Dr. Sarah Johnson
123 Dental Street
Smile Town, ST 45678
John Doe, 1 March 2025
Dear Dr. Sarah Johnson,
Thank you for your referral regarding John Doe, who attended for an endodontic consultation on 1 November 2024.
Tooth #14 presented with pain and swelling. The patient reported tenderness upon biting.
Clinical examination revealed a non-vital pulp in tooth #14, with an existing amalgam restoration. There was no mobility, but periodontal probing indicated mild pocketing. The soft tissue appeared normal.
Imaging findings showed a periapical radiolucency at the apex of tooth #14, suggesting chronic apical periodontitis. The previous root canal filling was inadequate, with missed canals visible on the CBCT scan.
Diagnosis: Chronic apical periodontitis of tooth #14.
Prognosis: The prognosis is fair, considering the restorability of the tooth and the periodontal condition. Long-term success is contingent on successful re-treatment.
Recommended treatment plan:
- Re-treatment of the root canal system
- Intracanal medication with calcium hydroxide
- Recall period of 3 months to assess healing
- Possible need for surgical intervention if symptoms persist
Follow-up and next steps:
- Review appointment scheduled in 3 months
- Post-treatment care includes avoiding hard foods on the affected side
- Recommend final restoration with a crown post-treatment
Thank you for your referral. Please feel free to contact me if you require any further information regarding John Doe’s treatment.
Sincerely,
Dr. Emily White
Endodontic Specialists
456 Dental Avenue
Smile Town, ST 45678
[Referring clinician's name and details] (include if available)
[Patient's name, date of consultation] (ensure correct identification of the patient and visit date)
Dear [Referring clinician's name],
Thank you for your referral regarding [patient's name], who attended for an endodontic consultation on [date of consultation].
[Tooth number/quadrant and presenting complaint] (describe the affected tooth or area and the symptoms reported by the patient, e.g., pain, swelling, tenderness)
[Clinical examination findings] (include pulp vitality testing results, presence of restorations, fractures, previous root canal treatment, mobility, periodontal condition, soft tissue status, and any other relevant clinical observations)
[Imaging findings] (describe relevant radiographic or CBCT findings, including periapical pathology, missed canals, quality of previous root fillings, fractures, resorption, etc.)
[Diagnosis] (state the primary diagnosis and any differential diagnoses, if applicable)
[Prognosis] (describe the expected outcome based on findings, considering restorability, periodontal condition, and long-term success of endodontic treatment)
[Recommended treatment plan] (outline the proposed course of action, including re-treatment, exploratory removal of restorations, intracanal medication, recall period, possible need for further intervention such as surgery or extraction)
[Follow-up and next steps] (mention planned review appointments, post-treatment care, and any recommendations for the referring clinician, including potential final restorative options)
Thank you for your referral. Please feel free to contact me if you require any further information regarding [patient’s name]’s treatment.
Sincerely,
[Clinician title, name & surname]
[Clinician practice details (if available)]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
(Use as many bullet points as needed to capture all the relevant information from the transcript.)