Informed Consent for Emergency or Palliative Treatment Form

Informed Consent for Emergency or Palliative Treatment ITEM 419 - Commonly referred to as: ’Open and Drain'

The partial or thorough removal of pulp and/or debris from the root canal system of a tooth. This is an emergency or palliative procedure.

Extirpation involves removing the pulp from inside the tooth as part of the root canal procedure. You may need to have this treatment if you experience the following symptoms:

• Pain or discomfort when biting down.

• Pain that ranges from dull to severe in the roots and gum.

• Discolouration on the gum that excretes pus.

• Gum swelling around the infected tooth or teeth.

As part of the root canal procedure, your dentist will need to remove the pulp of your tooth or teeth. The pulp is a soft material that includes blood vessels and nerves. The pulp allows you to sense hot and cold and is the part of the tooth that feels pain when it becomes infected. Without the pulp, the tooth is basically dead and can’t feel anything, though the outer shell can still function perfectly well without the inner living matter.  

During a pulp extirpation, your dentist will basically remove all of the infected inner tissue of the affected tooth. This will remove all the bacteria that’s causing the pain and infection and prevent it from travelling into the tooth. After the pulp is removed, it can be replaced with an inert material that preserves the strength of the tooth, saves it from extraction, and allows it to function as normal. With this procedure, the treatment will include the following:  

• You will be given a local anaesthetic.

• Your dentist will make a hole in your tooth.

• The pulp extirpation is performed and the infected pulp is removed.

• The inside of the tooth is cleaned to prepare for the next stage of the root canal.

• Inert material is put into the tooth.

• The hole in the tooth is sealed.

If the infection is severe, the pulp extirpation, may require several trips to the dentist before the infection is cleared completely.

Patient Name:
I hereby authorise (Doctor’s name)
and any associates to perform a ‘419’ on tooth/teeth number(s):

The doctor has explained to me that the purpose of this procedure is to retain teeth that may otherwise need to be extracted.

The doctor has explained to me the treatment and the anticipated results of the treatment.

I understand that this is an elective procedure and that there are alternative treatments and the doctor has explained the risks and benefits of the alternatives.

The doctor has explained to me that there are certain potential risks in the procedure.

These risks include:
• Fracture or breakage of the root or crown portion during or after treatment.
• Inadvertent breakage of files or instruments within the root canal system that is unable to be retrieved.
• Perforation of the tooth or root of the tooth during treatment.
• Damage to existing fillings, crowns or porcelain veneers.
• As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle tenderness or even a resultant temporary or permanent numbness of the tongue, lips, teeth, jaws and/or facial tissues.
• The possible need for a crown 6-12 months (maybe earlier maybe later) due to this tooth becoming brittle.

Unforeseen conditions may arise that require a procedure that is different than set forth above, a repeat treatment, or I might be referred to a specialist for further treatment.

I authorize the doctor and any associates to perform such procedures when, in their professional judgment, the procedures are necessary, after discussing the option with me, and obtaining my verbal consent (except in emergent circumstances where consent might not be practical to obtain).

I understand that the medications, drugs, anesthetics and prescriptions taken for this procedure may cause drowsiness and lack of awareness and coordination.

I further understand that drugs and anesthetics may cause unanticipated reactions, which might require medical treatment.
Please do not hesitate to ask the doctor or the staff if you have any questions.

Patient Signature:
Date:
Dentist Name:
Date: