Comprehensive Oral Evaluation Note (New Patient)

Comprehensive Oral Evaluation (New Patient)

Note Type: Comprehensive Oral Evaluation (New Patient)
Date/Time: [Date and time]
Location: [Clinic location]
Provider: [Provider name, credentials]
Assistants/Hygienist: [Names and roles]
Data Sources: [patient / caregiver / prior records / outside radiographs] (Note reliability concerns if applicable; specify sources reviewed.)
Interpreter: [Language and interpreter ID / not used]

Chief Concern

[Patient-stated primary reason for visit] (Use a direct quote when helpful. Include patient goals such as pain relief, aesthetics, function, or medical clearance.)

Dental Urgency Screening: [pain / swelling / fever / trauma / airway concerns / none reported] (If no acute complaints, state that the patient presents for baseline comprehensive evaluation.)

History of Present Illness

[Narrative history of active complaint] (Only include when the patient has an active complaint. Describe onset, duration, triggers, relieving factors, location, severity, character, radiation, thermal sensitivity, bite pain, associated symptoms such as swelling, drainage, trismus, paresthesia, and any prior treatments with outcomes.)

Medical History

• [Major diagnoses relevant to dental care] (Cardiac conditions, diabetes control, immunosuppression, bleeding disorders, renal/hepatic disease, osteoporosis/antiresorptive use, pregnancy status when relevant.)
• [Relevant surgeries and hospitalizations]
• [Anesthesia/sedation history and complications]
• [ASA classification] (Include if used by practice.)
• [Medical consult/clearance needs] (Specify clinical question and pending procedure if applicable.)

Medications and Allergies

Current Medications: [Medication list with name, dose, route, frequency; include relevant OTC/supplements] (If patient is unsure, document uncertainty and plan to reconcile.)

Allergies: [Allergen with reaction type and severity / NKDA] (If unable to obtain, document the barrier and plan to reconcile.)

Social History

• Tobacco/Nicotine: [type, quantity, duration / none]
• Alcohol: [frequency and pattern / none]
• Recreational Drugs: [type, frequency / none] (Include when clinically relevant for sedation, anesthesia, or oral findings.)
• [Occupational or behavioral factors affecting care] (Include if pertinent.)

Dental History

• [Date of last dental visit and last radiographs]
• [Prior dental experiences and anxiety level]
• [Past caries/restorative burden: fillings, crowns, root canals, extractions]
• [Periodontal history: prior scaling/root planing, diagnoses, maintenance]
• [Home care: brushing frequency, interdental cleaning, fluoride exposure, mouthrinse]
• [Diet and sugar exposure patterns: frequency and timing]
• [Parafunction: clenching/grinding; occlusal guard use]
• [Orthodontic history]
• [Existing prostheses or implants and their age/maintenance]

Risk Assessment

Caries Risk Level: [low / moderate / high / extreme] — [Key drivers] (Cite disease indicators, biological risk factors, and protective factors that justify the level.)

Periodontal Risk: [low / moderate / high] — [Key drivers] (Consider tobacco use, diabetes control, prior periodontitis, plaque control, relevant medications.)

Vital Signs

• Blood Pressure: [Value]
• Pulse: [Value]
• Pain Score: [0–10] (Include when pain is a complaint or impacts care.)

(If vital signs not obtained, document the reason and mitigation plan.)

Extraoral Examination

• General Appearance: [Findings]
• Head/Face: [Symmetry and skin findings]
• TMJ: [Range of motion, tenderness, joint sounds, deviations]
• Lymph Nodes: [Cervical and submandibular findings]
• Salivary Glands: [Swelling, tenderness, flow]

Intraoral Soft Tissue Examination

• Labial/Buccal Mucosa: [Findings]
• Gingiva/Alveolar Mucosa: [Findings]
• Tongue: [Dorsal, ventral, lateral border findings]
• Floor of Mouth: [Findings]
• Hard and Soft Palate: [Findings]
• Oropharynx/Tonsillar Pillars: [Findings]

[Lesion description if present: location, size, color, surface characteristics, borders, induration, ulceration, pain, duration, photos taken] (For suspicious lesions, document urgency, counseling, and biopsy/referral plan.)

Oral Cancer Screening: [Completed with no suspicious lesions identified / suspicious lesion identified with plan documented above]

Hard Tissue Examination

• Missing/Unerupted Teeth: [Tooth numbers]
• Caries: [Tooth and surface; cavitated vs noncavitated]
• Existing Restorations: [Type and condition: margins, fractures, overhangs]
• Cracks/Fractures: [Tooth and description]
• Wear Patterns: [Attrition, erosion, abrasion]
• Endodontic Concerns: [Percussion/palpation sensitivity, sinus tracts, swelling]
• Prostheses/Implants: [Condition, hygiene, stability, occlusion]

Periodontal Examination

Screening/Overview: [Gingival inflammation distribution, plaque/calculus burden, bleeding on probing, periodontal screening score if used]

Full Charting: [Probing depths, recession, clinical attachment level, bleeding on probing, suppuration, furcation involvement, mobility, mucogingival defects] (If full charting deferred, document reason and plan to complete.)

Occlusion and Functional Evaluation

• Occlusal Classification: [Class I / Class II / Class III]
• Occlusal Relationships: [Overjet, overbite, crossbite, midline discrepancies]
• Wear and Parafunction: [Functional wear indicators]
• Fremitus/Mobility: [Findings related to occlusion]
• Interferences: [Centric or excursive interferences if present]

(Include this section when occlusal evaluation is clinically relevant.)

Radiographic Review

Indication: [Clinical rationale based on history, exam, and risk assessment]

Images Obtained Today: [Type, count, regions] (Note quality limitations if applicable.)

Prior Images Reviewed: [Type, date, source] (Note quality limitations if applicable.)

Findings: [Interproximal caries, recurrent caries, periapical pathology, bone levels and loss patterns, calculus, impacted teeth, anatomic variants, other pathology]

Radiographic Impression: [Concise summary linked to clinical diagnoses]

(If no radiographs taken, document whether not indicated or patient declined, plus follow-up plan.)

Assessment

[Clinical summary in 2–5 sentences covering caries risk with drivers, periodontal status with drivers, urgent findings, and key constraints such as medical risk or patient preferences]

Problem List

• [Problem title with tooth/region]
  Supporting Findings: [Pertinent clinical and radiographic data]
  Working Diagnosis: [Diagnosis] (Include differential if uncertain.)
  Urgency: [urgent / soon / routine]
  Next Diagnostic Step: [Planned tests or evaluations if needed]

(List problems in order of urgency/severity. Add additional problems as needed.)

Diagnoses

• Caries: [Diagnoses by tooth and surface]
• Periodontal: [Gingivitis / periodontitis / stable treated periodontitis; include stage, grade, and extent if staging/grading system is used]
• Periapical/Endodontic: [Diagnoses by tooth]
• Oral Mucosal: [Diagnosis or confirmation of no suspicious lesions]
• Peri-implant: [Health / mucositis / peri-implantitis] (Include when implants are present.)
• Rule Out: [Conditions requiring further evaluation] (Use for uncertain diagnoses only.)

Treatment Plan

Shared Decision-Making: [Findings reviewed with patient; treatment options discussed including no treatment; risks, benefits, and alternatives summarized; patient questions addressed; patient decisions with reasoning]

Urgent/Stabilization

• [Procedure and tooth/region] — [Rationale]; [Prerequisites]; [Timing/Priority]

Disease Control

• [Caries control measures / periodontal initial therapy / oral hygiene instruction] — [Rationale]; [Prerequisites]; [Timing]

Definitive Care

• [Restorative / endodontic / prosthodontic / surgical procedure with tooth/region] — [Rationale]; [Prerequisites]; [Timing]

Maintenance

• [Periodontal maintenance / caries recall] — [Risk-based interval]

(Include only phases relevant to this patient's treatment plan.)

Preventive Plan

• [Home care instructions provided]
• [Fluoride strategy: OTC vs prescription; varnish application]
• [Dietary counseling provided]
• [Sealants or antimicrobials recommended]
• [Tobacco cessation counseling or referral]
• [Recommended recall interval based on risk assessment]

Referrals

• [Specialist referral and reason]
• [Medical consult request with specific clinical question and pending procedure]
• [Attachments sent: radiographs, photos, clinical summary]

(Omit section if no referrals indicated.)

Prescriptions

• [Drug, dose, route, frequency, duration, refills, indication, counseling provided]

(Omit section if no prescriptions written.)

Follow-Up

[Next planned visit type and timeframe; contingencies such as return sooner if symptoms worsen]

Consent and Communication

• [Informed consent obtained for diagnostics performed]
• [Informed refusal if applicable, with documentation of discussion]
• [Educational materials or written instructions provided]

Provider Signature

Signature: [Electronic or written signature]
Date/Time Signed: [Date and time]

(Missing Information Handling: Omit sections that are not relevant to this visit. For relevant sections that were deferred, document "Not assessed" with reason and plan. For information the patient could not provide, document "Unknown / not reported." For information unable to be obtained due to barriers, document "Unable to obtain" with the barrier and mitigation plan. Maintain objective, factual language throughout. Do not infer diagnoses, medication use, or health status.)