What is a Befund?
A Befund is the result of a clinical examination. The dentist systematically examines the oral cavity and records everything observed. The assistant's job is to accurately document this data as dictated.
A Befund is taken at every first visit and regularly updated. Without a current Befund, no treatment plan can be created.
Zahnbefund — status of each individual tooth, recorded in the tooth chart.
Parodontalbefund — condition of the gums, periodontium and surrounding bone.
Mundschleimhautbefund — examination of the oral mucosa, tongue and lips.
FDI Tooth Numbering System
Germany uses the FDI system. Each tooth has a two-digit number. First digit = quadrant, second = position from midline outward.
11 — upper right central incisor
36 — lower left first molar
48 — lower right wisdom tooth
Zahnbefund — Complete Symbol Reference
The assistant must know these symbols by heart. The dentist dictates fast — no time to think.
Tooth status
| Symbol | German | Meaning |
|---|---|---|
| e | gesund | Healthy tooth |
| x | fehlend | Missing tooth |
| xk | kariesbedingt fehlend | Extracted due to caries |
| xp | parodontal fehlend | Extracted due to periodontitis |
| n | nicht angelegt | Congenitally absent |
| W | Wurzel | Root only |
| ↓ | retiniert | Impacted tooth |
| → | verlagert | Displaced tooth |
Restorations and prosthetics
| Symbol | German | Meaning |
|---|---|---|
| f | Füllung | Filling |
| fk | Kunststofffüllung | Composite filling |
| fa | Amalgamfüllung | Amalgam filling |
| K | Krone | Crown |
| TK | Teilkrone | Partial crown |
| VK | Vollkeramikkrone | All-ceramic crown |
| B | Brücke | Bridge |
| I | Implantat | Implant |
| V | Veneer | Veneer |
| Inl | Inlay | Inlay |
| Onl | Onlay | Onlay |
Pathological conditions
| Symbol | German | Meaning |
|---|---|---|
| k | Karies | Caries |
| k¹ | Initialkaries | Initial caries |
| k² | Dentinkaries | Dentine caries |
| k³ | Pulpanahe Karies | Deep caries |
| k⁴ | Pulpaeröffnung | Pulp exposure |
| ws | Wurzelspitze | Periapical pathology |
| WB | Wurzelbehandlung | Root canal treatment |
| WF | Wurzelfüllung | Root filling |
| A | Abrasion | Abrasion |
| E | Erosion | Erosion |
46 — WB, WF, K, 45 — k², 44 — e, 43 — e
Parodontalbefund
The periodontal assessment records the condition of the supporting structures — gums, periodontal ligament and alveolar bone. Performed using a Parodontalsonde with millimetre markings.
Taschentiefe (TT) — probing depth in millimetres, measured at 6 points per tooth.
Attachmentverlust (AV) — attachment loss — indicates the extent of bone destruction.
BOP — bleeding on probing — sign of inflammation, recorded as + or –.
Normal probing depth values:
| Depth | Status | Action |
|---|---|---|
| 1 – 3 mm | Normal | Prevention |
| 4 mm | Borderline | Monitor |
| ≥ 5 mm | Pathological pocket | Treatment required |
PSI — Periodontal Screening Index:
Furcation involvement: F1 — probe enters up to 3 mm. F2 — more than 3 mm, not through. F3 — probe passes through.
Oral Mucosa Examination
The dentist examines not only the teeth but the entire oral cavity. The assistant records any mucosal changes.
Every pathological change is documented with a precise description: size, shape, colour, location. Special attention to suspicious lesions that may indicate malignancy.
X-Ray Documentation
Radiographs are mandatory documentation. Every exposure must be justified under the Strahlenschutzgesetz (Radiation Protection Act).
Mandatory documentation per X-ray:
| Field | Example |
|---|---|
| Date | 14.03.2025 |
| Type | OPG |
| Indication | Routine check |
| Region | Full jaw |
| Radiation dose | 0.025 mSv |
| Dentist signature | Dr. Müller |
Medical History (Anamnese)
The Anamnese is the collection of patient health information before treatment begins. Legally mandatory. Completed in writing by the patient and reviewed with the dentist.
Medications important in dentistry:
Latex (the assistant wears latex gloves!), local anaesthetics (lidocaine, articaine), metals (nickel, chromium), antibiotics (penicillin), pregnancy and breastfeeding.
Documentation Software
Most German practices use specialist software. The assistant must be able to work with these programs.
Assistant tasks in the software:
| Task | Details |
|---|---|
| New patient | Create record, enter personal data |
| Anamnese | Enter health information |
| Befund | Record as dictated by dentist |
| X-rays | Document with date and indication |
| Billing | Generate invoices per BEMA and GOZ |
Treatment Plan
After the examination, the dentist creates a Behandlungsplan — a detailed plan of all necessary treatment.
Patient Consent
Before any major procedure, the patient signs a written consent form — Aufklärung und Einwilligung.
| Procedure | Consent |
|---|---|
| Tooth extraction | Written consent required |
| Implant placement | Written consent required |
| Oral surgery | Written consent required |
| X-ray | Written consent required |
| Anaesthesia | Written consent required |
Treatment Documentation
A record of everything that happened at each appointment. Must be completed the same day.
| Field | Example |
|---|---|
| Date and time | 14.03.2025, 10:30 |
| Patient complaint | Pain at tooth 46 when biting |
| Procedure | Caries excavation, composite restoration |
| Materials | Tetric EvoCeram A2, batch #2547 |
| Anaesthesia | Ultracain D-S forte 1.7 ml |
| Complications | None |
| Dentist signature | Dr. Schmidt |
Kariesexkavation. Kompositfüllung Optibond FL + Tetric EvoCeram A2.
Occlusion checked. Patient pain-free.
Legal Requirements
Common Mistakes
Glossary
Key German terms the assistant must know by heart: