Microsoft word - ttfe4d5.tmp.consent for endo treatament june 2012 w spencer.docx

Root canal treatment is an attempt to save a tooth which otherwise may require extraction. It should be a very positive experience. While you may be anxious, the doctors and staff will explain the need for treatment, the process involved and provide post-operative instructions concerning your comfort and final restoration of the treated tooth. Success of treatment is dependent upon many variables that are not under the control of the dentist or patient. Based on scientific literature, root canal therapy is successful 85-98% of the time. It is important that you understand and accept the potential complications that may occur during treatment and may affect the outcome of treatment. Such complications include, but are not limited to the following: Post-operative discomfort lasting a few hours to a few days that may require pain-relieving medications as deemed necessary by the dentist. Post-operative swelling of the surrounding gum tissue or face that may require antibiotics as deemed necessary by the dentist. Separation of instruments in the canal that may, at the judgment of the dentist, be left in the canal or require surgery for healing. Perforation of the tooth/root that may require additional treatment and associated fees or result in loss of the tooth. Crack or fracture of the tooth/restoration (especially porcelain restorations) during treatment that may require a new restoration and/or possibly loss of the tooth. Permanent crowns may come off during treatment and require replacement. Inability to complete root canal treatment due to calcifications, which may require additional treatment and associated fees or result in loss of the tooth. Complications associated with the administration of local anesthetics, including allergic reaction, fainting, heart palpitations, overdose, bruising, numbness and hematoma, which may last for days/ weeks/ months/ permanently. Exacerbation/creation of TMJ/TMD symptoms due to the length of time required to maintain an open mouth during root canal therapy procedures. Complications associated with past or current use of bisphosphonate therapies (i.e. Actonel®, Boniva®, Fosamax®, or Zometa®), which may impact surgical or non-surgical endodontic treatment. Following the completion of root canal therapy, it is crucial that you return to your dentist for definitive restoration of the treated tooth. This should be done within 2-4 weeks, unless you continue to have symptoms. If this occurs, please contact our office for further evaluation. Failure to complete this important phase of treatment may result in recontamination of the root canal system. This may lead to the need for retreatment, surgery or result in loss of the treated tooth. I am aware that root canal treatment is the best attempt to save a tooth that would otherwise require extraction. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions. A follow up evaluation in 12 months is needed. This is considered a part of the therapy and there is no fee for this service. The goal of this office is to provide the best endodontic care in a secure and compassionate environment. Your comfort is our main consideration. We trust that your experience in our office will be satisfying. Please sign and date this form indicating that you have read and understand the information. If you have any questions regarding treatment, please ask Dr. Barr, Dr. Spencer or Dr. Madison. Patient’s (or Parent/Legal Guardian’s) Signature


Stis - final

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