Clinical records are a vital part of delivering safe, effective, and evidence-based dental care.

In this article, we’ve highlighted the key guidelines that we think should be considered when writing dental notes.

Kiroku's Guide to Dental Guidelines

While this isn’t an exhaustive list, it includes some of the most impactful standards relevant to consultation appointments and everyday practice.

These are the main guidelines that our clinical team uses when creating dental note templates for our Template Library.

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1. Clinical Examination and Record-Keeping (2016)

For UK-based dentists, this Faculty of General Dental Practice guide should be your go-to reference. The guidance details exactly what should be recorded in dental consultations and clinical notes, whether paper or digital.

It's what CQC inspections rely on so definitely one that we consider when creating our templates and one you should too!

Information is grouped into:

• Basic – Must be recorded unless there’s a clear reason not to (e.g. medical history, updated personal details).
• Conditional – Required in specific contexts (e.g. email address).
• Aspirational – Ideal to include when relevant (e.g. alcohol history).

The document outlines record-keeping expectations across full examinations, recalls, and emergency appointments. The summary tables provided are particularly useful for busy practitioners.

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This is all factored into the templates available in Kiroku's Template Library, so it's nice to hear customers such as Jaswinder Janu mention that CQC inspectors have been impressed with the quality of this notes!

If you use Kiroku's Audit function, Exam templates will also be reviewed for this information.

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2. Safe Use of X-ray Equipment (2020)

This update from The Faculty of General Dental Practice and Public Health England focused on radiation safety for both patients and staff.

One important change was the new radiographic quality grading system:

• Previously, this was done by grades of diagnostic quality:
  
  • 1 - 70% (Excellent)
  • 2 - 20% (Acceptable)
  • 3 - 10% (Unacceptable)
• Now, this is a simpler acceptable (A) vs not acceptable (N) metric:
  • Digital imaging: A – 95%, N  – 5%
  • Film imaging: A – 90%, N – 10%

This affects how dentists audit and document their radiographic quality, key for both compliance and clinical safety.

Anyone can download the second edition (2020) of "Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment" from the College of General Dentistry's website.

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3. Periodontal Classification Guidelines (2018)

These updated guidelines were a collaboration between the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP).

They replaced a 20-year-old system with one based on staging and grading, borrowed from oncology, with the aim to improve diagnostic accuracy and individualised care.

When documenting periodontal diagnoses, include:

• Extent: Localised, Generalised, or Molar-Incisor pattern
• Stage: Degree of tissue loss
• Grade: Rate of progression
• Status: Stability
• Risk factors: Smoking, diabetes, etc.

At Kiroku, we’ve built this into our consultation templates when a BPE score of 3 or 4 is recorded. Remember, once a patient is staged and graded, their periodontal status should be recorded continuously, even if they are currently stable.

4. Secondary Prevention of Periodontitis via PmPr (2015)

This guidance from the British Society of Periodontology included an important change of terminology. What was previously known as a “scale and polish” is now Professional Mechanical Plaque Removal (PmPr).

Similarly, Root Surface Debridement (RSD) became “PmPr on root”.

Before performing PmPr on root, the patient should demonstrate:

• Engagement with their treatment
• Evidence of improvement in periodontal health metrics

The guidance also includes recommendations for follow-up care, depending on whether stability has been achieved.

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5. Delivering Better Oral Health: Prevention Toolkit (2017)

This evidence-based guide from Public Health England outlines preventive advice and treatments by age group, from infants to adults. It’s an essential reference for:

• Toothpaste fluoride levels
• Fluoride varnish frequency
• General oral hygiene instructions

Even if you're familiar with it, it's a useful document to revisit regularly to ensure consistent, high-quality preventive care.

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6. Prevention and Management of Dental Caries in Children (2018)

While much of this guidance may feel familiar, it’s vital to revisit regularly. The SDCEP offers clear, easy-to-follow flowcharts for:

• Managing dental pain
• Treating primary and permanent dentition
• Preventive care in children

These resources serve as helpful reminders of best practices and may inspire you to reintroduce treatments you don’t use often. Their mobile apps are also a handy tool for quick reference in clinical settings.

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7. Making an Orthodontic Referral (2014)

Timely and appropriate orthodontic referrals can significantly improve long-term outcomes for patients.

This guidance, from Kiroku's partner organisation the British Orthodontic Society (BOS), outlines:

• Criteria for early referrals in deciduous and mixed dentition
• Referral timing in permanent dentition using IOTN (Index of Orthodontic Treatment Need)
• The patient’s right to seek a second opinion

Ensure your referral decisions are clearly documented, including the rationale and discussions had with the patient or guardian.

You can also access an IOTN template from the Kiroku Template Library.

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8. Endodontic Case Difficulty Assessment and Referral (2005)

While some general practitioners are confident with complex endodontic cases, others may prefer to refer.

The American Association of Endodontists provides a clear system for case difficulty:

• Minimal
• Moderate
• High – Often warrants referral even for experienced clinicians

Factors increasing complexity include root curvature, tooth rotation, and posterior positioning. If referring, document the reason clearly in the patient’s records to support clinical decision-making and continuity of care.

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9. Intervals Between Oral Health Reviews (2004)

NICE provides guidance on appropriate recall intervals based on patient risk:

• Minimum: Every 3 months
• Maximum:
  • Children (<18) – 12 months
  • Adults – 24 months

Interval decisions should be personalised based on disease risk assessment.

These discussions, and the agreed review date, should always be recorded in the patient’s notes and communicated clearly. That's why we include it at the bottom of all Kiroku's ready-to-use templates.

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Ready-made Dental Note Templates

Kiroku's library of over 50 to ready-to-use templates not only includes those created by our team, but other amazing partners and individuals who are experts in their field.

Anyone with a Kiroku account can use these templates and edit them to suit their note-taking workflow. Alongside our Audit function, Kiroku's templates are designed with care to be robust and clinically safe. When guidelines change, so do our templates.

Get started now with any of our templates, or upload your own, when you create a Kiroku account today.

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