Treatment Consent For Root Canal Therapy


  • I have been made aware of the condition of tooth#, and understand that endodontic (root canal) treatment has been recommended by my dentist. Root canal therapy is performed in order to save a tooth which otherwise might need to be removed. I am aware that the practice of dentistry is not an exact science, and root canals are no exception. There is a 5-10% chance that the root canal therapy may not work, and in this instance further treatment may be required. This may include, but is not limited to, root surgery, retreatment of the root canal, or extraction of the tooth. The fees for these added procedures would be in addition to, and are not included in the fee for root canal you are receiving.

    Your treatment may be completed in one or multiple visits. Between or after appointments, post-operative pain or discomfort is normal and can be expected. Please take any medications recommend by your dentist.

    I am aware that the alternatives to root canal treatment are:

    1. Not performing any treatment, which may result in: worsening of symptoms and health of the tooth and its supporting structure, loss of the tooth, further infection, pain, swelling, cyst formation, and systemic disease
    2. Removal of the tooth

    Some possible complications of root canal treatment are, but not limited to:

    1. Post-operative pain, swelling, bruising, and/or restricted jaw openings that may persist
    2. Breakage of instruments inside the canal during treatments or perforation of the canal or tooth with instruments may occur which will likely require additional treatment
    3. Damage to sinuses or nerves resulting in temporary/transient or possible permanent (more infrequent) numbness or tingling of the lip, chin, tongue or other areas
    4. Encountering calcified or blocked canals
    5. A crown, bridge, veneer (cosmetic cover), natural crown, a dental restoration or my natural tooth may break or crack because of the root canal treatment
    6. Failure of the procedure necessitating re-treatment, tooth surgery, or extraction
    7. Periodontal damage or infection
    8. Loosening of tooth, cracked or fractured teeth

    Between visits your tooth will likely have a temporary filling. If you notice that the entire filling comes out, please call to have it replaced. Once treatment is completed, please see your dentist as soon as possible to have a permanent restoration placed.

    Please note that the fee is for the root canal only and does NOT include a fee for the restoration of the tooth afterwards.
    Successful completion of the root canal procedure does not prevent further decay or fractures. An endodontically treated tooth will become more brittle and may discolour. In most cases a crown is recommended to help prevent fractures and increase the long term prognosis of the tooth.

    I, understand the recommended treatment, the risks of such treatment, any alternatives and the risks of these alternatives including the consequences of doing nothing. The fee(s) have also been discussed with me and I have had all my questions answered.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY