Endodontic Examination Form
Endodontic Examination
- Tooth/Teeth FDI No’s:
- Date of examination:
- Reason for Referral or Attendance:
Presenting Complaint1
- No pain
- Other problems:
 |  |
Pain
- Commenced:
- Duration/course:
- Dull ache
- Throbbing
- Cold
- Biting
- Lingering – How long?: ___ mins
- Sharp pain
- Spontaneous
- Heat
- Pressure
- Wakes at night
- Worse lying down
- Any other stimulus
General Notes and History
Past Pain History
- None
- Commenced:
- Duration/course:
- Dull ache
- Throbbing
- Cold
- Biting
- Lingering – How long?: ___ mins
- Sharp pain
- Spontaneous
- Heat
- Pressure
- Woke at night
- Worse lying down
- Any other stimulus
Previous Endodontic Treatment
- Endo started prior to referral – by whom:
- Previous Endo: Tooth: ___, When: ___, By whom: ___
- Retreat: When: ___, By whom: ___
- Surgery: When: ___, By whom: ___
Clinical Tests (Tooth Chart)
| Gr 0, I, II, III Mobility | | | | | | | | | | | | | | | | | | | Tender to Palpation | | | | | | | | | | | | | | | | | | | Tender to Percussion | | | | | | | | | | | | | | | | | | | Sensitivity: Heat | | | | | | | | | | | | | | | | | | | | Sensitivity: CO2 | | | | | | | | | | | | | | | | | | | | Sensitivity: Electric | | | | | | | | | | | | | | | | | |
8 7 6 5 4 3 2 1 | | | | | | 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 | | | | | | 1 2 3 4 5 6 7 8
- Pulp Sensitivity Tests: Electric, CO2, Heat
- Tender to Percussion
- Tender to Palpation
- Gr 0, I, II, III Mobility
Patient and Clinician Information
Use Patient Barcode Label
- Given Name:
- Surname:
- DOB:
- TEMP:
Clinician Name: Clinician ID: Supervisor Name: (if student clinician) Supervisor ID:
Clinical Findings and Observations
Findings:
- Discolouration of tooth: _______________
- Draining sinus: _______________ Location
- Caries: _______________ Tooth and colour
- Restoration(s): _______________ Material, quality and surfaces
Fractures:
- Restoration(s)
- Tooth: [ ] Crown and/or [ ] Root
Cracks (surfaces): _______________
Enamel infractions (surfaces): _______________
Swelling2
- None
- Diffuse
- Localised
- Region: _________________
- Hard
- Soft
- Fluctuant
- Tender: [ ] to palpate [ ] to pressure
Occlusion
- Traumatic occlusion (teeth): _______________
- Tenderness of masticatory muscles (muscles): _______________
Periodontal Status
- Local: _______________ General: _______________
Radiographic Report
Films viewed:
- PA’s: _______________ Date(s)
- BW’s: _______________ Date(s)
- OPG: _______________ Date(s)
Diagnoses
Cause(s)
Management Plan
Prognosis
- Reassess after treatment/review
- Good
- Fair
- Poor
- Hopeless (advise Exo)
Probable Restoration Required
- Any alternative restoration(s) possible? List type(s): ______________________
Recommendations for Other Treatment
Other Notes
| Clinician Signature: | Clinician ID: | Supervisor Signature: | Supervisor ID: |
|---|---|---|---|
| (If student clinician) |
Structural Integrity and Swelling
(Content integrated under Clinical Findings and Observations above)
Footnotes
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Original PDF page 1: Form 70 - Endodontic Examination, p.1 ↩
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Original PDF page 2: Form 70 - Endodontic Examination, p.2 ↩