I hereby authorize Dr. John J. Spurr DDS, and/or whomever he may designate as his assistant(s), to perform root canal therapy on the tooth or teeth previously agreed upon.
I understand that root canal therapy is a procedure to retain a tooth which may otherwise require extraction.
Root canal therapy is a biologic procedure with a high degree of success. When properly restored and cared for, teeth treated with root canal therapy, are likely to be retained for a lifetime. Root canal therapy, however is a biological procedure and therefore the success of the procedure CANNOT BE GUARANTEED.
Other treatment choices besides root canal therapy include: no treatment, waiting or delaying treatment, or tooth extraction. Risks with these other choices include but are not limited to: pain, infection, swelling, loss of tooth and/or adjacent teeth, infection in other areas, trismus (restricted jaw opening), sinus involvement, and numbness or tingling of the lip, tongue, gums, cheek, teeth, chin and adjacent tissues (which in rare cases could be permanent).
The success of root canal treatment is influenced by many factors, some of which are beyond our control. Examples include, but are not limited to: root fracture, complex root anatomy, your age and general health condition, the amount of infection in or around the tooth and gum problems. On rare occasions a tooth treated with a root canal may require retreatment, surgical correction or extraction.
Possible complications with root canal treatment and local anesthesia include but are not limited to: instrument separation within the root canals, perforations (extra opening made in the tooth), missed canals, damage to existing bridges, crowns, veneers or fillings, swelling, trismus (restricted jaw opening), infection, numbness or tingling of the lip, tongue, gums, cheek, chin and adjacent tissues (which in rare cases could be permanent).
I further consent to the administration of local anesthesia and/or sedation analgesia (nitrous oxide), antibiotics, analgesics or any other drugs that may be deemed necessary in my case, and understand that there is a slight element of risk inherent in the administration of any drug or anesthesia. This risk includes but is not limited to; allergic reaction, adverse drug response, cardiac arrest, aspiration. Medication, drugs, anesthesia and prescribed medication may cause drowsiness and lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I have been advised not to operate any vehicle or hazardous devices or work until fully recovered from these effects.
A full explanation for complications to the contemplated procedure and anesthesia is available to me upon request from Dr. Spurr or his staff.