PRINT OUT FORM - COMPLETE FORM - BRING FORM TO APPOINTMENT ENDODONTIC TREATMENT AND INFORMED CONSENT Acacia Endodontics, Lance P. Schneider, D.D.S. / Shaun R. Cullimore D.M.D. I UNDERSTAND that ROOT CANAL THERAPY includes possible inherent risks such as, but not limited to the following: The tooth may remain tender or even quite painful for a period of time both during and after completed treatment. If pain is severe or swelling occurs, please call our office immediately. In some teeth, regular root canal therapy alone may not be sufficient. If the canals are blocked, excessively curved, inaccessible, inadvertent pulp chamber or root perforation, or if there is substantial infection in the bone around the tooth, additional oral surgery, including apicoectomy(s) or possibly extraction may become necessary. Root canal treated teeth may become somewhat brittle and subject to cracking or fracturing. Crowning (capping) the tooth is the best prevention to avoid this problem from occurring. Root canal treated teeth must be protected. During and after treatment, your tooth will only have a temporary filling. (Should this come out, please call us for a replacement), It is advisable to crown (cap) the tooth as soon as possible. Root canal therapy is not always successful. Many factors influence success: adequate gum tissue attachment and bone support; oral hygiene; previous and present dental care; general health; absence of trauma; pre-existing undetectable root fractures. No matter how successfully a tooth may appear to be treated, there is the possibility of failure and consequent extraction. Root fracture is one of the main reasons why root canals fail. Unfortunately, "hairline" cracks are almost always invisible and undetectable. Causes of root fracture are trauma, inadequately protected teeth, cracking of the tooth, large fillings, improper bite, wear/tear, habitual grinding of teeth, etc. Root fractures after or prior to treatment, usually necessitates extraction. There are alternatives to root canal treatment. These alternatives include: no treatment; extraction; extraction followed by bridge placement or partial denture placement; and/or extraction followed by implant and individual crown placement. Because of the fragility and small diameter of root canal instruments used in root canal treatment, there is the possibility of instrument separation. This may in some instances necessitate either apical surgery or extraction of the tooth. ONCE TREATMENT IS BEGUN, it is absolutely necessary that the root canal treatment is completed. One or more appointments may be required to complete treatment. It is a patient's responsibility to seek attention should any undue circumstances occur; and the patient must diligently follow any and all preoperative and/or postoperative instructions given to them. Porcelain Restorations can be subject to cracking, chipping and fracture when drilled through for endodontic treatment access. Acacia Endodontics and Dr. Lance P. Schneider will be unable to accept responsibility for the failure of these restorations. INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of root canal treatment and have received answers to my satisfaction. 1 do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which mayor may not be achieved. No promises or guarantees have been made to me concerning the results. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. Lance P. Schneider and/or his associates to render any treatment necessary and/or advisable to my dental condition(s), including any and all anesthetics and/or medications. Patients name (please print): _______________________________ _____________________________________________________ Signature of patient, legal guardian or authorized representative Witness to signature: ____________________________________ Date: _________________ Date: _________________ Date: _________________ Home Page © Copyright 2008 Acacia Endodontics. All Rights Reserved.