Informed Consent for Root Canal (RCT) Please complete this Consent for Root Canal Therapy form below. If you have any questions call us on (615) 915-6090. HiddenVersion historyv1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : Receive a copy by email (add), 2020-06-05 v1.3 : New header and no captcha (change), 2020-06-04 v1.2 : DOB changed to date dropdowns (change)Patient name:(* required) First Last Patient date of birth:(* required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Consent for Root CanalRoot Canal Therapy (RCT), what is it? A root canal may be needed if decay (caries) extends into the nerve of the tooth or if a tooth has been traumatized to the point of now having an infection at the end of the root. If determined to be restorable, a tooth can be saved via the process of root canal, or debridement of tooth’s nerve and pulpal tissue with careful placement of an inert filling placed into the nerve canal of the tooth. Will it hurt? RCTs themselves are painless when performed under adequate local anesthesia, but can also be completed in conjunction with some sort of sedation treatment for maximum comfort. Some patients have extensive infection, which can make numbing the tooth difficult, so please notify the doctor if you are feeling discomfort. While one may be sore after the initial treatment, the tooth should start to feel a lot better after the first visit. Some patients feel discomfort for the first few days after treatment, and over the counter Ibuprofen and Tylenol can be used in alternating 600 mg and 500 mg doses respectively up to 4 times a day. Please note that prior to receiving a root canal, the decay/infection may be so extensive that it causes spontaneous pain in the tooth that can often keep one up at night. Definitive treatment (RCT or extraction) is the only way to cure the infection. How long does it take? RCT may be completed in either one or two visits 1-2 hours at a time and will require subsequent visits to complete necessary restorative treatment, most teeth will require a build-up and a crown. Will I require medications? Depending on the extent of the infection, your dentist may elect to give you antibiotics or pain medications before or after the RCT. Please alert the dentist of any allergies or adverse reactions to any medications. What comes after the RCT? Literature states that the best outcome for saving a tooth with RCT is when a final restoration (determined by your dentist) is placed immediately after RCT. Benefits of treatment: Removes infection, therefore alleviating pain Restores ability to function with the tooth, including biting and chewing without pain or discomfort Helps maintain smile by saving original tooth Prevents irreversible loss of bone that can occur due to infection or as the result of an extraction Risks of treatment: Postoperative discomfort, swelling, or restricted jaw opening which may persist several days or longer Recurring infection that may require further endodontic or surgical intervention Fracture/breakage of the tooth during or after treatment due to brittleness from caries or infection Inadvertent breakage of files (endo files are fine instruments and stresses can sometimes cause breakage in tooth during treatment) Inability to fill to completion due to calcification or unique curvature. These complications may cause RCT to be short or require the procedure to be redone by a root canal specialist (endodontist) Risk of perforation during root canal procedure, causing tooth loss Eventual failure of root canal, necessitating retreatment or extraction Root canal filling material may extend past the apex of the root, which does not affect the RCT success Tooth may discolor over time Alternative treatment: extraction or no treatment, which can cause dangerous spread of infection. The dentist has explained that the purpose of RCT is to retain teeth that may otherwise need to be extracted. The treatment and anticipated results have been explained to me. I understand that while RCT has a very high success rate, the doctor has not guaranteed or warranted a perfect result, and complications can occur that may cause me to lose my tooth despite all efforts. I understand that I must return to receive all necessary restorative treatment following RCT, which may include a build-up and crown, and that I am risking fracture and reinfection without receiving final restorative treatment. All risks and benefits have been explained to me and I have had opportunity to ask questions. I understand that this is an elective procedure and that not receiving any treatment can lead to infection, which may lead to other potentially serious systemic infections. By signing this form, I am freely giving my consent to allow and authorize Michael D. Vaughan, D.D.S., PLC to perform the necessary and affiliated procedures for tooth #:(* required) SubmitName of Legal Guardian or Authorized Representative:(* required) If not applicable use 'self'Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Consent?(* required) Yes No E-mail address:(* required) Please sign(* required)Important: You consent to sign this document electronically.
