INFORMED CONSENT FORM FOR APICOECTOMY SURGERY

You have the right to be informed about your condition and the recommended treatment plan to be used so that you may make an informed decision as to whether or not to undergo the procedure after knowing the risks involved. This disclosure is not meant to alarm you, but rather is an effort to properly inform you so that you may give or withhold your consent.

 
An apicoectomy is a surgical procedure involving the use of local anesthetic to numb the tooth and root structure and surrounding gum and bone. I understand that the administration of local anesthesia carries with it, its own inherent risks including but not limited to nerve damage, permanent numbness, temporary numbness, discoloration, rashes, swelling, infection, and even in very rare instances cardiac death. The numbness can affect my chin, lips, gums, teeth, tongue, and surrounding tissue structures.
 
An Apicoectomy is a common endodontic treatment which is necessitated in the rare instance that there is inflammation or infection at the tip of the root subsequent to 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 stitches. Additional tests may be performed on the infected/inflamed tissue which was removed.
 
There are certain inherent and potential risks and side effects in any surgical procedure, and in this specific instance, such risks include, but are not limited to, the following:
  • Post-operative discomfort and swelling that may require several days of at-home recuperation.
  • Prolonged or heavy bleeding that may require additional treatment.
  • Post-operative infection that may require additional treatment.
  • Injury or damage to adjacent teeth or fillings.
  • Stretching the corners of the mouth that may cause cracking and bruising and may heal slowly.
  • Restricted mouth opening for several days, sometimes related to swelling and muscle soreness; and sometimes related to stress on the joints of the jaw (TMJ).
  • If apicoectomy is done in the mandible, injury to the nerve underlying lower teeth resulting in numbness or tingling of the chin, lip, cheek, gums and/or tongue which may persist for several weeks, months or, in rare instances, permanently.
  • If an apicoectomy is done to an upper posterior tooth, then the opening of the sinus (a cavity situated above the upper teeth) may occur requiring additional surgery. 
I understand that apicoectomy surgery is not always successful but that the purpose of the procedure is to try to salvage the tooth. Many factors influence the treatment outcome including the patient's general health, bone support around the tooth, the strength of the tooth including possible fracture lines, shape, and condition of the roots, and nerve canals. I also understand that apicoectomies do, from time to time, fail and that there is a material risk to the procedure. Should my apicoectomy fail, I understand that I would require a repeat procedure or even possibly the extraction of the tooth or adjacent teeth involved. I also understand that, by undergoing an apicoectomy, my problem may not be cured.
 
I also understand that, with respect to an apicoectomy, the tooth is in a weakened state compared to a healthy, untreated tooth. That makes the tooth subject to the risk of fracturing or breaking during the surgery and also in the future. I understand that a tooth, which has had an apicoectomy, is at risk for further decay and even infection.
 
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 and;
  • 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. 
Additional appointments after the surgery may be required to monitor the healing of the surgery site.
 
 
Acknowledgment
By signing below, I am acknowledging I have read or had this document read to me in its entirety, have had the chance to ask questions and have them answered to my satisfaction so that I feel I understand the information as it is presented. I understand the potential risks, complications, and side effects. I have elected to proceed with this dental treatment after having considered both the known and unknown risks, complications, side effects, and alternative treatment methods.