Regenerative Endodontics/Apexification Procedure Note

(Complete only sections relevant to the current procedure pathway and visit stage. Omit sections that do not apply. Do not infer irrigant concentrations, medicament compositions, or material choices—include only what was explicitly documented. If any field lacks documentation, omit it rather than inserting placeholder text, except for Allergy Status, which should state "not documented" if missing.)

Date: [Date]

Provider: [Provider name and credentials]

Tooth: [Tooth number (Universal or FDI notation)]

Procedure Pathway: [REP / Apexification]

Procedure Stage: [Initial Disinfection / Interim Medicament Replacement / Completion Visit]

Visit: [#] of [planned total]

Indication and Baseline Assessment

[Chief concern and indication for treatment]

[Tooth status and diagnosis] (Document etiology [trauma / caries / developmental anomaly], pulpal diagnosis, periapical findings [radiolucency / sinus tract / swelling: present / absent], and root development stage [open apex, dentinal wall thickness].)

• [Diagnostic testing results] (Percussion, palpation, probing, mobility, sensibility testing with interpretation. Note reliability limitations in immature teeth if relevant.)
• [Pre-operative imaging] (PA and/or CBCT with clinical justification if obtained. Summarize apical pathology, root length, wall thickness, canal anatomy.)

(For follow-up visits, focus on interval history and changes since last visit rather than repeating full baseline assessment.)

[Clinical decision: REP / Apexification] (1–2 sentences stating rationale and alternatives discussed with patient/guardian.)

Consent and Safety

[Informed consent obtained from: patient / guardian] (Document discussion of staged treatment, antimicrobial irrigants and intracanal medicaments, material-related risks including discoloration potential, expected outcomes, uncertainties, and alternatives.) [Assent obtained: yes / no / not applicable]

Allergy Status: [Documented allergies with attention to antibiotics] (If unknown, state "not documented" and note that antibiotic-containing medicaments were avoided or specify mitigation approach.)

[Relevant medications and medical conditions] (Include conditions affecting anesthesia, bleeding, infection risk, or healing.)

Procedure

Anesthesia: [Agent], [concentration], [volume], [route: block / infiltration], [vasoconstrictor: with / without]. (For REP completion visits, explicitly note if vasoconstrictor-free anesthetic used.) [Profound anesthesia achieved: yes / no]

Isolation: [Rubber dam placed: yes / no]. (If no, document alternative isolation method and reason.)

Access: [Access performed / existing access refined]. Working length determined by [method: EAL / radiograph / tactile]. Recorded working length: [measurement].

Irrigation: (Document exactly what was performed. Do not default to assumed protocols.)

• [Irrigant: solution, concentration, volume, dwell time, delivery method/needle type, placement depth relative to apex]
• (Repeat for each irrigant used in sequence.)

Canal Drying: [Method: paper points / suction / other]

Intracanal Medicament: [Medicament type: calcium hydroxide / TAP / DAP / other], [components if mixture], [vehicle], [concentration if antibiotic paste], [placement method], [placement extent relative to CEJ]. (If medicament removed this visit, document removal method.)

Temporary Restoration: [Material], [thickness], [dentin bonding agent: yes / no], [occlusion checked: yes / no]

Intraoperative Imaging: [Working length / verification radiograph obtained: yes / no] [Findings confirmed]

Complications/Variance: [Complications and management] (e.g., irrigant extrusion, persistent exudate, inability to achieve bleeding, patient intolerance) or "No complications."

REP Completion Visit Details

(Include only for REP pathway completion visits.)

Pre-conditions: [Symptom status], [swelling: present / absent], [sinus tract: present / absent]

Final Irrigation: [Solution], [concentration], [volume], [dwell time], [delivery method], [placement depth]

Bleeding Induction: [Instrument used], [depth beyond apex], [target blood level achieved within canal]. (If bleeding not achieved, document alternative scaffold or decision to defer.)

Scaffold: [Blood clot / PRP / PRF / other] (If PRP/PRF, note preparation method or reference separate procedure note.)

Hemostasis: [Level at which bleeding stopped]

Matrix/Barrier Adjunct: [Collagen plug / other / none], [indication if used]

Capping Material: [Material: MTA / bioceramic / other], [thickness]

Coronal Restoration: [Base material], [final or temporary restoration details]

Apexification Completion Visit Details

(Include only for apexification pathway completion visits.)

Medicament Removal: [Method and solutions used]

Final Irrigation: [Solution(s)], [concentration(s)], [volume(s)], [delivery method], [placement depth]

Apical Barrier: [Material: MTA / bioceramic / other], [thickness], [placement method]. [Apical matrix used: yes / no], [indication if used]

Verification: [Method: radiograph / tactile confirmation]

Backfill: [Material and technique if obturated same visit] or [Plan for subsequent obturation]

Reinforcement Strategy: [Approach for thin-walled roots] and [coronal seal plan] (If not applicable, omit.)

Post-Procedure

[Patient tolerance]. [Hemostasis status if relevant]. [Immediate complications and management] or "None."

Prescriptions: [Drug, dose, route, frequency, duration, quantity] or "No prescriptions."

Post-operative Instructions: [Provided: written / verbal]. (Include return precautions: swelling, fever, escalating pain, lost temporary restoration; dietary and chewing guidance.)

Follow-up Plan

[Next appointment timing and purpose]. (For completion visits: REP recall typically at 6, 12, 24 months then annually; apexification per clinical judgment.) [Responsible party for follow-up imaging]

Success Criteria to Monitor: [Symptom resolution, radiographic healing, and for REP: continued root development (wall thickening, length increase)]