Root Canal Retreatment Procedure Note (Nonsurgical)

Date of Service: [Date]

Clinician: [Name, credentials]

Practice/Location: [Practice name and address]

Patient Name: [Full name]

Date of Birth: [MM/DD/YYYY]

MRN: [Medical record number]

Referring Provider: [Name and contact, if applicable]

Restorative Provider: [Name and contact, if different from referring]

Tooth Number and Name: [Tooth number and common name]

Anticipated Canal Anatomy: [Expected canal nomenclature appropriate to the tooth]

Visit Type: [Retreatment—Disinfection visit (no obturation) / Retreatment—Obturation/completion visit / Retreatment—Single-visit completion]

Attachments: [Pre-op radiographs / Working length radiographs / Post-op radiographs / Clinical photos] (List only those actually attached)

Chief Complaint

[Patient's stated concern] (Use direct quote when available; if asymptomatic, state this explicitly and note the retreatment indication)

[Symptom details: onset, duration, severity, provoking/alleviating factors] (Include pertinent negatives for urgency such as swelling, drainage, fever)

Focused History and Safety Review

[Relevant medical history impacting endodontic care, anesthesia, or medication selection] (Reference that comprehensive health history was reviewed separately if applicable)

• Allergies: [Allergies and reactions] (Prioritize local anesthetics, antibiotics, analgesics, latex)
• Pertinent medications: [Current medications relevant to procedure] (Note anticoagulants, immunosuppressants, bisphosphonates)
• Pregnancy status: [Status if relevant to imaging or medications]
• Prior endodontic treatment: [History for this tooth including approximate date/provider] (If unknown, state "Date unknown; prior RCT evident radiographically." Attribute uncertain details to source)

Pre-Procedure Findings

• Extraoral/Intraoral: [Findings including swelling, sinus tract, cellulitis, lymphadenopathy] (Document pertinent negatives)
• Tooth-specific tests: Percussion [result], Palpation [result], Mobility [result], Bite test [result]
• Periodontal assessment: [Probing depths at sites of concern, furcation involvement] (Include findings relevant to prognosis)
• Restorability assessment: [Cracks, missing cusps, recurrent caries, existing restoration/post/core status]
• Imaging reviewed: [PA / Bitewing / CBCT]
• Radiographic findings prompting retreatment: [Periapical pathosis / Underfill / Overfill / Voids / Missed canal suspicion / Post or obstruction / Extruded material / Resorption / Perforation / Ledge / Pre-existing separated instrument]

Assessment

• Pulpal diagnosis (AAE): [Diagnosis]
• Apical diagnosis (AAE): [Diagnosis]
• Retreatment indication: [Persistent symptoms / Persistent periradicular pathosis / Radiographic deficiency / Suspected contamination or leakage / Restorative needs jeopardizing existing obturation]
• Baseline prognosis: [Good / Fair / Guarded / Poor] with rationale: [Primary drivers such as restorability, periodontal support, root anatomy, perforation, lesion size, fracture suspicion]

Informed Consent

Decision-maker: [Patient / Guardian] (Note interpreter use if applicable)

[Summary of consent discussion] (Document that discussion covered: diagnosis and nature of retreatment; material risks including flare-up, missed canals, perforation, separated instruments, inability to remove posts/obstructions, sodium hypochlorite accident, persistent infection/failure, need for surgery or extraction; prognosis and influencing factors; alternatives including monitoring, apical surgery, extraction with implant/bridge, referral. Note that questions were invited and answered)

Consent outcome: [Patient consents to proceed / Patient declines or defers with reason and plan]

Procedure

Verification: Correct patient, tooth, and procedure verified; allergies confirmed; imaging reviewed; isolation method confirmed.

Anesthesia: [Agent, concentration, vasoconstrictor, route, total volume] (Note topical if used; for adjuncts such as nitrous oxide include concentration range; for IV sedation reference sedation record)

Isolation: [Rubber dam placement method] (If rubber dam not used, document explicit reason and mitigation)

Access and Material Removal

• Access approach: [Existing restoration status, access technique, removal of restorative material and caries] (Note intraoperative findings on entry; distinguish pre-existing versus iatrogenic findings)
• Posts/obstructions: [Type, location, removal technique, outcome] (Include only if present; if unable to remove, document bypass attempt versus left in situ with rationale)
• Previous root filling removal: [Material type or "appears consistent with..."], [Techniques used by canal], [Patency status after removal by canal]

Working Length

Canal Name	Patency (Y/N)	Working Length (mm)	Reference Point	Method	Notes
[Canal]	[Y/N]	[Value]	[Reference cusp/incisal edge/restoration]	[Apex locator / Radiographic / Paper point]	[Ledge / Blockage / Other, if applicable]
[Canal]	[Y/N]	[Value]	[Reference point]	[Method]	[Notes]

(If working length cannot be re-established for a canal, document maximum negotiated length and reason)

Cleaning, Shaping, and Disinfection

• Instrumentation: [System and approach, glide path method, final apical size by canal, recapitulation approach]
• Irrigation protocol: [Primary irrigant and concentration, activation method, chelation agent, final rinse protocol]
• Drying: [Paper points / Other method]
• Inter-appointment medicament: [Intracanal medicament agent and placement method, temporary material, occlusal reduction if performed] (Include only if obturation deferred)

Obturation

(Include this section only if obturation performed today)

• Technique: [Warm vertical compaction / Carrier-based / Single cone] with [Sealer type]
• Master cone fit: [Verification method and tug-back confirmation]
• Extent and quality: [Obturation to working length, void assessment] (Document any overextension or sealer extrusion and patient notification)
• Post-op radiograph: [Obtained / Interpretation summary]
• Coronal seal: [Temporary material type]

Complications

[Complications: None] (If complications occurred, document for each: objective description, timing during procedure, anatomic location, immediate management, impact on prognosis and plan changes, disclosure to patient and their understanding. For separated instruments: specify pre-existing versus new, approximate fragment location and length, retrieval/bypass attempts with stopping rationale, and plan)

Post-Procedure

• Patient tolerance: [Tolerated well / Complications noted]
• Occlusion: [Checked and adjusted if applicable]
• Medications in-office: [Drug, strength, dose, route, time]
• Prescriptions: [Drug name, strength, dose, frequency, duration, quantity, indication] (If antibiotics prescribed, document clinical justification)
• Post-operative instructions: [Verbal / Written handout provided] (For multi-visit cases, include guidance to protect temporary and actions if dislodged)

Updated Prognosis and Restoration Guidance

• Updated prognosis: [Good / Fair / Guarded / Poor] (Provide rationale for any change from baseline)
• Definitive restoration recommendation: [Core buildup / Crown / Onlay / Post considerations] with timing: [Urgency] (Note restorability limitations or fracture suspicion if applicable)
• Follow-up imaging: [Time interval] for [Purpose]

Follow-Up Plan

• Next visit: [Timing and planned stage] (If treatment not completed)
• Recall interval: [Time frame for evaluation and radiographs]
• Provider communication: [Sent / Will be sent to referring or restorative provider]

Signature

Electronically signed by: [Clinician name, degree, specialty] on [Date/Time]

(Addendums should be entered as separate, dated entries stating what is being clarified and why)