creates a small opening in the surface of the tooth that will allow it to be disinfected and then sealed with inert rubber-like substance. The sealing of the canals will prevent subsequent passage of bacteria into or out of the tooth.

The health risks if this procedure is not performed may include but are not limited to: increased pain, swelling, loss of the tooth, loss of other teeth nearby, loss of supporting bone, spread of infection, cyst formation and/or deterioration of general health, due to systemic infection.

I have been informed of possible alternative treatment should any exist. Further, I understand that there are certain inherent and potential risks in any treatment or procedure, and in that specific instance, such risk may include the following:

• Failure to completely eliminate the infection requiring retreatment, root surgery or removal of the tooth at a later day.
• Postoperative pain, swelling, or bruising or limited mouth opening.
• Seperation (breakage) of an instrument within the canal during treatment. Broken instrument tips are sometimes allowed to remain in the canal, and only rarely are they the cause of the subsequent problems. If removal is indicated, the patient may be referred to an endodontic specialist.
• Perforation of the root from within the canal can occur requiring additional treatment by a specialist.
• Damage to nerve supplying the teeth resulting in temporary or in rare cases permanent numbness or tingling of the lip, chin, or other areas of the face.
• Inability to adequately clean the canal(s) due to unforeseen calcified obstructions or severely bent roots. The patient may be referred to a specialist for successful completion of the procedure where loss of the tooth may occur.
• A fracture of the treated tooth may occur during or after endodontic treatment. Treated teeth sometimes break due to the tooth loss of strength resulting from the procedure. In most cases, a crown is recommended after treatment to prevent such an occurrence.

Once treatment has begun, it is essential that it be completed in a timely manner. Root canal treatment will require from 1-5 appointments.

I understand that successful treatment does not prevent further decay or fracture of the treated tooth. I understand the recommended treatment, the risks, alternative treatment should any exist and the consequence of no treatment.