Vital Pulp Therapy Procedure Note (Pulpotomy/Pulp Cap/Apexogenesis)

Date: [Date]    Time: [Time]

Clinician: [Clinician name, credentials]

Patient: [Patient identifiers per system standard]

Tooth/Teeth: [Tooth number(s) with notation system] (If multiple teeth treated, repeat Indication & Case Selection, Operative Details, and Follow-Up Plan sections for each tooth.)

Procedure: [indirect pulp treatment / direct pulp cap / partial pulpotomy / full pulpotomy]

Baseline Imaging: [Pre-procedure radiograph type(s), date(s), and key baseline findings]

Indication & Case Selection

Chief concern / precipitating event: [One-sentence reason prompting evaluation or treatment]

Diagnostic data: (Document actual observed responses. If a standard test was not performed, state "not obtained" with reason.)

• Symptom history: [Provoked vs spontaneous pain; duration; nocturnal symptoms; lingering/non-lingering thermal response; analgesic use]
• Clinical exam: [Caries extent; restorability; presence/absence of swelling or sinus tract; relevant periodontal findings]
• Sensibility testing: Cold test: [response description / not obtained—reason]; EPT: [threshold value and sensation / not obtained—reason]; Heat test: [response / not obtained—reason] (Include only tests performed.)
• Periapical testing: Percussion: [tender / not tender]; Palpation: [tender / not tender]; Mobility: [grade / physiologic]
• Radiographic findings: [Caries depth relative to pulp; periapical status; root maturity—open vs closed apex; any resorption]

Pulpal diagnosis: [Standard terminology] (State uncertainty if present.)

Apical diagnosis: [Standard terminology] (State uncertainty if present.)

Uncertainty mitigation: [Magnification, direct visualization, or hemostasis assessment used to refine diagnosis] (Only include if uncertainty existed.)

Inclusion rationale for VPT: [Vital tissue anticipated or observed; tooth restorable; no signs of spreading infection] (For immature teeth: note open apex status and apexogenesis intent.)

Alternatives & Treatment Plan

Selected procedure and rationale: [Why this VPT approach best fits goals given diagnosis, restorability, and patient factors]

Alternatives considered: [Observation / alternative VPT option(s) / root canal therapy / regenerative endodontic procedure / extraction] (Note why alternatives were not appropriate if relevant.)

Consent & Medical Review

Informed consent: [Obtained from patient / guardian]; interpreter: [yes—language / no]; risks, benefits, alternatives, and no treatment discussed; questions answered. (If any recommended component was declined, document informed refusal.)

VPT-specific risks discussed: post-operative pain/sensitivity; treatment failure requiring RCT or extraction; infection; possible discoloration; restoration failure (For immature teeth: include risk of arrested root development.)

Medical review: [Allergies; conditions affecting bleeding or infection risk; antibiotic prophylaxis decision if applicable]

Time-out / correct-site verification: [completed / not applicable] (Per organizational policy.)

Operative Details

Anesthesia: [Local anesthetic type, concentration, volume; injection technique and site; adjuncts if used] (If omitted, state reason.)

Isolation: [rubber dam / alternative method with reason rubber dam not used]

Caries removal and exposure: [Selective vs complete caries removal; exposure—yes/no; if yes: type (carious / mechanical / traumatic), size (pinpoint / small / moderate), location; for partial pulpotomy: depth of pulp removed]

Direct pulp visualization: [Tissue appearance; presence/absence of purulence; necrotic tissue removed if applicable; magnification used—yes/no] (Only include if pulp directly visualized.)

Hemostasis assessment: (Do not estimate time; state "time not measured" if not recorded.)

• Method: [Irrigant type and concentration; application method; duration of each application]
• Duration of hemostasis attempt: [minutes / time not measured]
• Bleeding after management: [controlled / persistent / profuse]
• Threshold to proceed met: [yes / no]
• Conversion: [Converted to (pulpotomy / pulpectomy / RCT) due to (trigger)] (Only include if procedure was converted.)

Biomaterials placed: [Material category and product name; placement site; thickness if protocol specifies; base/liner over material if applicable]

Coronal restoration: [Temporary / definitive]; [Restoration type and materials]; margin verified; occlusion checked and adjusted. (If definitive restoration deferred: document reason, plan, timeframe, and that patient counseled on failure risk.)

Post-op radiograph: [obtained—type / not obtained—reason]

Complications

(Only include this section if complications or deviations occurred.)

Deviation: [Description] Reason: [Contributing factors] Management: [Actions taken]

Outcome & Post-Op Instructions

Immediate outcome: [Patient tolerance; hemostasis status at end; restoration integrity]

Post-operative instructions: [verbal / written / both]

Pain management: [Analgesic guidance provided] (Only include antibiotics if indicated; document indication and regimen.)

Return precautions discussed: increasing pain, swelling, sinus tract, fever, bite sensitivity, restoration loss.

Follow-Up Plan

Follow-up intervals: [Specific dates or timeframes for clinical and radiographic reassessment] (Immature teeth/apexogenesis: radiographic follow-up at ~6 and 12 months, then periodically. Mature teeth: clinical reassessment at routine intervals; radiographs as indicated.)

Success indicators: asymptomatic; no swelling or sinus tract; normal percussion/palpation; no periapical pathology or resorption on radiograph (For apexogenesis: continued root development and apical maturation.)

Failure criteria → contingency: [Persistent/spontaneous pain; swelling; sinus tract; periapical radiolucency; pathologic resorption; arrested root development] → [pulpotomy / RCT / regenerative procedure / extraction / referral]

Scheduling: [Follow-up appointment scheduled / patient advised to schedule] (If patient declined follow-up radiographs, document informed refusal and alternative monitoring approach.)