General Practitioner Template

Dental Note - Concise

A professional General Practitioner template for healthcare professionals.

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Specialty

General Practitioner

Used

4 times

Type

Note

Last edited

14/10/2025

Created by

Oscar Bown

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About this template

This concise dental note template is designed for general practitioners to efficiently document patient visits related to dental concerns. It includes sections for recording the reason for the appointment, COVID-19 screening results, chief complaints, and detailed history of present complaints. The template also covers dental hygiene habits, relevant medical history, and social factors affecting oral health. It provides a structured format for extraoral and intraoral examinations, oral hygiene assessments, caries risk classification, and clinical examination observations. Additionally, it outlines available treatment options, agreed treatment plans, and next visit plans, making it an ideal tool for dental documentation.

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RFA: Routine check-up and evaluation of recent tooth sensitivity. Covid questions: Negative C/o: - Tooth sensitivity in the upper right molar region - Onset: 2 weeks ago - Severity: Moderate - Aggravating factors: Cold beverages - Relieving factors: Warm water rinses HPC: The patient reports experiencing moderate sensitivity in the upper right molar region for the past two weeks. The sensitivity is exacerbated by cold beverages and somewhat relieved by warm water rinses. No previous self-management attempts have been made. PDH: - Brushes twice daily - Flosses occasionally - Last professional cleaning: 6 months ago - Previous dental procedures: Filling in lower left molar PMH: - Hypertension, managed with medication - No other relevant medical conditions SH: - Smokes 5 cigarettes per day - Moderate alcohol consumption E/O: Nil I/O ST: Nil OH: Fair Caries risk: Moderate O/E: Clinical examination reveals plaque accumulation and mild gingivitis. No visible caries in the upper right molar region, but sensitivity tests confirm heightened response in the area. Diagnosis: - Tooth sensitivity in upper right molar region - Mild gingivitis NHS and private Options: - NHS: Desensitizing toothpaste and fluoride varnish application - Private: In-office desensitizing treatment and custom fluoride trays Tx plan: - Use desensitizing toothpaste twice daily - Schedule fluoride varnish application - Follow-up in 4 weeks to reassess sensitivity n.v.: Follow-up appointment in 4 weeks for sensitivity reassessment and potential further treatment.