Perforation Repair Procedure Note

Date/Time of Procedure: [Date and time]

Location: [Clinic/Operatory]

Treating Clinician: [Name, credentials]

Tooth Number and Site: [Tooth number and specific site of defect]

Indication and Diagnosis

"[Chief complaint in patient's own words]" (Use quotation marks for direct quotes.) [Symptom synopsis: pain/swelling/sinus tract with duration and severity]. Working diagnosis: [Perforation type/etiology: iatrogenic / caries-related / resorptive / traumatic]; [Pulpal diagnosis]; [Periradicular diagnosis]. Suspected communication with [periodontium / oral cavity / neither] — [rationale]. Baseline restorability: [restorable / questionable / non-restorable] — [reason].

• Perforation etiology: [Type/etiology]
• Pulpal diagnosis: [Diagnostic label]
• Periradicular diagnosis: [Diagnostic label]
• Communication suspected: [yes / no] — [Rationale]
• Symptoms: [Pain/swelling/sinus tract/other] — [Duration, severity, modifiers]
• Restorability: [restorable / questionable / non-restorable] — [Reason]

Pertinent History

(Include only when relevant; otherwise omit this section entirely. If reviewed and unchanged, state "Reviewed—no changes.")

• [Medical conditions affecting bleeding, healing, or infection risk]
• [Allergies: anesthetics, antibiotics, latex]
• [Anticoagulants or relevant medications]
• [Prior endodontic or restorative treatment on this tooth]

Diagnostic Findings

• Visual findings at access/defect: [Findings]
• Contamination signs: [saliva / purulence / sulcular communication / clean] — [Details]
• Canal findings: [Calcification / ledge / separated instrument / transportation / none] — [Details]

Perforation Characterization

(This section is critical for prognosis and must be specific.)

Anatomic Location: [coronal / radicular]; [cervical-crestal / within alveolar bone / apical third]; [furcal / strip / lateral]; [Relation to CEJ and crestal bone in mm]

Size: [Diameter in mm, note if approximate]; [Shape: round / oval / linear]; [Margin quality: regular / irregular]

Timing: [immediate recognition / delayed discovery] — [Basis for estimate]

Contamination Status: [clean / contaminated] — [Rationale]

Periodontal Communication: [likely / unlikely] — [Rationale based on clinical findings, probing, imaging]

Periodontal and Restorative Baseline

(Include when perforation is near crestal bone or furcation, or when prognosis is uncertain; otherwise omit.)

• Probing depths: [Sites and measurements in mm]; [targeted / full charting]
• Furcation involvement: [Grade] (If multi-rooted tooth)
• Mobility: [Grade]
• Sinus tract: [present / absent]; [Tracing results if performed]
• Existing restoration: [Type]; [Seal quality and margin assessment]

Informed Consent

Informed consent obtained prior to repair. [Signed form attached / Verbal consent per policy]. Discussion included diagnosis and nature of perforation, proposed approach, repair material and rationale, risks, alternatives including no treatment, and prognosis. Patient questions were addressed. [Direct quotes for significant preferences or refusals]

• Proposed approach: [nonsurgical orthograde / surgical / combined / staged]
• Material and rationale: [Material class] — [Reason for selection]
• Risks discussed: [Persistent infection, periodontal breakdown, material extrusion, need for additional procedures or extraction, other]
• Alternatives discussed: [Observation/no treatment, extraction, surgical repair, retreatment, other]
• Prognosis expectations: [Summary of discussion]

Anesthesia and Isolation

• Local anesthesia: [Agent and concentration]; [Volume]; [Injection type and site]
• Isolation: [rubber dam / alternative method] (If rubber dam not used, document reason and alternative employed.)
• Magnification: [operating microscope / loupes / none]

Procedure

[Narrative operative account including: Approach and staging (nonsurgical orthograde vs surgical vs combined; same-visit definitive vs temporization with rationale). Access method and post/core removal if applicable. Hemorrhage degree, hemostasis methods, and confirmation hemostasis achieved before material placement. Irrigation and disinfection with agents, concentrations, and precautions to avoid extrusion. Matrix or barrier if used with indication and material. Repair material placement including product name, mix/setting method, placement technique, thickness estimate, measures to minimize extrusion, and management of any extrusion. Verification of seal with clinical assessment method, decision to proceed with obturation or defer, and temporization or restoration placed.]

Imaging

• Pre-op: [Type and date]; [Key findings]
• Intra-op: [Working and verification images]; [Findings]
• Post-op: [Image confirming material position]; [Findings]
• CBCT: [Indication for 3D imaging]; [Field of view]; [Key findings] (If obtained)
• (If imaging not obtained, document reason and mitigation.)

Complications and Patient Tolerance

• Complications: [material extrusion / instrument separation / soft tissue injury / other / no complications observed] — [Management if applicable]
• Patient tolerance: [well tolerated / limited tolerance] — [Details]

Prognosis

Prognosis: [favorable / guarded / poor]. Prognosis and contingencies discussed with patient, including potential need for surgical repair, retreatment, periodontal therapy, or extraction.

• Size and location: [Relative to crestal bone and furcation]
• Timing to seal: [immediate / delayed]
• Periodontal findings: [Probing, furcation status, sinus tract]
• Hemostasis achieved: [yes / no]
• Material position on imaging: [Contained / extruded / other]

Restoration Plan

• Restoration placed today: [temporary / permanent] — [Material]
• Definitive restoration: [Recommendation]; [Cuspal coverage: indicated / not indicated] (For posterior teeth)
• Post/core: [indicated / contraindicated] — [Rationale]
• Timeline and coordination: [Urgency and referring/restoring clinician]
• Contingency: [Referral or plan if restorability questionable]

Periodontal Monitoring

(Include when cervical, crestal, or furcal defects present; otherwise omit.)

• Baseline status: [Probing depths and furcation if not documented above]
• Periodontal risks discussed: [Summary]
• Referral: [Periodontist referral indicated: yes / no]
• Monitoring plan: [Re-probe interval]; [Follow-up imaging timeline]
• Escalation triggers: [Persistent bleeding on probing, deepening pockets, sinus tract development]

Post-Operative Instructions and Follow-Up

• Instructions provided: [written / verbal / both]
• Medications prescribed: [Name, dose, frequency, duration] — [Indication]
• Return precautions: [Swelling, fever, increasing pain, drainage]
• Follow-up: [Short-term clinical check]; [Radiographic follow-up timeline]; [Coordination with restorative dentist]