Nonsurgical Root Canal Therapy Procedure Note

Date of Service: [Date of service]
Location/Operatory: [Clinic/Operatory]
Clinician: [Name, credentials]
Tooth Number: [Tooth number with root designation if applicable] (Required—do not leave blank)
Canals Treated: [List canals treated this visit]

Pre-Procedure Context and Indications

[Brief narrative summarizing chief complaint in patient's own words when relevant, indication for NSRCT, and restorability assessment] (2–4 sentences; include whether tooth is restorable and any prerequisites for restorability)

• [Pertinent history: onset, provoking factors, spontaneous pain, swelling, sinus tract, prior endodontic/restorative history]
• [Clinical tests performed and findings: thermal with controls, EPT with controls, percussion, palpation, probing depths, mobility, transillumination if relevant]
• [Pre-op imaging reviewed and pertinent findings]
• [If continuation visit: reference prior diagnostic documentation and restate working diagnosis] (Omit if initial visit)

Pre-Operative Diagnosis

• Pulpal Diagnosis: [Normal pulp / Reversible pulpitis / Symptomatic irreversible pulpitis / Asymptomatic irreversible pulpitis / Pulp necrosis / Previously treated / Previously initiated therapy]
• Periapical Diagnosis: [Normal apical tissues / Symptomatic apical periodontitis / Asymptomatic apical periodontitis / Acute apical abscess / Chronic apical abscess / Condensing osteitis]
• Additional Findings: [None / Cracked tooth suspicion / Calcified canals / Internal resorption / External resorption / Root perforation / Open apex / Other findings]

[Brief rationale linking diagnosis to documented tests and imaging] (If diagnostic uncertainty exists, state explicitly and describe plan to clarify)

Consent and Safety Verification

• [Informed consent discussion completed: diagnosis, nature of procedure, risks/complications, benefits, alternatives including extraction and no treatment, and prognosis]
• Consent Documentation: [Signed form / Verbal per policy] (If consent not documented, note: "Consent incomplete—follow-up required prior to proceeding")
• [Medical history and allergies reviewed: pertinent positives/negatives]
• [Relevant considerations: anticoagulation, immunocompromise, pregnancy, antibiotic prophylaxis] (Omit if none)
• [Time-out performed: patient identity, procedure, tooth number, site confirmed] (Omit if not performed per facility protocol)

Anesthesia

• Agent and Concentration: [Agent and concentration]
• Vasoconstrictor: [None / Vasoconstrictor type and concentration]
• Amount: [Number of cartridges or mL]
• Technique: [IAN block / Infiltration / PDL / Intraosseous / Intrapulpal / Other]
• Topical: [Agent and concentration / None]
• Effect: [Profound anesthesia achieved / Partial anesthesia with supplemental techniques / Inadequate anesthesia and management]

(If no anesthesia administered, state explicitly with brief rationale and omit list above)

Isolation and Asepsis

• [Dental dam placed and maintained throughout instrumentation, irrigation, and obturation] (Note latex-free if applicable)
• [Operating field disinfected: agent and method] (Omit if not performed)

(If dental dam not used, document exceptional circumstance, alternative protective measures, and contamination/aspiration risk management—this is a significant variance from standard of care)

Pre-Operative Imaging

• [Periapical radiograph(s) reviewed: views and key findings relevant to treatment planning]
• [Additional angulated views: description and findings] (Omit if not obtained)
• [CBCT: clinical justification and pertinent findings] (Omit if not obtained)
• Images stored in patient record.

Procedure

Access and Pulpal Status

• [Access cavity design and approach; caries removal and/or existing restoration management; use of magnification/microscope if applicable]
• Pulpal Status on Entry: [Vital hemorrhagic tissue / Necrotic tissue / Purulence/exudate / Malodor / Other findings]

Canal Identification and Anatomy

• Canals Located: [Canals using standard nomenclature: MB1, MB2, DB, P, ML, DL, M, D, etc.]
• Anatomic Variations: [None / Additional canals / Severe curvature / Calcifications / Resorption / Merging canals / Other]

Working Length Determination

(Document actual intraoperative measurements; do not infer from post-operative radiographs)

• Method(s): [Electronic apex locator model / Radiographic verification]
• [Canal name]: EAL [reading] mm, WL radiograph [obtained / not obtained], final WL [length] mm from [reference point], patency [confirmed / not confirmed]
• (Repeat for each canal treated)

Instrumentation

• Glide Path: [Method and files/system used]
• Instrumentation System: [System name and sequence summary]
• Final Apical Preparation: [Size and taper for each canal]
• Challenges and Management: [None / Ledge / Transportation / Calcification / Curvature / Blockage—describe management] (Omit if none)

Irrigation and Disinfection

• Primary Irrigant(s): [Agent(s) and concentration(s)]
• Delivery: [Needle type/size, insertion depth relative to WL, safety measures]
• Activation: [Ultrasonic / Sonic / Manual dynamic / Negative pressure / None]
• Smear Layer Management: [EDTA concentration and duration / Not performed]
• Final Rinse: [Sequence and solutions]
• Drying: [Paper points / Micro-suction / Other]

Obturation

(Include only if obturation performed this visit; otherwise omit and complete Temporization section)

• Technique: [Warm vertical / Lateral condensation / Single cone / Carrier-based]
• Master Cone: [Material and size/taper by canal]
• Sealer: [Type/brand]
• Apical Termination: [To WL / Short of apex by distance / Extrusion present—describe]
• Open Apex Management: [Apical barrier technique and material] (Omit if not applicable)
• Coronal Backfill: [Material and placement]
• Quality: Canals obturated to working length with dense fill; post-obturation radiograph shows [findings].

Temporization

(Include only if multi-visit and obturation not performed; otherwise omit this section)

• Intracanal Medicament: [Agent, concentration, placement method]
• Temporary Restoration: [Material and technique]
• Occlusion: Checked and adjusted as needed.
• Next Visit Plan: [Planned procedural step]

Intraoperative Imaging

• WL Verification: [View(s) and interpretation]
• Master Cone Fit: [View(s) and interpretation] (Omit if not obtained)
• Post-Obturation: [View(s) and interpretation] (Omit if obturation not performed)
• Intraoperative images stored in patient record.

Complications

[No procedural complications] (If complications occurred, replace with the following)

• Event: [Instrument separation / Ledge / Perforation / NaOCl accident / Overextension / Canal not located / Other]
• Management: [Immediate management and outcome]
• Prognosis Impact: [Effect on prognosis and modifications to plan]
• Patient Communication: [Information provided to patient regarding event]

Coronal Seal and Restorative Plan

• Placed Today: [Temporary restoration / Bonded core buildup / Definitive restoration—materials and technique]
• Recommendation: [Crown / Onlay / Direct restoration] within [timeframe] (Timely coronal seal is essential for long-term success)
• Restorative Provider: [Referring dentist / In-house—information communicated]

Post-Operative

• Patient Tolerance: [Procedure tolerated well / Specific concerns]
• Hemostasis/Tissue Status: [Description] (Omit if not applicable)
• Occlusion: Checked and adjusted as needed.
• Medications Administered: [Drug, dose, route, time / None]
• Prescriptions: [Drug, dose, directions, quantity, indication / None] (If antibiotic prescribed, document clinical indication)
• Post-Op Instructions: [Instructions provided covering expected course, analgesics, dietary precautions, temporary protection, return precautions; handout provided if applicable]

Follow-Up

• Next Appointment: [Date/timeframe and planned procedure] (For multi-visit cases; omit if treatment complete)
• Recall: [Recommended follow-up imaging timeline per protocol]
• Referring Provider Communication: [Completed / Planned—records shared]