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Nelson G. Woo, D.M.D.

 

Patient Information



 

 

Endodontic Root Canal Therapy Informed Consent Form

 

Brief description of endodontic (root canal):  The soft tissue of the tooth, called pulp, is a very fragile tissue with a poor blood supply.  All of the injuries received by the tooth over its lifetime result in the formation of fibrous and calcified scars within the pulp, which decrease the blood supply even further.  The most common injury is deep decay.  Endodontic therapy removes the soft tissue and replaces it with an inert material in the center space or canal, in each root of the tooth.  Patients needing root canal treatment usually have a DIAGNOSIS of pulp disease; the pulp is either dead or in the process of dying.

 

Recommended treatment:  The recommended treatment for your tooth is endodontic root canal therapy.  Under local anesthesia, an opening is made in the middle of the tooth, and the pulp tissue is removed.  The canal spaces are smoothed and filled.  The EXPECTED BENEFIT is to prolong the life of the tooth by removing the diseased pulp.  Outcome studies generally find about a 90% success rate at five years. In some cases, modern surgery of the root tip can save teeth that would have been lost.  This is a separate procedure with a separate fee.

 

Risks of treatment:  Risks include, but are not limited to, the following: damage to existing restoration (i.e. crowns, bridges, fillings) cyst formation, acute or chronic infection, separation of delicate instruments within the canal, chronic biting sensitivity, and root fracture.  This treatment does not change the possibility for gum disease or new decay, which can occur without your feeling it, since the nerve function within the tooth is gone.

 

Alternatives to this treatment:

1.       While it is possible to live with a chronic infection, it is very unhealthy.  The infection from around the roots could travel to other parts of your system, with the potential to cause serious problems.

2.       Extraction of the tooth also solves the problem.  In most cases, the tooth should then be replaced with a bridge, an implant, or a partial denture.

 

Other:  THERE IS NO GUARANTEE THAT TREATMENT WILL BE SUCCESSFUL.  We make every effort to treat you according to the most modern and scientific methods.  CDC Guidelines for preventing the spread of infection are strictly adhered to.  Every instrument that enters your mouth is heat sterilized. 

 

What next?  It is your responsibility to have the tooth restored with a “permanent” filling or crown, by your regular dentist or dental student, after the root canal therapy is completed.  Often a crown is needed.  However, that service is not available at this specialty clinic.  It is highly recommended that you have your mouth checked by your regular dentist on a regular basis.  We recommend that you return to our office for an exam, about six months later, to check your healing.

 

THERE ARE NO GUARANTEES OF TREATMENT SUCCESS.  NO REFUNDS WILL BE MADE.

 

Your signature below affirms that you have read and understand the information provided on this form, or have had it explained to you.

 

-          You understand that the treatment’s success cannot be guaranteed.

-          You understand that no refunds will be given.

-          You have been advised and understand that, you will need to see another dentist for a “permanent” restoration, usually a crown (cap), following a root canal.

-          You understand that your consent to endodontic treatment is given freely.

-          You agree that it is your responsibility to see further dental treatment elsewhere, as may be needed.

 

 

Patient’s Printed Name                                                                                                      Tooth No.

 

 

Patient’s Signature or Signature of Parent or Guardian (if a minor child)                                Date

 

 

Faculty’s Printed Name

 

 

Faculty’s Signature                                                                                                             Date