APICECTOMY CONSENT FORM

I understand dentistry is not an exact science and there is no guarantee of results. When undergoing an Apicoectomy there are certain risks and the potential for unsuccessful results.

An Apicoectomy is a common endodontic treatment which is necessitated in the rare instance there is inflammation or infection at the tip of the root after root canal therapy. An incision is made in the gum tissue near the affected tooth and the inflamed or infected tissue is removed and the area filled and sealed. The gum is then sutured with small stiches. Additional tests may be performed on the infected/inflamed tissue which was removed

The benefit of an Apicoectomy will be relief of current symptoms and avoiding the spread of infection to other teeth, damaging oral health.

Alternatives to an Apicoectomy depend on the diagnosis; however, the most common alternatives are:

  • Extraction of the tooth/teeth
  • Extraction followed by an implant and crown
  • Extraction followed by a bridge or partial denture
  • No treatment which could worsen the condition leading to severe pain and swelling, infection which could be fatal, and/or loss of the tooth/teeth

An Apicoectomy, like all dental care, has risks. The most common risks associated with this treatment include but are not limited to:

  • Swelling, bruising and discomfort postoperatively
  • Bleeding and postoperative infection accompanied by malaise or fever which may require immediate additional treatment
  • Injury to a nerve resulting in numbness, burning, or tingling of the chin, lip, cheek, gum on the side on this the procedure in being performed as well as loss of taste in the case of the tongue. These nerve injuries can last for several weeks, months or in rare instances, be permanent
  • Drug and medication reactions, although rare, may occur. These reactions could include redness, swelling, pain, itching, vomiting and/or anaphylactic shock
  • Sinus involvement which would require additional surgery
  • Recession of gums away from the crown exposing more tooth and/or root

Prior to surgery, an antibiotic or anti-inflammatory medication may be prescribed to treat the inflammation or infection. It should be noted that antibiotics may interfere with the effectiveness of oral contraceptives. Therefore, additional forms of birth control for one complete cycle should be utilized after the course of antibiotics is completed.

Additional appointments after the surgery may be required to monitor the healing of the surgery site.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

  • Pre and post-treatment instructions have been explained to me.
  • I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
  • I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
  • Must notify the clinician if my medical history changes prior to subsequent treatments.
  • I consent to clinical photographs being taken of my treated areas for my personal health record only.
  • There are no refunds for services rendered and/or after a year from purchase and not used.
  • The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.



Patient Name :
Signature:

Doctor Name :
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date