Dental examination and consultation
Created by
Laura Evans
Specialty
Prosthodontist
Last edited
10/20/2026
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About this template
A reusable dental documentation template for recording the presenting complaint, relevant medical, social, and dental history, oral hygiene, examination findings, risk assessments, investigations, diagnosis, treatment discussions, and follow-up advice.
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Nurse: Chloe Smith
CO: Sharp pain LRQ on cold and sweet stimuli. Started 2 weeks ago, lasts 5–10 seconds, relieved once stimulus is removed. No spontaneous or nocturnal pain.
MH: fit and healthy with no known drug allergies
SH: Non-smoker Drinking 6 units/week Software engineer
DH: 18 months ago
Oral hygiene regime: brushing 2x daily with electric toothbrush; flossing/ID brushes: floss 2x weekly
OE
E/O: TMJ, muscles of mastication, facial symmetry, lips, and lymph nodes: no abnormality identified. No trismus or lymphadenopathy. I/O: Soft tissues: hard palate, soft palate, buccal mucosa, tongue, and floor of mouth: no abnormality identified. Moist and pink throughout.
Dentition: LR6 occlusal caries with cavitary breakdown; TTP negative, normal response to cold testing (Endo-Frost). Gingivae: mildly inflamed posteriorly, healthy anteriorly Calculus: supragingival calculus lingual to lower anteriors BPE: 1 / 1 / 2 | 2 / 2 / 2 Occlusion: Class I RHS - canine-guided LHS - canine-guided
Caries risk: high risk Periodontitis risk: low risk Oral cancer risk: low risk
Rads - R+L BWs taken, Q1 (quality grade 1). Assess caries and crestal bone levels: Radiolucency in LR6 occlusal dentine, outer 1/3, well clear of pulp. Normal crestal bone levels (< 10% bone loss), no other interproximal caries noted.
Dx: Reversible pulpitis secondary to occlusal caries LR6; chronic gingivitis.
Discussed the diagnosis with the patient
- Option 1: No treatment (risk of progression to irreversible pulpitis, dental abscess, and eventual tooth loss).
- Option 2: Caries removal and direct restoration of LR6 (composite resin vs amalgam), alongside ultrasonic scale and polish.
Treatment options, including their advantages and disadvantages, discussed with the patient
Pt opted for: Posterior composite restoration LR6 and routine scale and polish.
Oral hygiene advice given to the patient - advised to brush along the gingival margins and interproximally with TePe brushes or floss. Dietary advice given - advised to restrict sugar to mealtimes only.
Recall 6 months
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.