Root canal therapy is indicated when the pulp chamber of a tooth is contaminated by bacteria causing the canals to become infected. The procedure is accomplished when the dentist creates a small opening in the biting surface of the tooth that will allow it to be disinfected and then sealed with an inert rubber-like substance. The sealing of the canals prevents subsequent passage of bacteria into or out of the tooth.

I have been informed that the risks to my health if this procedure is not performed may include, but are not limited to: increased pain, swelling, loss of the tooth (teeth), loss of other teeth nearby, loss of the supporting bone, spreading infection, cyst formation, and/or deterioration of general health due to systemic infection.

I have been informed of possible alternative methods of treatment should any exist. Further, I understand that there are certain inherent and potential risks in any treatment or procedure, and that in this specific instance, such risks may include the following:

A failure to completely eliminate the infection requiring re-treatment, root surgery or removal of the tooth at a later date;
Post-operative pain, swelling, bruising, and/or limited jaw opening that may persist for several days;
Separation (breakage) of an instrument within the canal during treatment. Broken instrument tips are typically allowed to remain in the canal, and only rarely are they the cause of subsequent problems. If removal is indicated the patient may be referred to an endodontic specialist.
Perforation of the root from within the canal can occur requiring additional treatment by a specialist. Such complications will occasionally result in the loss of the tooth.
Damage to nerves supplying the teeth resulting in temporary or, in rare instances, permanent numbness or tingling of the lip, chin, or other areas of the jaws or face:
Inability to adequately clean the canal(s) due to unforeseen calcified obstructions or severely bent roots. Under certain circumstances the patient may be referred to a specialist for successful completion of the procedure. Loss of the tooth may occur:
A fracture of the treated tooth, occuring during or after endodontic treatment. Treated teeth sometimes break due to the tooth’s loss of strength resulting from the procedure. In most cases a crown is recommended after treatment to prevent such an occurrence.
Once treatment has begun, it is essential that it be completed in a timely manner. Root canal treatment will require from 1-5 appointments. Also, I understand that successful treatment does not prevent future decay or fracture of the treated tooth.

Patient Consent
I, the undersigned, do hereby state and confirm as follows:

I have been explained the following in terms and language that I understand. I have been explained the following in {{LANGUAGE}} (Language) that is spoken and understood by me.
I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above
I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment .
I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.