Endodontic Consultation Note (Referred Tooth Evaluation)

Date/Time: [Encounter date and time]

Patient Name: [Full legal name]

Date of Birth: [DOB]

Referring Dentist: [Referring dentist name and practice] (If unknown, document: "Referring provider: unknown (patient report only)")

Referred Tooth/Teeth: [Tooth number(s) with plain-language descriptor, e.g., #19 – mandibular left first molar]

Reason for Referral: [Verbatim reason from referral when available; otherwise concise summary]

Records Reviewed: [List of records reviewed with dates: periapicals, bitewings, panoramic, CBCT, photos, prior notes, etc.]

Chief Complaint

[Patient's chief complaint in their own words]

[One-sentence visit goal clarifying the clinical question, e.g., "Evaluate #30 for pulpal/periapical diagnosis and recommend treatment options to referring dentist."] (If asymptomatic and referral-driven, document: "No current symptoms; evaluation requested due to radiographic finding / restorative plan.")

History

[Focused endodontic history narrative addressing onset/timeline, pain quality and triggers (cold, heat, biting, spontaneous, positional), duration of thermal response (lingering vs transient with seconds if known), ability to localize, severity and functional impact, relieving factors, associated signs (swelling, drainage, sinus tract), and relevant prior dental interventions (recent restorations, trauma, prior root canal treatment). Include restorative context if relevant to treatment planning.] (Conclude with "Most suspicious tooth by history: #__" if applicable. For asymptomatic incidental findings, provide a brief referral context paragraph instead.)

Medical History

• Relevant conditions: [Diabetes, immunocompromise, bleeding disorders, cardiac conditions, pregnancy, bisphosphonate/denosumab therapy, head/neck radiation, or other conditions impacting endodontic care]
• Allergies: [Drug allergies, especially antibiotics and local anesthetics, or "NKDA" if explicitly confirmed]
• Pertinent medications: [Anticoagulants/antiplatelets, steroids, immunosuppressants, others relevant to treatment]

(If allergy or medication information is unavailable, document why and state plan to verify before prescribing.)

Clinical Examination

Extraoral: [Facial symmetry, swelling, lymphadenopathy, TMJ findings if relevant]

Intraoral soft tissues: [Vestibular swelling, sinus tract presence/location, mucosal tenderness, other soft tissue findings]

Tooth/restorative assessment: [Existing restorations and quality, caries, cracks/craze lines, occlusion, previous RCT, cuspal coverage on referred and adjacent teeth]

Periodontal screening (referred tooth): Probing depths: MB [mm], B [mm], DB [mm], ML [mm], L [mm], DL [mm]. Furcation involvement: [none / Class I / II / III]. Mobility: [none / Class I / II / III].

(If examination was limited due to patient tolerance, document the limitation and note that results may be less reliable.)

Vitals: [BP, HR, temp if obtained] (Include only if medically complex, febrile, or sedation planned; otherwise omit.)

Diagnostic Testing

(Always test control teeth—adjacent and/or contralateral—and document results for baseline comparison.)

Pulp Sensibility Testing

Tooth	Cold	Heat	EPT	Notes
[Control tooth #]	[none / normal / exaggerated / delayed; lingering duration in seconds if applicable]	[none / normal / exaggerated / not performed]	[EPT reading or "not performed"]	[Reason if not performed; additional observations]
[Referred tooth #]	[none / normal / exaggerated / delayed; lingering duration in seconds if applicable]	[none / normal / exaggerated / not performed]	[EPT reading or "not performed"]	[Reason if not performed; additional observations]

(Add rows for additional teeth tested. Note when a test was not performed and why, e.g., full-coverage crown.)

Periradicular Testing

• Percussion: [negative / mild / moderate / severe tenderness] (Specify vertical and/or horizontal.)
• Palpation: [negative / mild / moderate / severe tenderness over apical mucosa]
• Bite test: [negative / positive on biting / positive on release] (Note instrument used and cusp-specific findings if relevant to crack evaluation.)

Additional Tests

(Omit this subsection entirely if no additional tests were performed.)

• Transillumination/magnification: [Crack location and extent if detected]
• Selective anesthesia: [Anesthetic used, injection site, and effect on symptoms/localization]
• Sinus tract tracing: [Material used and radiographic result]

Imaging

Inventory: [Image type] — [taken today / provided by referrer], [date], [diagnostic adequacy and limitations]. (List each image set.)

2D radiographic findings: [Caries/restoration depth and pulp proximity; pulp chamber/canal morphology and calcifications; PDL space changes; periapical status (radiolucency, condensing osteitis); resorptive defects if present; quality of prior root canal therapy if applicable]

CBCT Findings

(Omit this subsection entirely if no CBCT was obtained or reviewed.)

• Indication: [Diagnostic question prompting CBCT]
• Technique/quality: [FOV, region, image quality, artifacts affecting interpretation]
• Key endodontic findings: [Periapical status, canal anatomy/variations, fractures, resorption, missed canals, perforations]
• Incidental findings: [Incidental findings and routing/follow-up plan] (Document even if none: "No incidental findings identified.")

Assessment

Problem 1: [Referred tooth # and descriptor]

Supporting findings: [Concise synthesis of history, exam, testing, and imaging findings relevant to diagnosis]

• Pulpal diagnosis (AAE): [Normal pulp / Reversible pulpitis / Symptomatic irreversible pulpitis / Asymptomatic irreversible pulpitis / Pulp necrosis / Previously treated / Previously initiated therapy]
• Apical diagnosis (AAE): [Normal apical tissues / Symptomatic apical periodontitis / Asymptomatic apical periodontitis / Acute apical abscess / Chronic apical abscess / Condensing osteitis]
• Differential diagnosis: [Ranked by likelihood: endodontic, cracked tooth, periodontal, occlusal trauma, non-odontogenic]
• Restorability: [favorable / guarded / unfavorable] — [Brief rationale]
• Prognosis: Endodontic: [favorable / guarded / unfavorable]. Restorative: [favorable / guarded / unfavorable].

(If diagnosis is uncertain, use "Inconclusive / requires re-evaluation" and document plan to clarify. Both pulpal AND apical diagnoses are required for each tooth.)

Problem 2: [Secondary tooth or incidental finding]

(Include only if additional teeth or imaging findings require documentation; otherwise omit this subsection.)

• Pulpal diagnosis (AAE): [Standardized pulpal diagnosis]
• Apical diagnosis (AAE): [Standardized apical diagnosis]
• Key findings: [Brief supporting summary]
• Recommendation: [Follow-up plan or referral]

Plan

Recommended treatment: [Nonsurgical RCT / retreatment / vital pulp therapy / apicoectomy / extraction referral / monitoring] — [1–2 sentence rationale linked to diagnosis and restorability]

Sequence of care: Endodontist: [responsibilities]. Referring dentist: [core buildup, crown, caries control, occlusal adjustment as applicable].

Urgency/timing: [urgent / soon / routine] — [Recommended timing and follow-up interval]

Alternatives discussed: [Endodontic treatment vs extraction vs monitoring/no treatment with brief benefits/risks for each]

Medications: [Analgesic regimen. Antibiotic if prescribed: indication, drug, dose, duration. Escalation instructions if systemic symptoms develop.] (Omit if none prescribed.)

Counseling/Consent: [Summary: diagnosis, proposed procedure, risks/benefits, prognosis, alternatives including no treatment discussed. Patient had opportunity for questions. Decision: accept / defer / refuse.] (If refused, document stated reason.)

Summary for Referring Dentist

[Tooth #]: [Pulpal diagnosis] / [Apical diagnosis]

• Key findings: [2–5 most relevant positive findings]
• Imaging reviewed: [Types and dates]
• Recommendation: [Plan with concise rationale]
• Coordination: [Restoration timing, caries management, other shared care needs]
• Concerns: [Restorability, crack suspicion, periodontal prognosis, or "None"]