Traumatic Dental Injury Note (Endodontic Assessment/Plan)

Date/time of encounter: [Date and exact time of encounter]

Clinic/location: [Clinic or site name]

Provider name and role: [Name, degree, role]

Referral source and reason: [Referring provider/clinic and specific reason for referral] (If no referral, state "self-referred")

Records reviewed: [Internal records reviewed; outside records status] (Note if outside records were requested but not received and date requested)

Chief Complaint

[Patient-centered reason for visit in one line] (Example: Evaluation of [tooth/teeth] after [injury type] to assess pulp status and treatment timing)

History of Present Illness

[Narrative description of trauma timeline and context] (Include: date and time of injury [exact or best estimate with basis], time elapsed since injury, mechanism [fall / sports / MVA / assault / other], teeth involved, immediate symptoms [pain, bleeding, displacement, sensitivity], and systemic/neurologic symptoms [loss of consciousness, nausea, headache, neck pain]. If times are unknown, document "unknown" with best estimate and basis. Include any ED/urgent care visits or prior dental evaluations since injury.)

Avulsion-Specific Details (if applicable)

• Extra-oral dry time (minutes): [Value or unknown with basis]
• Total extra-oral time (minutes): [Value or unknown with basis]
• Storage medium: [milk / HBSS / saline / saliva / water / dry / unknown]
• Handling prior to replantation: [held by crown / root contact / rinsed / scrubbed / unknown]
• Replantation details: [when replanted; by whom; socket management]

Luxation-Specific Details (if applicable)

• Direction and degree of displacement: [intrusive / extrusive / lateral] [mm estimate]
• Repositioning performed: [yes / no]; if yes, [when and by whom]
• Occlusal interference: [present / absent]

Splint Details (if applicable)

• Splint type: [passive flexible / semi-rigid / rigid / arch bar / other]
• Teeth included: [List]
• Date placed: [Date]; Planned removal date: [Date]
• (If recently removed, document removal date and condition on removal)

Interim Course Since Injury

• Medications taken: [analgesics / NSAIDs / antibiotics; agent, dose, duration]
• Symptoms/changes: [discoloration, swelling, sinus tract, mobility changes, sensitivity changes]
• Prior pulp testing results and timing: [methods, results, dates]

Relevant Medical History

• Allergies: [List or NKDA]
• Current medications: [List or none]
• Conditions affecting treatment: [immunosuppression, bleeding disorders, bisphosphonates, pregnancy, or none]
• Tetanus status: [up to date / unknown / due] (Document especially for contaminated wounds or avulsion)

Examination

Extraoral

• Facial symmetry: [symmetric / asymmetric]; Swelling/ecchymosis: [present / absent; location]
• Lacerations/abrasions: [present / absent; location and size]
• TMJ function: [normal / limited / painful / deviation]
• Neurologic concerns: [none / concussion suspected / paresthesia] (If facial fracture, concussion, or neck injury suspected, document referral or ED direction)

Intraoral Soft Tissue

• Lips/gingiva/mucosa/tongue/palate: [normal / findings]
• Lacerations/foreign bodies/hematoma: [present / absent; details]
• Tooth fragment status: [fragment available / missing] (If missing, document whether soft tissue radiograph was considered)

Occlusion and Dentoalveolar Stability

• Occlusion: [normal / interference / open bite]; Midline: [centered / shifted]
• Segment mobility: [present / absent; location] (If present, suggestive of alveolar fracture)

Tooth-by-Tooth Findings

Tooth notation system: [Universal / FDI]

(Repeat block for each injured tooth and relevant control teeth)

• Tooth #: [Number]
• Visual findings: [fracture type; cracks; discoloration; displacement estimate]
• Mobility: [grade or mm] (Note if segment mobility present)
• Percussion: Tenderness: [none / mild / moderate / severe]; Tone: [normal / dull / metallic]
• Palpation: Vestibular tenderness: [present / absent]
• Probing: [WNL / localized deep pocket ___ mm suggestive of root fracture]
• Sensibility testing:
  • Method: [cold / EPT / heat]; Control tooth response: [describe]
  • Tested tooth response: [positive / negative / exaggerated / lingering / inconclusive]
  • (In early post-trauma period, include statement: Pulp sensibility testing may be unreliable at this stage; a negative response alone does not confirm necrosis.)
  • (If test not performed, document reason: [pain / splint prevents access / patient intolerance])

Imaging

Studies obtained or reviewed: [Periapicals with angulations / occlusal / panoramic / CBCT] (Include dates; note if clinical photographs obtained)

Findings by tooth:

• Tooth #[Number]: Root development: [open apex / closed apex]; PDL space: [widened / normal / irregular]; Root fracture: [present / absent / suspected; level]; Alveolar fracture: [present / absent]; Periapical pathology: [present / absent]; Resorption signs: [none / surface / inflammatory / replacement]; Position: [satisfactory / displaced]
• (Add entries for additional teeth as needed)

(If prior imaging unavailable, document that baseline imaging was obtained today for future comparison)

Assessment

(Organize by tooth. Do not declare pulp necrosis based solely on early negative sensibility tests; document supporting evidence for diagnosis.)

Tooth #[Number]

Trauma diagnosis: [concussion / subluxation / extrusive luxation / lateral luxation / intrusive luxation / avulsion / uncomplicated crown fracture / complicated crown fracture / crown-root fracture / root fracture / alveolar fracture]

Endodontic diagnosis: Pulpal: [normal pulp / reversible pulpitis / symptomatic irreversible pulpitis / asymptomatic irreversible pulpitis / pulp necrosis / previously treated / previously initiated therapy]; Apical: [normal apical tissues / symptomatic apical periodontitis / asymptomatic apical periodontitis / acute apical abscess / chronic apical abscess]

Diagnostic uncertainty: [Differentials if applicable, e.g., transient sensibility loss vs pulp necrosis]

Prognostic modifiers: [time to replant/reposition; dry time/storage quality; root maturity; concurrent injuries; infection signs]

(Repeat assessment block for each involved tooth)

Plan

Today's Actions

[Procedures or interventions performed today] (If none: Evaluation and planning only; no procedures performed today.)

Tooth-Specific Management

(Repeat block per tooth)

• Tooth #[Number]:
• Monitoring plan: [Clinical signs to reassess; radiographic intervals; success/failure criteria]
• Endodontic timing: [RCT initiation timeframe with rationale for mature teeth / observation strategy with intervention triggers for immature teeth]
• Intracanal medicament: [agent; duration; replacement interval] (if applicable)
• Restorative coordination: [temporary sealing; fragment reattachment; definitive restoration sequencing]
• Splint plan: [type; teeth included; removal date] (if applicable)
• Deferred items: [Recommended but deferred actions and reasons] (if applicable)
• Time-sensitive flags: [Critical deadlines: RCT window, splint removal, antibiotic timing]

Follow-Up Schedule

• Early review: [Date/interval] — [Purpose: symptom check, mobility, splint removal, sensibility retesting]
• Medium-term: [Dates at appropriate months] — [Reassessment: symptoms, mobility, sensibility, radiographs, resorption screening]
• Long-term: [1–5 year intervals for high-risk injuries] — [Annual radiographic review for resorption and periapical status]

Patient Instructions

• Diet: [Soft diet duration]
• Oral hygiene: [Instructions for injured area; splint care if applicable]
• Rinses: [Chlorhexidine regimen if prescribed]
• Return precautions: [swelling, fever, increasing pain, sinus tract, splint loosening, discoloration, mobility changes, bite changes]
• Protective equipment: [Mouthguard counseling if appropriate]

Medications

• [Drug; dose; route; frequency; duration; indication]
• (If antibiotics/analgesics considered but not prescribed, document rationale)

Referrals

• [Specialty: OMFS / ED / pediatric dentist / orthodontist / restorative dentist]; [Reason]
• [Communication method]; [Records sent/requested with dates]

Consent

[Discussion of risks, benefits, alternatives including no treatment, and prognosis uncertainty documented. Patient/guardian decision and consent obtained.] (If treatment refused or deferred, document informed refusal and follow-up plan.)

Procedure Note

(Include only if procedure performed today)

• Procedure: [splint placement/removal / pulp extirpation / intracanal medicament / incision and drainage / suturing]
• Tooth/region: [# or site]
• Anesthesia: [agent; concentration; volume; technique]
• Technique and materials: [Description]
• Complications: [none / describe]
• Post-procedure instructions: [Provided; details]

Missing information handling: For any element that cannot be obtained, document whether it was not assessed, unknown, or unable to be obtained. Do not leave fields blank without explanation.