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Consent Form

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You will need to bring this with you on the day of your appointment. (If you would like to discuss before signing, please bring this with you unsigned)

Please read the following information on endodontic treatment below. If you have any queries about your treatment, one of our trained dental staff can answer your questions over the phone.

Endodontic Treatment

Root therapy is a procedure that retains a tooth, which may otherwise require extraction. Although root canal therapy has a very high degree of success, results cannot be guaranteed. Occasionally a tooth which has root canal therapy may require retreatment, surgery or even extraction. Following treatment, the tooth may be brittle and subject to fracture. A restoration (fi lling), crown and/or post and core will be necessary to restore the tooth, and your general dentist will perform these procedures. For a post and core your dentist may require that we do this, there will be an additional fee but this will be discussed as necessary. During endodontic treatment, there is a possibility of instrument separation within the root canals, perforations (extra openings), damage to bridges, existing fi llings, crowns or porcelain veneers, missed canals, loss of tooth structure in gaining access to canals, and fractured teeth. Also there are times when a minor surgical procedure (apicectomy) may be indicated or when the tooth may not be amenable to endodontic treatment at all. Other treatment choices include no treatment, a waiting period for more defi nitive symptoms to develop, or tooth extraction. Risks involved in those choices might include, but are not limited to, pain, infection, swelling, loss of teeth and infection to other areas.

Your dental surgeon has referred you for specialist endodontic treatment (root canal therapy) and this is a brief explanation of what is involved:

Each tooth has its own nervous and vascular system known as a pulp. For a variety of reasons the pulps of teeth may become infected with bacteria - usually as a result of tooth decay, or injury. Because the pulp is in a confined space its ability to overcome infection is limited and it is destroyed. Eventually an abscess forms in the pulp anal and spreads to the surrounding tissues with consequent pain and swelling.

The damaged pulp is removed from the root canal and any abscess that may have formed is drained and the canal space is thoroughly cleaned. The root canal is prepared and cleaned. Very careful and precise instrumentation is required at this stage, since some canals may be only 1/60th of a millimetre in diameter. The canal space is filled and sealed. Occasionally, a second appointment may be required in particularly difficult cases.

A root filled tooth is still healthy tissue. All that has happened is that the central blood supply inside the tooth has been removed. Endodontic treatment simply tries to ensure a balance of health is maintained and there is no recurrence of infection, while providing a sound foundation upon which your dentist can restore the tooth to normal function and appearance. Restoration of the tooth may require that your own dentist eventually places a crown on the rootfilled tooth, in particular if it is a molar, or premolar tooth. The cost of this will be additional to the rootfilling.

A price list has been enclosed so you have an estimate of what you will be paying. If this has not been done and you are unsure, please make sure you clarify with us what the likely costs will be before attending your appointment. Please note the price list is a guideline only, and in some cases the work done is more complicated than originally anticipated. If this were the case we would explain the necessary changes to you and would not continue without your consent. All treatment must be paid for in full on the day of the appointment either by cash or credit/debit card. A finance option is available, please call for more details. Please note a consultation is required for this in the first instance. (Failure to pay for treatment will result in the debt being collected by a third party and the cost of this added to your bill).

Unless you have been booked in specifically for sedation (a consultation is required in the fi rst instance), the treatment is done under local anaesthetic and you will not be given any drugs that will affect your concentration or ability to drive home. You do not need to bring someone with you, but if you would like too they will be most welcome. (If you are having the treatment done under sedation please read the separate sedation information).

We hope this has answered all of your questions. We look forward to seeing you on the day of your appointment.

Photographs of the treatment may be taken during the procedure for our records. These may be shared for educational purposes but your personal details remain confi dential. Please let us know if you do not wish for this to happen.

Patient Declaration

I have read and understand all the information sent to me and I am fully aware of what treatment is required, and what will be carried out, by private contract, on the understanding that if it needs to be changed in any way I will be consulted and informed of the changes. I understand all the risks associated with this treatment as detailed above.

Tick here to agree with the above declaration: (If patient is under the age of 18, a parent or guardian is required to tick the box) *