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Dental Progress Note Template
A dental progress note records a treatment visit: the medical history update, consent, anesthetic, what was done to each tooth and surface, and the post-operative instructions. Copy the free template, see a composite restoration and an extraction example, and check what goes in each section.
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- Word and text downloads
- Two filled examples
Blank dental progress note template
FreeDENTAL PROGRESS NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Dentist: [Name, credentials] Assistant: [Name] Tooth numbering: [Universal, or FDI if your practice uses it] CHIEF CONCERN Reason for visit: [Planned treatment, or the patient's concern in their words] Symptoms: [Pain, sensitivity to cold, heat, or biting, swelling, and for how long] MEDICAL HISTORY UPDATE Changes: [New conditions, hospital stays, or pregnancy since the last visit, or no changes] Medications: [Current list, including blood thinners and bone-modifying drugs] Allergies: [Drug, latex, and other allergies, with reactions] Premedication: [Antibiotic prophylaxis if indicated, with drug, dose, and time taken; or not indicated] Vital signs: [BP and pulse, if taken] CONSENT Discussed: [Diagnosis, proposed treatment, risks, benefits, and alternatives, including no treatment] Consent: [Verbal or written; questions answered] ANESTHESIA Topical: [Agent and site, or none] Local anesthetic: [Agent, concentration, and vasoconstrictor] Amount: [Number of cartridges and total volume in mL] Technique and site: [Block or infiltration, nerve or tooth, and side] Aspiration and effect: [Aspiration result, depth of anesthesia, any reaction] PROCEDURE Tooth and surfaces: [Tooth number and surfaces, such as #30 MO] Diagnosis: [Caries, fracture, non-restorable tooth, or other] Isolation: [Rubber dam, cotton rolls, or isolation system] Details: [Steps, preparation depth, pulp exposure or not, complications] Materials: [Liner, adhesive, restorative material and shade, sutures, hemostatic agents] Occlusion and contacts: [Checked and adjusted; floss through contacts] Radiographs: [Type, teeth, and findings, or none taken] Tolerance: [How the patient tolerated the procedure] POST-OPERATIVE INSTRUCTIONS Instructions: [Verbal and written; what was covered] Pain relief: [Medication, dose, and frequency, or none needed] When to call: [Bleeding, swelling, fever, lingering pain, or a high bite] NEXT VISIT Next appointment: [Treatment, teeth, and time frame] Remaining treatment: [Outstanding items in the treatment plan] Signed: [Dentist name, credentials, date and time]
Use it for
- Restorative visits
- Tooth extractions
- Emergency visits
- Endodontic visits
- Post-op checks
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Dental progress note: composite restoration
General dental practice, restorative visit
Chief concern
34-year-old woman here for a planned filling on the lower right. Brief sensitivity to cold on that side for 2 months, gone within seconds. No pain on biting, no pain at night, no swelling.
Medical history update
No changes since her exam 3 weeks ago. Hypothyroidism, on levothyroxine 75 mcg daily. Allergic to penicillin (hives); no latex allergy. Not pregnant. Premedication not indicated. BP 118/76, pulse 70.
Consent
Explained caries into dentin on the mesial of #30, seen on bitewing radiographs, and the proposed composite filling. Risks: sensitivity afterward, inflammation of the pulp that could need root canal treatment if the decay is deep, and wear or fracture of the filling. Alternatives: amalgam, an indirect restoration, or no treatment, with the risk that the decay grows. Questions answered; verbal and written consent.
Anesthesia
Topical benzocaine 20% at the injection sites. Right inferior alveolar nerve block and long buccal infiltration: 2% lidocaine with 1:100,000 epinephrine, 1 cartridge, 1.8 mL total. Aspiration negative. Profound anesthesia; no reaction.
Procedure
Tooth #30 (FDI 46), MO. Diagnosis: caries into dentin, mesial. Rubber dam isolation. Caries removed to firm dentin; moderate depth, no pulp exposure. Sectional matrix and wedge. Selective enamel etch, universal adhesive, light cured. Composite placed in increments of 2 mm or less, each light cured; shade A2. No liner. Occlusion checked with articulating paper and adjusted; floss passes the mesial contact with a firm snap. No radiographs today. Tolerated well.
Post-operative instructions
Verbal and written. Numb for 2 to 3 hours: no chewing or hot drinks until it wears off, to avoid biting the cheek or tongue. Mild cold sensitivity for a few days to a few weeks is common. Ibuprofen 400 mg every 6 hours as needed, with food, for soreness at the injection site. Call if the bite feels high, or for pain that lingers or wakes her at night.
Next visit
#19 (FDI 36) DO composite in 2 weeks. Hygiene recall in 5 months.
Dental progress note: extraction of a non-restorable molar
General dental practice, surgical visit
Chief concern
61-year-old man here for planned extraction of the upper left first molar. Lingering pain to cold and throbbing at night for a week; seen 2 days ago and diagnosed with a non-restorable tooth. Taking ibuprofen 400 mg every 6 hours, with partial relief. No facial swelling or fever.
Medical history update
Hypertension, on amlodipine 5 mg daily, taken this morning. No blood thinners, bisphosphonates, or other bone-modifying drugs. No head and neck radiation. No known drug allergies; no latex allergy. Premedication not indicated. BP 132/82, pulse 76.
Consent
Explained that #14 is not restorable: caries extends below the bone level on the distal. Proposed extraction. Risks: pain, swelling, bleeding, infection, dry socket, damage to nearby teeth or fillings, a root tip needing surgical removal, and an opening into the sinus. Alternatives: root canal treatment with crown lengthening and a crown, with a poor outlook, or no treatment, with the risk of infection. Replacement options discussed: implant, bridge, partial denture, or leaving the space. Questions answered; written consent signed.
Anesthesia
Topical benzocaine 20%. Buccal and palatal infiltration at #14: 2% lidocaine with 1:100,000 epinephrine, 1.5 cartridges, 2.7 mL total. Aspiration negative. Profound anesthesia; no reaction.
Procedure
Tooth #14 (FDI 26), extraction. Periapical radiograph from 2 days ago reviewed: caries below the bone level on the distal; three separate roots, no unusual curvature. Gingival attachment released with a periosteal elevator; tooth luxated with a straight elevator and delivered intact with upper molar forceps. All 3 roots complete on inspection. Socket curetted and irrigated with sterile saline. No sign of an opening into the sinus. Hemostasis with gauze pressure; no sutures needed. Tolerated well.
Post-operative instructions
Verbal and written. Bite on gauze for 30 to 45 minutes. For 24 hours: no rinsing, spitting, or drinking through a straw; soft foods, chewing on the other side. From tomorrow, gentle warm salt-water rinses after meals. Ibuprofen 400 mg every 6 hours as needed, with food, adding acetaminophen 500 mg every 6 hours if needed. Call for bleeding that doesn’t stop after 30 minutes of firm pressure, swelling or pain that gets worse after day 3, fever, or air or fluid passing between the mouth and nose. Go to an emergency department for swelling that affects breathing or swallowing.
Next visit
Post-op check in 1 week, sooner if needed. Consultation on replacing #14 once healed, in about 8 to 12 weeks.
What goes in each part.
Medical history update
Confirm the medical history at every treatment visit, not only at recall, and record what changed.
- New diagnoses, hospital stays, or pregnancy
- Blood thinners, and bone-modifying drugs such as bisphosphonates
- Allergies, including latex and local anesthetics
- Whether antibiotic prophylaxis is indicated, and if taken, the drug, dose, and time
- Blood pressure and pulse, when your protocol calls for them
Avoid: “Medical history reviewed” with no detail. Write “no changes,” or list what changed.
Consent
The conversation, not just the signature: what you proposed, the risks and alternatives, and the patient’s agreement.
- The diagnosis and the proposed treatment
- The material risks of this procedure
- Alternatives, including no treatment
- Questions answered, and verbal or written consent
Avoid: Relying on a signed form alone. Note what was discussed for this procedure.
Anesthesia
Everything a colleague would need if the patient had a reaction or needed more anesthetic.
- Topical agent
- Agent, concentration, and vasoconstrictor
- Number of cartridges and total volume
- Injection technique, nerve or tooth, and side
- Aspiration, effect, and any reaction
Avoid: Writing “local given.” The agent and the amount matter for maximum doses and for any reaction.
Procedure
What was done, tooth by tooth, with surfaces and materials, so the chart matches the mouth.
- Tooth number and surfaces, such as #30 MO
- Isolation and the steps performed
- Depth, pulp exposure, and any complications
- Materials, with shades
- Occlusion and contacts checked
Avoid: Charting surfaces that weren’t restored, or leaving out ones that were. The note and the tooth chart must match.
Post-operative instructions
What you told the patient to do and watch for, and the medication advised.
- Verbal and written instructions given
- Pain relief, with dose and frequency
- Warning signs, and who to call
- Restrictions, such as not eating while numb
Avoid: “Post-op instructions given” without saying which. If something goes wrong, the note shows what the patient was told.
Next visit
What comes next in the treatment plan, so the next appointment starts in the right place.
- Next procedure, teeth, and time frame
- Remaining treatment
- Recall interval
Avoid: Leaving outstanding treatment off the note. The whole team should see what is still to do.
Common mistakes, and how to avoid them.
Wrong tooth, or the wrong numbering system
Mixing Universal and FDI numbers can put a procedure on the wrong tooth. Name the system, and check the tooth against the radiograph and the chart before you start, especially for extractions.
Cloned restorative notes
Pasting the same paragraph for every filling hides what differed: depth, how close to the pulp, liner, and any complication. Edit each note to match the tooth.
No record of informed refusal
When a patient declines recommended treatment or radiographs, write what you recommended, the risks you explained, and their decision.
Complications left out
A pulp exposure, a root tip left in place, or an opening into the sinus belongs in the note, with what you told the patient and the plan.
Medication advice with no dose
“Over-the-counter pain relief as needed” isn’t a plan. Write the drug, dose, and frequency, and note any reason the patient shouldn’t take it.
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Frequently asked questions.
What should a dental progress note include?
The reason for the visit, a medical history update, consent, the anesthetic used, the procedure by tooth and surface with materials, the post-operative instructions, and the next visit.
Which tooth numbering system should I use?
This template uses the Universal system: 1 to 32 for permanent teeth, starting at the upper right third molar, and A to T for primary teeth. The two-digit FDI system is also common. Use the system your practice uses, and name it in the note.
How do you document local anesthetic in a dental note?
Record the agent, concentration, and vasoconstrictor; the number of cartridges and the total volume; the technique and site; the aspiration result; and any reaction.
Can I write dental notes in SOAP format?
Yes, and SOAP suits emergency and limited exams. For planned treatment, many dentists prefer a procedure-focused progress note like this one.
Is this dental progress note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More dentistry templates, and guides.
Dental note examples
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Seven worked notes in different formats, with review checks.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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