Cass City, MI 48726
Copyright © 2003
D. Thomas, DDS, PC
All Rights Reserved
Consent For Root Canal Treatment
text of the Informed Consent is below. You may download the form in
Adobe Acrobat PDF format by clicking on the image to the right. You
may then print, sign and bring the form to our office.
view and print the document, you'll need Adobe Acrobat Reader on your
computer. You may click on the Acrobat logo button to download the software.
Canal Treatment (endodontic therapy) is about 95% successful. Many
factors affect the success of the treatment: your general
health, condition of the nerve and the root canal(s),
bone support around the tooth, strength of the tooth (fracture
of Treatment. Root
Canals are sometimes completed in a single appointment
or may take several appointments, if the treatment spans
several appointments, you will have a temporary filling
placed on the tooth to protect the canal. If the
filling should come out, please call the office so we
can replace it. Once treatment is begun, it is
absolutely necessary that the treatment be completed,
and the patient must diligently follow any and all instructions.
like with fillings, a root canal tooth can be sensitive
both during and after final treatment. Usually this sensitivity
disappears in several weeks. If it does not or appears
to worsen, please call the office to let us know.
crown is usually recommended for any tooth that has
a root canal. This is because root canal teeth no longer
have a blood supply to them and become more brittle
than your other teeth. This is especially true of your
back chewing teeth—the molars and bicuspids. A
crown goes over the root canal tooth to strengthen it
and protect it from breakage.
of Fracture. One
of the main reasons root canals fail is because of breakage
or fracture of the tooth. A fractured tooth (especially
a vertical fracture) can require extraction of the tooth.
One of the best ways to prevent fracture of a root canal
tooth is to have a crown put over the tooth to strengthen
it. Other causes of fracture include grinding of teeth,
improper bite, trauma, etc. These fractures can occur
either before or after the root canal and often are
invisible and/or hard to detect.
canal teeth have no nerve, but they can still decay. It
is important to take care of root canal teeth just as
you would any other tooth: good home care, proper diet,
and regular dental checkups.
treatment may be necessary. Occasionally, root canal
treatment alone does not complete the treatment. The
canals of the tooth can be very narrow or curved or
calcified. There may be infection around the roots of
the tooth. Instruments used to treat the tooth
may become separated in the canal. The tooth may
remain or become sensitive. A surgical procedure or
possibly extraction may be necessary to try to resolve
nature and purpose of root canal treatment has been explained
to me, and I have had an opportunity to have my questions
answered. I understand that dentistry is not an exact science
and success with root canals cannot be guaranteed. In view
of the above information, I authorize the doctor and/or
such associates and assistants as necessary to render any
treatment necessary and/or advisable to my dental condition
including any and all anesthetics and/or medications.