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Informed Consent for Pulpotomy in Primary Teeth

Informed Consent for Pulpotomy in Primary Teeth

Precautions must be taken for Pulpotomies in certain circumstances. You MUST inform the dentist prior to treatment if your child has any of the following medical conditions:
• heart condition;
• history of rheumatic heart disease;
• artificial heart valves;
• known allergies to antibiotics.

Potential Complications
As with all dental and medical procedures, pulpotomies are not without risk. Some of the potential complications of this treatment include, but are not limited to:
• Fracture – Due to the extensive nature of the procedure, combine with primary tooth’s original injury or decay, the tooth will be weaker than a healthy tooth. As such, the tooth may fracture or break. If the tooth fractures catastrophically, it may require extraction.
• Pain/sensitivity – In most cases, once the pulpotomy has been performed and the post-operative discomfort has subsided, the tooth is typically free of symptoms. However, in some cases, pain or sensitivity may persist. In this case, the tooth may require a pulpectomy or an extraction.
• Infection –The tooth may become infected after a pulpotomy is performed. In this case, the tooth may require a pulpectomy or an extraction.
After the completion of a pulpotomy, a permanent restoration (in the form of a filling or stainless steel crown) will be required to seal and protect the primary tooth. Failure to properly restore the tooth in a timely manner (generally within 30 days) significantly increases the possibility of infection of the tooth or tooth fracture.

Alternative Treatment Options
The following are other treatment options which might be possible:
• no treatment at all;
• proceeding to pulpectomy;
• extraction of tooth.

The cost of pulpotomy is as outlined in the attached treatment plan. Full payment is required on the day of the appointment.

Teeth requiring Pulpotomy

• I have read and understand the conditions and information in this Consent Form.
• I have discussed the information contained in the Consent Form concerning Pulpotomy with my dentist, and am satisfied with the answers that I have received.
• I have had explained to me the cost of the treatment and I accept responsibility for that cost.
• I authorise my dentist to provide my child with Pulpotomy.