Endodontic Treatment Note

Completed note

Endodontist Note

Patient Identification: adult patient presenting with pain in a lower molar.

History of Present Illness:
The patient reports several days of intermittent aching in a lower left molar, worsened by cold drinks and chewing. Cold sensitivity lingers briefly after the stimulus. No facial swelling or fever. No prior root canal treatment on this tooth.

Past Dental History:
- Routine dental care
- No dental trauma reported
- No previous endodontic treatment

Medications:
- No regular medications reported

Allergies:
- No known drug allergies

Social History:
- No tobacco use
- Occasional alcohol use
- Office worker

Clinical Examination:
- Afebrile by report; no acute distress
- Extraoral: No swelling or palpable lymphadenopathy
- Intraoral: Deep caries on mandibular left first molar; mild percussion tenderness; no sinus tract
- Pulp testing: Lingering response to cold; adjacent teeth respond normally
- Radiographs: Deep caries approaching pulp; no definite periapical radiolucency

Diagnosis:
- Mandibular left first molar: Findings consistent with symptomatic irreversible pulpitis
- Periapical tissues: Findings consistent with symptomatic apical periodontitis

Treatment Plan:
- Recommend root canal therapy after discussion of alternatives.
- No antibiotics indicated in the absence of systemic or spreading infection signs.
- Advise definitive cuspal coverage restoration after endodontic treatment.
- Reviewed risks, benefits, and consent; patient elects to schedule treatment.
- Return promptly for swelling, fever, or worsening pain.

Illustrative case with invented patient details. This is not a real patient record or clinical guidance. Review each note against your own consultation.

Clinical facts behind the note

Reusable template structure

Endodontist Note

Patient Identification: [Patient name, age, gender, relevant dental history, presenting complaint]

History of Present Illness:
[Description of chief complaint, onset, duration, character of pain or symptoms, aggravating/alleviating factors, previous dental treatments, relevant medical history]

Past Dental History:
(hyphenated list)
- [Previous dental procedures]
- [History of trauma]
- [Previous endodontic treatments]
- [Other relevant dental history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug/other allergies or NKDA]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration]
- [Alcohol use: type, amount, frequency]
- [Occupation]
- [Other relevant social factors]

Clinical Examination:
(hyphenated list)
- [Vital signs if relevant]
- [Extraoral findings: swelling, lymphadenopathy, tenderness]
- [Intraoral findings: tooth number, caries, restorations, mobility, percussion/palpation tenderness, sinus tract, periodontal status]
- [Pulp testing results: cold, heat, EPT]
- [Radiographic findings: periapical radiolucency, root morphology, canal anatomy, other findings]

Diagnosis:
(hyphenated list)
- [Tooth number: pulpal diagnosis (e.g., irreversible pulpitis, necrotic pulp)]
- [Tooth number: periapical diagnosis (e.g., symptomatic apical periodontitis, chronic apical abscess)]

Treatment Plan:
(hyphenated list)
- [Recommended endodontic procedure (e.g., root canal therapy, retreatment, apicoectomy)]
- [Adjunctive treatments (e.g., antibiotics, analgesics)]
- [Restorative recommendations]
- [Patient counselling and consent]
- [Referrals if needed]
- [Follow up plan]
- [Return precautions]