A dental notes template is a standardized documentation framework that ensures comprehensive, consistent recording of patient dental examinations, treatments, and care plans. Effective dental notes include patient history, clinical findings, tooth charting, treatment performed, materials used, and follow-up recommendations. Below you’ll find free templates for common dental documentation needs, plus guidance on transitioning to AI-powered documentation that generates notes automatically during patient visits.
Introduction
Quality dental documentation serves multiple critical purposes: supporting continuity of care, meeting legal and regulatory requirements, facilitating insurance reimbursement, and protecting against liability. Yet many dental professionals struggle with documentation that’s either too brief to be useful or so time-consuming it cuts into patient care.
This comprehensive guide provides ready-to-use dental notes templates for various clinical scenarios, explains documentation best practices, and shows how modern AI documentation tools can automate the process entirely.
Essential Components of Dental Notes
Comprehensive dental documentation should capture all relevant clinical information in a structured, consistent format. Every dental note should include these core elements:
Patient Identification
Patient name and date of birth, medical record number, date and time of visit, treating dentist or hygienist, and visit type (routine, emergency, follow-up).
Medical History Review
Current medications including changes since last visit, allergies and adverse reactions, relevant medical conditions such as diabetes, heart conditions, and bleeding disorders, history of antibiotic prophylaxis requirements, and vital signs when indicated.
Chief Complaint
Patient’s primary concern in their own words, duration and onset of symptoms, pain level if applicable, and aggravating and relieving factors.
Clinical Examination
Extraoral examination findings, intraoral soft tissue examination, hard tissue examination, periodontal assessment, occlusion evaluation, and TMJ assessment when indicated.
Diagnostic Findings
Radiographic findings, diagnostic test results, tooth charting updates, and periodontal charting including probing depths and bleeding points.
Treatment Documentation
Procedures performed with tooth numbers, anesthesia used including type, amount, and location, materials used with brands and lot numbers when required, complications or unusual findings, and patient tolerance of procedure.
Treatment Plan and Follow-Up
Diagnosis and treatment plan, patient education provided, home care instructions, prescriptions written, follow-up appointments scheduled, and referrals made.
Template 1: Comprehensive Dental Examination
Use for: New patient exams, periodic comprehensive exams
COMPREHENSIVE DENTAL EXAMINATION
Patient: [Name] | DOB: [Date] | Date: [Visit Date] | Provider: [Dentist Name] | MRN: [Number] | Visit Type: Comprehensive Exam
MEDICAL HISTORY REVIEW: Medical history reviewed and updated. No changes since last visit OR Changes noted: ___. Current Medications: ___. Allergies: ___. Relevant Conditions: ___. Vital Signs: BP ___/___ HR ___ (if indicated).
CHIEF COMPLAINT: Patient presents for: Routine exam OR Specific concern: ___. Pain: None OR Present – Location: ___ Level: ___/10.
EXTRAORAL EXAMINATION: Head/Neck: WNL OR Findings: ___. Lymph Nodes: WNL OR Findings: ___. TMJ: WNL / Click / Pop / Crepitus / Pain / Limited opening. Muscles of Mastication: WNL OR Tenderness: ___.
INTRAORAL EXAMINATION: Lips: WNL OR Findings: ___. Buccal Mucosa: WNL OR Findings: ___. Tongue: WNL OR Findings: ___. Floor of Mouth: WNL OR Findings: ___. Hard Palate: WNL OR Findings: ___. Soft Palate/Oropharynx: WNL OR Findings: ___. Gingiva: Healthy / Gingivitis / Periodontitis. Oral Hygiene: Good / Fair / Poor. Plaque Index: ___ Bleeding on Probing: ___.
HARD TISSUE EXAMINATION: Dentition: Primary / Mixed / Permanent. Missing Teeth: ___. Caries: None detected OR Present: ___. Existing Restorations: Satisfactory OR Defective: ___. Fractures/Wear: ___.
RADIOGRAPHIC FINDINGS: Images Taken: BWX / PA / Pano / FMX / CBCT. Findings: ___.
PERIODONTAL SUMMARY: Healthy periodontium / Gingivitis (localized/generalized) / Periodontitis Stage ___ Grade ___. Probing Depths: All 3mm or less / 4-5mm sites: ___ / 6mm or greater sites: ___.
OCCLUSION: Classification: Class I / Class II / Class III. Findings: WNL / Wear facets / Fremitus / Mobility: ___.
DIAGNOSIS: 1. ___ 2. ___ 3. ___
TREATMENT PLAN: Priority 1 (Urgent): ___. Priority 2 (Near-term): ___. Priority 3 (Elective): ___.
PATIENT EDUCATION: Oral hygiene instruction, diet counseling, treatment options discussed, risks/benefits explained, questions answered.
NEXT STEPS: Treatment scheduled: ___ / Referral to: ___ / Recall interval: ___ months.
Provider Signature: ___ Date: ___
Template 2: Restorative Treatment Note
Use for: Fillings, crowns, bridges, inlays/onlays
RESTORATIVE TREATMENT NOTE
Patient: [Name] | DOB: [Date] | Date: [Visit Date] | Provider: [Dentist Name]
MEDICAL HISTORY: Reviewed – No changes OR Changes noted: ___. Allergies verified: ___.
PRE-OPERATIVE ASSESSMENT: Tooth/Teeth: No.___. Diagnosis: Caries / Fracture / Defective restoration / Other: ___. Pre-op symptoms: None / Sensitivity / Pain: ___/10. Pulp vitality: Vital / Non-vital / Not tested. Pre-op radiograph: Reviewed / Taken today.
ANESTHESIA: Type: Lidocaine 2 percent with epi / Articaine 4 percent / Mepivacaine 3 percent / Other: ___. Amount: ___ carpules. Location: Infiltration / Block: ___. Complications: None OR ___.
PROCEDURE: Tooth No.: ___ Surfaces: M / O / D / B / L. Isolation: Rubber dam / Cotton rolls / Isolite / Dry angles.
Caries Removal: Complete / Indirect pulp cap performed. Deepest extent: Enamel / Dentin / Near pulp.
Restoration: Type: Composite / Amalgam / GIC / Crown / Other: ___. Material/Shade: ___. Bonding Agent: ___. Matrix: Sectional / Tofflemire / None. Liner/Base: None OR ___.
Crown Preparation (if applicable): Finish Line: Chamfer / Shoulder / Feather edge. Impression: Digital scan / PVS / Alginate. Temporary: Material: ___ Cement: ___. Shade Selected: ___.
POST-OPERATIVE: Occlusion: Adjusted and verified. Contacts: Checked – appropriate. Patient tolerance: Good / Fair / Poor. Complications: None OR ___.
POST-OP INSTRUCTIONS PROVIDED: Numbness precautions, bite sensitivity expected, diet modifications, when to call office, written instructions given.
PRESCRIPTIONS: None / Analgesic: ___ / Antibiotic: ___.
FOLLOW-UP: PRN / Scheduled: ___ / Continue with treatment plan.
Provider Signature: ___ Date: ___
Template 3: Dental Hygiene Note
Use for: Routine cleanings, periodontal maintenance
DENTAL HYGIENE NOTE
Patient: [Name] | DOB: [Date] | Date: [Visit Date] | Hygienist: [Name] | Supervising Dentist: [Name]
MEDICAL HISTORY UPDATE: No changes since last visit OR Changes: ___. Medications updated: Yes / No changes. Premedication required: No / Yes – Taken: ___.
PERIODONTAL ASSESSMENT: Probing completed: Yes / Deferred – Reason: ___. Periodontal Status: Healthy / Gingivitis (Localized/Generalized) / Periodontitis Stage ___ Grade ___ / Periodontal maintenance. Probing Summary: Sites 1-3mm: ___ percent | Sites 4-5mm: ___ percent | Sites 6mm or greater: ___ percent. Bleeding on Probing: ___ percent. Changes from last visit: Improved / Stable / Worsening.
CLINICAL FINDINGS: Plaque Score: ___ percent. Calculus: None / Light / Moderate / Heavy (Supragingival/Subgingival). Stain: None / Light / Moderate / Heavy (Extrinsic/Intrinsic). Gingival Description: ___. Areas of Concern: ___.
SERVICES PROVIDED: Adult prophylaxis (D1110) / Child prophylaxis (D1120) / Periodontal maintenance (D4910) / Scaling and root planing: Quads: ___ / Full mouth debridement (D4355). Instrumentation: Ultrasonic / Hand scaling / Both. Areas requiring extra attention: ___. Polish: Prophy paste (Fine/Medium/Coarse) / Air polishing / Selective polishing. Fluoride: Declined / Fluoride varnish / Fluoride gel / Fluoride foam.
Additional Services: Radiographs: ___ / Sealants: Teeth No.___ / Desensitizing agent: ___ / Irrigation: ___.
PATIENT EDUCATION: Brushing technique, flossing instruction, interdental aids, electric toothbrush recommendation, diet/nutrition counseling, tobacco cessation, dry mouth management.
DENTIST EXAM: Exam performed by Dr. ___. Findings discussed with patient.
NEXT VISIT: Recall interval: 3 months / 4 months / 6 months / Other: ___. Next appointment: ___. Treatment needed: ___.
Hygienist Signature: ___ Date: ___ | Dentist Signature: ___ Date: ___
Template 4: Extraction Note
Use for: Simple and surgical extractions
EXTRACTION NOTE
Patient: [Name] | DOB: [Date] | Date: [Visit Date] | Provider: [Dentist/Surgeon]
PRE-OPERATIVE: Medical history reviewed: Yes. Anticoagulation status: N/A / Managed: ___. Allergies verified: ___. Consent obtained: Written / Verbal. Pre-op radiograph reviewed: Yes. Tooth/Teeth: No.___. Indication: Non-restorable caries / Periodontal disease / Fracture / Orthodontic / Impaction / Failed endo / Other: ___.
ANESTHESIA: Type: ___. Amount: ___ carpules. Location: ___. Adequate anesthesia confirmed: Yes.
PROCEDURE: Extraction Type: Simple / Surgical.
Simple Extraction: Elevators used: ___. Forceps used: ___.
Surgical Extraction: Flap: Envelope / Triangular / Other: ___. Bone removal: None / Buccal / Lingual / Interradicular. Sectioning: None / Crown / Roots. Instruments: ___.
Tooth delivered: Intact / Sectioned / Fragments: ___. Socket inspection: Intact OR ___. Curettage performed: Yes / No. Irrigation: Saline / Other: ___. Hemostasis achieved with: Pressure / Sutures / Gelfoam / Surgicel / Other: ___. Sutures: None / Type: ___ Number: ___.
Socket preservation (if applicable): N/A / Graft material: ___ / Membrane: ___.
Complications: None / Root fracture (Retrieved/Left in place – Reason: ___) / Sinus communication (None/Managed: ___) / Excessive bleeding (Managed: ___) / Other: ___.
SPECIMEN: Discarded / Sent to pathology / Given to patient.
POST-OPERATIVE INSTRUCTIONS: Verbal and written instructions provided. Instructions reviewed: Bite on gauze 30-45 minutes, no spitting/straws/smoking, soft diet, ice pack application, elevation of head when sleeping, gentle salt water rinses after 24 hours, signs of dry socket explained, when to call office.
PRESCRIPTIONS: Pain management: OTC (Ibuprofen ___ mg plus Acetaminophen ___ mg alternating) / Rx: ___. Antibiotic: Not indicated / Rx: ___.
FOLLOW-UP: Suture removal: ___ / PRN – Call if concerns / Post-op check scheduled: ___.
Patient tolerated procedure: Well / With difficulty: ___. Patient departed in: Stable condition / With escort.
Provider Signature: ___ Date: ___
Template 5: Emergency Dental Visit Note
Use for: Toothaches, trauma, swelling, broken teeth
DENTAL EMERGENCY NOTE
Patient: [Name] | DOB: [Date] | Date: [Visit Date] | Time: [Time] | Provider: [Dentist Name]
TRIAGE INFORMATION: Chief Complaint: ___. Duration: ___. Onset: Sudden / Gradual. Pain Level: ___/10. Pain Character: Sharp / Dull / Throbbing / Constant / Intermittent. Aggravating factors: Hot / Cold / Biting / Sweets / Spontaneous. Relieving factors: ___. Previous treatment attempted: ___.
MEDICAL HISTORY: Reviewed in full. Relevant conditions: ___. Current medications: ___. Allergies: ___. Last dental visit: ___.
VITAL SIGNS: BP: ___/___ mmHg | HR: ___ bpm | Temp: ___ degrees F (if indicated).
EXTRAORAL EXAMINATION: Swelling: None / Present – Location: ___. Lymphadenopathy: None / Present: ___. Asymmetry: None / Present: ___. Trismus: None / Present – Opening: ___ mm.
INTRAORAL EXAMINATION: Location of concern: Tooth No.___ / Area: ___. Soft tissue: ___. Swelling: None / Localized / Diffuse. Drainage: None / Purulent / Serous. Fistula: None / Present – Location: ___.
TOOTH-SPECIFIC FINDINGS: Tooth No.: ___. Inspection: Caries / Fracture / Restoration defect / Discoloration. Percussion: Normal / Sensitive / Severe. Palpation: Normal / Sensitive / Fluctuant. Mobility: None / Grade: ___. Probing: WNL / Isolated deep pocket: ___ mm. Cold test: Normal / Hypersensitive / Lingering / No response. EPT: Normal / No response / Not performed.
RADIOGRAPHIC FINDINGS: Images taken: ___. Findings: ___.
DIAGNOSIS: Reversible pulpitis / Irreversible pulpitis / Pulp necrosis / Acute apical periodontitis / Acute apical abscess (with cellulitis/with swelling) / Cracked tooth / Dental trauma: ___ / Periodontal abscess / Pericoronitis / Other: ___.
TREATMENT PROVIDED: Palliative treatment only / Pulpotomy/pulp cap / Pulpectomy/emergency access / Incision and drainage / Extraction / Temporary restoration / Occlusal adjustment / Irrigation/debridement / Other: ___. Anesthesia: ___. Procedure details: ___.
MEDICATIONS PRESCRIBED: Analgesic: ___. Antibiotic: Not indicated OR ___. Other: ___.
PATIENT EDUCATION: Diagnosis explained, treatment options discussed, prognosis discussed, warning signs reviewed.
DISPOSITION: Symptoms expected to resolve / Definitive treatment needed: ___ / Referral to: ___ / Return if: ___.
Follow-up: PRN / Scheduled: ___.
Provider Signature: ___ Date: ___
Dental Documentation Best Practices
Legal and Compliance Standards
Dental records serve as legal documents. Follow these standards: every entry must include date with time for procedures, entries must be legible or typed, corrections should use single line through errors with initials and date (never erase or white-out), provider signature on all clinical entries, document at time of service or as soon as possible, use objective clinical terminology and avoid subjective opinions, and remember that if it was not documented it was not done.
Insurance and Billing Documentation
Proper documentation supports insurance claims: document medical necessity explaining why treatment was needed, use Universal or ISO tooth numbering consistently, clearly indicate all surfaces treated, ensure documentation supports CDT codes billed, include detailed narratives for complex or unusual cases, and reference supporting diagnostic images.
Common Documentation Errors to Avoid
Watch out for incomplete entries with missing tooth numbers, surfaces, or materials. Avoid copy-paste errors with information from wrong patient or visit. Do not use vague descriptions like “filling done” without specifics. Ensure informed consent is documented with risks discussed. Record verbal instructions and conversations. Avoid delayed documentation written days after treatment. Ensure charting matches narrative to avoid inconsistencies.
AI-Powered Dental Documentation
While templates improve consistency, they still require manual data entry. Modern AI documentation solutions transform dental charting by automatically capturing clinical information during patient interactions.
How AI Dental Documentation Works
The process involves ambient listening where AI captures the dentist-patient conversation during exam, clinical extraction where relevant findings, diagnoses, and treatments are identified, structured formatting where information is organized into proper dental note format, coding suggestions where appropriate CDT codes are recommended, and finally review and sign where the dentist reviews, edits if needed, and approves.
Benefits Over Manual Templates
| Factor | Manual Templates | AI Documentation |
|---|---|---|
| Time per note | 5-10 minutes | 30-60 seconds review |
| Completeness | Variable (human dependent) | Consistent capture |
| Real-time charting | No (documented after) | Yes (during visit) |
| Error risk | Higher (manual entry) | Lower (automated) |
| Patient engagement | Reduced (typing during visit) | Improved (hands-free) |
Learn more about voice recognition in healthcare and how it applies to dental practice.
Specialty-Specific Considerations
Orthodontic Notes: Include bracket positions, wire sequences, elastic configurations, progress photos, cephalometric measurements, and treatment phase documentation.
Periodontal Notes: Include full periodontal charting, recession measurements, furcation involvement, mobility grades, bleeding points, and comparison to previous charting.
Endodontic Notes: Include working lengths, file sequences, irrigation protocols, obturation techniques, sealer used, post-operative radiographs, and canal anatomy.
Oral Surgery Notes: Include ASA classification, anesthesia details, surgical technique, specimens, blood loss estimation, suture details, and pathology submission.
Pediatric Dental Notes: Include behavior management techniques, parent present or absent, growth and development observations, and anticipatory guidance provided.
Frequently Asked Questions
How long should dental notes be kept?
Retention requirements vary by state but generally range from 7-10 years after the last treatment date, or until the patient reaches age of majority plus the retention period for minors. Many practices retain records indefinitely given low storage costs for digital records.
Should I use Universal or ISO tooth numbering?
In the United States, the Universal Numbering System (1-32 for permanent teeth) is standard. Internationally, the ISO/FDI system is more common. Choose one system and use it consistently throughout your practice.
How do I document patient non-compliance?
Document objectively: “Patient reports brushing once daily. Plaque index 45 percent. Recommended twice daily brushing and daily flossing. Patient stated understanding of recommendations.” Avoid judgmental language.
What if I need to correct a documentation error?
Draw a single line through the error, write “error” or “correction,” initial and date. Then add the correct information. In electronic records, use the amendment function that preserves the original entry with audit trail.
Do I need to document declined treatment?
Yes, absolutely. Document recommended treatment, that risks and consequences of non-treatment were explained, and that patient declined. Have patient sign a treatment refusal form for significant recommendations.
Can dental assistants write clinical notes?
Dental assistants can document objective findings, patient statements, and procedures they observed or assisted with. Clinical diagnoses and treatment decisions must be documented by the licensed dentist. Requirements vary by state.
Automate Your Dental Documentation
Templates are a great starting point, but AI can take your documentation to the next level, generating comprehensive notes automatically while you focus on patient care.
NoteV’s AI documentation captures your clinical conversations and produces detailed, properly formatted dental notes in seconds. No more end-of-day charting marathons.
Dental practices using NoteV report:
- 75 percent reduction in documentation time
- More complete clinical records
- Improved CDT coding accuracy
- Better patient engagement during visits
- Seamless integration with dental practice management software
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Disclaimer: These templates are provided for educational purposes and should be adapted to meet your specific practice requirements, state regulations, and software systems. Consult with your dental board and legal counsel regarding documentation requirements in your jurisdiction.
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