Dental examination template
An exam note is a checklist you fill, not a story. If a line is normal, write that it was checked.
Template
Age: Accompanied by: Clinician: clinicians Assisted by: assistants Patient attended for: New patient examination Recall examination Urgent appointment Referral Presenting Complaints History Medical history: Allergies: None Penicillin Aspirin Plasters Smoking and tobacco: Non-smoker Smoker Past smoker Currently vapes Alcohol: Never Low risk Increasing risk Higher risk Dependent Sugary drinks (fruit, fizzy, tea, coffee): Never/Rarely 2-3 times a week Daily Multiple times a day Sweets, cakes, biscuits, and chocolates: Never/Rarely 2-3 times a week Daily Multiple times a day Acidic fruits, drinks, and lemon water: Never/Rarely 2-3 times a week Daily Multiple times a day Tooth brushing: Adjuncts: Clinical Examination Extra-oral: NAD - symmetry, lips, TMJ and muscles of mastication, salivary glands, lymph nodes Other Intra-oral: NAD - buccal mucosa, tongue, palate, floor of the mouth, lips Other Gingiva: Healthy Bleeding Inflammation Recession Hyperplastic BPE Bleeding on probing: None Immediate Delayed Intra-Oral Hard Tissues Hard tissue chart: Updated No changes Oral hygiene: Good Fair Poor Plaque: None Localised Generalised Caries: None Deficient restorations: None Reason for watched teeth: Occlusal fissure staining Early enamel caries ?Deficient restoration Mobility Tooth surface loss: Benefit cuspal coverage: None Planning for tooth replacement: None Upper denture: Lower denture: Further Investigations Intraoral photos (pt explicit consent obtained) Intraoral scan Radiographs Diagnoses Patient Risks Caries risk: Low Moderate High Periodontal risk: Low Moderate High Tooth surface loss risk: Low Moderate High Oral cancer risk: Low Moderate High Discussion Treatment Plan: NHS Private Consent obtained: Verbally Written Estimate given Stabilisation Restorative Maintenance Dentist recall: Bitewings interval: 6 months 12 months 18 months 24 months Hygienist recall: 2 months 3 months 6 months Next Visit
A filled-in example
Age: 72
Pt attended for: New pt examination
Last dental visit: Approximately 20 years ago
PRESENTING COMPLAINTS
A fall in February or March knocked out a crown and the adjacent tooth attached to it. No pain afterwards.
Upper plate, approximately 40 years old, no longer fits and is held in with an adhesive pad
HISTORY
Medical history: Liver disease and bronchitis. Awaiting hip replacement, on the waiting list. Liver blood test subsequently came back normal
Medication: Stopped all medication approximately 1 year ago
CLINICAL EXAMINATION
Gingiva: Bleeding, painful on probing in some areas
BPE -
3 4 1
3 4 3
Bleeding on probing: Extensive
Intra-Oral Hard Tissues -
Hard tissue chart: Updated
Plaque: Lower anterior plaque and heavy calculus
Caries: LL5 D
Deficient restorations: LL5 partially lost MO amalgam
Mobility: LL5 grade 1, LR1 grade 2, LR2 grade 1, LR4 grade 1, LR5 grade 3. Lower anterior assessment limited by calculus
Benefit cuspal coverage: None
Planning for tooth replacement: Upper and lower dentures following stabilisation
Upper denture: Partial, poorly fitting, retained with adhesive pad
FURTHER INVESTIGATIONS
None
RADIOGRAPHS
Radiographs not indicated
DIAGNOSES
Generalised periodontitis - Stage IV Grade C - Currently unstable - Risk factors: none
UL3, LL5 caries
DISCUSSION
Generalised periodontitis: Explained that longstanding plaque solidifies into calculus. Heavy lower anterior calculus may be holding mobile teeth in place, so their true mobility and prognosis cannot be assessed until it is removed. Teeth may firm up or become more mobile after cleaning, and the outcome cannot be predicted. Bleeding and tenderness were noted on probing. PMPR and effective home cleaning are both important to control periodontal disease.
1. Leave and monitor - risk of progression and further tooth loss
2. PMPR by the dentist or hygienist, with OHI and TBI from the oral health nurse while restorative treatment proceeds. Initial clean planned after fillings and improvement in home care. Future choice of dentist or hygienist to be considered when cleaning is due
LR5: Markedly mobile. Clinician recommended extraction before denture provision
1. Leave and monitor - risk of worsening mobility and tooth loss
2. Extract LR5
LL5: Part of the existing filling has been lost and the whole restoration requires replacement
1. Leave and monitor - risk of caries progression and further tooth damage
2. NHS amalgam filling
3. Private composite filling - less natural tooth removal than with a amalgam filling. Pt said this was affordable, but did not make an explicit choice
Tooth replacement: Clinician advised retaining as many natural teeth as possible rather than extracting all teeth for full dentures. Gums and teeth must be stabilised before denture planning. A lower denture would currently be painful against the tender gums. Allow healing and reassess the lower anterior teeth after cleaning before planning dentures.
1. Leave and monitor - ongoing problems with the fit and function of the existing denture
2. Plan replacement dentures after stabilisation
TREATMENT PLAN
Consent obtained: Estimate given
Stabilisation -
OHI
PMPR
LL5 fill (undecided)
LR5 extraction
Restorative -
UL4 crown
Denture planning (after stabilisation and healing)
NEXT VISIT
UL4 restoration
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