CONSENT FOR ROOT CANAL THERAPY


I hereby authorize Dr. to perform root canal therapy on tooth/teeth:

If any unforeseen condition should arise during treatment, calling for the judgement of the doctors, or for procedures in addition to or different from those now contemplated I further request and authorize the doctor to do what he may deem advisable. Further, I have been informed of other possible alternative and/or supplemental methods of treatment.

Post-operative risks for the proposed procedure include but are not limited to:

  • Pain
  • Restricted mouth opening for days, weeks or longer
  • Clicking or pain of the temporomandibular joints (jaw joints)
  • Tooth sensitivity to hot or cold for days, weeks or on occasion, several months
  • In rare cases transient or in some cases permanent tooth mobility (looseness)
  • Food lodging between the teeth after meals requiring cleaning with floss for removal
  • In extremely rare cases paresthesia (numbness) of the jaw or gums
  • Possible complications may require referral to a specialist

These complications include but aren’t limited to: calcified canals, root canal files breaking and/or not being able to find secondary canals.

I further understand that a crown is often recommended to be placed on the root canalled tooth within a month of completing of the root canal. If I do not, I risk the tooth breaking which may require extraction (at patient’s own expense).

I further understand that if no treatment is rendered, my present condition will probably worsen in time.

No guarantee, warranty or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction. Due to the individual patient differences that exist, a risk of failure, relapse, selective re-treatment or worsening of my present condition despite the best of care.


I understand that long term success requires my long term continued performance of mechanical plaque removal (daily home care) and my commitment to regular cleaning visits with the dental hygienist along with regular recall visits with the dentist.

CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH; IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.