Child Dental Exam Notes Template for UK Practices

Child exam notes need to capture two extra things adult notes don't: who brought them and what consent applies. Below is a paediatric template for UK clinicians to paste into their PMS — SDCEP-aligned, mixed-dentition aware, safeguarding-conscious.

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.

The template (paste into your PMS notes field)

Paste the child dental exam template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

ACCOMPANYING ADULT: [Name — relationship — parental responsibility: Y/N]
CONSENT BASIS: [Parental consent / Gillick competent — documented capacity assessment]

REASON FOR ATTENDANCE: [Routine / new patient / specific concern]

MHx (from parent + child): [Reviewed — medications, allergies, conditions, immunisations]
SAFEGUARDING: [No concerns / explained injury / referral noted — link to safeguarding policy]

SOCIAL / HABITS: [Diet — sugar frequency / OH routine — supervised brushing Y/N / dummy / thumb / juice in bottle]

EXTRA-ORAL: [Facial development NAD / asymmetry / bruising — note site if unexplained]
INTRA-ORAL SOFT TISSUE: [NAD / lesions]
ORAL CANCER SCREEN: [Not indicated routinely in <16 / completed]

DENTITION: [Primary / mixed (age expected per chronology) / permanent]
ERUPTION STATUS: [Age-appropriate / delayed / accelerated]

PERIODONTAL: [Below age 7: not routine. Age 7-11: simplified BPE (codes 0-2 only, 6 teeth). Age 12+: full BPE]
Plaque score: [Visible plaque sites — qualitative]
Gingival health: [NAD / gingivitis]

CHARTING: [Caries — FDI / restorations / hypoplasia / hypomineralisation / MIH]
Caries risk (SDCEP): [Low / Standard / Increased — basis: previous caries, diet, social, fluoride exposure, OH]

RADIOGRAPHS: [Type — justification per FGDP selection criteria for children — quality A/N — report / declined: reason]

DIAGNOSIS:
1.
2.

OPTIONS, RISKS, ALTERNATIVES (Montgomery): [Explained to parent + age-appropriate to child. Decision recorded.]

PREVENTION:
- Fluoride varnish 22,600 ppm: [Applied — date / declined / contraindication]
- Dietary advice: [Sugar frequency target — reduce snacks / drinks]
- OHI: [Parent-supervised brushing until age 7 / brushing technique / Hall technique discussion if caries present]
- Fluoride toothpaste: [1450 ppm from age 3 / 1000-1450 ppm under 3 if standard risk / 2800 ppm if 10+ increased risk]

TREATMENT PLAN:
1.
2.

RECALL: [3 / 6 / 12 months — SDCEP risk-based]

Try the child dental exam note in the live demo → No account needed.

What good looks like — a worked example

The same child dental exam template, completed for a realistic case.

ACCOMPANYING ADULT: Mum (Sarah Patel — mother with parental responsibility).
CONSENT BASIS: Parental consent for clinical examination and any treatment proposed today.

REASON FOR ATTENDANCE: Routine 6-month recall.

MHx (from parent + child): No medications. No allergies. No medical conditions. Up to date with childhood immunisations.
SAFEGUARDING: No concerns. Child engaged, age-appropriate behaviour, no unexplained injury.

SOCIAL / HABITS: Sugar — 2 snacks/day (biscuits, fruit pots), milk at bedtime (no juice). OH — parent-assisted brushing 2x daily, supervised, fluoride 1450 ppm. No dummy. No thumb sucking.

EXTRA-ORAL: Facial development NAD. No asymmetry. No bruising.
INTRA-ORAL SOFT TISSUE: NAD.
ORAL CANCER SCREEN: Not indicated routinely at age 8.

DENTITION: Mixed dentition. UL1, UR1 erupted. ULA, URA exfoliated. ULB, URB, ULC, URC, ULD, URD, ULE, URE present primary. LR6, LL6, UR6, UL6 erupted. Lower incisors permanent.
ERUPTION STATUS: Age-appropriate (8 years).

PERIODONTAL: Simplified BPE age 7-11 — codes 0-2 only. All sextants: 0. No gingivitis.
Plaque score: Light plaque interproximally, lower incisors.
Gingival health: NAD.

CHARTING:
- ULD — occlusal cavitation, deep into dentine, soft. Probable carious lesion. (Confirmed on BW)
- LRE — small occlusal restoration, intact
- LL6, LR6 — partially erupted, sound
- UR6, UL6 — fully erupted, sound, deep fissures (sealant candidates)
Caries risk (SDCEP): INCREASED — based on new lesion ULD, sugar frequency >3/day.

RADIOGRAPHS: BW R+L. Justification — caries assessment in mixed dentition with new cavitated lesion. Quality A. Report: ULD distal carious lesion extending into pulpal third. No other interproximal caries. Permanent successors developing normally.

DIAGNOSIS:
1. ULD — caries, into pulpal third, asymptomatic. Likely vital but pulp involvement possible.
2. Increased caries risk.

OPTIONS, RISKS, ALTERNATIVES (Montgomery): Explained to mum and (age-appropriately) to patient. Options: (i) Hall crown — preformed metal crown over ULD, no LA, minimal preparation, retains tooth until natural exfoliation (~age 11); (ii) Pulpotomy + stainless steel crown — if pulp involved; (iii) Extraction — simpler, space maintenance unlikely needed at this position. Mum elects Hall crown given child anxiety and SDCEP recommendation as first-line for primary molar caries not needing pulp therapy.

PREVENTION:
- Fluoride varnish 22,600 ppm: Applied to all erupted teeth including UR6, UL6 (caries-risk teeth).
- Dietary advice: Reduce snack frequency to 2 main + 1 between-meal. Water/milk only between meals. No bedtime milk after brushing.
- OHI: Continue parent-supervised brushing until age 7. Demonstrated parent-led technique. Disclosing tablet given for home use.
- Fissure sealants: UR6, UL6 sealants booked.

TREATMENT PLAN:
1. ULD Hall crown — separator visit next week, fit in 2 weeks
2. UR6, UL6 fissure sealants
3. Reinforce diet at recall

RECALL: 3 months. Increased caries risk per SDCEP.

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 documentation mistakes

• 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.

Sources

• GDC Standards for the Dental Team, Principle 3: Obtain valid consent (accessed 18 October 2026)
• CGDent: Selection Criteria for Dental Radiography (3rd edition) (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• NICE CG19: Dental checks: intervals between oral health reviews (October 2004) (accessed 18 October 2026)
• SDCEP: Prevention and Management of Dental Caries in Children (3rd edition, February 2025) (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Paediatric Dental Doses (UK): Antibiotics, Analgesics and Local Anaesthetic by Age and Weight
• NICE CG19 Recall Intervals: What to Record in Dental Notes
• Dental Therapist New Graduate UK Guide

Patient leaflets for this treatment

• Understanding Tooth Decay
• Your Guide to Fissure Sealants
• Your Guide to Fluoride Varnish

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