Headings
Parent or guardian present · Medical history · Diet and habits · Extraoral and intraoral exam · Caries risk · Cleaning and fluoride · Guidance given · Recall interval
When to use it
Use this for exams on children, from first visits through mixed dentition. It records who came with the child, diet and habits, and a caries risk level, which drive the guidance and the recall. Unlike an adult periodic exam, the advice section is written for the parent.
Example
Fictional example
Parent or guardian present
Mother present. Child age 4.
Medical history
Mild asthma, inhaler as needed. No allergies.
Diet and habits
Juice in a cup at bedtime. Thumb sucking at night.
Extraoral and intraoral exam
Primary dentition. Cavitated occlusal lesions #K and #L. Mild anterior open bite.
Caries risk
High.
Cleaning and fluoride
Toothbrush prophy, knee to knee. 5% sodium fluoride varnish.
Guidance given
Water only after brushing at night. Parent brushes twice daily with a pea-sized amount of fluoride toothpaste. Discussed ways to reduce the thumb habit.
Recall interval
Fillings #K and #L next visit. Recall every 3 months.