The Child Dental Exam Notes Template UK Practices Use
A child dental exam notes template captures the paediatric oral health assessment — accompanying adult, consent (parental or Gillick-competent), medical history with safeguarding awareness, caries risk per SDCEP, mixed/primary dentition charting, BPE from age 7, fluoride varnish application, and parent/child preventive advice — meeting SDCEP, BSPD, and GDC standards.
Child exam notes need to capture two extra things adult notes don't: who brought them and what consent applies. Below is the paediatric template UK dentists paste into their PMS — SDCEP-aligned, mixed-dentition aware, safeguarding-conscious.
Download the free Child Dental Exam template — plain text, GDC/FGDP(UK)-aligned.
Why this child dental exam template wins
- Accompanying adult + consent basis recorded explicitly — critical with separated parents, foster carers, grandparents bringing children.
- Gillick competence assessment prompt — defensible if older child consents for themselves on routine treatment.
- Safeguarding line — even when no concern, the explicit "no concerns" statement protects you AND prompts you to look (the omission is the indemnity issue).
- SDCEP caries risk grading with explicit basis — prevention plan and recall interval flow from this.
- Age-appropriate BPE (none under 7, simplified 7-11, full 12+) — matches BSP guidance, no overdocumentation in young children.
Compliance: the medico-legal angle
- SDCEP Prevention and Management of Dental Caries in Children (3rd ed, 2025) — caries risk stratification, Hall technique, fluoride varnish dosing all aligned.
- BSPD guidance — paediatric examination structure, parental involvement, age-appropriate examination.
- GDC Standards Principle 3 (consent) — parental consent for under-16s, with documented Gillick assessment where relevant.
- SDCEP PSM Children's Assessment — accompanying adult recorded, safeguarding consideration documented, age-appropriate examination.
- Children Act 1989 — parental responsibility framework. Recording "who has PR" matters when consenting to treatment.
Common mistakes UK dentists make
- Not recording WHO accompanied the child — leaves consent basis undocumented if parents are separated or different adult brings child.
- BPE recorded for under-7s using adult format — should be simplified codes only.
- No safeguarding consideration documented — even "no concerns" should appear; the GDC expects you to look.
- Fluoride varnish applied without recording caries risk basis — Children's Fluoride Varnish programme requires the risk assessment to justify the application.
- Hall technique placed without documenting pulp vitality assessment — exposes clinician to claim if tooth subsequently needs pulpectomy.
Frequently asked questions
Who can consent for a child?
For under-16s, normally a person with parental responsibility (PR) — typically the mother automatically, the father if married to the mother at birth or named on birth certificate, or court-appointed guardians. Step-parents, grandparents, and unmarried partners without PR cannot consent. Where a child aged 13-16 demonstrates Gillick competence (understanding the nature, purpose, and consequences of treatment), they can consent themselves for routine treatment. Document either way.
When should I start BPE in children?
BSP guidance: no BPE under age 7. Age 7-11: simplified BPE on 6 index teeth, using codes 0-2 only (codes 3-4 indicate periodontitis, which is unusual in this age group and warrants specialist referral). Age 12+: full adult BPE all six sextants.
What's the Hall technique?
A preformed metal crown sealed over a carious primary molar with GIC, without local anaesthetic or caries removal. SDCEP recommends it as first-line for cavitated primary molar caries without pulpal involvement. The seal arrests caries by depriving bacteria of nutrients. Crown stays until natural exfoliation. Excellent acceptance in anxious children.
How often should I apply fluoride varnish?
SDCEP: standard-risk children — twice yearly from age 3. Increased-risk children — 4 times yearly from age 3 (or 2 times yearly under age 3). Document the risk basis and the application explicitly.
Do I need to record safeguarding at every child appointment?
Yes — even "no concerns" should appear in the note. The GDC and CQC expect you to actively consider safeguarding at every paediatric visit. Look for: unexplained injuries, parent-child interactions, child's engagement, dental neglect (untreated obvious disease). The explicit line in the template prompts the consideration.
What recall interval for children?
NICE CG19: children at increased caries risk every 3-6 months. Standard-risk every 6-12 months. The template prompts SDCEP risk classification which directly informs the interval.