New Patient Dental Exam Notes Template for UK Dentists

A good dental exam note is the difference between a defensible patient record and a GDC fitness-to-practise headache. Below is a template for UK clinicians to paste into their PMS — no patient demographics (your PMS captures those), just the clinical narrative you need to write a defensible record every time.

Why this dental examination template wins

• Every section the GDC and FGDP(UK) expect — medical history review, soft-tissue exam, oral cancer screen, BPE, charting, radiograph justification, risk assessment, Montgomery-informed consent prompts (options, material risks, alternatives, decision), prevention advice, and risk-based recall.
• Risk-based recall built in (NICE CG19) — 3/6/9/12 months explicitly prompted, not left for the dentist to remember.
• Oral cancer screen is its own line — a frequent gap in exam-note audits.
• Consent discussion uses the Montgomery test format — options, risks, alternatives, decision — protecting you medico-legally if a treatment outcome is challenged.
• Sign-off field includes GDC number — required for any defensible record under GDC Standards Principle 4 (record-keeping).

The template (paste into your PMS notes field)

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

REASON FOR ATTENDANCE:

MHx: [Reviewed / unchanged / changes:]
Allergies: [NKDA / list]
Medications:
Smoking: [Never / Ex / Current — cigs/day]
Alcohol: [Units/week]
Pregnancy/BF: [N/A]

DENTAL Hx: [Last visit — frequency — OH routine — previous concerns]

EXTRA-ORAL: [NAD / TMJ / lymph nodes / asymmetry]

INTRA-ORAL SOFT TISSUE: [Lips, buccal mucosa, tongue (dorsal/ventral/lateral), floor of mouth, palate, oropharynx — NAD / lesions described]
ORAL CANCER SCREEN: Completed — [no suspicious lesions / referred]

PERIODONTAL — BPE:
  UR _   UA _   UL _
  LR _   LA _   LL _
Plaque/BoP:
OHI given: [technique / interdental / mouthwash]

CHARTING: [Tooth-by-tooth findings — caries (FDI), restorations, wear, missing, occlusion]
Occlusion: [Class I / II div 1 / II div 2 / III]
BEWE:

SPECIAL TESTS: [Sensibility / percussion / mobility / palpation — where indicated]

RADIOGRAPHS: [Type — justification (IR(ME)R) — quality score A/N — report]

DIAGNOSIS:
1.
2.
Risk: caries [L/M/H] · perio [L/M/H] · TSL [L/M/H] · oral cancer [L/M/H]

OPTIONS, RISKS, BENEFITS, ALTERNATIVES DISCUSSED: [Montgomery — list each option with risks, benefits, alternative of no treatment, patient questions, decision]

TREATMENT PLAN AGREED:
1.
2.

PREVENTION: [OHI / diet / fluoride 22,600 ppm / smoking cessation / alcohol]

RECALL: [3 / 6 / 9 / 12 months] — rationale: [NICE CG19 risk-based]

CLINICIAN: [Name]   GDC No.: [ ]   DATE: [ ]

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

What good looks like — a worked example

The same dental examination template, completed for a realistic case.

REASON FOR ATTENDANCE: New patient registration. No acute complaint. Wishes full assessment.

MHx: Reviewed. Hypertension — amlodipine 5mg OD.
Allergies: Penicillin (rash — confirmed). NKDA otherwise.
Smoking: Never. Alcohol: 8 units/week. Pregnancy/BF: N/A.

DENTAL Hx: Last visit 3 years ago (moved area). Brushes twice daily, fluoride toothpaste. No interdental cleaning. Moderate sugar intake.

EXTRA-ORAL: NAD. Lymph nodes non-palpable. TMJ — no click/crepitus/pain on loading. MO normal range.

INTRA-ORAL SOFT TISSUE: Lips, buccal mucosa, tongue (all surfaces), floor of mouth, palate, oropharynx — NAD.
ORAL CANCER SCREEN: Completed — no suspicious lesions.

PERIODONTAL — BPE:
  UR 2   UA 1   UL 2
  LR 2   LA 1   LL 3
Plaque/BoP: Interdental plaque UR & LL. BoP UR4/5 mesial, LL5 distal.
OHI given: Modified Bass technique demonstrated. TePe 0.4mm for UR & LL embrasures. Reinforce 2x daily, 2 min, fluoride 1450 ppm+.

CHARTING: UR6 mesial amalgam, margins intact. UL6 distal caries suspected (BW taken). UL8 fully erupted, no pathology. LR6 MO composite, minor staining at margins — monitor. LL4 crown, stable. Missing UR5, LL6.
Occlusion: Class I. BEWE 0 generalised.

SPECIAL TESTS: UL6 — Endo-Ice non-vital. Percussion non-tender. Mobility grade 0.

RADIOGRAPHS: BWs R+L. Justification — caries assessment, 3-year gap, suspected lesion UL6. Quality A. Report: UL6 distal enamel caries. UR6 amalgam — no 2° caries. Slight horizontal bone loss LL, <2 mm from the CEJ, consistent with BPE 3.
PA UL6. Justification — negative sensibility test UL6; assess periapical status for endodontic diagnosis. Quality A. Report: periapical radiolucency UL6.

DIAGNOSIS:
1. UL6 — non-vital, chronic apical periodontitis
2. UL6 distal caries
3. Localised periodontitis (LL sextant), Stage I, Grade A — worst site <2 mm bone loss from the CEJ on bitewings (bitewings only, so staged on bone loss from the CEJ); % bone loss ÷ age <0.5 (BSP implementation of the 2017 classification). Current stability to be confirmed with a 6-point pocket chart LL sextant. Risk factors: non-smoker
Risk: caries M · perio M · TSL L · oral cancer L

OPTIONS, RISKS, BENEFITS, ALTERNATIVES DISCUSSED:
UL6 — (i) RCT + crown: success 85-90% at 4yr; risks post-op pain, fracture, failure → extraction; (ii) extraction: simpler, lower cost, space loss, drifting of UL5/UL7, reduced posterior occlusal support (LL6 already missing); (iii) no treatment: symptom progression, abscess risk. Patient elects RCT.
UL6 caries — composite vs amalgam discussed. Risks: sensitivity, marginal failure, possible pulpal involvement (close to pulp). Patient elects composite.
Periodontitis LL — risk of further attachment loss if OHI not improved. Initial periodontal therapy and 3-month review offered.

TREATMENT PLAN AGREED:
1. Initial periodontal therapy — OHI, PMPR; 6-point pocket chart LL sextant; review in 3 months
2. UL6 RCT (2 visits)
3. UL6 distal composite after RCT
4. Monitor LR6 margins at recall

PREVENTION: OHI as above. Fluoride 22,600 ppm applied. Diet diary suggested. Sugar frequency advice given.

RECALL: 6 months. Caries M / perio M — NICE CG19. Hygiene at 3 months.

Compliance: the medico-legal angle

• GDC Standards for the Dental Team — Principle 4.1.1: "you must make and keep contemporaneous, complete and accurate patient records." This template prompts every required element so nothing is omitted.
• FGDP(UK) Clinical Examination and Record-Keeping (2021) lists 20+ recommended fields for the new patient examination. All are present.
• CQC Regulation 17 (Good governance) requires providers to "maintain securely an accurate, complete and contemporaneous record in respect of each service user". The dedicated oral-cancer-screen line records the soft-tissue check so it is evidenced.
• NICE CG19 (Dental Recall): choose each patient's recall interval from their risk assessment — 3 to 24 months for adults, 3 to 12 months for under-18s — and record it with the reason. The recall field prompts this.

Common documentation mistakes

• Recording "MH NAD" without listing actual medications. Audit graders mark this down — explicit medication list (or "nil") is the standard.
• Forgetting the BPE at a routine examination. BSP 2019: record a BPE at every routine examination for codes 0–2. For patients treated for periodontitis, use 6-point charting (full mouth at least annually in maintenance) instead of BPE.
• Treating "OPG taken" as a radiograph note without justification. IR(ME)R 2017 requires recorded clinical justification for every radiograph.
• Listing options 1/2/3 but not documenting the patient's questions or final decision — half the Montgomery test is the discussion, not the menu.
• No recorded risk assessment for caries / perio / TSL / oral cancer — the four risks NICE expects you to grade.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• CGDent: Clinical Examination and Record-Keeping, Good Practice Guidelines (3rd edition) (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (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)
• BSP: The Basic Periodontal Examination (BPE), 2019 (accessed 18 October 2026)
• BSP: Implementing the 2018 Classification of Periodontal Diseases to Reach a Diagnosis in Clinical Practice (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• GDPR Compliance for Dental Software in the UK
• Voice-to-Text for Dental Notes: UK Practice Guide
• UK Dental Charting & Clinical Notes: A Guide for Overseas-Trained Dentists
• ORE vs LDS: Which GDC Registration Route Should Overseas Dentists Choose?
• Dental Notation Systems: FDI vs Palmer vs Universal (with Charts)
• GDC Registration for Overseas Dentists: Complete Route Guide (UK)

Patient leaflets for this treatment

• Understanding Tooth Decay
• Understanding Gum Disease
• Your Guide to Dental X-rays

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