Broken Tooth Extraction SOAP Note: Ready-to-Copy Templates for Clinicians

Nov 10, 2026 - 56 Min read

More like this in Tooth Extraction and Oral Surgery SOAP Notes

Broken Tooth Extraction SOAP Note is a ready-to-copy, mobile-friendly template that clinicians can paste and adapt instantly.

SOAP note

Subjective: 35-year-old female, CC: “Sharp pain in upper right first premolar after fall.” HPI: Pain 10/10, sharp, triggered by biting, no swelling. PMH: {medical history}. NKDA.
Objective: Tooth #13 fractured distal 1/2, radiograph shows complete crown fracture, no periapical pathology.
Assessment: Non-restorable fracture, extraction indicated.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.5 mL infiltration; simple closed extraction; gauze pressure 20 min; POI: soft diet, ice, ibuprofen 400 mg PRN. Follow-up in 7 days.

S: 35-year-old female, CC: “Sharp pain in upper right first premolar after fall.” HPI: Pain 10/10, sharp, triggered by biting, no swelling. PMH: {medical history}. NKDA.
O: Tooth #13 fractured distal 1/2, radiograph shows complete crown fracture, no periapical pathology.
A: Non-restorable fracture, extraction indicated.
P: 2% lidocaine with 1:100,000 epinephrine, 1.5 mL infiltration; simple closed extraction; gauze pressure 20 min; POI: soft diet, ice, ibuprofen 400 mg PRN. Follow-up in 7 days.

Additional grouped examples follow.

Emergency Visit for Fractured Upper Incisor

SOAP note

Subjective: 67-year-old female, asthma, NKDA, CC: “I hit my front tooth while playing basketball and it’s broken and bleeding”; HPI: fractured incisor with no pulpal exposure, 2 mm intraoral swelling, afebrile, pulse 78, BP 128/76.
Objective: Extraoral: no swelling, intraoral: tooth #7 fractured into two pieces, no erythema, 2 mm swelling; periodontal: intact BOP; radiograph: fracture line extends to pulp chamber, no sinus tract; vital signs: pulse 78, BP 128/76.
Assessment: Fractured tooth #7, pulpal exposure absent, consistent with radiographic fracture line extending to pulp chamber.
Plan: Infiltration with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL; extracted #7 via closed technique, socket irrigated with saline, gauze pressure for 20 min; verbal POI given; no medications prescribed; next visit: follow-up in 7 days for healing assessment.

S: 67-year-old female, asthma, NKDA, CC: “I hit my front tooth while playing basketball and it’s broken and bleeding”; HPI: fractured incisor with no pulpal exposure, 2 mm intraoral swelling, afebrile, pulse 78, BP 128/76.
O: Extraoral: no swelling, intraoral: tooth #7 fractured into two pieces, no erythema, 2 mm swelling; periodontal: intact BOP; radiograph: fracture line extends to pulp chamber, no sinus tract; vital signs: pulse 78, BP 128/76.
A: Fractured tooth #7, pulpal exposure absent, consistent with radiographic fracture line extending to pulp chamber.
P: Infiltration with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL; extracted #7 via closed technique, socket irrigated with saline, gauze pressure for 20 min; verbal POI given; no medications prescribed; next visit: follow-up in 7 days for healing assessment.

Emergency Extraction After Sports Injury

SOAP note

Subjective: 69-year-old female, no significant medical history, allergic to penicillin (rash). Chief complaint: “I fell and my lower right canine popped out, it’s painful and I can’t bite.” History: acute sports injury, pain localized to tooth #27, no systemic symptoms. PMH: none.
Objective: Extraoral: mild pericoronal swelling, no lymphadenopathy. Intraoral: tooth #27 completely luxated, root exposed. Periodontal: BOP present, PD 3 mm. Radiographic: PA shows root fracture at middle third, no sinus tract. Vital signs: temperature 37.0 °C.
Assessment: Luxated tooth with root fracture, symptomatic apical periodontitis. Findings: complete luxation, root exposure, periapical fracture, mild swelling, normal temperature.
Plan: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration. Extracted tooth #27, curetted socket, achieved hemostasis with gauze pressure. Instructed patient to avoid chewing on that side, keep soft diet, apply ice packs, and return if pain worsens or swelling increases. No medications prescribed.

S: 69-year-old female, no significant medical history, allergic to penicillin (rash). Chief complaint: “I fell and my lower right canine popped out, it’s painful and I can’t bite.” History: acute sports injury, pain localized to tooth #27, no systemic symptoms. PMH: none.
O: Extraoral: mild pericoronal swelling, no lymphadenopathy. Intraoral: tooth #27 completely luxated, root exposed. Periodontal: BOP present, PD 3 mm. Radiographic: PA shows root fracture at middle third, no sinus tract. Vital signs: temperature 37.0 °C.
A: Luxated tooth with root fracture, symptomatic apical periodontitis. Findings: complete luxation, root exposure, periapical fracture, mild swelling, normal temperature.
P: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration. Extracted tooth #27, curetted socket, achieved hemostasis with gauze pressure. Instructed patient to avoid chewing on that side, keep soft diet, apply ice packs, and return if pain worsens or swelling increases. No medications prescribed.

SOAP note

Subjective: 48-year-old female, smoker, NKDA, reports “I broke my lower right first molar while playing soccer, it’s shattered and bleeding.” HPI: acute fracture with pulp exposure, no systemic symptoms. PMH: smoking 5 cigarettes/day. O: tooth #30 fractured into multiple pieces, pulp exposed; PA shows fracture line to apex; moderate swelling 5 mm, no erythema; afebrile, pulse 82, no trismus. A: fractured tooth with pulpal exposure, acute apical abscess not present. P: extracted tooth #30 with surgical technique; 4 % articaine 1:100 000, 1.8 mL infiltration; socket irrigated, hemostasis achieved with gauze; POI given (bite on gauze 30-60 min, no spitting/rinsing/straws for 24 h, soft diet, cold packs, analgesic if needed); next visit in 7-10 days for healing assessment.

S: 48-year-old female, smoker, NKDA, reports “I broke my lower right first molar while playing soccer, it’s shattered and bleeding.” HPI: acute fracture with pulp exposure, no systemic symptoms. PMH: smoking 5 cigarettes/day. O: tooth #30 fractured into multiple pieces, pulp exposed; PA shows fracture line to apex; moderate swelling 5 mm, no erythema; afebrile, pulse 82, no trismus. A: fractured tooth with pulpal exposure, acute apical abscess not present. P: extracted tooth #30 with surgical technique; 4 % articaine 1:100 000, 1.8 mL infiltration; socket irrigated, hemostasis achieved with gauze; POI given (bite on gauze 30-60 min, no spitting/rinsing/straws for 24 h, soft diet, cold packs, analgesic if needed); next visit in 7-10 days for healing assessment.

SOAP note

Subjective: 40-year-old male, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “I broke my upper right canine in a bike crash, it’s broken and I can’t bite”; HPI: fractured #6 into two fragments, pulp exposed, moderate swelling 3 mm, no erythema, T 36.8 °C, no lymphadenopathy; PMH: hypothyroidism.
Objective: Extraoral: mild 3 mm swelling, no erythema, no lymphadenopathy; Intraoral: #6 fractured into two fragments, pulp exposed; Radiographic: PA shows fracture to middle third; Tests: none.
Assessment: Fractured tooth with pulpal exposure, symptomatic apical periodontitis, supported by exposed pulp, radiographic fracture, and clinical pain.
Plan: Extracted tooth #6 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; socket curetted, hemostasis achieved; advised to avoid chewing on that side, no medications prescribed; next visit for healing assessment.

S: 40-year-old male, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “I broke my upper right canine in a bike crash, it’s broken and I can’t bite”; HPI: fractured #6 into two fragments, pulp exposed, moderate swelling 3 mm, no erythema, T 36.8 °C, no lymphadenopathy; PMH: hypothyroidism.
O: Extraoral: mild 3 mm swelling, no erythema, no lymphadenopathy; Intraoral: #6 fractured into two fragments, pulp exposed; Radiographic: PA shows fracture to middle third; Tests: none.
A: Fractured tooth with pulpal exposure, symptomatic apical periodontitis, supported by exposed pulp, radiographic fracture, and clinical pain.
P: Extracted tooth #6 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; socket curetted, hemostasis achieved; advised to avoid chewing on that side, no medications prescribed; next visit for healing assessment.

Extraction After Failed Root Canal Therapy

SOAP note

Subjective: 80-year-old male, NKDA, reports “My root canal didn’t fix the pain, the tooth is still hurting and I can’t eat.” He has no significant medical history, is afebrile, pulse 76, no trismus, and moderate swelling 4 mm without erythema.
Objective: Tooth #11 previously endodontically treated, crown missing, fractured at the cervical third. Periapical radiograph shows a 6 mm periapical radiolucency. Extraoral exam reveals no facial asymmetry; intraoral exam shows the fractured crown fragment and surrounding mucosa intact.
Assessment: Pulp necrosis, previously treated, acute apical abscess—supported by the periapical radiolucency, persistent pain after RCT, and localized swelling.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; tooth #11 extracted, socket irrigated, hemostasis achieved with gauze pressure. POI: bite on gauze for 30 min, avoid chewing hard foods, keep the area clean, return to clinic in 2 days for healing assessment.

S: 80-year-old male, NKDA, reports “My root canal didn’t fix the pain, the tooth is still hurting and I can’t eat.” He has no significant medical history, is afebrile, pulse 76, no trismus, and moderate swelling 4 mm without erythema.
O: Tooth #11 previously endodontically treated, crown missing, fractured at the cervical third. Periapical radiograph shows a 6 mm periapical radiolucency. Extraoral exam reveals no facial asymmetry; intraoral exam shows the fractured crown fragment and surrounding mucosa intact.
A: Pulp necrosis, previously treated, acute apical abscess—supported by the periapical radiolucency, persistent pain after RCT, and localized swelling.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; tooth #11 extracted, socket irrigated, hemostasis achieved with gauze pressure. POI: bite on gauze for 30 min, avoid chewing hard foods, keep the area clean, return to clinic in 2 days for healing assessment.

Extraction After Failed Root Canal Therapy in a Middle-Aged Female

SOAP note

Subjective: 61-year-old female, seasonal allergies, NKDA, reports “The root canal didn’t help, the tooth keeps hurting after my tennis match.” She has a history of endodontic treatment on tooth #28 with a missing crown and a middle-third fracture.
Objective: Extraoral: moderate swelling 3 mm, no erythema, temperature 36.9 °C, no lymphadenopathy. Intraoral: fractured tooth #28, crown missing, periapical radiograph shows 5 mm radiolucency. No other findings.
Assessment: Pulp necrosis, previously treated, acute apical abscess – supported by fractured tooth, periapical radiolucency, and pain after trauma.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; tooth #28 extracted, socket irrigated, hemostasis achieved. Patient instructed to avoid chewing on that side and to monitor for swelling or pain; next visit scheduled for follow-up in 7 days.

S: 61-year-old female, seasonal allergies, NKDA, reports “The root canal didn’t help, the tooth keeps hurting after my tennis match.” She has a history of endodontic treatment on tooth #28 with a missing crown and a middle-third fracture.
O: Extraoral: moderate swelling 3 mm, no erythema, temperature 36.9 °C, no lymphadenopathy. Intraoral: fractured tooth #28, crown missing, periapical radiograph shows 5 mm radiolucency. No other findings.
A: Pulp necrosis, previously treated, acute apical abscess – supported by fractured tooth, periapical radiolucency, and pain after trauma.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; tooth #28 extracted, socket irrigated, hemostasis achieved. Patient instructed to avoid chewing on that side and to monitor for swelling or pain; next visit scheduled for follow-up in 7 days.

Post-Operative Follow-Up & Complications

Smoker, Day 3 After Lower Molar Extraction

SOAP note

Subjective: 45-year-old male, former smoker, NKDA, presents for a post-operative follow-up after extraction of tooth #30; in his own words, “I’m here to check on the extraction site.” He reports no pain, no discomfort, and no bleeding or swelling since the procedure. He has no systemic complaints and denies any medication use.
Objective: Extraoral examination shows no facial edema or asymmetry; intraoral inspection reveals the socket at tooth #30 exhibiting normal healing with intact mucosa, no exposed bone, no purulent drainage, and no tenderness on palpation. Periodontal probing around the adjacent teeth is within normal limits; radiographic assessment was not performed as the clinical findings are reassuring. No additional tests were required.
Assessment: The patient is experiencing uncomplicated post-extraction healing with no signs of infection, dry socket, or other complications.
Plan: Reviewed the healing status, reinforced postoperative instructions: continue gentle rinsing with 0.12% chlorhexidine twice daily, maintain a soft diet, avoid smoking for at least 48 hours, and monitor for any sudden pain or swelling. No medication was prescribed. Scheduled a follow-up visit in 7 days to confirm complete resolution and to discuss any future restorative options.

S: 45-year-old male, former smoker, NKDA, presents for a post-operative follow-up after extraction of tooth #30; in his own words, “I’m here to check on the extraction site.” He reports no pain, no discomfort, and no bleeding or swelling since the procedure. He has no systemic complaints and denies any medication use.
O: Extraoral examination shows no facial edema or asymmetry; intraoral inspection reveals the socket at tooth #30 exhibiting normal healing with intact mucosa, no exposed bone, no purulent drainage, and no tenderness on palpation. Periodontal probing around the adjacent teeth is within normal limits; radiographic assessment was not performed as the clinical findings are reassuring. No additional tests were required.
A: The patient is experiencing uncomplicated post-extraction healing with no signs of infection, dry socket, or other complications.
P: Reviewed the healing status, reinforced postoperative instructions: continue gentle rinsing with 0.12% chlorhexidine twice daily, maintain a soft diet, avoid smoking for at least 48 hours, and monitor for any sudden pain or swelling. No medication was prescribed. Scheduled a follow-up visit in 7 days to confirm complete resolution and to discuss any future restorative options.

Smoker, Day 1 After Extraction, Broken Lower Molar

SOAP note

Subjective: 30-year-old male, smoker 5 cigarettes/day, on low-dose aspirin, NKDA; CC: “I have a lot of pain and some swelling”; HPI: pain 4/10 throbbing, relieved by ibuprofen, swelling 1 cm around #30 extraction site, mild controlled bleeding, no exposed bone, no trismus, no systemic signs.
Objective: Socket shows mild bleeding, controlled; swelling 1 cm; pain 4/10 throbbing; no exposed bone; no trismus; no systemic signs; anesthesia not required.
Assessment: Post-extraction pain with early dry socket risk, supported by mild bleeding, swelling, throbbing pain, and patient’s smoking status.
Plan: Prescribed ibuprofen 400 mg PO q6 h PRN up to 3 days; advised avoid smoking, continue POI, monitor for worsening pain or exposed bone; next visit in 3 days for reassessment.

S: 30-year-old male, smoker 5 cigarettes/day, on low-dose aspirin, NKDA; CC: “I have a lot of pain and some swelling”; HPI: pain 4/10 throbbing, relieved by ibuprofen, swelling 1 cm around #30 extraction site, mild controlled bleeding, no exposed bone, no trismus, no systemic signs.
O: Socket shows mild bleeding, controlled; swelling 1 cm; pain 4/10 throbbing; no exposed bone; no trismus; no systemic signs; anesthesia not required.
A: Post-extraction pain with early dry socket risk, supported by mild bleeding, swelling, throbbing pain, and patient’s smoking status.
P: Prescribed ibuprofen 400 mg PO q6 h PRN up to 3 days; advised avoid smoking, continue POI, monitor for worsening pain or exposed bone; next visit in 3 days for reassessment.

Non-smoker, Day 2 After Extraction, Broken Upper Molar

SOAP note

Subjective: 64-year-old female, smoker 5 cigarettes/day, controlled hypertension on lisinopril, NKDA, reports “The pain is still there and there's some swelling” after extraction of tooth #18.
Objective: Socket demonstrates normal healing; swelling measures 1.5 cm; pain intensity 6/10, dull, relieved by ibuprofen; no active bleeding; no exposed bone; extraoral exam shows no trismus; vital signs stable.
Assessment: Post-extraction pain without dry socket, evidenced by intact socket, absence of exposed bone, and lack of purulent discharge.
Plan: Prescribed ibuprofen 400 mg PO every 6 h PRN for up to 3 days; continue postoperative instructions (avoid smoking, maintain soft diet, apply cold packs as needed); advise to return if swelling exceeds 2 cm, pain escalates above 7/10, or signs of infection appear.

S: 64-year-old female, smoker 5 cigarettes/day, controlled hypertension on lisinopril, NKDA, reports “The pain is still there and there's some swelling” after extraction of tooth #18.
O: Socket demonstrates normal healing; swelling measures 1.5 cm; pain intensity 6/10, dull, relieved by ibuprofen; no active bleeding; no exposed bone; extraoral exam shows no trismus; vital signs stable.
A: Post-extraction pain without dry socket, evidenced by intact socket, absence of exposed bone, and lack of purulent discharge.
P: Prescribed ibuprofen 400 mg PO every 6 h PRN for up to 3 days; continue postoperative instructions (avoid smoking, maintain soft diet, apply cold packs as needed); advise to return if swelling exceeds 2 cm, pain escalates above 7/10, or signs of infection appear.

Extraction With Post-operative Dry Socket Monitoring

SOAP note

Subjective: 58-year-old female, type 2 diabetes on metformin, NKDA, reports “the socket hurts a lot and I taste something bad” after extraction of tooth #30.
Objective: Socket shows exposed bone 2 cm in diameter; pain 8/10 radiating to the ear; bad taste and foul odor; no swelling or bleeding; systemic signs absent.
Assessment: Alveolar osteitis (dry socket) supported by exposed bone, severe pain, and halitosis.
Plan: Gentle saline irrigation performed; medicated dressing applied; prescribe ibuprofen 400 mg every 6 h PRN, max 3 days; advise oral hygiene, avoid smoking, and return in 5 days for reassessment.

S: 58-year-old female, type 2 diabetes on metformin, NKDA, reports “the socket hurts a lot and I taste something bad” after extraction of tooth #30.
O: Socket shows exposed bone 2 cm in diameter; pain 8/10 radiating to the ear; bad taste and foul odor; no swelling or bleeding; systemic signs absent.
A: Alveolar osteitis (dry socket) supported by exposed bone, severe pain, and halitosis.
P: Gentle saline irrigation performed; medicated dressing applied; prescribe ibuprofen 400 mg every 6 h PRN, max 3 days; advise oral hygiene, avoid smoking, and return in 5 days for reassessment.

Extraction With Post-operative Dry Socket Monitoring in a Smoker

SOAP note

Subjective: 50-year-old male, smoker (5 cigarettes/day), asthma on albuterol PRN, NKDA, reports “the socket hurts a lot and I taste something bad.”
Objective: Tooth #30 socket shows 2 cm exposed bone; pain 8/10 radiating, bad taste, foul odor; no swelling or bleeding; systemic signs absent.
Assessment: Alveolar osteitis (dry socket) supported by exposed bone, severe pain, and characteristic taste/odor.
Plan: Gentle saline irrigation performed; medicated dressing placed in socket; prescribed ibuprofen 400 mg PO every 6 h PRN for up to 3 days; advised to avoid smoking, maintain oral hygiene, and return in 5 days for reassessment.

S: 50-year-old male, smoker (5 cigarettes/day), asthma on albuterol PRN, NKDA, reports “the socket hurts a lot and I taste something bad.”
O: Tooth #30 socket shows 2 cm exposed bone; pain 8/10 radiating, bad taste, foul odor; no swelling or bleeding; systemic signs absent.
A: Alveolar osteitis (dry socket) supported by exposed bone, severe pain, and characteristic taste/odor.
P: Gentle saline irrigation performed; medicated dressing placed in socket; prescribed ibuprofen 400 mg PO every 6 h PRN for up to 3 days; advised to avoid smoking, maintain oral hygiene, and return in 5 days for reassessment.

Re-evaluation After Failed Splint

SOAP note

Subjective: 55-year-old male, allergic to penicillin (rash), reports “The tooth still hurts and the splint is broken.” He has no significant medical history and no systemic signs.
Objective: Tooth #30 shows mobility grade 2, pain 5/10; splint fractured; no swelling, no bleeding, no exposed bone.
Assessment: Failed orthodontic splint with symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
Plan: Splint removed, pulp status evaluated; extraction of tooth #30 planned if pulpal necrosis confirmed. No anesthesia or medication administered today. Patient instructed to maintain oral hygiene, avoid chewing on the area, and report any increase in pain or swelling. Next visit scheduled in 3 days for reassessment and possible extraction.

S: 55-year-old male, allergic to penicillin (rash), reports “The tooth still hurts and the splint is broken.” He has no significant medical history and no systemic signs.
O: Tooth #30 shows mobility grade 2, pain 5/10; splint fractured; no swelling, no bleeding, no exposed bone.
A: Failed orthodontic splint with symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
P: Splint removed, pulp status evaluated; extraction of tooth #30 planned if pulpal necrosis confirmed. No anesthesia or medication administered today. Patient instructed to maintain oral hygiene, avoid chewing on the area, and report any increase in pain or swelling. Next visit scheduled in 3 days for reassessment and possible extraction.

Re-evaluation After Failed Splint in a Diabetic

SOAP note

Subjective: 47-year-old female, type 2 diabetes on metformin, smoker 5 cigarettes/day, NKDA. Chief complaint: “The tooth still hurts and the splint is broken.” History: splint placed on teeth #30 and #31; now fractured, pain persists.
Objective: Tooth #30 shows mobility grade 2, pain 5/10; splint fractured; no swelling, no bleeding, no exposed bone. No systemic signs.
Assessment: Failed orthodontic splint with symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
Plan: Remove fractured splint, evaluate pulp status of #30; if pulpal inflammation persists, plan extraction. No anesthesia or medications administered. Instruct patient to maintain oral hygiene, avoid chewing on that side, and report any increase in pain or swelling. Schedule next visit in 7 days for reassessment and to discuss definitive treatment.

S: 47-year-old female, type 2 diabetes on metformin, smoker 5 cigarettes/day, NKDA. Chief complaint: “The tooth still hurts and the splint is broken.” History: splint placed on teeth #30 and #31; now fractured, pain persists.
O: Tooth #30 shows mobility grade 2, pain 5/10; splint fractured; no swelling, no bleeding, no exposed bone. No systemic signs.
A: Failed orthodontic splint with symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
P: Remove fractured splint, evaluate pulp status of #30; if pulpal inflammation persists, plan extraction. No anesthesia or medications administered. Instruct patient to maintain oral hygiene, avoid chewing on that side, and report any increase in pain or swelling. Schedule next visit in 7 days for reassessment and to discuss definitive treatment.

Re-evaluation After Failed Splint in a Hypertensive Patient

SOAP note

Subjective: 56-year-old female, hypothyroid on levothyroxine, allergic to penicillin (rash), reports “The tooth still hurts and the splint is broken.” HPI: pain 5/10, ongoing after splint placement. PMH: hypothyroidism, no other systemic disease.
Objective: Tooth #30 shows mobility grade 2, pain 5/10, splint fractured; no swelling, no bleeding, no exposed bone. Tooth #31 stable, no pain. Extraoral exam WNL.
Assessment: Failed orthodontic splint; symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
Plan: Remove fractured splint; evaluate pulpal response; if pulpal inflammation persists, plan extraction of #30. No medication prescribed. Instruct patient to maintain oral hygiene, avoid chewing on the area, use soft diet, and report increased pain, swelling, or bleeding. Schedule follow-up in 3 days to reassess pain and healing.

S: 56-year-old female, hypothyroid on levothyroxine, allergic to penicillin (rash), reports “The tooth still hurts and the splint is broken.” HPI: pain 5/10, ongoing after splint placement. PMH: hypothyroidism, no other systemic disease.
O: Tooth #30 shows mobility grade 2, pain 5/10, splint fractured; no swelling, no bleeding, no exposed bone. Tooth #31 stable, no pain. Extraoral exam WNL.
A: Failed orthodontic splint; symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
P: Remove fractured splint; evaluate pulpal response; if pulpal inflammation persists, plan extraction of #30. No medication prescribed. Instruct patient to maintain oral hygiene, avoid chewing on the area, use soft diet, and report increased pain, swelling, or bleeding. Schedule follow-up in 3 days to reassess pain and healing.

Re-evaluation After Failed Splint in a Post-Op Patient on Anticoagulants

SOAP note

Subjective: 46-year-old male, NKDA, presents with “the tooth still hurts and the splint is broken”; reports 5/10 pain in tooth #30, splint fractured, no swelling.
Objective: Tooth #30 shows mobility grade 2, pain 5/10, splint fractured; mild bleeding controlled with gauze; no exposed bone; tooth #31 stable.
Assessment: Failed orthodontic splint with symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
Plan: Removed fractured splint, inspected pulp chamber, noted no pulpal exposure; advised to avoid anticoagulants if possible, scheduled follow-up in 3 days to reassess pain and consider extraction if pulpal inflammation persists.

S: 46-year-old male, NKDA, presents with “the tooth still hurts and the splint is broken”; reports 5/10 pain in tooth #30, splint fractured, no swelling.
O: Tooth #30 shows mobility grade 2, pain 5/10, splint fractured; mild bleeding controlled with gauze; no exposed bone; tooth #31 stable.
A: Failed orthodontic splint with symptomatic irreversible pulpitis of tooth #30, supported by mobility, pain, and splint failure.
P: Removed fractured splint, inspected pulp chamber, noted no pulpal exposure; advised to avoid anticoagulants if possible, scheduled follow-up in 3 days to reassess pain and consider extraction if pulpal inflammation persists.

Immediate Implant Placement

Extraction With Immediate Implant Placement

SOAP note

Subjective: 24-year-old female, seasonal allergies, NKDA, reports “I need my tooth removed and a new one placed right away.” She has no systemic signs, no swelling or trismus, and no periodontal pockets >3 mm.
Objective: Radiograph shows extensive caries into outer dentin with a root fracture; tooth #30 is non-restorable. Extraoral exam is unremarkable; intraoral exam shows no mobility, no bleeding on probing, and no periapical radiolucency beyond the fracture line.
Assessment: Pulp necrosis with symptomatic apical periodontitis, confirmed by radiographic fracture and clinical pain.
Plan: An IANB with 2% lidocaine + 1:100,000 epinephrine (1.8 mL) was administered. Tooth #30 was extracted, socket irrigated, clot stabilized, and a 4.0 mm × 10 mm implant with provisional healing abutment was immediately placed. Ibuprofen 400 mg PO q6h PRN for 5 days prescribed; patient advised on postoperative care and to return for implant integration check.

S: 24-year-old female, seasonal allergies, NKDA, reports “I need my tooth removed and a new one placed right away.” She has no systemic signs, no swelling or trismus, and no periodontal pockets >3 mm.
O: Radiograph shows extensive caries into outer dentin with a root fracture; tooth #30 is non-restorable. Extraoral exam is unremarkable; intraoral exam shows no mobility, no bleeding on probing, and no periapical radiolucency beyond the fracture line.
A: Pulp necrosis with symptomatic apical periodontitis, confirmed by radiographic fracture and clinical pain.
P: An IANB with 2% lidocaine + 1:100,000 epinephrine (1.8 mL) was administered. Tooth #30 was extracted, socket irrigated, clot stabilized, and a 4.0 mm × 10 mm implant with provisional healing abutment was immediately placed. Ibuprofen 400 mg PO q6h PRN for 5 days prescribed; patient advised on postoperative care and to return for implant integration check.

Extraction With Immediate Implant Placement in a Young Adult

SOAP note

Subjective: 28-year-old male, hypertension, NKDA, CC: “My tooth broke and I want a new one right away.” HPI: fractured #30, patient reports pain after break, no swelling or trismus. PMH: hypertension, no other systemic signs.
Objective: Extraoral: no facial asymmetry, no swelling. Intraoral: #30 non-restorable, root fracture, extensive outer dentin caries, no mobility, periodontal pockets ≤3 mm. Radiograph: periapical shows root fracture, symptomatic apical periodontitis. No other findings.
Assessment: Pulp necrosis with symptomatic apical periodontitis, confirmed by radiograph and clinical exam.
Plan: Extraction of #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; immediate placement of a 4.0 mm × 10 mm implant with provisional healing abutment; socket irrigated, clot stabilized. Ibuprofen 400 mg PO q6h PRN for 5 days. POI: soft diet, avoid chewing on site, use ice packs, keep head elevated. Next visit: implant review in 2 weeks.

S: 28-year-old male, hypertension, NKDA, CC: “My tooth broke and I want a new one right away.” HPI: fractured #30, patient reports pain after break, no swelling or trismus. PMH: hypertension, no other systemic signs.
O: Extraoral: no facial asymmetry, no swelling. Intraoral: #30 non-restorable, root fracture, extensive outer dentin caries, no mobility, periodontal pockets ≤3 mm. Radiograph: periapical shows root fracture, symptomatic apical periodontitis. No other findings.
A: Pulp necrosis with symptomatic apical periodontitis, confirmed by radiograph and clinical exam.
P: Extraction of #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; immediate placement of a 4.0 mm × 10 mm implant with provisional healing abutment; socket irrigated, clot stabilized. Ibuprofen 400 mg PO q6h PRN for 5 days. POI: soft diet, avoid chewing on site, use ice packs, keep head elevated. Next visit: implant review in 2 weeks.

Medical Condition-Specific Extractions

Pregnant, First Trimester, Broken Upper Central Incisor

SOAP note

Subjective: 81-year-old female, pregnant, first trimester, on low-dose aspirin, NKDA; CC: “My front tooth is broken and hurts when I bite.” HPI: fractured upper central incisor #8, no pulpal exposure, no swelling, erythema, trismus, or lymphadenopathy; afebrile.
Objective: Extraoral: normal. Intraoral: fractured #8, intact periapical tissues on PA. Periodontal: healthy. Radiograph: intact periapical tissues. Tests: none.
Assessment: Fractured tooth #8, pulpal exposure absent, based on clinical and radiographic findings.
Plan: Simple extraction of #8 with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Elevation and forceps extraction, socket curetted and irrigated, gauze pressure 30 min. POI: bite on gauze, no spitting or rinsing for 24 h, soft diet, cold packs as needed, monitor for bleeding or pain. No medications prescribed. RTC in 7 days for healing assessment.

S: 81-year-old female, pregnant, first trimester, on low-dose aspirin, NKDA; CC: “My front tooth is broken and hurts when I bite.” HPI: fractured upper central incisor #8, no pulpal exposure, no swelling, erythema, trismus, or lymphadenopathy; afebrile.
O: Extraoral: normal. Intraoral: fractured #8, intact periapical tissues on PA. Periodontal: healthy. Radiograph: intact periapical tissues. Tests: none.
A: Fractured tooth #8, pulpal exposure absent, based on clinical and radiographic findings.
P: Simple extraction of #8 with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Elevation and forceps extraction, socket curetted and irrigated, gauze pressure 30 min. POI: bite on gauze, no spitting or rinsing for 24 h, soft diet, cold packs as needed, monitor for bleeding or pain. No medications prescribed. RTC in 7 days for healing assessment.

Diabetic, Controlled, Broken Lower Second Molar

SOAP note

Subjective: 53-year-old female, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “My back molar is broken and it’s painful when I chew”; HPI: fractured #19 with pulpal exposure, pain on chewing, no swelling or trismus; PMH: T2DM, HTN, no other meds; allergies: NKDA.
Objective: Extraoral: no facial swelling, no trismus; Intraoral: fractured #19 with exposed pulp, soft tissue intact; Periodontal: healthy; Radiographic: PA shows acute apical periodontitis around #19; Tests: afebrile, no lymphadenopathy.
Assessment: Fractured tooth #19 with pulpal exposure and symptomatic apical periodontitis, confirmed by PA radiograph and clinical findings.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; simple extraction with elevation and forceps, socket curetted and irrigated, gauze pressure for 30 min; prescribed ibuprofen 400 mg PO q6h PRN for pain; POI: soft diet, avoid hard foods for 24 h, keep gauze for 30 min, rinse with warm saline after 24 h; next visit: follow-up in 7 days for healing assessment.

S: 53-year-old female, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “My back molar is broken and it’s painful when I chew”; HPI: fractured #19 with pulpal exposure, pain on chewing, no swelling or trismus; PMH: T2DM, HTN, no other meds; allergies: NKDA.
O: Extraoral: no facial swelling, no trismus; Intraoral: fractured #19 with exposed pulp, soft tissue intact; Periodontal: healthy; Radiographic: PA shows acute apical periodontitis around #19; Tests: afebrile, no lymphadenopathy.
A: Fractured tooth #19 with pulpal exposure and symptomatic apical periodontitis, confirmed by PA radiograph and clinical findings.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; simple extraction with elevation and forceps, socket curetted and irrigated, gauze pressure for 30 min; prescribed ibuprofen 400 mg PO q6h PRN for pain; POI: soft diet, avoid hard foods for 24 h, keep gauze for 30 min, rinse with warm saline after 24 h; next visit: follow-up in 7 days for healing assessment.

NSAID Allergy, Broken Upper Lateral Incisor

SOAP note

Subjective: 23-year-old female, type 2 diabetes on metformin, reports “My upper lateral tooth is broken and it hurts when I bite.” No swelling, erythema, trismus or lymphadenopathy; afebrile. No known drug allergies except NSAID rash.
Objective: Tooth #9 fractured, no pulpal exposure. Periapical radiograph shows intact periapical tissues. Extraoral and intraoral exam WNL.
Assessment: Fractured tooth #9, pulpal exposure absent.
Plan: Simple extraction of tooth #9 performed with 2% lidocaine 1:100,000 epinephrine, 1.8 mL maxillary infiltration; aspiration negative. Elevation and forceps extraction, socket curetted and irrigated, gauze pressure for 30 min. Post-op: acetaminophen 500 mg PO q6h PRN; advise soft diet, avoid NSAIDs, monitor for infection; next visit for healing assessment.

S: 23-year-old female, type 2 diabetes on metformin, reports “My upper lateral tooth is broken and it hurts when I bite.” No swelling, erythema, trismus or lymphadenopathy; afebrile. No known drug allergies except NSAID rash.
O: Tooth #9 fractured, no pulpal exposure. Periapical radiograph shows intact periapical tissues. Extraoral and intraoral exam WNL.
A: Fractured tooth #9, pulpal exposure absent.
P: Simple extraction of tooth #9 performed with 2% lidocaine 1:100,000 epinephrine, 1.8 mL maxillary infiltration; aspiration negative. Elevation and forceps extraction, socket curetted and irrigated, gauze pressure for 30 min. Post-op: acetaminophen 500 mg PO q6h PRN; advise soft diet, avoid NSAIDs, monitor for infection; next visit for healing assessment.

Elderly, Osteoporosis, Broken Lower Third Molar

SOAP note

Subjective: 62-year-old male, asthma, NKDA, reports “My lower wisdom tooth is broken and it’s painful when I chew.” HPI: fractured #32 with pulpal exposure, no swelling, no trismus, afebrile, no lymphadenopathy.
Objective: Extraoral normal; intraoral shows fractured #32 with exposed pulp; periodontal probing within normal limits; PA radiograph shows symptomatic apical periodontitis; aspiration negative.
Assessment: Fractured tooth #32 with pulpal exposure and symptomatic apical periodontitis.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB administered; simple extraction performed with elevation and forceps; socket curetted, irrigated, gauze pressure for 30 min; ibuprofen 400 mg PO q6h PRN; advised soft diet, avoid hard foods for 48 h, report excessive pain or swelling; next visit in 7 days for healing assessment.

S: 62-year-old male, asthma, NKDA, reports “My lower wisdom tooth is broken and it’s painful when I chew.” HPI: fractured #32 with pulpal exposure, no swelling, no trismus, afebrile, no lymphadenopathy.
O: Extraoral normal; intraoral shows fractured #32 with exposed pulp; periodontal probing within normal limits; PA radiograph shows symptomatic apical periodontitis; aspiration negative.
A: Fractured tooth #32 with pulpal exposure and symptomatic apical periodontitis.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB administered; simple extraction performed with elevation and forceps; socket curetted, irrigated, gauze pressure for 30 min; ibuprofen 400 mg PO q6h PRN; advised soft diet, avoid hard foods for 48 h, report excessive pain or swelling; next visit in 7 days for healing assessment.

Pregnancy, Second Trimester, Broken Upper Canine

SOAP note

Subjective: 75-year-old pregnant female presents with “My upper canine is broken and it hurts when I bite.” HPI: fractured #11, no pulpal exposure, afebrile, no swelling, erythema, trismus, or lymphadenopathy. PMH: pregnancy; allergy to penicillin (rash). O: extraoral normal; intraoral shows fractured #11, intact periapical tissues on PA radiograph; no swelling or erythema; vital signs WNL. A: fractured tooth #11, pulpal exposure absent. P: simple extraction of #11 performed with 2% lidocaine 1:100,000 epinephrine, 1.8 mL maxillary infiltration, aspiration negative; elevation, forceps, socket curettage and irrigation; gauze pressure for 30 min; prescribed acetaminophen 500 mg PO q6h PRN; instructed to avoid hot foods, maintain a soft diet, use cold packs, and report severe pain or bleeding; next visit in 7 days for healing assessment.

S: 75-year-old pregnant female presents with “My upper canine is broken and it hurts when I bite.” HPI: fractured #11, no pulpal exposure, afebrile, no swelling, erythema, trismus, or lymphadenopathy. PMH: pregnancy; allergy to penicillin (rash). O: extraoral normal; intraoral shows fractured #11, intact periapical tissues on PA radiograph; no swelling or erythema; vital signs WNL. A: fractured tooth #11, pulpal exposure absent. P: simple extraction of #11 performed with 2% lidocaine 1:100,000 epinephrine, 1.8 mL maxillary infiltration, aspiration negative; elevation, forceps, socket curettage and irrigation; gauze pressure for 30 min; prescribed acetaminophen 500 mg PO q6h PRN; instructed to avoid hot foods, maintain a soft diet, use cold packs, and report severe pain or bleeding; next visit in 7 days for healing assessment.

Hypertensive, Broken Lower Premolar

SOAP note

Subjective: 66-year-old male, smoker, NKDA, reports “My lower premolar is broken and it’s painful when I chew.” History: fractured tooth #20, no pulpal exposure, afebrile, no swelling, erythema, trismus, or lymphadenopathy.
Objective: Extraoral: normal. Intraoral: fractured #20, intact periapical tissues on PA radiograph. Periodontal: no BOP. Radiographic: PA shows intact periapical tissues. Tests: none.
Assessment: Fractured tooth #20, pulpal exposure absent; supported by absence of pulpal signs, intact periapical tissues, and normal PA findings.
Plan: Simple extraction of #20 with 2% lidocaine 1:100,000, 1.8 mL (IANB, aspiration negative). Elevation, forceps, socket curetted and irrigated, gauze pressure 30 min. POI: ibuprofen 400 mg PO q6h PRN for pain; avoid hard foods, maintain oral hygiene. Next visit: review healing in 7 days.

S: 66-year-old male, smoker, NKDA, reports “My lower premolar is broken and it’s painful when I chew.” History: fractured tooth #20, no pulpal exposure, afebrile, no swelling, erythema, trismus, or lymphadenopathy.
O: Extraoral: normal. Intraoral: fractured #20, intact periapical tissues on PA radiograph. Periodontal: no BOP. Radiographic: PA shows intact periapical tissues. Tests: none.
A: Fractured tooth #20, pulpal exposure absent; supported by absence of pulpal signs, intact periapical tissues, and normal PA findings.
P: Simple extraction of #20 with 2% lidocaine 1:100,000, 1.8 mL (IANB, aspiration negative). Elevation, forceps, socket curetted and irrigated, gauze pressure 30 min. POI: ibuprofen 400 mg PO q6h PRN for pain; avoid hard foods, maintain oral hygiene. Next visit: review healing in 7 days.

Allergic to Penicillin, Broken Upper Molar

SOAP note

Subjective: 51-year-old male, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “My upper molar is broken and it hurts when I bite.” History: fractured tooth #16, no pulpal exposure, afebrile, no swelling, erythema, trismus, or lymphadenopathy.
Objective: Extraoral: no swelling, erythema, or lymphadenopathy. Intraoral: fractured tooth #16, intact periapical tissues on PA radiograph, no pulpal exposure, no trismus. Radiographic: PA shows intact periapical tissues. Vital signs: afebrile.
Assessment: Fractured tooth #16 with no pulpal exposure, confirmed by clinical and radiographic findings.
Plan: Simple extraction of #16 performed with 2% lidocaine with 1:100,000 epinephrine, 1.8 mL maxillary infiltration; elevation, forceps, socket curetted and irrigated; gauze pressure for 30 min. Post-op: acetaminophen 500 mg PO q6 h PRN for pain; advise soft diet, avoid hard foods, and return if pain worsens or signs of infection develop.

S: 51-year-old male, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “My upper molar is broken and it hurts when I bite.” History: fractured tooth #16, no pulpal exposure, afebrile, no swelling, erythema, trismus, or lymphadenopathy.
O: Extraoral: no swelling, erythema, or lymphadenopathy. Intraoral: fractured tooth #16, intact periapical tissues on PA radiograph, no pulpal exposure, no trismus. Radiographic: PA shows intact periapical tissues. Vital signs: afebrile.
A: Fractured tooth #16 with no pulpal exposure, confirmed by clinical and radiographic findings.
P: Simple extraction of #16 performed with 2% lidocaine with 1:100,000 epinephrine, 1.8 mL maxillary infiltration; elevation, forceps, socket curetted and irrigated; gauze pressure for 30 min. Post-op: acetaminophen 500 mg PO q6 h PRN for pain; advise soft diet, avoid hard foods, and return if pain worsens or signs of infection develop.

Pregnant, Third Trimester, Broken Lower Molar

SOAP note

Subjective: 77-year-old pregnant female, NKDA, reports “My lower molar is broken and it hurts when I chew.” She has no swelling, erythema, fever, trismus or lymphadenopathy; HPI: fractured tooth #30 with no pulpal exposure. O: Extraoral normal; intraoral shows fractured #30, no pulpal exposure, no swelling; Periodontal: BOP absent, PD 2 mm; Radiograph: periapical PA shows intact periapical tissues, no pathology; patient afebrile, no trismus. A: Fractured tooth #30, pulpal exposure absent, indicating simple extraction. P: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge) via IANB, aspiration negative; performed simple extraction with elevation and forceps, socket curetted and irrigated, gauze pressure for 30 min; prescribed ibuprofen 400 mg PO q6h PRN; instructed soft diet, avoid hard foods, maintain oral hygiene, and return if pain worsens or bleeding persists.

S: 77-year-old pregnant female, NKDA, reports “My lower molar is broken and it hurts when I chew.” She has no swelling, erythema, fever, trismus or lymphadenopathy; HPI: fractured tooth #30 with no pulpal exposure. O: Extraoral normal; intraoral shows fractured #30, no pulpal exposure, no swelling; Periodontal: BOP absent, PD 2 mm; Radiograph: periapical PA shows intact periapical tissues, no pathology; patient afebrile, no trismus. A: Fractured tooth #30, pulpal exposure absent, indicating simple extraction. P: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge) via IANB, aspiration negative; performed simple extraction with elevation and forceps, socket curetted and irrigated, gauze pressure for 30 min; prescribed ibuprofen 400 mg PO q6h PRN; instructed soft diet, avoid hard foods, maintain oral hygiene, and return if pain worsens or bleeding persists.

Elderly, Arthritis, Broken Lower Molar

SOAP note

Subjective: 29-year-old female, seasonal allergies, NKDA, CC: “My lower right molar broke after a fall and it’s painful”; HPI: vertical split of tooth #30, no pulpal exposure, no swelling, no mobility, no BOP.
Objective: Extraoral: mouth closed, no swelling. Intraoral: tooth #30 fractured, intact root, no periapical radiolucency on PA radiograph. Periodontal: no BOP, no mobility. Radiographic: PA shows intact root structure, no periapical pathology.
Assessment: Symptomatic apical periodontitis with pulp necrosis, previously untreated, supported by vertical fracture, intact root, and clinical pain.
Plan: Simple extraction of tooth #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative. Socket curetted, irrigated with saline; gauze pressure for 30 min. POI: soft diet, no hard foods for 24 h, no smoking, keep gauze in place. Return to clinic in 7 days for healing assessment.

S: 29-year-old female, seasonal allergies, NKDA, CC: “My lower right molar broke after a fall and it’s painful”; HPI: vertical split of tooth #30, no pulpal exposure, no swelling, no mobility, no BOP.
O: Extraoral: mouth closed, no swelling. Intraoral: tooth #30 fractured, intact root, no periapical radiolucency on PA radiograph. Periodontal: no BOP, no mobility. Radiographic: PA shows intact root structure, no periapical pathology.
A: Symptomatic apical periodontitis with pulp necrosis, previously untreated, supported by vertical fracture, intact root, and clinical pain.
P: Simple extraction of tooth #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative. Socket curetted, irrigated with saline; gauze pressure for 30 min. POI: soft diet, no hard foods for 24 h, no smoking, keep gauze in place. Return to clinic in 7 days for healing assessment.

Diabetic, Uncontrolled, Broken Lower Molar

SOAP note

Subjective: 59-year-old female, type 2 diabetes on metformin, former smoker, NKDA, reports “My lower left molar snapped and I can’t chew”; history shows mild trismus, 98.6 °F, swelling in left mandibular vestibule, no BOP.
Objective: Extraoral: mild swelling left mandibular vestibule. Intraoral: tooth #19 fractured with horizontal split, pulpal exposure, periapical radiolucency 3 mm, no root resorption. Periodontal: no BOP. Radiographic: PA shows 3 mm periapical radiolucency. Vital signs: temperature 98.6 °F.
Assessment: Pulp necrosis, previously untreated, acute apical abscess, supported by pulpal exposure, periapical radiolucency, and clinical swelling.
Plan: Simple extraction of tooth #19 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative. Socket irrigated with saline, gauze pressure for 45 min. POI: ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days, soft diet, avoid chewing on site, keep gauze for 30 min, return if pain >4/10, swelling increases, or fever develops.

S: 59-year-old female, type 2 diabetes on metformin, former smoker, NKDA, reports “My lower left molar snapped and I can’t chew”; history shows mild trismus, 98.6 °F, swelling in left mandibular vestibule, no BOP.
O: Extraoral: mild swelling left mandibular vestibule. Intraoral: tooth #19 fractured with horizontal split, pulpal exposure, periapical radiolucency 3 mm, no root resorption. Periodontal: no BOP. Radiographic: PA shows 3 mm periapical radiolucency. Vital signs: temperature 98.6 °F.
A: Pulp necrosis, previously untreated, acute apical abscess, supported by pulpal exposure, periapical radiolucency, and clinical swelling.
P: Simple extraction of tooth #19 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative. Socket irrigated with saline, gauze pressure for 45 min. POI: ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days, soft diet, avoid chewing on site, keep gauze for 30 min, return if pain >4/10, swelling increases, or fever develops.

Pregnancy, First Trimester, Broken Upper Molar

SOAP note

Subjective: 35-year-old female, pregnant, on low-dose aspirin, NKDA; CC: “My upper left molar broke and I’m in pain”; HPI: vertical split of tooth #16, no pulpal exposure, pain localized to the tooth, no swelling or mobility; PMH: pregnancy, aspirin; medications: low-dose aspirin; allergies: NKDA.
Objective: Extraoral: no swelling, no BOP; Intraoral: tooth #16 fractured with vertical split, intact root, no periapical radiolucency on PA; Periodontal: no mobility, BOP WNL; Radiographic: PA shows intact root, no periapical radiolucency; Tests: none.
Assessment: Pulp necrosis, previously untreated, symptomatic apical periodontitis, supported by vertical fracture, intact root, periapical radiolucency absent but pain present.
Plan: Simple extraction of tooth #16 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative; socket curetted, irrigated with saline; gauze pressure for 30 min; POI: avoid hard foods, use ice packs, follow postoperative instructions; next visit: follow-up in 7 days for healing assessment.

S: 35-year-old female, pregnant, on low-dose aspirin, NKDA; CC: “My upper left molar broke and I’m in pain”; HPI: vertical split of tooth #16, no pulpal exposure, pain localized to the tooth, no swelling or mobility; PMH: pregnancy, aspirin; medications: low-dose aspirin; allergies: NKDA.
O: Extraoral: no swelling, no BOP; Intraoral: tooth #16 fractured with vertical split, intact root, no periapical radiolucency on PA; Periodontal: no mobility, BOP WNL; Radiographic: PA shows intact root, no periapical radiolucency; Tests: none.
A: Pulp necrosis, previously untreated, symptomatic apical periodontitis, supported by vertical fracture, intact root, periapical radiolucency absent but pain present.
P: Simple extraction of tooth #16 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative; socket curetted, irrigated with saline; gauze pressure for 30 min; POI: avoid hard foods, use ice packs, follow postoperative instructions; next visit: follow-up in 7 days for healing assessment.

Allergic to Aspirin, Broken Lower Molar

SOAP note

Subjective: 68-year-old male, controlled hypertension on lisinopril, allergic to aspirin (rash); chief complaint: “My lower right molar broke and it hurts when I bite”; history: tooth #30 fractured with horizontal split, pulpal exposure, periapical radiolucency 2 mm, no swelling, no mobility, no BOP; PMH: hypertension; allergy: aspirin; no other meds.
Objective: extraoral normal; intraoral: tooth #30 horizontal fracture, exposed pulp, 2 mm periapical radiolucency on PA, no root resorption, no swelling, no mobility, BOP negative; periodontal: healthy; radiograph: periapical radiolucency 2 mm; tests: none.
Assessment: symptomatic apical periodontitis, pulp necrosis, previously untreated, supported by exposed pulp, radiolucency, pain on biting.
Plan: simple extraction of tooth #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; socket irrigated with saline; gauze pressure for 30 min; POI given: avoid hard foods, use ice packs, take acetaminophen 500 mg q6h PRN for pain; schedule follow-up in 7 days for healing assessment.

S: 68-year-old male, controlled hypertension on lisinopril, allergic to aspirin (rash); chief complaint: “My lower right molar broke and it hurts when I bite”; history: tooth #30 fractured with horizontal split, pulpal exposure, periapical radiolucency 2 mm, no swelling, no mobility, no BOP; PMH: hypertension; allergy: aspirin; no other meds.
O: extraoral normal; intraoral: tooth #30 horizontal fracture, exposed pulp, 2 mm periapical radiolucency on PA, no root resorption, no swelling, no mobility, BOP negative; periodontal: healthy; radiograph: periapical radiolucency 2 mm; tests: none.
A: symptomatic apical periodontitis, pulp necrosis, previously untreated, supported by exposed pulp, radiolucency, pain on biting.
P: simple extraction of tooth #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; socket irrigated with saline; gauze pressure for 30 min; POI given: avoid hard foods, use ice packs, take acetaminophen 500 mg q6h PRN for pain; schedule follow-up in 7 days for healing assessment.

Diabetic, Controlled, Broken Upper Molar

SOAP note

Subjective: 79-year-old male, type 2 diabetes on metformin, NKDA, reports “My upper left molar snapped and I can’t chew”; fractured vertical split with pulpal exposure.
Objective: Tooth #16 fractured, pulpal exposure, periapical radiolucency 3 mm, no root resorption, no swelling, no mobility, no BOP; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
Assessment: Symptomatic apical periodontitis with pulp necrosis, previously untreated, diagnosed from fracture, exposure, and radiolucency.
Plan: Simple extraction of tooth #16 performed; socket irrigated with saline, gauze pressure applied for 45 min; patient received POI, advised soft diet, avoid chewing on side, use ice packs; next visit in 7 days for healing check.

S: 79-year-old male, type 2 diabetes on metformin, NKDA, reports “My upper left molar snapped and I can’t chew”; fractured vertical split with pulpal exposure.
O: Tooth #16 fractured, pulpal exposure, periapical radiolucency 3 mm, no root resorption, no swelling, no mobility, no BOP; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
A: Symptomatic apical periodontitis with pulp necrosis, previously untreated, diagnosed from fracture, exposure, and radiolucency.
P: Simple extraction of tooth #16 performed; socket irrigated with saline, gauze pressure applied for 45 min; patient received POI, advised soft diet, avoid chewing on side, use ice packs; next visit in 7 days for healing check.

Extraction With Anticoagulant Management

SOAP note

Subjective: 21-year-old female, asthma, NKDA, reports “My lower right molar broke and I’m in pain”; fractured #30 with horizontal split, pulpal exposure, 2 mm periapical radiolucency, no swelling, no mobility, no BOP.
Objective: Extraoral normal; intraoral tooth #30 fractured, exposed pulp; periodontal BOP negative; radiograph PA shows 2 mm periapical radiolucency, no root resorption; aspiration negative.
Assessment: Pulp necrosis, previously untreated, symptomatic apical periodontitis, supported by pulpal exposure, radiolucency, and pain.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; simple extraction of #30; socket irrigated with saline; gauze pressure 30 min; POI given: avoid hard food, use ice packs, return if bleeding >24 h or pain worsens.

S: 21-year-old female, asthma, NKDA, reports “My lower right molar broke and I’m in pain”; fractured #30 with horizontal split, pulpal exposure, 2 mm periapical radiolucency, no swelling, no mobility, no BOP.
O: Extraoral normal; intraoral tooth #30 fractured, exposed pulp; periodontal BOP negative; radiograph PA shows 2 mm periapical radiolucency, no root resorption; aspiration negative.
A: Pulp necrosis, previously untreated, symptomatic apical periodontitis, supported by pulpal exposure, radiolucency, and pain.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; simple extraction of #30; socket irrigated with saline; gauze pressure 30 min; POI given: avoid hard food, use ice packs, return if bleeding >24 h or pain worsens.

Extraction in a Patient With Bisphosphonate Therapy

SOAP note

Subjective: 31-year-old female, allergic to penicillin (rash), reports “My lower right molar broke and it’s painful”; history of a vertical split with no pulpal exposure; PMH non-significant.
Objective: Extraoral WNL; intraoral tooth #30 fractured, no mobility, no BOP; periodontal probing normal; PA radiograph shows intact root, no periapical radiolucency; no swelling; IANB anesthesia 2% lidocaine 1:100,000, 1.8 mL, aspiration negative.
Assessment: Pulp necrosis, previously untreated, symptomatic apical periodontitis—supported by vertical fracture, pain, and radiographic lack of periapical pathology.
Plan: Simple extraction of tooth #30 performed; socket curetted and irrigated with saline; gauze pressure for 30 min; POI given—avoid hard foods, use ice packs; next visit in 7 days for healing assessment.

S: 31-year-old female, allergic to penicillin (rash), reports “My lower right molar broke and it’s painful”; history of a vertical split with no pulpal exposure; PMH non-significant.
O: Extraoral WNL; intraoral tooth #30 fractured, no mobility, no BOP; periodontal probing normal; PA radiograph shows intact root, no periapical radiolucency; no swelling; IANB anesthesia 2% lidocaine 1:100,000, 1.8 mL, aspiration negative.
A: Pulp necrosis, previously untreated, symptomatic apical periodontitis—supported by vertical fracture, pain, and radiographic lack of periapical pathology.
P: Simple extraction of tooth #30 performed; socket curetted and irrigated with saline; gauze pressure for 30 min; POI given—avoid hard foods, use ice packs; next visit in 7 days for healing assessment.

Extraction of a Fractured Tooth in a Pregnant Patient (Second Trimester)

SOAP note

Subjective: 34-year-old female, pregnant, smoker 5 cigarettes/day, NKDA, presents with “My upper left molar broke and I’m in pain”; history shows a horizontal split of tooth #16 with pulpal exposure, periapical radiolucency 3 mm, no swelling, no mobility, no BOP; PMH: pregnancy, smoking.
Objective: Extraoral: no swelling, extraoral symmetry normal. Intraoral: tooth #16 fractured with horizontal split, pulpal exposure, no mobility, no BOP. Periodontal: probing depths within normal limits, no recession. Radiographic: PA shows 3 mm periapical radiolucency, no root resorption, no sinus tract. Tests: none performed.
Assessment: Pulp necrosis, previously untreated, symptomatic apical periodontitis of tooth #16, supported by pulpal exposure, radiolucency, and pain.
Plan: Simple extraction of tooth #16 performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration; aspiration negative. Socket irrigated with saline; gauze pressure applied for 45 min. POI: avoid hard foods, maintain soft diet, use cold packs, rinse with warm water after 24 h, report bleeding or severe pain. Next visit: follow-up in 7 days for healing assessment.

S: 34-year-old female, pregnant, smoker 5 cigarettes/day, NKDA, presents with “My upper left molar broke and I’m in pain”; history shows a horizontal split of tooth #16 with pulpal exposure, periapical radiolucency 3 mm, no swelling, no mobility, no BOP; PMH: pregnancy, smoking.
O: Extraoral: no swelling, extraoral symmetry normal. Intraoral: tooth #16 fractured with horizontal split, pulpal exposure, no mobility, no BOP. Periodontal: probing depths within normal limits, no recession. Radiographic: PA shows 3 mm periapical radiolucency, no root resorption, no sinus tract. Tests: none performed.
A: Pulp necrosis, previously untreated, symptomatic apical periodontitis of tooth #16, supported by pulpal exposure, radiolucency, and pain.
P: Simple extraction of tooth #16 performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration; aspiration negative. Socket irrigated with saline; gauze pressure applied for 45 min. POI: avoid hard foods, maintain soft diet, use cold packs, rinse with warm water after 24 h, report bleeding or severe pain. Next visit: follow-up in 7 days for healing assessment.

Extraction With Antibiotic Prophylaxis for Cardiac Condition

SOAP note

Subjective: 32-year-old male, hypothyroidism on levothyroxine, penicillin allergy (rash), chief complaint: “I have a broken tooth that’s painful and I’m worried about my heart.” HPI: fractured tooth, no pulpal exposure, no swelling or trismus, INR 2.4 stable, no systemic signs. PMH: hypothyroidism, cardiac condition requiring antibiotic prophylaxis.
Objective: Extraoral: no swelling, trismus WNL. Intraoral: fractured tooth #30, intact soft tissues, no periapical radiolucency on PA. Periodontal: healthy gingiva, no BOP. Radiographic: PA shows no periapical pathology. Tests: INR 2.4, no other abnormal labs.
Assessment: Non-restorable caries of tooth #30, supported by fracture, absence of pulpal exposure, and clear radiograph.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Extraction of tooth #30, socket curetted, hemostasis with gauze pressure. Antibiotic prophylaxis: amoxicillin 2 g orally 30 min pre-procedure, single dose. Chlorhexidine gluconate 0.12% 15 mL rinse 30 sec twice daily POI. Next visit: follow-up in 7 days for healing assessment.

S: 32-year-old male, hypothyroidism on levothyroxine, penicillin allergy (rash), chief complaint: “I have a broken tooth that’s painful and I’m worried about my heart.” HPI: fractured tooth, no pulpal exposure, no swelling or trismus, INR 2.4 stable, no systemic signs. PMH: hypothyroidism, cardiac condition requiring antibiotic prophylaxis.
O: Extraoral: no swelling, trismus WNL. Intraoral: fractured tooth #30, intact soft tissues, no periapical radiolucency on PA. Periodontal: healthy gingiva, no BOP. Radiographic: PA shows no periapical pathology. Tests: INR 2.4, no other abnormal labs.
A: Non-restorable caries of tooth #30, supported by fracture, absence of pulpal exposure, and clear radiograph.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Extraction of tooth #30, socket curetted, hemostasis with gauze pressure. Antibiotic prophylaxis: amoxicillin 2 g orally 30 min pre-procedure, single dose. Chlorhexidine gluconate 0.12% 15 mL rinse 30 sec twice daily POI. Next visit: follow-up in 7 days for healing assessment.

Extraction in a Patient With Aspirin Allergy

SOAP note

Subjective: 33-year-old male, no significant medical history, aspirin allergy (rash); CC: “My molar is broken and it hurts when I bite”; HPI: fractured tooth with pulpal exposure, pain on biting, no swelling or trismus; PMH: none; aspirin allergy noted.
Objective: Extraoral: no swelling, trismus, or facial asymmetry; Intraoral: fractured #30 with exposed pulp, moderate caries; Periodontal: healthy gingiva, no BOP; Radiograph: periapical radiolucency around #30, no root resorption; Tests: none.
Assessment: Symptomatic apical periodontitis of tooth #30, supported by pulpal exposure, pain on biting, and periapical radiolucency.
Plan: 4% articaine with 1:100,000 epinephrine, 1.8 mL infiltration buccal, aspiration negative; extraction of #30 performed, socket curetted, hemostasis achieved with gauze pressure; POI: bite on gauze for 30-60 min, no spitting, rinsing, or smoking for 24 h, soft diet, cold packs as needed; schedule follow-up in 7 days for healing assessment.

S: 33-year-old male, no significant medical history, aspirin allergy (rash); CC: “My molar is broken and it hurts when I bite”; HPI: fractured tooth with pulpal exposure, pain on biting, no swelling or trismus; PMH: none; aspirin allergy noted.
O: Extraoral: no swelling, trismus, or facial asymmetry; Intraoral: fractured #30 with exposed pulp, moderate caries; Periodontal: healthy gingiva, no BOP; Radiograph: periapical radiolucency around #30, no root resorption; Tests: none.
A: Symptomatic apical periodontitis of tooth #30, supported by pulpal exposure, pain on biting, and periapical radiolucency.
P: 4% articaine with 1:100,000 epinephrine, 1.8 mL infiltration buccal, aspiration negative; extraction of #30 performed, socket curetted, hemostasis achieved with gauze pressure; POI: bite on gauze for 30-60 min, no spitting, rinsing, or smoking for 24 h, soft diet, cold packs as needed; schedule follow-up in 7 days for healing assessment.

Extraction of a Fractured Tooth in a Child

SOAP note

Subjective: 8-year-old male, seasonal allergies, NKDA, reports “My front tooth is broken and it hurts when I eat”; history shows no pulpal exposure and no swelling or trismus.
Objective: Extraoral normal; intraoral shows fractured tooth #8 with intact surrounding tissues; periodontal probing WNL; PA radiograph shows no periapical radiolucency; no abnormal findings on other teeth.
Assessment: Non-restorable caries of tooth #8, supported by fracture, lack of pulpal exposure, and clear periapical radiograph.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration buccal, aspiration negative; extracted tooth #8, socket curetted, hemostasis achieved with gauze pressure; instructed to bite gauze 30-60 min, avoid hard foods, use soft diet, apply cold packs, and return if pain worsens or bleeding persists.

S: 8-year-old male, seasonal allergies, NKDA, reports “My front tooth is broken and it hurts when I eat”; history shows no pulpal exposure and no swelling or trismus.
O: Extraoral normal; intraoral shows fractured tooth #8 with intact surrounding tissues; periodontal probing WNL; PA radiograph shows no periapical radiolucency; no abnormal findings on other teeth.
A: Non-restorable caries of tooth #8, supported by fracture, lack of pulpal exposure, and clear periapical radiograph.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration buccal, aspiration negative; extracted tooth #8, socket curetted, hemostasis achieved with gauze pressure; instructed to bite gauze 30-60 min, avoid hard foods, use soft diet, apply cold packs, and return if pain worsens or bleeding persists.

Extraction of a Fractured Tooth in a Child with Anemia

SOAP note

Subjective: 67-year-old female, asthma on albuterol PRN, NKDA, CC: “My molar is broken and it’s painful,” HPI: fractured tooth with pulpal exposure, no swelling or trismus, PMH: asthma, medications: albuterol, no known drug allergies.
Objective: Extraoral: no facial swelling, intraoral: fractured #19 with exposed pulp, periodontal: BOP present, radiograph: periapical radiolucency around #19, no sinus tract, tests: normal bite, no paresthesia, vital signs: BP 128/78, pulse 76.
Assessment: Symptomatic apical periodontitis of tooth #19, supported by pulpal exposure, periapical radiolucency, pain on biting, and absence of systemic signs.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB buccal, aspiration negative; extraction of #19 performed, socket curetted, hemostasis achieved with gauze pressure, postoperative instructions given (bite gauze 30-60 min, no spitting or rinsing for 24 h, soft diet, cold packs, NSAID as needed, return to clinic in 7 days for healing assessment).

S: 67-year-old female, asthma on albuterol PRN, NKDA, CC: “My molar is broken and it’s painful,” HPI: fractured tooth with pulpal exposure, no swelling or trismus, PMH: asthma, medications: albuterol, no known drug allergies.
O: Extraoral: no facial swelling, intraoral: fractured #19 with exposed pulp, periodontal: BOP present, radiograph: periapical radiolucency around #19, no sinus tract, tests: normal bite, no paresthesia, vital signs: BP 128/78, pulse 76.
A: Symptomatic apical periodontitis of tooth #19, supported by pulpal exposure, periapical radiolucency, pain on biting, and absence of systemic signs.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB buccal, aspiration negative; extraction of #19 performed, socket curetted, hemostasis achieved with gauze pressure, postoperative instructions given (bite gauze 30-60 min, no spitting or rinsing for 24 h, soft diet, cold packs, NSAID as needed, return to clinic in 7 days for healing assessment).

Extraction With Dental Anxiety Management in a Young Adult

SOAP note

Subjective: 26-year-old female, takes low-dose aspirin, NKDA, chief complaint: “I’m nervous about the extraction and it’s painful”; fractured #30, pulpal exposure absent, periapical radiograph shows no radiolucency, no swelling, no trismus, systemic signs none.
Objective: extraoral: no asymmetry, intraoral: fractured #30, periodontal: healthy, radiograph: PA of #30 shows intact periapical area, no swelling, no trismus; tests: none.
Assessment: non-restorable caries of #30, supported by fracture, lack of pulpal exposure, and periapical radiograph showing no pathology.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; extraction of #30 performed, socket curetted, hemostasis with gauze pressure; anxiety managed with verbal reassurance and nitrous oxide 50%; no drugs prescribed; POI: bite on gauze 30-60 min, no spitting, rinsing, or smoking for 24 h, soft diet, cold packs, return to clinic in 7 days for healing assessment.

S: 26-year-old female, takes low-dose aspirin, NKDA, chief complaint: “I’m nervous about the extraction and it’s painful”; fractured #30, pulpal exposure absent, periapical radiograph shows no radiolucency, no swelling, no trismus, systemic signs none.
O: extraoral: no asymmetry, intraoral: fractured #30, periodontal: healthy, radiograph: PA of #30 shows intact periapical area, no swelling, no trismus; tests: none.
A: non-restorable caries of #30, supported by fracture, lack of pulpal exposure, and periapical radiograph showing no pathology.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; extraction of #30 performed, socket curetted, hemostasis with gauze pressure; anxiety managed with verbal reassurance and nitrous oxide 50%; no drugs prescribed; POI: bite on gauze 30-60 min, no spitting, rinsing, or smoking for 24 h, soft diet, cold packs, return to clinic in 7 days for healing assessment.

Extraction With Dental Anxiety Management

SOAP note

Subjective: 78-year-old female, controlled hypertension on lisinopril, NKDA, reports “My molar is broken and I’m scared of the pain.” Fractured #32 with exposed pulp absent; periapical radiograph shows no radiolucency; no swelling or trismus.
Objective: Extraoral: normal; Intraoral: fractured #32, no swelling, no trismus. Periodontal: healthy. Radiographic: PA of #32 shows intact periapical tissues, no radiolucency. Tests: none.
Assessment: Non-restorable caries of tooth #32, supported by fracture, lack of pulpal exposure, and radiographic absence of periapical pathology.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB buccal, aspiration negative. Extraction of #32 performed; socket curetted, hemostasis achieved with gauze pressure. Anxiety managed with 50% nitrous oxide. Post-operative instructions: bite on gauze 30-60 min, avoid spitting, rinsing, straws, smoking for 24 h, soft diet, cold packs. Schedule follow-up in 7 days for healing assessment.

S: 78-year-old female, controlled hypertension on lisinopril, NKDA, reports “My molar is broken and I’m scared of the pain.” Fractured #32 with exposed pulp absent; periapical radiograph shows no radiolucency; no swelling or trismus.
O: Extraoral: normal; Intraoral: fractured #32, no swelling, no trismus. Periodontal: healthy. Radiographic: PA of #32 shows intact periapical tissues, no radiolucency. Tests: none.
A: Non-restorable caries of tooth #32, supported by fracture, lack of pulpal exposure, and radiographic absence of periapical pathology.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB buccal, aspiration negative. Extraction of #32 performed; socket curetted, hemostasis achieved with gauze pressure. Anxiety managed with 50% nitrous oxide. Post-operative instructions: bite on gauze 30-60 min, avoid spitting, rinsing, straws, smoking for 24 h, soft diet, cold packs. Schedule follow-up in 7 days for healing assessment.

Extraction With Anticoagulant Management in a Warfarin User

SOAP note

Subjective: 67-year-old female, asthma, NKDA, reports fractured molar and concerns about bleeding.
Objective: Extraoral: no swelling, no trismus. Intraoral: fractured #30, no pulpal exposure. Radiograph: periapical radiolucency absent. No other findings.
Assessment: Non-restorable caries of #30, supported by fracture, absence of periapical pathology, and patient’s complaint.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative; extracted #30, socket curetted; hemostasis with gauze pressure and oxidized cellulose; patient instructed to keep warfarin regimen unchanged, avoid strenuous activity, use ice packs, and return if bleeding exceeds 24 h.

S: 67-year-old female, asthma, NKDA, reports fractured molar and concerns about bleeding.
O: Extraoral: no swelling, no trismus. Intraoral: fractured #30, no pulpal exposure. Radiograph: periapical radiolucency absent. No other findings.
A: Non-restorable caries of #30, supported by fracture, absence of periapical pathology, and patient’s complaint.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative; extracted #30, socket curetted; hemostasis with gauze pressure and oxidized cellulose; patient instructed to keep warfarin regimen unchanged, avoid strenuous activity, use ice packs, and return if bleeding exceeds 24 h.

When to Use a Broken Tooth Extraction Note vs. a Retained Root Extraction Note

Broken tooth extraction notes apply when a tooth is removed intact or in pieces, with no root fragment left in the socket. Use a retained-root extraction note only if a root tip or fragment remains after the fractured tooth is removed. Splinting is required for mobile fractured teeth that are extracted as a unit; it is not indicated when the tooth is extracted intact or when a root tip is left behind. Presence of a root fragment is the decisive factor: if the radiograph shows a remaining root stump, document a retained-root extraction. If the radiograph shows complete removal of crown and root, document a broken tooth extraction.

Checklist / decision tree

Step 1: Radiograph reviewed.
- Root fragment present → Retained-Root Extraction.
- No fragment → proceed to Step 2.
Step 2: Tooth removed intact or in fragments?
- Intact or fragments removed → Broken Tooth Extraction.
- Fragment remains in socket → Retained-Root Extraction.
Step 3: Mobility and splinting?
- Mobile tooth extracted as a unit → note splinting in plan.
- Tooth not mobile → splinting not required.

The retained-root note records the root tip left in the socket, the decision to avoid removal, and any follow-up for potential root resorption or infection.

Key Elements of a Broken Tooth Extraction SOAP Note

Subjective (S) – Pain & Swelling Assessment

Record CC in patient words and HPI.
Note pain intensity 0-10, character, triggers, and relief.
Document swelling: location, size, progression.
Include PMH, allergies, tobacco use, pregnancy status.

Objective (O) – Fracture Type & Tooth Identification

Identify tooth number and surfaces involved.
Classify fracture: crown, root, or combined; note completeness.
Report radiographic findings: PA or PAN, fracture line, periapical status.
Note mobility (Miller grade) and adjacent tooth condition.

Assessment (A) – Severity & Splinting Decision

State fracture severity and extraction indication.
Decide on splinting: mobile fractured tooth → splint; intact extraction → none.
Record root fragment status: retained or removed.

Plan (P) – Anesthesia, Splinting/Restoration, Follow-Up

Specify anesthesia: agent, concentration, vasoconstrictor, volume, technique.
Outline splinting: type, material, duration if applicable.
Detail restoration plan: extraction, immediate placement, or referral.
Provide POI: diet, ice, analgesic, bleeding control.
Schedule follow-up: day 7 for healing, earlier if complications.

Pain & Swelling Documentation

Pain Assessment

Record the patient’s exact words for the chief complaint, then detail pain location, onset, duration, character (sharp, dull, throbbing), triggers (cold, biting, sweet), relief, and numeric rating 0-10. Example: “I feel a sharp 8/10 pain in the left upper canine when I bite.” Include whether the pain is spontaneous or provoked, any radiation, and effect on sleep. Note if the tooth was removed intact or in pieces: “Tooth #13 removed in two fragments; pain now 5/10, dull.”

Swelling Assessment

Document swelling size (e.g., “moderate, 1 cm × 1 cm on buccal gingiva”), location, progression, and associated symptoms (trismus, erythema, warmth). Example: “Swelling 2 cm buccally, progressing over 4 h; patient reports mild tenderness and difficulty opening mouth.” Indicate whether swelling is localized to the extraction site or diffuse, and note any associated signs such as facial edema or lymphadenopathy.

Fracture Documentation

Fracture Type

Record the fracture as crown-only, root-crown, root-only, vertical, or horizontal. Use a concise phrase: “crown-only fracture, oblique, involving the labial surface of tooth #19” or “vertical root fracture, apical third of tooth #30”. When the fracture is incomplete, note the extent: “partial crown fracture, 2 mm labial extension”. If the tooth was removed in pieces, write “tooth #13 extracted in two fragments, crown and root separated”. If removed intact, write “tooth #13 extracted intact, no fragments left”.

Tooth Identification

Identify the tooth with the Universal numbering system and include the surface(s) involved. Example: “tooth #13, mesio-distal fracture of the incisal edge” or “tooth #30, vertical root fracture, palatal surface”. When the tooth was removed intact, note the intact status: “tooth #13 removed intact, no residual fragments”. When extracted in pieces, note the pieces: “tooth #13 extracted in crown and root fragments, both removed”. Use the same format for primary teeth, e.g., “tooth K, crown fracture, occlusal surface”.

Splinting, Anesthesia, and Follow-Up Planning

Splinting Indication & Type

Splint when the fractured tooth is mobile (Miller ≥ 1) and extracted as a unit.
Rigid splint: stainless-steel wire with composite or acrylic, fixed for 2–4 weeks.
Flexible splint: fiber-reinforced composite or elastic band, used when adjacent teeth are healthy and mobility is mild.
Document: “Splint: rigid, stainless-steel wire + composite; duration 4 weeks; applied to tooth #13 and adjacent #12.”

Anesthesia Details

Topical: 20 % benzocaine, 30 s application.
Agent: 2 % lidocaine with 1:100,000 epinephrine.
Volume: 1.8 mL (1 cartridge).
Technique: infiltration at buccal and lingual sites.
Aspiration: negative.
Record: “Anesthesia: 20 % benzocaine topical, 2 % lidocaine + 1:100,000 epi, 1.8 mL, infiltration, aspiration negative.”

Follow-Up Schedule

Next visit: 7 days post-extraction.
Purpose: evaluate socket healing, remove splint, assess need for restoration.
Document: “RTC in 7 days: check healing, remove splint, plan restoration.”

These examples show structure and wording only. Record what you actually found and did, and follow your practice’s documentation requirements.

About the author

Dr. Rahul Joshi

Specialist Orthodontist

Dr. Rahul Joshi is a Specialist Orthodontist with extensive clinical experience in orthodontics, dentofacial orthopaedics, and dental aesthetics. Holding a Master of Dental Surgery (MDS) in Orthodontics and Dentofacial Orthopaedics and a Bachelor of Dental Surgery (BDS) from Manipal Academy of Higher Education, he brings expertise in orthodontic treatment planning, teeth alignment, and Invisalign treatment. With professional experience across India and the Netherlands, Dr. Joshi combines clinical knowledge with practical experience in orthodontic care, dental aesthetics, and improving patients' oral health.

Master of Dental Surgery (MDS) in Orthodontics and Dentofacial Orthopaedics — Manipal Academy of Higher Education
Bachelor of Dental Surgery (BDS) — Manipal Academy of Higher Education

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Emergency Sports-Related Extractions

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Emergency Extraction for Sports-Related Fracture in a Teenager

Extraction After Failed Root Canal Therapy

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Extraction With Post-operative Dry Socket Monitoring in a Smoker

Re-evaluation After Failed Splint

Re-evaluation After Failed Splint in a Diabetic

Re-evaluation After Failed Splint in a Hypertensive Patient

Re-evaluation After Failed Splint in a Post-Op Patient on Anticoagulants

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Extraction With Immediate Implant Placement

Extraction With Immediate Implant Placement in a Young Adult

Medical Condition-Specific Extractions

Pregnant, First Trimester, Broken Upper Central Incisor

Diabetic, Controlled, Broken Lower Second Molar

NSAID Allergy, Broken Upper Lateral Incisor

Elderly, Osteoporosis, Broken Lower Third Molar

Pregnancy, Second Trimester, Broken Upper Canine

Hypertensive, Broken Lower Premolar

Allergic to Penicillin, Broken Upper Molar

Pregnant, Third Trimester, Broken Lower Molar

Elderly, Arthritis, Broken Lower Molar

Diabetic, Uncontrolled, Broken Lower Molar

Pregnancy, First Trimester, Broken Upper Molar

Allergic to Aspirin, Broken Lower Molar

Diabetic, Controlled, Broken Upper Molar

Extraction With Anticoagulant Management

Extraction in a Patient With Bisphosphonate Therapy

Extraction of a Fractured Tooth in a Pregnant Patient (Second Trimester)

Extraction With Antibiotic Prophylaxis for Cardiac Condition

Extraction in a Patient With Aspirin Allergy

Extraction of a Fractured Tooth in a Child

Extraction of a Fractured Tooth in a Child with Anemia

Extraction With Dental Anxiety Management in a Young Adult

Extraction With Dental Anxiety Management

Extraction With Anticoagulant Management in a Warfarin User

When to Use a Broken Tooth Extraction Note vs. a Retained Root Extraction Note

Key Elements of a Broken Tooth Extraction SOAP Note

Subjective (S) – Pain & Swelling Assessment

Objective (O) – Fracture Type & Tooth Identification

Assessment (A) – Severity & Splinting Decision

Plan (P) – Anesthesia, Splinting/Restoration, Follow-Up

Pain & Swelling Documentation

Pain Assessment

Swelling Assessment

Fracture Documentation

Fracture Type

Tooth Identification

Splinting, Anesthesia, and Follow-Up Planning

Splinting Indication & Type

Anesthesia Details

Follow-Up Schedule

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