Informed consent for endodontic retreatment of previous root canal

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Patient name:(Required)

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.


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 artificial tooth by means of 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 possible other teeth, severe swelling, and/or severe infection that may spread to other areas and could be potentially fatal.

Risks and infection to other areas


  • I understand that 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 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, the size, shape and location of the canals. My case may be more difficult if my tooth has blocked, curved or narrow canals.
  • I understand that root canal treatment may not relieve my symptoms and treatment can sometimes fail for unexplained reasons. If treatment fails, other procedures including retreatment, a surgical procedure or an extraction of the tooth.
  • I understand that during and after treatment, I may experience some pain or discomfort, swelling, bleeding and loosening of dental restorations. I may also need antibiotics to treat any associated infections. I may also continue to develop an infection despite all reasonable attempts to treat the affected tooth.
  • I understand that root canal instruments sometimes separate (break) inside the canal which may or may not affect the prognosis. If the separated fragment cannot be retrieved, it may be sealed inside the root canal or require additional treatment in the future. There could also be tooth root perforation which would require additional treatment or extraction.
  • I understand that other risks include perforation by the instrument, sinus perforation and/or nerve disturbances.
  • I understand that once root canal treatment is completed, I must have a permanent restoration placed by my regular dentist within a few weeks. If I fail to have the tooth restored, I risk a failure of the root canal treatment, decay, infection, tooth fracture and/or loss of the tooth. I also understand that there is still a chance of tooth fracture even after the tooth is crowned.
  • I understand local anaesthetic will be given. Some discomfort following treatment may develop from the injection area and from opening my mouth during treatment. On rare occasions, paresthesia of the nerve may occur. There may be an alteration of sensation of the lip or cheek as well as trauma to the nerve tissue and/ or blood vessels as well as a risk of an infection.
  • Although Retreatment has a very high degree of clinical success, results cannot be guaranteed.If a root canal must be done after a restoration or crown in its place, I understand that during the root canal treatment, the existing restoration or crown, bridge etc. may have to be damaged or removed and subsequently may require repair or replacement. In such an event it will not be the responsibility of the treating dentist to repair or provide me with a replacement of that restoration.
  • I understand that upon successful completion of the root canal therapy, this tooth will have to be restored as a separate procedure. Such a restoration may require a filling , and most often a post/core and crown. A crown provides the necessary strength to withstand the biting forces during normal long term function. This crown should be completed immediately to avoid possible tooth fracture. Your dentist and you will make that decision.
  • Occasionally, and despite our best efforts, a tooth that has undergone non-surgical root canal therapy may require retreatment or even root canal surgery.
  • Even after root canal therapy approximately 5% of treated teeth may eventually require extraction. There is no liability on the part of the treating Dentist for the loss of the tooth involved.
  • Oftentimes the root canal cannot be completed in one visit; As a result, if I abandon the completion of the root canal treatment procedure including the post procedure restoration before it is completed, I accept responsibility for consequences which may arise from my decision to discontinue treatment. Such consequences are described as “risks” above and may also include decay of the tooth and may result in loss of the tooth.

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 root canal procedure for me.

I acknowledge that I have provided an accurate medical history, 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.


Once fully read and reviewed, please make sure that the above document is filled out appropriately. By submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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