Division Family Dental

2484 NE Division St, Gresham Or 97030


Root Canal Therapy Consent Form

Root Canal Therapy (RCT) is a procedure to save your tooth by treating the nerve of the tooth (pulp). A root canal can save teeth that may otherwise require extraction (removal). Root canal therapy is an elective procedure and there are alternatives. Although Root Canal Therapy has a high success rate, success cannot be guaranteed. It is the opinion of the dentist that the treatment will be helpful and that your condition may worsen without treatment.

I understand that i may need multiple appointments to complete the RCT and restore the tooth. The initial therapy, (pupal debridement) may relieve many of my symptoms, but is only the the first step in treating the tooth and that Division Family Dental may not be able to provide services beyond the initial therapy.

I have been informed that i require Root Canal Therapy (RCT) and that there are risks to the recommended treatment which include (But are not limited to) the following:

  1. Adverse reactions (allergic reaction or inflammation) to the materials, medications and anesthetic that are used during the procedure are possible during or after the procedure
  2. It is possible that the doctor may be unable to completely fill the root due to calcifaction or curvature of the root.
  3. An instrument may separate due to manufacturing, sterilization or anatomic differences and become lodged in the tooth.
  4. Infection may occur or continue to occur, requiring additional treatment that may not be covered by your insurance, If applicable.
  5. Fracture or breakage of the root or tooth or damage to existing dental work can occur during or anytime following treatment.
  6. A perforation (Hole in the root wall) caused by an instrument may result. This can require surgical correction or extraction of the tooth.
  7. Post-Operative pain and swelling. Your doctor can help manage your pain.
  8. Root Canal Failure. If the treatment is unsuccessful, additional procedures, such as periapical surgery may be required to save the tooth, if possible. Many of these treatments are not covered by insurance and cannot be performed at Division Family Dental. Treatment with an Endodontist (specialist) would be required

I understand that many of these complications may require extraction of the tooth if other treatments are not available.

The tooth will require a long-term restoration to protect the RCT and restore function. This may involve a filling, post, build up, and/or crown depending on the clinical status of the tooth.

I am also aware that i may have continuing temporary symptoms throughout and following treatment, such as pain, swelling, infection, drainage, fever and numbness.

Successful completion of RCT does not prevent future decay or fracture of the tooth.

I agree to contact the clinic if I have excessive pain or swelling or have follow up questions or concerns. Failure to do so may result in loss of the tooth, bone destruction and/or local systemic infection.

The Risks and benefits of Root Canal Therapy and of alternative treatments have been explained to me. Root canal Therapy is my treatment of choice after discussing treatment options with the doctor.