Dental Exam Findings
A dental examination findings record — practice and dentist, patient and chief complaint, extraoral/intraoral soft-tissue exam, tooth-by-tooth charting, periodontal findings, existing restorations, radiographs, diagnosis, and a phased treatment plan with signature.
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Bright Smile Dental
DENTAL EXAMINATION FINDINGS
Dentist: Dr. Nina Patel, DDS Exam: Periodic / recall
Patient: Alex Morgan Date: June 19, 2026
Chief complaint: Routine checkup; occasional cold sensitivity on lower right.
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EXAM
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Extraoral: Head/neck, lymph nodes, TMJ WNL; no facial asymmetry or lesions.
Intraoral / soft tissue: Tongue, floor of mouth, palate, cheeks, gingiva WNL. Oral cancer screen negative. Oral hygiene fair; moderate plaque, light calculus lower anteriors.
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TOOTH CHARTING
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#3: existing MO amalgam, intact
#14: suspicious occlusal stain, watch
#19: distal caries (D), recommend composite
#30: sensitivity to cold, no caries; possible recession
#1, #16, #17, #32: impacted/absent — see notes
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PERIODONTAL
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Generalized probing depths 2–3 mm; localized 4 mm #18–19 with bleeding on probing. No mobility. Mild gingivitis. Recommend perio maintenance.
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RADIOGRAPHS
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4 bitewings taken today (last FMX 2024). No interproximal caries except #19 distal. Bone levels stable.
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DIAGNOSIS
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Dental caries #19 (D); localized gingivitis; #14 to monitor; #30 dentinal sensitivity / possible recession.
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TREATMENT PLAN
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Phase 1: prophylaxis + OHI today; composite restoration #19 D (schedule). Phase 2: re-evaluate #14 at next recall; desensitizing for #30. Maintenance: 6-month recall, bitewings in 12 months. Discussed findings and options; patient consented to #19 restoration.
Dentist signature: _______________________________ Date: ______________
Dr. Nina Patel, DDS
About this template
A dental exam findings record captures what the dentist saw and what happens next, in the standard order that makes it both clinically useful and chart-ready. It opens with the **chief complaint** and the **exam type** (comprehensive new-patient, periodic recall, limited, or emergency — which sets the scope), then the **extraoral** and **intraoral/soft-tissue** exam, including the oral-cancer screen that belongs in every exam. The heart is the **tooth-by-tooth charting** — existing restorations, caries with the surface noted (M/O/D/etc.), areas to watch, sensitivity, and missing/impacted teeth — written tooth by tooth so it transfers cleanly to the odontogram and the next provider can act on it. **Periodontal findings** (probing depths, bleeding on probing, recession, mobility) drive the perio diagnosis and recall interval, and **radiographs** should note what was taken, why, and the findings, consistent with justification/ALARA. From there the **diagnosis** summarizes the problems and the **treatment plan** lays them out in **phases or priorities** (urgent care first, then restorative, then maintenance), with a note that findings and options were discussed and consent obtained. Two practice points: dental records are **protected health information** under HIPAA with state content/retention rules, so store them securely; and the note documents the exam — it does not replace performing it or obtaining informed consent for treatment. Chart contemporaneously and specifically enough to support diagnosis, the plan, and any billing.
When to use it
- Documenting a dental examination and charting findings.
- Recording periodontal status and radiographic findings.
- Stating a diagnosis and a phased treatment plan.
- Supporting continuity of care and insurance documentation.
What to include
- Practice, dentist, patient, date, exam type, and chief complaint.
- Extraoral and intraoral/soft-tissue exam (incl. oral cancer screen).
- Tooth-by-tooth charting (restorations, caries/surfaces, watch items).
- Periodontal findings and radiographs.
- Diagnosis and a phased treatment plan with signature.