Patient Consent Form

Thomas G. Acierno, D.D.S.

Health History, Endodontic (root canal) Therapy, Local Anesthesia and Medications

Informed Consent:
It is our belief that you should be informed about the following treatment and that you should give consent before starting treatment. Discussion of complications is not meant to alarm you to the point of being afraid of needing the procedure. Rather, it is a recognized arena to “inform” the patient of possible risks associated with these procedures-either general dental procedures or that specific to endodontic (consultation, root canal or surgical root canal) therapy.

About the proposed treatment:
Consultations are sometimes required to determine if a root canal needs to be done or whether the tooth can be saved with a root canal done by a specialist. The endodontist will perform a series of tests and along with the x-rays, determine a preliminary prognosis and diagnosis for the tooth or teeth involved. An appointment will then be made to complete root canal therapy or surgical root canal therapy (apicoectomy).

Root Canal Therapy/Retreatment Therapy is an attempt to retain a tooth that may otherwise require extraction. Treatment involves drilling through the biting surface of the tooth to expose the inner surface of the roots. The center of the root is then cleaned with very fine metal files. The root is then shaped and filled with a rubber-like material and medicated cement. The opening of the tooth is closed with a temporary filling. Twisted, curved or blocked root canals may prevent removal of all inflamed or infected pulp in the center of the roots. Since leaving any pulp in the root canal may or may not cause your symptoms to continue or worsen, you may require an additional procedure called an apicoectomy.

Apicoectomy or surgical root canal therapy is done through a small opening incision in the gums and surrounding bone, any remaining pulp is removed and the root canal is sealed. An apicoectomy or retreatment may also be required if your symptoms continue or your infection does not heal.

Once the root canal treatment is completed, it is essential to return promptly to your general dentist to have your restorative treatment completed (crown or permanent filling). Because a temporary seal is designed to last only a Short time, failing to return as directed to have the tooth sealed permanently with a crown or filling could lead to an invasion of bacteria from your saliva. This will cause deterioration to the seal of the temporary resulting in decay, infection, gum disease, possible retreatment of the root canal/apicoectomy or premature loss of the tooth.

Benefits and Alternatives:
Root canal treatment is intended to allow you to keep your tooth for a longer period, which will help maintain your natural bite and the healthy functioning of your jaws. Treatment will be done in a manner to minimize or avoid risks. Although root canal therapy/surgery has a high degree of success, the results cannot be guaranteed. Other alternatives include not treatment, waiting for more definitive symptoms to develop or having the tooth extracted. Risks involved with these choices may include pain, swelling, infection, loss of the tooth and infection to other areas.

Risks may include, but is NOT limited to some or all of the below:
Loss of taste, speech, sight or feeling (numbness-temporary or permanent) may also result with any, but is not limited to
the risks below:

  1. Bleeding, pain, soreness and infection: During and after treatment you may experience bleeding, pain, swelling or discomfort for varying lengths of time which may be treated with pain medication. You may also experience an infection or swelling following treatment, which may or may not be treated with antibiotics or further treatment.
  2. Reaction to anesthesia and/or sedation: To keep you comfortable during treatment you will receive a local anesthetic given in different modalities with the possibility of receiving other sedation medications. In rare instances, patients may have an allergic reaction which may require emergency medical attention. Other complications include numbness (temporary or permanent), tingling sensation in the lip and or tongue, muscle cramps and spasms, referred pain to the ear, neck and head, nausea, vomiting, allergic reactions, itching, bruising, delayed healing, sinus complications, hearing or sight impairment, further surgery or even death.
  3. Stiff or sore jaw joint: Holding your mouth open during treatment may temporarily leave your jaw feeling stiff and sore and may make it difficult for you to open your mouth wide for several days afterward. Treatment also may leave the corners of your mouth red or cracked for several days. A may also result.
  4. Broken/incorporated Nickel Titanium/stainless steel instrument: Occasionally a instrument will break off in a that is twisted, curved or blocked with calcium deposits (calcified canals). Depending on its location, the fragment can be retrieved or it may be necessary to it in the root canal (these instrument are made of sterile, non-toxic surgical stainless steel or nickel-titanium, so this causes no harm). It
    may also be necessary to perform an apicoectomy to retrieve the instrument and to the in the future, depending if an abscess forms/pain results or not.
  5. Overfill: As a result of filing in the , the-incomplete formation of your tooth or an abscess at the end of the tooth (the apex), an opening may exist between the and the bone or tissue surrounding the tooth. This opening can allow material to be forced out of the space into the bone or tissue surrounding the tooth, An apicoectomy maybe necessary for retrieving the material and sealing the root canal in the future.
  6. Need for further treatment: In some cases, treatment may not relieve all symptoms. Without proper attention to getting the tooth restored and general good oral hygiene, a retreatment or apicoectomy may be needed in the future. that receive treatment may be more prone to breaking over time which may ultimately require a bridge, implant or partial denture. If you suffer from gum disease, this can increase the chance of losing a tooth even though treatment was successful (healed).
  7. Need for new crowns: Porcelain may crack or chip off at any time during your treatment. A new crown may be necessary even if it was just placed. Porcelain is more prone to cracking, though every precaution is taken to insure its integrity. The crown could also come loose during treatment and your general may decide to do a new crown.

Consequences of not performing: This course of treatment usually will help to relieve your symptoms though there are no guarantees. If you do not have treatment, your discomfort could continue and you could face the risk of a serious, potentially life-threatening , abscesses in the tissue and bone surrounding your and eventually, the loss of the tooth. Every reasonable effort will be made to ensure that your condition is treated properly, although it is not possible to guarantee perfect results. By signing below, acknowledge that you have received adequate information about the proposed treatment, that you understand this information and that all your of your questions have been answered

I give my consent for the proposed treatment as described above.