Clinic name
Dentist name, qualifications
Consent for root canal treatment
Patient nameAge/SexOP No.DateTooth / teeth
The treatment
Removal of the infected or inflamed pulp from inside the tooth named above under local anaesthesia, then cleaning, shaping and filling of the root canals. It may take more than one visit.
Possible risks and complications
- Pain, swelling or an abscess during or after treatment, which may need medicines or an extra visit.
- A small instrument may break inside a canal. It may be left in place or need further treatment.
- Some root canals may not be found or fully cleaned, because canals can be narrow, curved or blocked.
- A perforation of the root during treatment.
- The tooth may crack or break, during or after treatment.
- For upper back teeth: involvement of the sinus.
- The treatment may not succeed, and the tooth may later need retreatment, surgery at the root tip (apicoectomy) or extraction.
- The tooth will usually need a crown or other restoration afterwards to protect it, at extra cost.
Other options
- Extraction of the tooth.
- Surgery at the root tip (apicoectomy), in some cases.
- No treatment.
If no treatment is done: Pain, swelling and infection may continue or spread, and the tooth may be lost.
Estimated cost (Rs)Medical conditions / medicines / allergies
Consent
The dentist has explained the treatment, its risks and the other options to me in a language I understand, and I have been able to ask questions. I understand that no result can be guaranteed. I agree to this treatment, and to any further treatment the dentist finds necessary during the procedure for my safety.
Patient, or parent / guardianDentistWitness
Name of parent / guardian, if signingRelation