Referring Dentist Report (Endodontic Treatment Summary)

Date of Report: [Date]

Patient Name: [Patient full name]

Date of Birth: [DOB]

Tooth Treated: [Tooth number and descriptor (e.g., "#19, mandibular left first molar")]

Referring Dentist: [Referring dentist name, practice name]

Treating Endodontist: [Endodontist name, credentials, practice name, phone]

(Use a single tooth numbering system consistently throughout. Do not leave required fields blank; if information is unknown, state this explicitly.)

Executive Summary

[Concise 2–4 sentence summary including: tooth treated and procedure type; completion status; final pulpal and apical diagnoses; any major complications or anatomic complexities (single phrase); key restorative directive; and follow-up plan.]

Diagnosis & Treatment

Pulpal Diagnosis: [AAE standardized pulpal diagnosis]

Apical Diagnosis: [AAE standardized apical diagnosis]

Procedure: [Procedure type], [date(s)], [number of visits], [complete / incomplete] (If incomplete, state what remains and why.)

Intraoperative Findings: [Pulp status on entry, notable anatomy, crack/fracture findings, or other significant observations] (Omit this field entirely if unremarkable.)

Canal Anatomy:

Canal	Working Length (mm)	Obturation Status	Notes
[Canal name]	[Working length]	[complete / incomplete / not treated]	[Calcification, curvature, separated instrument, "suspected but not located," or other pertinent details]
[Canal name]	[Working length]	[complete / incomplete / not treated]	[Notes]

(Add or remove rows so all canals treated, attempted, or suspected are represented.)

Temporary Restoration: [Material placed, any occlusal adjustment, and limitations] (Note if tooth was left in provisional state or if definitive coronal restoration was initiated.)

Findings & Prognosis

Key Findings: [Calcified canals, complex morphology, periapical lesion characteristics, crack observations, or other clinically significant findings] (If unremarkable, state "None.")

Complications: [Any procedural complications with location, immediate management, and impact on prognosis] (If none, state "No procedural complications.")

Prognosis: [favorable / fair / guarded / poor] — [Brief rationale referencing restorability, periodontal status, anatomy, lesion characteristics, and/or complications] (If prognosis depends on the quality or timing of definitive restoration, state this explicitly.)

Recommendations

Restoration: [Timing (e.g., "within 2–4 weeks"), recommended restoration type with rationale (e.g., "full cuspal coverage recommended for posterior tooth"), post/core guidance if applicable, and any restorability warnings] (Emphasize the need for definitive coronal seal for long-term success.)

Follow-Up: [Recall interval (e.g., "clinical and PA radiograph at 6–12 months")], [location of follow-up (endodontist / general dentist)], [triggers for earlier reassessment (persistent symptoms, swelling, sinus tract)]

Attachments

[List attached images: pre-op PA, working length image, post-op PA, CBCT slices, intraoral photos as applicable] (If no attachments, state "None.")

[Endodontist name], [Credentials]
[Practice name]
[Phone] | [Email]