This authorization and consent for treatment is given to Dr. Skinner and staff after first having had a full explanation of the proposed treatment.  This disclosure is not meant to frighten, it is simply an effort to make me better informed so I may give or withhold my consent.

The doctor  has advised me that his/her opinion for root canal treatment is indicated.  The doctor has advised me in his/her opinion and the consequences of not treating this condition include but are not limited to: worsening of the disease, infection, cystic formation, swelling, pain, loss of tooth, and/or other systemic disease manifestations.  The doctor has advised me of alternative treatments, benefits, and risks which include are not limited to: extraction of the infected tooth (teeth) or not treatment.  I, however, believe that the root canal as noted above would be my preferred choice of treatment.

The doctor has advised me that there are certain risks and potential consequences of any treatment and such risks would include but are not limited to:

            -A certain percentage (approximately 5-10%) of root canals fail, necessitating re-                treatments, root surgery ,or extraction.

            -Postoperative discomfort, swelling, restricted jaw opening which may persist several days             or longer.

-Breakage of root canal instrument during treatment which may, in the judgment of the             doctor, be left in the treated root canal or require surgery for removal.

            -Perforation of the root canal with instruments which may require additional surgical             corrective treatment or result in loss of tooth.

            -Premature loss of tooth due to progressive periodontal (gum) disease.

            -Root canal treatment relies heavily on radiographic information.  Since radiographs are             essentially 2-dimensional shadows which provide reliable but not infallible information, this             may lead to root canal failures.

-Successful completion of the root canal procedure does not prevent future decay or             fracture.  The endontically treated tooth will be more brittle and may discolor.

in most cases, a crown and post filling is recommended after completion of the root canal             to prevent fracture and/or improve esthetics.

            -identification of crown or root fracture during or after treatment

            -damage to existing crowns, bridges, or other appliances

            -root canal filling material which extends beyond the end or the root

            -blocked root canals which may prevent successful treatment

            -loss of tooth structure/weakening of tooth

            -post-operative pain, swelling, and /or infection

            -possibility of future need of retreatment or  removal of tip of root(s) (apicoectomy) if failure occurs

            -Jaw pain, popping, clicking from opening for a long period of time

            -temporary or permanent numbness from root canal and or anesthesia

The benefits of successful root canal treatment include the relief of pain, removal of infection and the ability to retain the tooth in comfort and function.

Treatment alternatives include:   No treatment,  Extraction, reerral  etc.

I understand that during treatment, complications (including and not limited to those stated previously) may arise which complicate or make treatment more difficult, or which may require additional dental surgery.

I understand that root canal treatment weakens the crown of the tooth.  The dentist has explained to me the need for a restoration which adequately protects the tooth after root canal treatment has been completed.  I understand that no guarantee of success has been or can be given.  All of my questions  have been answered by the dentist and I fully understand all the above statements contained in this consent form.