Paediatric dental examination template
Say who came with the child, what you examined, and what you agreed with the adult who has parental responsibility.
Template
Age Accompanied by Cooperation Complaint Medical history Diet and brushing, as reported Extra-oral Soft tissues Teeth present Caries Restorations Occlusion Gingiva Plaque Caries risk Radiographs Discussion with parent Plan Next visit
A filled-in example
Age
7
Accompanied by
Mother
Cooperation
Good, sat in the chair for the exam.
Complaint
Hole noticed in a back tooth. No pain.
Medical history
Asthma, salbutamol inhaler. No allergies.
Diet and brushing, as reported
Juice in a bottle at night until last year, now water. Brushes once a day, unsupervised.
Extra-oral
Nothing abnormal.
Soft tissues
Nothing abnormal.
Teeth present
Mixed dentition. First permanent molars erupted.
Caries
LLE occlusal cavity.
Restorations
None.
Occlusion
Class I molars.
Gingiva
Healthy.
Plaque
Lower incisors.
Caries risk
High. Night-time juice history and once-daily brushing.
Radiographs
Bitewings not taken today. Child not ready. Planned for the next visit if cooperation allows.
Discussion with parent
Explained the cavity and the brushing. Options: 1. Monitor if it stays symptom-free, with prevention. 2. Filling when cooperation allows. Mother wants to try prevention first and come back in three months.
Plan
Brushing instruction with the mother. Fluoride varnish applied, dose recorded in the clinical system.
Next visit
3 months. Bitewings if the child will tolerate them.
Let Dentascribe fill this in from your appointment audio.
