Dental Prophylaxis/Extractions Procedure Note

Date: [Date]

Location: [Clinic location]

Provider(s): [Dentist name and role; Hygienist name if applicable]

Patient: [Patient name and DOB or ID]

Visit Type: [Prophylaxis / Periodontal Maintenance / Extraction(s) / Combined]

Chief Concern

[Chief concern or patient-stated goal, including onset, location, severity, and triggers; include brief patient quotes when helpful] (Include this section when the patient has symptoms, a patient-stated goal, or is presenting for extraction. Omit entirely for routine asymptomatic prophylaxis.)

Medical and Safety Review

• [Medical history updates since last visit] (Use "Medical history reviewed; no changes" when applicable.)
• [Relevant conditions: cardiac, diabetes, immunosuppression, bleeding disorders]
• [Current medications; note anticoagulants/antiplatelets and bisphosphonates/denosumab]
• [Allergies with reaction types]
• [Infective endocarditis prophylaxis status: indicated/not indicated; if indicated, administration details]
• [Vitals] (Include when sedation is used or for complex extractions.)

Oral Examination

• [Extraoral findings] (Include only if abnormal: asymmetry, lymphadenopathy, TMJ dysfunction.)
• [Intraoral soft tissue: mucosa, tongue, floor of mouth, palate, gingiva; describe lesions with location, size, and appearance]
• [Periodontal findings: probing depths or summary, bleeding on probing, plaque/calculus distribution, mobility, periodontal diagnosis] (Note if comprehensive charting not performed and why.)
• [Hard tissue findings by tooth: caries, fractures, defective restorations, missing teeth with tooth numbers and surfaces]

Radiographs

• [Images obtained: type, number, and clinical indication]
• [Interpretation: caries, periapical pathology, bone loss, extraction-relevant anatomy]
• [If not obtained: not indicated / deferred / patient declined — reason] (Include only if no images obtained.)

Assessment

• [Periodontal diagnosis per accepted classification]
• [Tooth-specific diagnoses with tooth numbers and indications]
• [Other oral pathology or conditions]
• [Risk modifiers: caries risk, periodontal risk, medical factors, behavioral factors]

Procedures Performed

(Include only subsections for procedures actually performed.)

Prophylaxis/Periodontal Maintenance

• [Procedure type: adult prophylaxis / child prophylaxis / periodontal maintenance / gross debridement]
• [Areas treated]
• [Instrumentation: ultrasonic / hand scaling / both]
• [Polishing: yes/no; paste type if relevant]
• [Adjuncts provided: fluoride varnish type, sealants with tooth numbers, antimicrobial agents] (Include only if performed.)
• [Gingival response and hemostasis]
• [Adjuncts recommended but declined] (Include only if applicable.)

Local Anesthesia

• [Agent and concentration with vasoconstrictor]
• [Total dose or number of cartridges]
• [Injection sites: nerve blocks and/or infiltrations]
• [Patient tolerance: tolerated well / complication — describe]

Extraction(s)

(Document per tooth. Repeat block for each extracted tooth.)

• Tooth [Number]: [Simple / Surgical — reason]

  • [Indication for extraction]
  • [Technique: flap design, bone removal, sectioning, elevation, forceps as applicable]
  • [Socket management: irrigation, curettage, hemostatic agents, grafting material]
  • [Hemostasis achieved: yes/no — method]
  • [Sutures: material, size, resorbable/non-resorbable, number] (Include only if placed.)
  • [Complications: none / describe]

• Informed consent: [Obtained verbally / written / both; or not obtained — reason]
• Patient condition at completion: [Stable / describe]
• Post-operative instructions: [Verbal / written / both provided]
• Medications: [Drug, dose, frequency, quantity, directions] (Include only if prescribed or recommended.)
• Follow-up: [Timeline for review or suture removal; urgent return criteria discussed]

Treatment Plan

• [Recommended treatments not performed today with tooth numbers, prioritized by urgency]
• [Deferred items with reason: time / medical clearance needed / patient preference / financial]
• [Declined treatments: document risks/benefits/alternatives discussed and patient understanding]

(Omit this section if no additional treatments recommended.)

Patient Education and Follow-up

• [Home care guidance: brushing technique, interdental cleaning, fluoride use] (Personalize to findings.)
• [Periodontal-specific guidance] (Include if inflammation present.)
• [Caries risk counseling: diet, fluoride, adjuncts] (Include if elevated caries risk.)
• [Tobacco cessation counseling] (Include if applicable.)
• [Recall interval: 3 mo / 4 mo / 6 mo / 12 mo / other] — [Scheduled / To be scheduled]

(Omit entire sections that do not apply. Do not leave sections empty. Use "Not assessed" or "Not performed" with brief reason only for high-stakes items such as radiographs or consent. Never infer instructions were given or procedures performed unless explicitly documented.)