***PLEASE READ ONLY*** Dr. Tolba will go over your case then signature of consent may be signed.

Stafford Endodontics

556 Garrisonville Road, Suite 200 Stafford, VA 22554 540-602-7889

Endodontic Treatment Consent and Information Form

What is a Root Canal? Root canal therapy is the cleaning, shaping, disinfecting and filling of the root canal(s) of the diseased tooth. A treated tooth usually functions normally as a pulpless tooth, not a dead tooth. Treatment will usually require one or more appointments, depending upon the condition of the tooth and may need additional x-rays to be taken throughout the process.

Following treatment, the tooth will be brittle and subject to fracture. A permanent restoration (filling), crown, and/or post and core will be necessary to restore the tooth to function. (The fees for these procedures will be additional and these services will be provided by your general dentist.) The alternatives to endodontic therapy include, no treatment, waiting for a more definite development of symptoms and/or tooth extraction. Risks involved in these choices might include pain, infection, swelling, and tooth loss.

PLEASE BE ADVISED OF THE FOLLOWING

As a rule, 90-95% of routine cases are successful. 70-75% of redo (retreatment) cases are successful. No warranty or guarantee of success can be given in root canal treatment. If the original treatment is not successful, it may have to be redone, a surgical procedure may be required or the tooth may need to be removed. Each of these procedures require additional fees to be charged.

Treatment of your case has a ______% of success. ___initialTreatment will be done using __Local Anesthetic __Oral Sedation _____Nitrous Oxide (dental gas, conscious sedation)

Your initial diagnosis is:

NORMAL PULP REVERSIBLE PULPITIS/IRREVERSIABLE PULPITIS/NECROTIC PULP/PREVIOUS ENDO THERAPY/PREVIOUSLY STARTED ENDODONTIC THERAPY WITH: NORMAL PERIAPEX/SYMPTOMATIC APICAL PERIODONTITIS/ASYMPTOMATIC APICAL PERIODONTITIS/ACTUE PERIRADULULAR ABSCESS

CHRONIC PERIRADICULAR ABSCESS ADDTL INFO:______Initial:______

POSSIBLE UNAVOIDABLE COMPLICATIONS MAY INCLUDE BUT NOT LIMITED TO:

1)Swelling, soreness/pain, infection, trismus (restricted jaw opening) or discoloration of the soft or hard tissue.

2)Breakage of root canal instruments during treatment, which may be in the judgment of Dr. Tolba to be left in the treated root canal or require surgery for removal.

3)Fracture of the crown or root of the tooth.

4)Perforation of the root canal with instruments, which may require additional surgical corrective treatment or result in premature tooth loss or extraction.

5)Under fill and/or over fill canal.

6)Sinus perforation.

7)Damage to bridges, existing filling and crowns.

8)Blocked canals due to fillings or prior treatment, natural calcification, severely curved roots, and root resorption.

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

10)Possible nerve damage during the administration of anesthesia.

There is a greater chance of failure of root canal therapy if a patient fails to keep scheduled appointments. Take pain medication as directed when you first feel discomfort. Pay attention to any warnings on the medication container from the pharmacy. If antibiotics are prescribed, it is VERY IMPORTANT that you take ALL of them as directed.

I ______have been advised by the Dr. Tolba that I require root canal treatment for my tooth/teeth #_____.I understand that I am to contact the office for an appointment six months and one year after treatment is completed so the root can be evaluated. (Included in the treatment fee.) I understand that it is my responsibility to set up and follow through with all appointments. Failure to do so may result in the loss of the tooth or damage to the other teeth and surrounding bone. I understand it is critical to return to my general dentist to follow-up with an appointment within30 days to complete the permanent restoration of this tooth. I understand that if the temporary filling placed byDr. Tolba comes out before I return to my general dentist, I am to return to have the temporary filling replaced (at no additional cost.) Failure to keep the tooth covered will allow saliva and food to contaminate my tooth and if this is allowed for more than a couple of days (less than a week), it will result in my needing to have this root canal retreated, which would be at my own expense. All of my questions have been answered by the treating dentist and I fully understand the above statements in this consent form. I hereby give my consent for administration of medications, local anesthetics and services deemed necessary to treat my endodontic problem, understanding the risks involved. I also understand that I may get additional information.

Signature of Patient/Guardian Date Mostafa S. Tolba, DDS, MS Date

CC: Patient Copy Rev:8/2016