Endodontic retreatment involves but is not limited to, the removal and treatment of the affected/infected root canal material. Complications from endodontic retreatment may include pain that comes and goes and swelling which may require medication(s). Endodontic retreatment may be the only possible treatment option to save your natural tooth. Other treatment choices may include no treatment or tooth extraction.

Alternatives to Re-Root Canal Treatment

Depending on my diagnosis, there may be alternatives to root canal treatment that involve other types of dental care. I understand the most common alternatives to root canal treatment are:

• Extraction: I may choose to have this tooth removed. The extracted tooth usually requires replacement by an artificial tooth using a fixed bridge, dental implant, or removable partial denture.
• No treatment: I may choose to not have any treatment performed at all. If I choose no treatment, my condition may worsen and I may risk serious personal injury. Including severe pain, localized severe pain, localized infections, loss of this tooth and possibly other teeth, severe swelling, and/or severe infection that may spread to other areas and could be potentially fatal.

Risks and Infection in Other Areas

Endodontic Re-Treatment Risks:

• I understand that re-root canal therapy is a procedure undertaken to retain a tooth that may otherwise require an extraction. I understand that although this procedure has a high degree of success, it is a biological procedure and success cannot be guaranteed.
• I understand that many factors contribute to the success of re-root canal treatment and not all factors can be determined in advance. Some of the factors are but are not limited to my resistance to infection, the bacteria causing the infection, and the size, shape, and location of the canals. My case may be more difficult if my tooth has blocked, curved, or narrow canals.

By signing below, I acknowledge that I have read and understand the recommended treatment, the risks of such treatment, and the alternatives including doing nothing. I have had the chance to have all of my questions answered. I understand that success is not guaranteed. I give my full consent to the treating Dentist to perform this re-root canal procedure for me.

I acknowledge that I have provided an accurate medical history, and will follow treatment recommendations as well as post-procedural instructions.

My treatment options have been explained to me as well as the indications and possible complications of endodontic retreatment and I offer my consent for treatment. Regardless of the outcome, once treatment is initiated the full fee has been incurred whether the case is completed or not due to whatever circumstances of the tooth. The Doctor will use his/her best skill and judgment to try to save the tooth but the outcome cannot be guaranteed.

Before treatment is initiated, be certain to have the doctor answer any questions you may have. All signatures must be by a parent or guardian if the patient is under the age of 18.

Tooth Number:

Alternatives to the above treatment

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :