> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Dental Examination
> How to use the Patient Encounter to document a complete dental examination - medical history review, dental charting, periodontal assessment, soft tissue findings, diagnosis, and treatment planning.
The Patient Encounter is the central clinical record for every dental visit. Whether the patient is attending for a full new patient examination, a routine recall, or a follow-up after treatment, the dentist documents findings, diagnosis, prescriptions, X-ray orders, and procedure orders from this single record. Everything recorded in the encounter flows into the patient's permanent history timeline.
***
## Before You Start
* The patient must be registered and have an appointment booked.
* The patient must be checked in (appointment status: Checked In or Open).
* You need the **Healthcare Practitioner** role to create and submit patient encounters.
***
## Opening or Creating a Patient Encounter
### From the Appointment
The fastest method: open the Patient Appointment record and click **Create Patient Encounter**. The encounter is pre-linked to the patient, the appointment, and the treating practitioner.
### From the Encounter List
1. Go to Healthcare workspace → Consultation card → **Patient Encounter** → New
2. Link the patient manually
***
## Step 1: Review Medical History and Chief Complaint
Before beginning the examination, review and update the patient's medical history. The most recently recorded medical history is visible on the patient record.
In the Patient Encounter, record:
| Field | What to Enter |
| ------------------------ | ------------------------------------------------------------------------------------------------------------------------ |
| Symptoms | Patient's chief complaint (Toothache, Sensitivity, Bleeding Gums, Swelling, Broken Tooth, Loose Tooth, Cosmetic Concern) |
| Patient History (HPI) | Onset, duration, severity, character of the complaint in the patient's words |
| Medical History (Review) | Confirm current medications, allergies, medical conditions since last visit |
For the chief complaint, use the **Complaint** library to select from pre-defined common dental complaints. This ensures consistent recording and feeds the Symptoms dashboard chart.
***
## Step 2: Extra-Oral Examination
Record extra-oral findings in the Encounter notes:
* Lymph nodes: submandibular, cervical (normal / enlarged / tender)
* Temporomandibular joint: clicking, crepitus, limited opening, deviation on opening
* Facial symmetry: swelling, asymmetry, sinus tenderness
* Lips, skin, facial muscles
These findings are recorded as free text in the examination notes section of the encounter.
***
## Step 3: Intra-Oral Examination
### Soft Tissue Assessment
Document the condition of:
* Oral mucosa: ulcers, white patches, red patches, pigmentation, swellings
* Tongue: coating, ulceration, movement
* Palate: hard and soft palate appearance
* Floor of mouth: sublingual area
* Oropharynx: tonsils, posterior wall
Any abnormal soft tissue finding should be described with its size, colour, character, and whether it is tender, fixed, or mobile. Suspicious lesions should be flagged for review or referral.
### Dental Chart
The dental chart is the tooth-by-tooth record of every tooth's clinical status. For each tooth, record:
| Status | What It Means |
| ------ | ------------------------------------------------------------------------- |
| UE | Unerupted |
| / or X | Missing (not present) |
| C | Caries (decay) - note surface (buccal, lingual, mesial, distal, occlusal) |
| F | Filled - note material (composite, amalgam, GIC, gold) |
| RCT | Root canal treated |
| Cr | Crown |
| Br | Bridge (abutment or pontic) |
| Im | Implant |
| D | Denture tooth |
| M | Mobile - grade (1, 2, or 3) |
| Ex | For extraction |
| WL | On waiting list for treatment |
Record surface-specific caries and existing restorations using the standard notation (M=mesial, D=distal, O=occlusal, B=buccal, L=lingual/palatal, I=incisal).
Use the Clinical Procedure record to document each treatment item rather than trying to fit all findings into a single text field.
### Periodontal Assessment
Basic Periodontal Examination (BPE) score for quick screening:
| BPE Code | Finding |
| -------- | -------------------------------------------- |
| 0 | Healthy - no bleeding, no pockets |
| 1 | Bleeding on probing - no pockets or calculus |
| 2 | Calculus or plaque retentive factor present |
| 3 | Pocket 3.5-5.5mm |
| 4 | Pocket 6mm or deeper |
| \* | Furcation involvement |
Record the BPE score for each sextant (upper right, upper anterior, upper left, lower right, lower anterior, lower left).
For patients with a BPE score of 3 or 4, a full periodontal chart is recommended. Record in Observations (via Service Request / Observation Template "Periodontal Probing Chart") for each tooth:
* Probing pocket depths (mesial, buccal, distal, lingual at each tooth) in mm
* Bleeding on probing (BoP) for each site
* Recession in mm
* Furcation involvement (Class I, II, III)
* Mobility (Grade 0, 1, 2, 3)
***
## Step 4: Recording Diagnosis
After the examination, record your diagnosis findings:
1. In the Patient Encounter, go to the **Diagnosis** section
2. Click Add Row
3. Select the diagnosis from the Diagnosis library (e.g., Dental Caries, Chronic Periodontitis, Irreversible Pulpitis, Periapical Abscess, Dentoalveolar Abscess, Impacted Third Molar, Fractured Tooth)
4. Note the code (ICD-10) if required
5. Specify whether the diagnosis is the primary presenting complaint or secondary finding
Diagnoses recorded here feed the **Diagnoses** dashboard chart, which shows your clinic's most common clinical findings over time.
***
## Step 5: Ordering X-Rays
When X-rays are clinically indicated, raise a Service Request from the encounter:
1. In the Patient Encounter, go to the **Orders** or **Investigations** section
2. Click **Add** under Service Requests
3. Select the X-ray type from the Clinical Procedure Templates:
* OPG (Orthopantomogram / Panoramic X-ray)
* IOPA (Intraoral Periapical X-ray) - specify tooth/region
* Bitewing X-rays (right, left, or bilateral)
4. The X-ray is performed and documented as a Clinical Procedure, with findings recorded in Observations
See [Dental Radiography](/health-wellness/dental-clinic/dental-radiography) for the full X-ray documentation workflow.
***
## Step 6: Recording Prescriptions
If the patient needs a prescription (post-extraction antibiotics, pain relief, treatment for an acute infection):
1. In the Patient Encounter, go to the **Drug Prescription** section
2. Click Add Row for each medication
| Field | What to Enter |
| ------------ | -------------------------------------------------------------------------------------------------- |
| Drug | Medication name (e.g., Amoxicillin 500mg, Metronidazole 400mg, Ibuprofen 400mg, Paracetamol 500mg) |
| Dosage Form | Tablet / Capsule / Gel / Mouthwash |
| Strength | Dose per tablet / capsule |
| Dosage | Frequency (e.g., "Three times daily") |
| Duration | Course length (e.g., "For 5 days", "For 7 days") |
| Instructions | Additional instructions (e.g., "Take with food", "Complete the course") |
Common dental prescriptions:
| Condition | Typical Prescription |
| ------------------------------------------ | ------------------------------------------------------ |
| Dental infection (no penicillin allergy) | Amoxicillin 500mg three times daily for 5 days |
| Dental infection (add if not resolving) | Metronidazole 400mg three times daily for 5 days |
| Penicillin allergy | Clindamycin 300mg four times daily for 5 days |
| Post-extraction pain | Ibuprofen 400mg three times daily with food for 3 days |
| Pain relief (cannot take NSAIDs) | Paracetamol 1g four times daily for 3 days |
| Pericoronitis / gum inflammation mouthwash | Chlorhexidine 0.2% mouthwash twice daily for 7 days |
***
## Step 7: Treatment Planning
After recording findings and diagnosis, discuss the recommended treatment plan with the patient.
In the Patient Encounter, record your treatment recommendations in the **Treatment Plan** section or in the encounter notes. Use the **Treatment Plan Template** feature if your clinic has pre-defined templates for common presentations (e.g., periodontal treatment plan, caries management plan).
A clear treatment plan should include:
* What treatment is needed (procedure, tooth number)
* Recommended sequence (urgent first, then elective)
* Estimated number of appointments and cost
* Patient's consent to proceed
***
## Step 8: Submitting the Encounter
When all findings, diagnoses, prescriptions, and orders have been recorded:
1. Click **Submit** in the Patient Encounter
2. Confirm the submission
After submission:
* The encounter status changes to Submitted
* A Patient Medical Record is auto-created and appears in the patient's history timeline
* The appointment status changes to Closed
* The appointment appears in the "Appointments to Bill" count if not already invoiced
**Do not submit an encounter until all information for the visit is recorded.** Submitted encounters can only be amended, not edited freely.
***
## Field Guide: Patient Encounter
| Field | Description |
| --------------------------------- | ------------------------------------------------------ |
| Patient | The patient being seen |
| Patient Age | Calculated from date of birth |
| Healthcare Practitioner | The treating dentist |
| Visit Department | General Dentistry / Oral Surgery / Orthodontics / etc. |
| Appointment | Linked Patient Appointment record |
| Date | Date of the visit |
| Symptoms | Chief complaint (links to Symptom library) |
| HPI | History of presenting illness (free text) |
| Examination | Clinical findings (free text) |
| Diagnosis | One or more diagnoses (links to Diagnosis library) |
| Drug Prescription | Medications prescribed at this visit |
| Drug Prescription Note | Note to patient (e.g., "take with food") |
| Investigations (Service Requests) | X-ray orders raised from this encounter |
| Clinical Notes | Free text for any additional notes |
| Status | Draft → Submitted |
***
## Best Practices
* Open the patient's previous encounters before beginning the examination to review what was found and what was planned at the last visit
* Record each tooth's status individually rather than using vague phrases like "multiple caries" - specific charting is essential for treatment planning and medico-legal purposes
* Always record the BPE at every examination visit - patients with undetected periodontitis are one of the most common clinical and legal risks in dentistry
* Soft tissue examination must be documented at every visit, not just the first - oral cancer screening is a professional obligation
* If you recommend treatment that the patient declines, document the recommendation and the patient's decision clearly in the encounter - this protects the clinic in the event of a future complaint
***
## Related Features
* [Dental Radiography](/health-wellness/dental-clinic/dental-radiography): X-ray ordering and findings documentation
* [Dental Treatments](/health-wellness/dental-clinic/dental-treatments): Clinical procedures ordered from the encounter
* [Oral Surgery](/health-wellness/dental-clinic/oral-surgery): Surgical procedures ordered from the encounter
* [Patient Management](/health-wellness/dental-clinic/patient-management): Medical history and allergy alerts reviewed in the encounter
* [Billing and Finance](/health-wellness/dental-clinic/billing-finance): Encounter submission triggers the billing workflow