Intracoronal Bleaching Procedure Note (Nonvital Bleaching)

Date: [Date]

Clinician: [Name, credentials]

Patient: [Per EHR convention]

Visit Type: [Initial Bleaching Visit / Bleaching Refill Visit / Completion Visit / Complication/Unscheduled Visit] (Complete sections below according to visit type.)

Procedure Identification

• Procedure: Intracoronal Bleaching — [walking bleach / thermocatalytic / other technique]
• Tooth/Teeth: [Tooth number(s) using Universal or FDI notation]
• Diagnosis: Intrinsic discoloration of endodontically treated tooth — [Etiology: trauma / pulpal necrosis / sealer staining / other / unknown]

Indication & Preconditions

[Patient's esthetic concern]

• Endodontic status: [RCT quality assessment] — [Periapical status from imaging] (Document from imaging actually reviewed; do not assume adequacy.)
• Coronal seal/restoration integrity: [Assessment of existing restoration, leakage, caries status]
• Cervical/periodontal considerations: [Recession, cervical defects, trauma history, prior resorption, risk factors]
• Contraindications/deferral triggers: [None identified / Active periapical pathology / Untreated caries or leakage / Unrestorable structure / High resorption risk — Action taken]
• Imaging status: [Radiograph obtained today and reviewed / External imaging reviewed with date and source / Bleaching deferred pending imaging]

Relevant History

• Allergies: [Relevant material allergies: latex, resin components, etc. / NKDA]
• Baseline symptoms: [Asymptomatic / Symptoms present with description]
• Procedure considerations: [Factors affecting isolation or tolerance] (Omit if none.)

Diagnostic Records

• Radiographs reviewed: [Type, date] — [Key findings: RCT quality, periapical status, cervical anatomy]
• Baseline shade: [Shade system and code] — [Description of mismatch vs adjacent teeth]
• Pre-operative photographs: [Obtained / Not obtained — Reason]

Informed Consent

• Diagnosis and treatment explained: [Yes / No] — [Multi-visit internal bleaching described in patient-friendly terms]
• Risks discussed: External cervical resorption (rare but serious); incomplete whitening or relapse; need for multiple visits; temporary restoration loss; soft tissue irritation; potential effects on bonding after bleaching
• Alternatives discussed: External bleaching; veneer or crown; no treatment; deferral
• Consent status: Verbal consent [obtained / not obtained] — Written consent [signed and filed / not obtained]

(Safety-critical: If consent not documented, note must be marked incomplete.)

Procedure Details

(Repeat the following tooth-specific subsection for each treated tooth.)

Tooth: [Tooth number]

Isolation and Access (Complete for Initial and Refill visits.)

• Isolation: [Rubber dam / Alternative with rationale]
• Anesthesia: [Type and volume] (Include only if administered.)
• Access: [Restoration removal/modification] — [Pulp chamber debridement and cleaning method]

Gutta-Percha Reduction (Complete for Initial visits; note if chamber not re-entered during Refill.)

• Depth: [Measured depth relative to CEJ] — Verification: [Periodontal probe measurement / Radiographic reference]

Cervical Barrier Placement (Safety-critical; complete whenever barrier is evaluated or placed.)

• Material: [RMGI / GI / MTA / Bioceramic / Other]
• Thickness: [Measured thickness in mm] (Minimum 2 mm recommended.)
• Level: [Position relative to CEJ, cervical contour]
• Verification: [Visual / Tactile / Radiograph with date]
• (If barrier not placed, document explicit rationale.)

(Safety-critical: Barrier details required before finalizing.)

Bleaching Agent Placement (Complete for Initial and Refill visits.)

• Agent: [Sodium perborate with water / Carbamide peroxide with concentration / Hydrogen peroxide with concentration]
• Preparation: [Mixing and consistency] — Confined to pulp chamber only
• Activation: [No heat or light used / Thermocatalytic used with details and additional risk discussion]

(Safety-critical: Agent identity and concentration required before finalizing.)

Temporary Seal

• Material: [Cavit / IRM / GI / Resin-based temporary / Other]
• Assessment: [Seal adequacy, occlusion check]

Tolerance and Complications

• Tolerance: [Tolerated well / Details]
• Complications: [None / Description with management provided]

Completion Visit Actions (Include only for Completion visits.)

• Agent removal: [Chamber cleaning method]
• Interim medicament: [Calcium hydroxide placed / None / Other] (Include duration if applicable.)
• Definitive restoration plan: [Material] — [Bonding timing: delayed with interval / immediate with antioxidant protocol]

Complication Visit Management (Include only for Complication/Unscheduled visits.)

• Presenting concern: [Chief complaint]
• Findings: [Clinical and imaging findings]
• Management: [Treatment provided today]
• Updated plan: [Revised treatment plan and precautions]

Post-Procedure Status

• Shade assessment: [Immediate observation] (Final shade confirmed at follow-up.)
• Post-operative radiograph: [Taken with findings / Not taken]
• Condition at discharge: [Patient status]

Post-Op Instructions

• Keep temporary intact; avoid hard biting on treated tooth
• Return if temporary dislodges, or if swelling, increasing pain, or soft tissue irritation occurs
• Written instructions: [Provided / Not provided]
• Analgesics: [Recommendations] (Include only if applicable.)

Follow-Up Plan

• Return interval: [Days until next agent change]
• Stopping criteria: [Shade match achieved / No further improvement after defined cycles / Patient preference / Safety concern]
• Resorption monitoring: [Radiographic follow-up plan with interval] (Include if trauma history or resorption risk factors present.)
• Definitive restoration: [Scheduled date and planned procedure / Not yet scheduled]
• (If follow-up not scheduled, document reason and care transfer details.)

(Safety-critical: Follow-up plan required before finalizing.)