What Are The Notes For A Dental Exam: Template + Example (2024)

Dental examinations are critical in diagnosing and planning treatment for patients. Accurate and detailed notes are essential to ensure continuity of care. This guide provides an overview of the key components for dental exam notes followed by a current template and an example reflecting 2024 practices.

Dental Exam Notes: Key Components

When writing notes for a dental exam, include the following elements:

• Documentation of the patient’s complaints and history
• Findings from both extraoral and intraoral examinations
• Assessment of the patient's oral hygiene practices
• Risk evaluations for caries, periodontal disease, and oral cancer
• Radiographic findings and other special investigations
• Diagnosis based on clinical findings
• Detailed discussion notes, including treatment options and advice given
• Clearly outlined treatment plan with scheduled recall

Dental Exam Notes Template

Copy the template provided above to get started.

Example of Dental Exam Notes

Here is an example of how the dental exam notes might appear after a patient visit:

EXAMINATION ADULT‍

‍Complaints: Mild discomfort on lower right quadrant

‍Medical History: See attached sheet - Non-contributory

‍Social History: Alcohol status: 6 units/week. Smoking status: Non-smoker

‍DIET: Moderate sugar intake, primarily with meals

‍Oral Hygiene Routine: Brushes 2x daily, occasional flossing                

Spit don’t rinse advised (NICE guidelines)

‍Extra-oral: NAD

‍Intra-oral Soft Tissues: Healthy appearance NAD

‍BPE: Code 2 in lower right quadrant

‍Oral Hygiene: Good, with room for improvement around molars

‍Intra-oral Hard Tissues Findings: Initial occlusal caries on #30

‍CARIES RISK: Moderate

‍PERIO RISK: Low

‍CANCER RISK: Low

‍RECALL: every 6 months

‍RADS:                

Op: Dr. Smith  Type: Right BW                

Reason: Assess for caries and bone levels.

Grade: A                

Findings: Initial caries #30, no significant bone loss

‍DIAGNOSIS:                

1. Initial caries lesion tooth #30

‍DISCUSSION:                

Findings and radiograph discussed with patient; emphasized good oral hygiene and potential effects of diet on oral health. Discussed treatment options including composite filling with explanation of procedure.

‍TREATMENT PLAN:                

1. Oral hygiene instruction and diet advice                

2. Composite filling tooth #30

‍Next visit: Scheduled for filling procedure in two weeks

Conclusion

With the template and example provided, dental professionals can ensure a comprehensive approach to recording dental exams. The consistent use of this format will help maintain accurate and detailed patient records, enabling effective treatment and tracking of oral health changes over time.