909-383-8931

Informed Consent Form & Information Form

Prepare for your first visit by downloading, printing, and completing our PDF form. Simply bring it with you when you come in.

It is the belief of this office that you should be informed about the treatment you are about to receive and that you should give your consent before starting that treatment.

  • I understand that prior to treatment, a consultation will be completed. The consultation will include some tests to aid in diagnosis of the correct tooth. I understand these tests may cause some discomfort and/or pain.

  • Root canal treatment requires anesthesia and multiple radiographs (x-rays).

  • Post-operative discomfort or swelling, lasting a few hours to several days, for which medication will be prescribed if deemed necessary by the Endodontist.

  • Allergic reactions to medication or anesthetics (including sodium hypochlorite).

  • Separation of root canal instruments during treatment which may, in judgment of the Endodontist, be left in the treated root canal or require surgical procedure for removal.

  • Perforation of the root canal due to curved roots or existing conditions. This may require additional surgical treatment or extraction.

  • Premature tooth loss may result from cracks or fractures that can occur during the root canal treatment or from progressive periodontal gum disease.

  • Access through a crown or bridge (existing restorations) may result in damage to restorations, which is not the responsibility of your endodontist.

  • Treatment may be discontinued due to calcified canals, separation of root canal instruments, or fractures of root or crown.

  • Success rate of first-time root canal treatment is approximately 95%. (If failure occurs, the treatment may have to be redone, have surgery, or be extracted.)

  • Post-surgical complications include: discomfort and pain, swelling, bruises, excessive bleeding, trismus, and injury to the nerve underlying the teeth which may result in numbness or tingling of the lip, chin, gums, or tongue on the operated side. This may persist for several weeks, months, or in remote instances permanently. Also, there may be exposure of the sinus in the upper teeth.

  • The crown of the tooth may darken eventually and/or become brittle due to loss of vitality. We recommend placement of the crown or any other proper restoration determined by your referring dentist as soon as possible after the root canal treatment.

Root Canal Therapy

Root Canal Therapy is a procedure whereby a tooth that may otherwise require extraction, may be retained.  This treatment is performed in such a manner so as to minimize or avoid risks. Although Root Canal Therapy has a high degree of success, it is a biological procedure and the results cannot be guaranteed. Occasionally, a tooth which has had Root Canal Therapy may require re-treatment, surgical intervention, or even extraction.

Although Infrequent

Although Infrequent in occurrence, there are risks involving Root Canal Therapy.  These can include but are not limited to: complications from local anesthetic injections such as temporary pain, bruising, swelling, or prolonged numbness and tingling sensations in the anesthetized tissues.  You may experience muscle spasms or cramps, temporomandibular joint (TMJ) pain, swelling and/or pain in the area of the tooth being treated due to infection and/or inflammation, or referred pain to other parts of the head and neck region.  There may be damage to existing restorations (fillings, crowns, or bridges), fractured teeth, or loss of tooth structure I gaining access to root canal spaces.  Portions of instruments may separate within the root canal spaces or perforations (extra openings) of the crown or root may occur.  This does not necessarily indicate failure of the procedure; however, it does increase the probability of surgical intervention to obtain a successful result.  Complications during treatment may be discovered that make conventional Root Canal Therapy impossible.  This may necessitate the need for Endodontic Surgery to adequately treat the tooth.  These complications may include, but are not limited to: blocked canals due to natural calcifications, fillings, separated instruments, prior treatment with materials that cannot be removed, severely curved roots, periodontal disease (gum disease/pyorrhea), and fractures of the teeth and/or roots.

If Endodontic Surgery

If Endodontic Surgery is performed, complications that can occur may include, but are not limited to: pain, swelling, and bruising in the surgical area, loosening of the teeth, sinus complication associated with the maxillary posterior (upper back) teeth, delayed healing, and post-operative infections.  If these occur, they are generally temporary in nature and treatable with medications or further surgery.  If you are prescribed medications for pain and/or infection, complications from their use may arise.  These complications may include, but are not limited to: allergic reactions (itching, rash, etc.), nausea, drowsiness and lack of awareness or coordination.  The effect of medications that you are prescribed may be influenced by the use of alcohol and/or other drugs and medications.  Thus, CAUTION is advised until you have recovered from their effects.

Other Treatment Choices

Other Treatment Choices include waiting for more definitive symptoms to develop before initiation of treatment, extraction of the tooth, or no treatment at all.  Risks involved with these choices might include, but are not limited to: pain, swelling, infection both around the involved tooth and that which can spread to other areas, or loss of the tooth.

My Signature

My Signature below verifies that I have read and understand the above information and give my consent to the performance of Root Canal Therapy required and to such other treatment deemed necessary or advisable by Debra A. Meadows, D.D.S., or her associates, if any.

909-383-8931

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