Root Canal Treatment, Pulpotomy, and Pulpectomy Consent Form

I understand that many factors contribute to the success of root canal treatment and not all factors can be determined in advance. Some of the factors include:

My body's ability to resist infection

The bacteria causing the infection

The size, shape, and location of the canals

I understand that root canal treatment may not always relieve my symptoms, and in some cases, treatment failure can occur due to unforeseen factors. If treatment fails, other procedures (including re-treatment or surgery) may be necessary to retain the tooth, or it may have to be extracted.

I understand that during and after treatment, I may experience some pain or discomfort, swelling, bleeding, and loosening of dental restorations. I may also need antibiotics to treat any associated infections.

I understand that root canal instruments sometimes separate (break) inside the canal and may or may not affect the prognosis. If the separated fragment cannot be retrieved, it may remain in the root canal without causing issues, or it may require additional treatment in the future. Other risks include perforation by an instrument, sinus perforation, and/or nerve disturbances.

I understand that local anesthetics will be given. Some discomfort following treatment may develop from the injection area and from opening my mouth during treatment. In rare cases, nerve sensation may only partially return after the procedure.

I understand that once root canal treatment is completed, I must have permanent restoration (endodontically treated teeth usually need a buildup and a crown ) placed within one month. If I fail to have the tooth restored, it risks a failure of the root canal treatment, decay, infection, tooth fracture, and/or loss of the tooth.

At any stage of treatment, the provider may refer the patient to an endodontist for further evaluation or treatment.

Depending on my diagnosis, there may be alternatives to root canal treatment involving other dental care types. The most common options to root canal treatment are:

Extraction: I may choose to have this tooth removed. The extracted tooth usually requires replacement by an artificial tooth by means of a fixed bridge, dental implant, or removable partial denture.

No Treatment: I may risk serious complications, including severe pain, localized infection, loss of this tooth and possibly others, severe swelling, or a spreading infection that could become life-threatening.

I acknowledge that I have provided accurate medical history and will follow treatment recommendations. I have had the opportunity to ask questions about root canal treatment and the risks associated with the procedure.