Ormond Beach Dentist LLC
Arif Zaman, DMD & paul Szott, DMD
802a Sterthaus Ave
Ormond Beach, Florida 32174

Endodontic Consent Form

I. Endodontic therapy has a high degree of success. Many factors influence the treatment outcome; the patient’s general health, bone support around the tooth, strength of the tooth including possible fracture lines, shape and condition of the root nerve canal(s), etc.
2. Teeth treated with endodontic therapy must be protected during treatment. Between appointments, your tooth will have a temporary cement filling. If this should come out, please call the office and arrange to have it replaced.
3. During root canal therapy, certain procedural complications can occur including, but not limited to, alteration of sensation, i.e., numbness, separated (broken) instruments, blocked canals, root perforation, and damage to restorations. The tooth may also become sensitive following appointments and even remain tender for sometime after treatment is completed. If sensitivity persists, and does not seem to be getting better, please let the doctor know.
4. Fractures are one of the main reasons why endodontic therapy fails. Unfortunately, some cracks that extend from the crown down into the root are invisible and hard to detect. They can occur on uncrowned teeth from traumatic injury, biting on hard objects, habitual clenching or grinding, or even just normal wear and tear. Whether the fracture occurs before or after the root canal, it may require extraction of the tooth.
5. Since teeth with root canals are more brittle than other teeth, we will always recommend a crown to prevent future damage. This is especially important with molar and bicuspid teeth. A post and core will also be required to reinforce and build up sufficient structure for the crown to be placed.
6. Teeth treated with endodontic therapy can still decay, but since the nerve is gone, there will be no pain. As with other teeth, the proper care of these teeth consists of good home care, a sensible diet, and periodic dental checkups.
7. With some teeth, conventional endodontic therapy alone may not be sufficietit. For example, if the canal(s) are severely bent or calcified, if there is substantial or long-standing infection in the bone around the roots, or if a metal file becomes separated within a canal, the tooth may remain sensitive and a surgery procedure (apicoectomy) may be necessary to resolve the problem, or the tooth may require extraction.
8. There are alternatives to endodontic therapy. They include no treatment at all, extraction with nothing to fill the space, and extraction followed by a bridge, partial denture, or implant to fill the space.

The nature of endodontic therapy has been explained to me and I have had a chance to have my questions answered. I realize the treatment could require post & core, buildup, and crown as well as my endodontic treatment. In addition, I understand that dentistry is not an exact science and success with endodontic therapy cannot be guaranteed. In light of the above information, I authorize the doctor to proceed with treatment.

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Patient or person authorized to consent for patient -  Date ----------Doctor ‘s Signature