Post/Post-and-Core Removal Procedure Note

Date/Time: [Date and time of procedure]

Clinician: [Name and credentials]

Tooth Treated: [Tooth number and full tooth name] (Require BOTH tooth number and complete tooth name for wrong-site prevention, e.g., "#19 mandibular left first molar.")

Procedure: [post removal / post-and-core removal]; [no crown sectioning / crown sectioned]

Chief Complaint / Indication

[Brief reason for procedure] (Limit to 1–3 sentences. If patient reports symptoms, capture in the patient's own words using quotation marks. If asymptomatic and referred, state clearly, e.g., "Referred for post removal to facilitate endodontic retreatment.")

History & Examination

(Document only clinically relevant items to this procedure; omit unrelated findings.)

• Medical history: [reviewed and updated / reviewed, no changes] (Explicit statement required.)
• Allergies: [relevant allergies including latex if rubber dam planned / NKDA]
• Medications affecting bleeding: [relevant medications / none] (Only if applicable.)
• Prior treatment on this tooth: [endodontic and restorative history with dates if known]
• Existing restoration: [crown condition, core exposure status, temporary vs definitive]
• Remaining coronal structure: [ferrule assessment and adequacy]
• Cracks/craze lines: [location if observed or suspected / none noted]
• Periodontal status: [findings relevant to access approach] (Only if it affects the approach.)

Imaging

• Imaging obtained/reviewed: [periapical / bitewing / CBCT / other] [taken today / reviewed from referral with date]
• Key findings: [estimated post type: cast metal / prefabricated metal / fiber / threaded / appears consistent with...], [approximate dimensions], [canal curvature], [remaining dentin thickness concerns] (If post type cannot be definitively determined, document as "appears consistent with…")
• CBCT justification: [indication] (Only if CBCT obtained.)
• If no new imaging: [rationale and prior images reviewed] (Only if no imaging taken today.)

Diagnosis & Indication

Diagnosis: [Tooth-level diagnosis or condition prompting disassembly]

Indication for post removal: [access for nonsurgical retreatment / fractured post or core / recurrent caries affecting post or core / loss of retention / other]

Planned downstream treatment: [retreatment / surgical referral / extraction discussion / other]

Informed Consent

Consent obtained from: [patient / guardian]; Interpreter/accommodations: [yes, specify / no]

Discussion documented: Benefits, alternatives (monitoring, surgical endodontics, extraction), and risks including perforation, root fracture, inability to remove post (possible need for referral, surgery, or extraction), thermal injury, and damage to existing crown/restoration. Patient questions answered; agreement to proceed obtained.

Signed consent form: [yes / no]; (Even if signed, confirm clinician personally discussed key points.)

(If consent refused, document informed refusal: what was declined and reason.)

Pre-Procedure Verification

Time-out completed: [patient identity confirmed, tooth number and name verified, procedure confirmed, imaging displayed for correct tooth] [no discrepancies / discrepancies identified and resolved]

Anesthesia

(Omit this section entirely if no anesthesia was used.)

• Local anesthetic: [agent, concentration, vasoconstrictor] (e.g., 4% articaine with 1:100,000 epinephrine)
• Route/site: [infiltration / block / PDL / intraosseous]; Volume: [amount administered]
• Topical: [yes / no]
• Adequacy: [adequate / supplemental required: type and site]
• Sedation: [none / nitrous oxide-oxygen / oral sedation / IV sedation] (If used, document indication, agents, route, dose, time, monitoring, and discharge status.)

Isolation

Rubber dam: [used / not used] (Rubber dam is mandatory per AAE standards. If not used, document specific reason and alternative safety measures for aspiration/ingestion prevention and contamination control.)

Magnification/illumination: [operating microscope / loupes / headlamp / none]

Procedure

(Document in chronological sequence. Prefer device class over brand names unless clinically necessary.)

Pre-disassembly condition: [existing restoration type and status; crown intact / defective / removed; core exposure status; adjacent tooth or bridge considerations]

Crown management: [retained intact / removed intact / sectioned and removed] (If sectioned or retained, document rationale.)

Core removal: [method: ultrasonic troughing / carbide reduction / sectioning / not applicable]; [extent of removal]; [complications avoided or encountered]

Post exposure: [trough or gutter creation method and orientation]

Post removal technique: [primary: ultrasonic vibration / unthreading / trephine or tap system / fiber post drill-out / combined]; [secondary technique if primary unsuccessful] (Include rationale for changing technique if applicable.)

Safeguards employed: [directional troughing, conservative dentin removal, avoided leverage against thin walls, monitored for tooth movement, limited force, water coolant, intermittent ultrasonic activation, high-volume evacuation, magnification] (Explicitly document measures taken to reduce perforation, root fracture, and thermal injury risks.)

Canal instrumentation this visit: [initiated / not initiated]

• (If initiated:) Canals identified: [list canals]
• Patency confirmed by: [visual / tactile / apex locator / radiograph]
• Irrigation: [solutions and sequence]
• Intracanal medicament: [type and location / none placed]

Findings & Outcome

• Post removal: [completely removed / partially removed / not removed] (If partial or not removed, document retained fragment location and rationale.)
• Post integrity: [intact / fragmented]; Residual cement: [removed / partially removed / not removed]
• Structural assessment: [minimal / moderate / extensive dentin removal]; [areas of thin walls if noted]
• Crack lines under magnification: [location / none observed]
• Perforation: [none suspected / suspected / confirmed] (If suspected or confirmed, document location, how assessed, and immediate management.)
• Hemostasis: [achieved / not applicable / difficulty, describe management]
• Patient tolerance: [well tolerated / limited tolerance, describe]
• Complications: [none encountered / describe event, immediate management, patient disclosure, and updated plan] (Explicit documentation required.)

Post-Procedure Imaging

(Omit this section if no post-procedure imaging was performed.)

• Imaging obtained: [periapical / bitewing / CBCT]
• Confirmed: [completeness of post removal, canal patency, perforation status, retained fragments]

Temporary Restoration & Instructions

Temporary seal: [material type and thickness]; Occlusion: [checked and adjusted as needed] (Explicit documentation required. If no temporary placed, document rationale.)

Post-procedure instructions: Provided to patient including expected symptoms vs red flags, chewing precautions, analgesic recommendations, and emergency contact. (Do not reproduce full instruction content in note.)

Follow-Up & Restoration Recommendations

Next steps: [continue endodontic treatment next visit / same-day continuation performed / referral planned]; Follow-up: [interval or date scheduled]

If removal incomplete: [options discussed: additional attempt / surgical approach / extraction consult]; [agreed plan]

Restoration handoff for referring/restorative dentist:

• Current status: [post removed completely / partially; temporary material placed]
• Structural concerns: [thin walls, ferrule adequacy, crack suspicion]
• Urgency of definitive coronal seal: [within X weeks / as soon as possible / other]
• Recommended restoration: [bonded buildup if minimal loss / cuspal coverage if structurally compromised / discuss prognosis if ferrule inadequate or crack suspected]
• Post replacement considerations: [avoid unnecessary post placement; if needed, conservative post-space preparation preserving apical seal]
• Images sent to referring provider: [yes / no]