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Root Canal Treatment Consent Form

1. Root canal therapy is about 90-95% successful. However, not all such procedures are successful
and oral surgery or extraction may be necessary. Some reasons for this are as follows:
• Infection, which does not respond to root canal treatment
• Curved, calcified, or otherwise inaccessible canals
• Fractured roots
• Separation (or breakage) of a file within the root canal
• The possibility of and accidental perforation through the root canal into the surrounding bone
• The possibility of an existing tooth/root fracture before treatment or the tooth fracturing after
• The possibility of over/under filling of the root canal
• In very rare circumstances, accidental pushing of the irrigating fluid (sodium hypochlorite) into the
surrounding tissues resulting in pain, swelling (and even more rarely, tissue necrosis).

2. Teeth treated with root canals must be protected during treatment. For two appointment root canals
(which we rarely do anymore), your tooth will have temporary filling, between visits. If this should come
out, please call us and arrange to have it replaced. Even a completed root canal, left open, can
become re-infected within six months and require another root canal.

3. Once completed, the tooth may normally be sensitive following appointments and even remain
tender for a time after treatment. If sensitivity persists, and is not getting better, even several weeks
after the root canal is finished, please let the dentist know.

4. Fractures are one of the main reasons why root canals fail. Unfortunately, some cracks that extend
from the crown down into the root are invisible and hard to detect. They can occur on uncrowned teeth
from traumatic injury, biting on hard object, habitual clenching or grinding, or even just normal wear
and tear. Whether the fracture occurs before or after the root canal, it may require extraction of the
tooth. Since teeth with root canals can sometimes be more brittle than other teeth, the dentist will
probably recommend a crown or similar full coverage restoration (a cap or tooth colored filling) to
prevent future damage. This is especially important with molar and bicuspid teeth (back teeth). The fee
for the Root Canal Treatment does not include the restoration of the crown portion of your tooth with a
crown buildup (core) and/or crown (cap).

5. Teeth treated with root canals can still decay, but since the dentist removed the nerve, there will
probably be no pain. As with other teeth, the proper care of these teeth consists of good home care,
fluoride use, a sensible diet, and regular dental checkups.

6. With some teeth, conventional root canal therapy alone may not be sufficient. For example, if the
canal(s) are severely bent or calcified (blocked), or if there is substantial or long-standing infection in
the bone around the roots. If a metal file becomes separated within a canal, the tooth may remain
sensitive and a surgical procedure may be necessary to resolve the problem.

7. There are alternatives to root canal therapy. The alternatives for treatment include no treatment at
all (leaving the infection in the tooth and body) and extraction of the tooth.

I confirm I have read and understood all the above and had the opportunity to ask any questions

Patient’s signature…………………………..………… PRINT NAME……………………………………….

Dentist’s Signature…………………………………….. Date………………