> ## 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 Treatments > How to set up clinical procedure templates for dental treatments and document procedures performed in the chair - fillings, root canal treatment, crowns, bridges, dentures, scaling, and more. Every dental procedure performed in the chair is documented as a Clinical Procedure record. Whether it is a simple filling or a complex crown placement, the procedure record captures what was done, on which tooth, with which materials, and links to the billing item for invoicing. *** ## Before You Start * **Clinical Procedure Templates** must be set up for each procedure type before they can be ordered from a Patient Encounter. * Procedure templates include the billing item and duration so that the system can invoice correctly. * You need the **Healthcare Practitioner** role to create and submit procedure records. *** ## Setting Up Clinical Procedure Templates Create a procedure template for each type of dental treatment your clinic offers. 1. Go to Healthcare workspace → Consultation Setup card → **Clinical Procedure Template** → New Clinical Procedure Template form showing procedure name, medical department, billing item, duration, consumable items section, and rate | Field | What to Enter | | --------------------------------- | --------------------------------------------------------------------------------------------------------- | | Procedure Template Name | Clear, specific name (e.g., "Composite Filling - 1 Surface", "Root Canal Treatment - Molar") | | Medical Department | General Dentistry / Oral Surgery / Orthodontics / Periodontics / Endodontics / Paediatric Dentistry | | Healthcare Practitioner (default) | Leave blank if any practitioner can perform it, or link to a specialist | | Rate | Fee for this procedure (used as default billing amount) | | Item | Billing item for the procedure | | Duration | Expected procedure duration in minutes | | Description | Brief description for patient-facing documentation | | Consumable Items | Dental materials used during this procedure (e.g., composite resin, GIC, bonding agent, endodontic files) | **Recommended Dental Procedure Templates:** | Category | Procedure Templates to Create | | ------------ | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Preventive | Scaling and Polishing, Fluoride Varnish Application, Fissure Sealant (per tooth) | | Restorative | Composite Filling (1 surface), Composite Filling (2 surfaces), Composite Filling (3+ surfaces), GIC Filling, Amalgam Filling, Cusp Replacement, Core Build-Up | | Endodontics | Root Canal Treatment (Anterior - 1 root), Root Canal Treatment (Premolar - 1-2 roots), Root Canal Treatment (Molar - 3-4 roots), Re-Root Canal Treatment, Pulpotomy (Milk Tooth) | | Prosthetics | Crown Preparation (Metal-Ceramic), Crown Preparation (Full Porcelain/Zirconia), Crown Fit and Cementation, Bridge Preparation, Bridge Fit and Cementation, Denture Impression, Denture Fit, Denture Adjustment, Denture Reline, Post and Core | | Periodontics | Scaling and Root Planing (per quadrant), Gum Treatment (full mouth), Curettage (per quadrant), Gingivectomy | | Oral Surgery | Tooth Extraction (Simple), Surgical Extraction, Wisdom Tooth Removal (per tooth), Dental Implant Placement, Implant Crown (fit), Bone Graft, Sinus Lift, Suture Removal | | Orthodontics | Fixed Brace Bond-Up, Orthodontic Adjustment, Wire Change, Bracket Rebond, Retainer Fit (upper), Retainer Fit (lower), Aligners - Issue Set | | Cosmetic | Teeth Whitening (in-office), Teeth Whitening (take-home kit), Composite Veneer, Porcelain Veneer Preparation, Porcelain Veneer Fit | | Paediatric | Pulpotomy (primary molar), Stainless Steel Crown (milk tooth), Space Maintainer Fit | *** ## Documenting a Dental Procedure ### Method 1: From the Patient Encounter While in the Patient Encounter, go to the **Orders** section and add a Clinical Procedure order. This creates the procedure record linked to the encounter. ### Method 2: From the Clinical Procedure List 1. Go to Healthcare workspace → Consultation card → **Clinical Procedure** → New 2. Link to the patient and the encounter manually *** ## Completing a Clinical Procedure Record After the procedure is performed: 1. Open the Clinical Procedure record (linked from the encounter or from the procedure list) 2. Set the **Status** to "In Progress" as you begin, then "Completed" when done 3. Complete the procedure details: | Field | What to Enter | | ----------------------- | ---------------------------------------------------------------------------------------------------------------------------------------- | | Patient | Linked patient | | Procedure Template | The type of procedure performed | | Healthcare Practitioner | The treating dentist | | Start Date / Time | When the procedure began | | Completion Date / Time | When the procedure was completed | | Notes | Procedure notes: tooth number, surfaces, materials used, anaesthetic type and dose, any complications, post-procedure instructions given | | Consumable Items | Confirm the materials used (auto-populated from template, adjust if different) | | Status | Initiated → In Progress → Completed | 4. Add tooth-specific details in the Notes field: * Tooth number (FDI notation preferred: e.g., tooth 16, 46) * Surface (e.g., MO, DO, MOD, buccal, composite to incisal edge) * Material used (e.g., nanofill composite shade A2, GIC Type II) * Anaesthetic given (e.g., Lignocaine 2% with 1:80,000 adrenaline, 1 cartridge, inferior alveolar block) * Post-procedure instructions (e.g., avoid hot drinks for 1 hour, no biting on hard food for 24 hours) 5. Submit the Clinical Procedure record. After submission: * The procedure appears in the patient's history timeline * The procedure's billing item becomes available for invoicing * The "Appointments to Bill" count reflects the unbilled procedure Completed Clinical Procedure record for a composite filling showing tooth 36, surfaces MOD, material used, anaesthetic given, and status as Completed *** ## Common Procedure Documentation Details ### Scaling and Polishing Notes to record: * BPE scores before and after (if reassessment performed) * Calculus location (supragingival, subgingival, generalised/localised) * Areas of special attention * Oral hygiene instruction given (brushing technique, interdental cleaning, mouthwash recommendation) * Planned recall interval (3 months, 6 months, 12 months) ### Composite Filling Notes to record: * Tooth number and surface(s) * Caries removed (extent: enamel only, into dentine, approaching pulp) * Cavity liner placed (e.g., Dycal, GIC base) * Composite shade selected * Bonding system used * Bite check and adjustment * Post-operative sensitivity warnings given ### Root Canal Treatment Notes to record: * Tooth number and root(s) * Pre-treatment radiograph (IOPA taken and attached) * Access cavity preparation: bur type, rubber dam used (yes/no) * Working length determination: apex locator and/or radiograph, working length in mm for each root * Canal preparation: hand files or rotary, final apical size * Irrigation protocol (NaOCl concentration, EDTA, final flush) * Obturation: technique (lateral condensation, warm vertical), material (gutta-percha + sealer) * Post-obturation radiograph (IOPA taken and attached) * Temporary or permanent seal placed * Treatment session: visit 1 of X, or single visit ### Crown Preparation Notes to record: * Tooth number and type of crown (metal-ceramic, full zirconia, EMAX, gold) * Occlusal and axial reduction achieved * Margin type (shoulder, chamfer, feather edge) and location (supra/sub-gingival) * Impression material and technique (alginate, silicone, digital scan) * Shade recorded (using shade guide system) * Temporary crown placed (material, cemented with temporary cement) * Shade and shape requirements communicated to laboratory * Expected laboratory return date ### Denture Impression Notes to record: * Dentition type (complete upper, complete lower, partial upper, partial lower) * Special tray or stock tray * Impression material * Shade and mould selected for teeth * Post-dam and special tray modifications for complete dentures * Patient's existing denture sent to lab for reference (if applicable) *** ## Dental Procedure Consumable Tracking The consumables section of the procedure template and procedure record allows you to track materials used: | Item | Tracked For | | ----------------------------- | ----------------------------------- | | Composite resin cartridges | Per filling (allows cost tracking) | | Endodontic files | Per RCT (for single-use compliance) | | Rubber dam (per piece) | Per isolated tooth | | Crown or bridge unit from lab | Per prosthetic case | | Impression material sachets | Per impression | Consumable tracking feeds into stock reports and helps with supply ordering. *** ## Field Guide: Clinical Procedure | Field | Description | | ----------------------- | -------------------------------------------------------------------- | | Patient | Linked patient record | | Procedure Template | Type of procedure | | Healthcare Practitioner | Performing dentist | | Patient Encounter | Linked encounter for this visit | | Appointment | Linked appointment | | Start Date / Time | When procedure began | | Completion Date / Time | When procedure was finished | | Notes | Full procedure notes including tooth, surface, material, anaesthetic | | Consumable Items | Materials used during procedure | | Status | Initiated / In Progress / Completed / Cancelled | | Invoiced | Ticked when a Sales Invoice has been created | *** ## Best Practices * Record the tooth number in FDI notation (international standard: 11-18, 21-28, 31-38, 41-48) rather than referring to "upper right back tooth" - clear tooth number notation is essential for records, lab orders, and medico-legal purposes * Always document what anaesthetic was given (type, dose, technique) - this is required in dental records and has medico-legal implications * For multi-visit treatments (root canal spread over 2 appointments), create a procedure record for each visit and link them both to the same patient - do not wait until the final appointment to document the first visit's work * Submit procedure records on the day of treatment - do not leave them in draft status, as this blocks billing and makes the patient history inaccurate * For crown and bridge procedures, note the lab return date in the procedure notes so the front desk knows when to book the fit appointment *** ## Troubleshooting **The billing item is not auto-filling on the procedure** Check that the Clinical Procedure Template has a billing item linked. Open the template and add the item, then re-link the template to the procedure record. **The procedure is not appearing in the patient's history timeline** Check that the procedure record has been submitted, not just saved. Only submitted records appear in the history timeline. **The consumable item is coming out of the wrong stock location** Check the default warehouse set on the Clinical Procedure Template. The consumable items are issued from this warehouse when the procedure is submitted. *** ## Related Features * [Dental Examination](/health-wellness/dental-clinic/dental-examination): Procedures are ordered from the Patient Encounter * [Dental Radiography](/health-wellness/dental-clinic/dental-radiography): X-rays are a type of Clinical Procedure * [Oral Surgery](/health-wellness/dental-clinic/oral-surgery): Surgical procedures follow the same workflow * [Laboratory](/health-wellness/dental-clinic/laboratory): Crown, bridge, and denture procedures involve lab orders * [Billing and Finance](/health-wellness/dental-clinic/billing-finance): Submitted procedures trigger billing