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Free dental exam note generator
Turn chairside shorthand into a complete dental examination note. Your tooth notation, surfaces and periodontal scores are kept exactly as you wrote them.
How to use it
- 01
Paste the history
Complaint, medical history, medication, allergies and smoking status. Shorthand is fine.
- 02
Add your findings by tooth
Use FDI (36) or Universal (#19) numbering, with surfaces, BPE or pocket depths and what the radiographs showed.
- 03
Check the plan
The draft lists diagnosis and treatment per tooth, plus hygiene and recall, without changing your notation.
What goes in a dental examination note?
A dental examination note records the full check-up: history, soft tissue screening, charting, periodontal status, radiographs and the agreed treatment plan. Tooth notation varies by country, with FDI two-digit numbering used in most of Europe and the Universal system common in the United States, so the note should stick to one system throughout.
- Presenting complaint
- The reason for attendance, such as a routine check-up or a specific symptom, with its history.
- Medical history
- Conditions, medication, allergies and habits such as smoking that affect dental care.
- Extraoral and intraoral examination
- Face, TMJ, lymph nodes, and soft tissues including tongue, floor of mouth and mucosa; this is also where an oral cancer screen is recorded.
- Charting and periodontal status
- Caries, restorations and missing or erupting teeth by tooth and surface; BPE or pocket charting, plaque and calculus.
- Radiographs
- Type and number of views taken, the justification if recorded, and the findings.
- Diagnosis and treatment plan
- Diagnosis per tooth or condition, planned treatment, preventive advice and recall interval.
Dental exam note example: new patient with cold sensitivity
Presenting complaint
New patient examination. 37-year-old woman with sensitivity to cold in a lower left posterior tooth for 2 weeks, lasting a few seconds. No spontaneous pain.
Medical history
Asthma, salbutamol inhaler as needed. No known drug allergies. Non-smoker.
Extraoral and intraoral examination
Extraoral: no abnormality detected; no TMJ click; no lymphadenopathy. Intraoral: soft tissues healthy; tongue and floor of mouth normal.
Charting and periodontal status
36 caries DO. 46 MO amalgam, sound. 38 partially erupted. BPE 2/1/2, 2/2/2. Plaque mainly lower left lingual; calculus on lower anteriors.
Radiographs
Two bitewings: 36 distal caries into the middle third of dentine; 25 distal enamel lesion; bone levels normal.
Diagnosis and treatment plan
36: reversible pulpitis due to DO caries; plan DO composite restoration. 25: incipient distal caries; fluoride varnish and monitor. Scale and polish. Oral hygiene instruction with interdental brushes. Recall in 6 months.
Need the diagnosis code too? Search ICD-10-CM codes
Tips for dental examination notes
- Choose one tooth notation (FDI, Universal or Palmer) and use it throughout the note and treatment plan.
- Record surfaces for every carious lesion and restoration (for example 36 DO), not just the tooth number.
- Write BPE as all six sextant scores, and record full pocket charting where the BPE calls for it.
- Note the soft tissue and oral cancer screen even when normal; it shows the check was done.
- For radiographs, record the type and number of views, the justification and the findings.
- Write the recall interval and the reasoning for it, based on the patient’s risk.
Frequently asked questions
Does it support FDI and Universal tooth numbering?
Yes. It keeps whichever notation you use, FDI (for example 36), Universal (for example #19) or Palmer, and does not convert between them. Stick to one system in your notes.
Can I use it for emergency appointments?
Yes. Paste the complaint, findings and treatment; sections you did not cover, such as a full BPE, are marked “Not documented”.
Will it suggest a diagnosis or treatment?
No. It writes up the diagnosis and plan you recorded. If they are missing from your notes, the section says “Not documented”.
Is it free?
Yes. You can write up to 10 notes a day without an account.
Is it safe to paste patient information?
Paste clinical details only, never names, ID numbers or contact details. The text is sent to our AI provider to write the note and is not saved by Docdemic.