Dental Follow-Up Visit SOAP Note: 30+ Ready-to-Copy Examples

Dr. Rahul Joshi

Nov 08, 2026 - Updated Nov 09, 2026 - 51 Min read

Extraction Follow-Up Visits

Smoker, Day 3 After Lower Molar Extraction

SOAP note

Subjective: 34-year-old male smoker, 5 cigarettes/day, controlled hypertension on lisinopril, NKDA; CC: “I still have a sore spot after the extraction.” HPI: mild soreness, pain 2/10, dull, relieved with cold, no drainage or erythema beyond socket.
Objective: Mild swelling 3 mm around extraction socket; pain 2/10, dull, relieved with cold; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration; extraoral and intraoral otherwise WNL.
Assessment: Healing extraction site, no infection.
Plan: No medication prescribed. Post-operative instructions given verbally and in writing: use ice packs, maintain soft diet, avoid smoking. Next review scheduled in 7 days.

S: 34-year-old male smoker, 5 cigarettes/day, controlled hypertension on lisinopril, NKDA; CC: “I still have a sore spot after the extraction.” HPI: mild soreness, pain 2/10, dull, relieved with cold, no drainage or erythema beyond socket.
O: Mild swelling 3 mm around extraction socket; pain 2/10, dull, relieved with cold; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration; extraoral and intraoral otherwise WNL.
A: Healing extraction site, no infection.
P: No medication prescribed. Post-operative instructions given verbally and in writing: use ice packs, maintain soft diet, avoid smoking. Next review scheduled in 7 days.

Pregnant, Day 7 After Upper Incisor Extraction

SOAP note

Subjective: 64-year-old pregnant female, hypothyroid on levothyroxine, allergic to penicillin (rash). Chief complaint: “I’m still a bit sore and the area feels tender.” HPI: pain 3/10, sharp, worsens with hot liquids; no swelling or drainage.
Objective: Extraoral: no swelling. Intraoral: slight erythema 5 mm around socket of #7; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration. Pain 3/10, sharp, hot-liquid trigger. No systemic signs.
Assessment: Healing extraction site, no infection.
Plan: Anesthesia used: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), infiltration, aspiration negative. Post-operative instructions: avoid hot foods, continue chlorhexidine 0.12% rinse twice daily. No medications prescribed. Next visit scheduled in 7 days.

S: 64-year-old pregnant female, hypothyroid on levothyroxine, allergic to penicillin (rash). Chief complaint: “I’m still a bit sore and the area feels tender.” HPI: pain 3/10, sharp, worsens with hot liquids; no swelling or drainage.
O: Extraoral: no swelling. Intraoral: slight erythema 5 mm around socket of #7; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration. Pain 3/10, sharp, hot-liquid trigger. No systemic signs.
A: Healing extraction site, no infection.
P: Anesthesia used: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), infiltration, aspiration negative. Post-operative instructions: avoid hot foods, continue chlorhexidine 0.12% rinse twice daily. No medications prescribed. Next visit scheduled in 7 days.

Non-smoker, Day 10 After Extraction of Third Molar

SOAP note

Subjective: 67-year-old female, smokes five cigarettes daily, NKDA, presents for day-10 follow-up after extraction of tooth #30. She reports that the molar area still hurts a bit; pain is 4/10, dull in character, relieved with cold, and she denies any drainage or worsening swelling. There is no systemic illness or new symptoms since the procedure.
Objective: Extraoral examination shows no facial asymmetry, no cervical lymphadenopathy, and normal mouth opening. Intraorally, the socket of #30 shows mild swelling of approximately 4 mm around the extraction site; the mucosa is pink with no ulceration or erythema beyond the socket. Probing depth is 2 mm, with no bleeding on probing, and the surrounding gingiva appears healthy.
Assessment: Healing extraction site with no evidence of infection or delayed healing.
Plan: Local anesthesia was administered during the extraction: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Post-operative instructions were reiterated, emphasizing avoidance of smoking, maintaining oral hygiene, and monitoring for any new pain, swelling, or drainage. No medications were prescribed at this visit. A follow-up review is scheduled for day 14 to assess continued healing.

S: 67-year-old female, smokes five cigarettes daily, NKDA, presents for day-10 follow-up after extraction of tooth #30. She reports that the molar area still hurts a bit; pain is 4/10, dull in character, relieved with cold, and she denies any drainage or worsening swelling. There is no systemic illness or new symptoms since the procedure.
O: Extraoral examination shows no facial asymmetry, no cervical lymphadenopathy, and normal mouth opening. Intraorally, the socket of #30 shows mild swelling of approximately 4 mm around the extraction site; the mucosa is pink with no ulceration or erythema beyond the socket. Probing depth is 2 mm, with no bleeding on probing, and the surrounding gingiva appears healthy.
A: Healing extraction site with no evidence of infection or delayed healing.
P: Local anesthesia was administered during the extraction: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Post-operative instructions were reiterated, emphasizing avoidance of smoking, maintaining oral hygiene, and monitoring for any new pain, swelling, or drainage. No medications were prescribed at this visit. A follow-up review is scheduled for day 14 to assess continued healing.

Geriatric, Day 1 After Crown & Bridge Placement

SOAP note

Subjective: 79-year-old female, no significant medical history, allergic to penicillin (rash); chief complaint: “I just had a crown placed and I'm wondering how it feels.” O: crown seated, margins intact; gingiva pink, mild 2-mm inflammation, no bleeding on probing; probing depth 1 mm, no pocketing; no ulceration; systemic signs none. A: post-operative healing of crown placement, evidenced by intact margins, absence of pain, and shallow probing depths. P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative; no medications prescribed; postoperative instructions: avoid hard foods for 24 h, maintain oral hygiene, report swelling or pain; next visit in 7 days for bridge cementation.

S: 79-year-old female, no significant medical history, allergic to penicillin (rash); chief complaint: “I just had a crown placed and I'm wondering how it feels.” O: crown seated, margins intact; gingiva pink, mild 2-mm inflammation, no bleeding on probing; probing depth 1 mm, no pocketing; no ulceration; systemic signs none. A: post-operative healing of crown placement, evidenced by intact margins, absence of pain, and shallow probing depths. P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative; no medications prescribed; postoperative instructions: avoid hard foods for 24 h, maintain oral hygiene, report swelling or pain; next visit in 7 days for bridge cementation.

Smoker, Day 1 After Extraction of Impacted Tooth

SOAP note

Subjective: 23-year-old female, smoker (5 cigs/day), NKDA, reports “I still feel pain after the extraction.” HPI: pain 5/10, sharp, worsens with pressure, no drainage or erythema beyond socket.
Objective: Mild swelling 5 mm around socket; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration; pain 5/10, sharp; no systemic signs.
Assessment: Healing extraction site, no infection.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative was used; no drugs prescribed. Post-operative instructions: use ice packs, soft diet, avoid smoking. Next review scheduled in 7 days.

S: 23-year-old female, smoker (5 cigs/day), NKDA, reports “I still feel pain after the extraction.” HPI: pain 5/10, sharp, worsens with pressure, no drainage or erythema beyond socket.
O: Mild swelling 5 mm around socket; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration; pain 5/10, sharp; no systemic signs.
A: Healing extraction site, no infection.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative was used; no drugs prescribed. Post-operative instructions: use ice packs, soft diet, avoid smoking. Next review scheduled in 7 days.

Diabetic, Day 7 After Extraction of Tooth 18

SOAP note

Subjective: 66-year-old female with type 2 diabetes on metformin, seasonal allergies, NKDA, reports “My lower right molar area still hurts a bit.” HPI: pain 4/10, dull, relieved with cold, no drainage, no erythema beyond socket, mild swelling 4 mm around socket.
Objective: Extraoral: mild swelling 4 mm around socket; intraoral: probing depth 2 mm, no bleeding on probing, gingiva pink, no ulceration; radiograph not taken; pain 4/10; anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, IANB, aspiration negative.
Assessment: Healing extraction site of tooth #30, no infection.
Plan: Post-operative instructions reiterated; advised strict glycemic control, avoid smoking; no medication prescribed; next review scheduled in 7 days (day 14).

S: 66-year-old female with type 2 diabetes on metformin, seasonal allergies, NKDA, reports “My lower right molar area still hurts a bit.” HPI: pain 4/10, dull, relieved with cold, no drainage, no erythema beyond socket, mild swelling 4 mm around socket.
O: Extraoral: mild swelling 4 mm around socket; intraoral: probing depth 2 mm, no bleeding on probing, gingiva pink, no ulceration; radiograph not taken; pain 4/10; anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, IANB, aspiration negative.
A: Healing extraction site of tooth #30, no infection.
P: Post-operative instructions reiterated; advised strict glycemic control, avoid smoking; no medication prescribed; next review scheduled in 7 days (day 14).

Elderly, Day 3 After Extraction of a Mandibular Incisor with Anticoagulant Therapy

SOAP note

Subjective: 44-year-old male, type 2 diabetic on metformin, NKDA, reports “I still have a bit of bleeding and soreness.” He is on anticoagulant therapy and has not interrupted it.
Objective: Mild bleeding controlled with gauze, no active oozing; 3 mm swelling around socket; pain 3/10 dull, relieved with cold; no drainage or erythema beyond socket; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration.
Assessment: Healing extraction site, no infection.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; postoperative instructions: continue anticoagulants, ice packs, soft diet; next review in 4 days (day 7).

S: 44-year-old male, type 2 diabetic on metformin, NKDA, reports “I still have a bit of bleeding and soreness.” He is on anticoagulant therapy and has not interrupted it.
O: Mild bleeding controlled with gauze, no active oozing; 3 mm swelling around socket; pain 3/10 dull, relieved with cold; no drainage or erythema beyond socket; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration.
A: Healing extraction site, no infection.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; postoperative instructions: continue anticoagulants, ice packs, soft diet; next review in 4 days (day 7).

Smoker, Day 1 After Molar Extraction with Graft

SOAP note

Subjective: 56-year-old female smoker, 5 cigarettes/day, asthma on albuterol PRN, NKDA; CC: “I still feel some soreness after the extraction.” HPI: pain 3/10, dull, relieved with cold, no drainage, mild swelling 4 mm around socket.
Objective: Graft in place, stable; mild swelling 4 mm; pain 3/10; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration; no erythema beyond socket; systemic signs none.
Assessment: Healing extraction site with graft, no infection.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; no drugs prescribed. POI: ice packs, soft diet, avoid smoking; next review in 7 days.

S: 56-year-old female smoker, 5 cigarettes/day, asthma on albuterol PRN, NKDA; CC: “I still feel some soreness after the extraction.” HPI: pain 3/10, dull, relieved with cold, no drainage, mild swelling 4 mm around socket.
O: Graft in place, stable; mild swelling 4 mm; pain 3/10; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration; no erythema beyond socket; systemic signs none.
A: Healing extraction site with graft, no infection.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; no drugs prescribed. POI: ice packs, soft diet, avoid smoking; next review in 7 days.

Non-smoker, Day 1 After Extraction of an Impacted Third Molar With Graft

SOAP note

Subjective: 21-year-old male, former smoker, NKDA, presents Day 1 after extraction of impacted third molar #30 with graft. He reports persistent pain, stating “I still have some pain after the extraction.” Pain is 4/10, dull in character, and is relieved by applying cold. No drainage, no erythema beyond the socket, and he denies fever or systemic symptoms.
Objective: Clinical findings reveal a stable graft in place and mild swelling measuring 5 mm around the socket. Probing depth is 2 mm with no bleeding on probing. The gingiva is pink, intact, and shows no ulceration. Anesthesia administered was 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, with negative aspiration.
Assessment: Healing extraction site with graft, no infection.
Plan: Post-operative instructions reiterated; patient advised to use ice packs, maintain a soft diet, and avoid smoking. No medications prescribed. Next review scheduled in 7 days.

S: 21-year-old male, former smoker, NKDA, presents Day 1 after extraction of impacted third molar #30 with graft. He reports persistent pain, stating “I still have some pain after the extraction.” Pain is 4/10, dull in character, and is relieved by applying cold. No drainage, no erythema beyond the socket, and he denies fever or systemic symptoms.
O: Clinical findings reveal a stable graft in place and mild swelling measuring 5 mm around the socket. Probing depth is 2 mm with no bleeding on probing. The gingiva is pink, intact, and shows no ulceration. Anesthesia administered was 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, with negative aspiration.
A: Healing extraction site with graft, no infection.
P: Post-operative instructions reiterated; patient advised to use ice packs, maintain a soft diet, and avoid smoking. No medications prescribed. Next review scheduled in 7 days.

Pregnancy, Day 14 After Wisdom Tooth Extraction

SOAP note

Subjective: 63-year-old pregnant female, on low-dose aspirin, NKDA, reports “I still have a bit of soreness after the extraction.” She has no systemic symptoms.
Objective: Mild swelling 4 mm around socket of tooth #30; pain 3/10, dull, relieved with cold; no drainage, no erythema beyond socket; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration.
Assessment: Healing extraction site, no infection, supported by minimal swelling, low pain score, and healthy gingival tissues.
Plan: 2 % lidocaine with 1:100 000 epinephrine, 1.8 mL IANB, aspiration negative. Post-operative instructions reiterated: ice packs, soft diet, avoid smoking. No medication prescribed. Next review scheduled in 7 days (day 21).

S: 63-year-old pregnant female, on low-dose aspirin, NKDA, reports “I still have a bit of soreness after the extraction.” She has no systemic symptoms.
O: Mild swelling 4 mm around socket of tooth #30; pain 3/10, dull, relieved with cold; no drainage, no erythema beyond socket; probing depth 2 mm, no bleeding on probing; gingiva pink, no ulceration.
A: Healing extraction site, no infection, supported by minimal swelling, low pain score, and healthy gingival tissues.
P: 2 % lidocaine with 1:100 000 epinephrine, 1.8 mL IANB, aspiration negative. Post-operative instructions reiterated: ice packs, soft diet, avoid smoking. No medication prescribed. Next review scheduled in 7 days (day 21).

Root Canal & Endodontic Follow-Up

Diabetic, Day 5 After Root Canal Therapy

SOAP note

Subjective: 29-year-old male, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “I’m here for my follow-up after the root canal on my upper first molar.” HPI: returns 5 days post-RCT, reports mild discomfort.
Objective: Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: gingiva around #14 pink, no erythema; mild tenderness to percussion, no swelling, no sinus tract. Radiograph: periapical film shows complete obturation, no periapical radiolucency.
Assessment: Previously treated tooth #14, normal apical tissues.
Plan: Reviewed healing, reinforced oral hygiene instructions, no medication prescribed. Scheduled next visit in 6 months for restoration placement.

S: 29-year-old male, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “I’m here for my follow-up after the root canal on my upper first molar.” HPI: returns 5 days post-RCT, reports mild discomfort.
O: Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: gingiva around #14 pink, no erythema; mild tenderness to percussion, no swelling, no sinus tract. Radiograph: periapical film shows complete obturation, no periapical radiolucency.
A: Previously treated tooth #14, normal apical tissues.
P: Reviewed healing, reinforced oral hygiene instructions, no medication prescribed. Scheduled next visit in 6 months for restoration placement.

Non-smoker, Day 6 After Root Canal Therapy

SOAP note

Subjective: 70-year-old female patient, smoker 5 cigarettes daily, NKDA, reports “I’m here for my follow-up after the root canal on my lower left molar.” She denies pain or swelling.
Objective: Tooth #18 shows no percussion tenderness, gingiva pink, no erythema. Extraoral exam: no facial swelling, lymph nodes not enlarged. Radiograph: periapical radiograph shows complete obturation, no periapical radiolucency.
Assessment: Previously treated tooth, normal apical tissues, supported by lack of tenderness, normal gingiva, and radiographic absence of pathology.
Plan: Reinforced oral hygiene instructions; no medication prescribed. Advised to return in 6 months for final restoration placement.

S: 70-year-old female patient, smoker 5 cigarettes daily, NKDA, reports “I’m here for my follow-up after the root canal on my lower left molar.” She denies pain or swelling.
O: Tooth #18 shows no percussion tenderness, gingiva pink, no erythema. Extraoral exam: no facial swelling, lymph nodes not enlarged. Radiograph: periapical radiograph shows complete obturation, no periapical radiolucency.
A: Previously treated tooth, normal apical tissues, supported by lack of tenderness, normal gingiva, and radiographic absence of pathology.
P: Reinforced oral hygiene instructions; no medication prescribed. Advised to return in 6 months for final restoration placement.

Diabetic, Day 2 After Endodontic Surgery

SOAP note

Subjective: 48-year-old female, type 2 diabetic on metformin, smoker 5 cigarettes/day, NKDA, reports “I’m here for my follow-up after the surgery on my upper left premolar.”
Objective: Tooth #12 shows mild buccal vestibular swelling, mild pain on biting; extraoral exam normal, no facial swelling or lymphadenopathy; intraoral surgical site healing with mild erythema; PA radiograph shows healing, no new radiolucency.
Assessment: Acute apical abscess, evidenced by localized swelling, pain on biting, and radiographic healing without new pathology.
Plan: Reassured patient, reinforced oral hygiene, advised to avoid hard foods, no medication prescribed; scheduled next visit in 7 days.

S: 48-year-old female, type 2 diabetic on metformin, smoker 5 cigarettes/day, NKDA, reports “I’m here for my follow-up after the surgery on my upper left premolar.”
O: Tooth #12 shows mild buccal vestibular swelling, mild pain on biting; extraoral exam normal, no facial swelling or lymphadenopathy; intraoral surgical site healing with mild erythema; PA radiograph shows healing, no new radiolucency.
A: Acute apical abscess, evidenced by localized swelling, pain on biting, and radiographic healing without new pathology.
P: Reassured patient, reinforced oral hygiene, advised to avoid hard foods, no medication prescribed; scheduled next visit in 7 days.

Pregnancy, Day 10 After Root Canal Therapy

SOAP note

Subjective: 55-year-old female, pregnant, allergic to penicillin (rash); CC: “I’m here for my follow-up after the root canal on my lower first molar.” HPI: 10 days post-RC; reports no pain or swelling. PMH: pregnancy; no other medications.
Objective: Tooth #30: no percussion tenderness, no swelling; extraoral: no facial swelling, lymph nodes not enlarged; intraoral: gingiva around #30 pink, no erythema; PA radiograph shows complete obturation, no periapical radiolucency.
Assessment: Previously treated tooth, normal apical tissues; findings support a healed periapical area with no pathology.
Plan: Reinforced oral hygiene instructions; no medications prescribed. Scheduled next visit in 6 months for restoration placement.

S: 55-year-old female, pregnant, allergic to penicillin (rash); CC: “I’m here for my follow-up after the root canal on my lower first molar.” HPI: 10 days post-RC; reports no pain or swelling. PMH: pregnancy; no other medications.
O: Tooth #30: no percussion tenderness, no swelling; extraoral: no facial swelling, lymph nodes not enlarged; intraoral: gingiva around #30 pink, no erythema; PA radiograph shows complete obturation, no periapical radiolucency.
A: Previously treated tooth, normal apical tissues; findings support a healed periapical area with no pathology.
P: Reinforced oral hygiene instructions; no medications prescribed. Scheduled next visit in 6 months for restoration placement.

Non-smoker, Day 3 After Root Canal of a Mandibular Premolar

SOAP note

Subjective: 71-year-old male, smoker (5 cigarettes daily), reports “I’m here for my follow-up after the root canal on my lower left premolar.” He denies pain, swelling or other symptoms, and has no known drug allergies.
Objective: Tooth #27: no percussion tenderness, gingiva pink and healthy, no erythema. Extraoral: no facial swelling, submandibular and cervical lymph nodes not enlarged. Intraoral: mucosa intact, no lesions. Radiograph: periapical view shows complete obturation of the canal, no periapical radiolucency, and the surrounding bone appears normal.
Assessment: Previously treated tooth, normal apical tissues – no pathology or complications identified.
Plan: Reinforced oral hygiene instructions given, advised to continue regular brushing and flossing. No medication prescribed. Next visit scheduled in 6 months for definitive restoration placement.

S: 71-year-old male, smoker (5 cigarettes daily), reports “I’m here for my follow-up after the root canal on my lower left premolar.”  He denies pain, swelling or other symptoms, and has no known drug allergies.
O: Tooth #27: no percussion tenderness, gingiva pink and healthy, no erythema. Extraoral: no facial swelling, submandibular and cervical lymph nodes not enlarged. Intraoral: mucosa intact, no lesions. Radiograph: periapical view shows complete obturation of the canal, no periapical radiolucency, and the surrounding bone appears normal.
A: Previously treated tooth, normal apical tissues – no pathology or complications identified.
P: Reinforced oral hygiene instructions given, advised to continue regular brushing and flossing. No medication prescribed. Next visit scheduled in 6 months for definitive restoration placement.

Pregnant, Day 5 After Endodontic Surgery of a Maxillary Incisor

SOAP note

Subjective: 20-year-old pregnant female; chief complaint: "I'm here for my follow-up after the surgery on my upper right central incisor." History: postoperative day 5, no systemic symptoms, NKDA, seasonal allergies.
Objective: Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: surgical site healing, mild erythema, mild swelling in vestibule, mild pain on biting. Tooth #8: mild swelling, no mobility. Radiograph: periapical shows healing, no new radiolucency.
Assessment: Acute apical abscess of tooth #8, supported by mild vestibular swelling, pain on biting, and periapical radiograph showing healing without new lesions.
Plan: Reassure patient, reinforce oral hygiene instructions, no medication prescribed. Schedule next visit in 7 days for restoration placement.

S: 20-year-old pregnant female; chief complaint: "I'm here for my follow-up after the surgery on my upper right central incisor." History: postoperative day 5, no systemic symptoms, NKDA, seasonal allergies.
O: Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: surgical site healing, mild erythema, mild swelling in vestibule, mild pain on biting. Tooth #8: mild swelling, no mobility. Radiograph: periapical shows healing, no new radiolucency.
A: Acute apical abscess of tooth #8, supported by mild vestibular swelling, pain on biting, and periapical radiograph showing healing without new lesions.
P: Reassure patient, reinforce oral hygiene instructions, no medication prescribed. Schedule next visit in 7 days for restoration placement.

Non-smoker, Day 2 After Endodontic Surgery for a Maxillary Canine

SOAP note

Subjective: 82-year-old male, smoker, type 2 diabetic on metformin, NKDA; chief complaint: “I’m here for my follow-up after the surgery on my upper right canine.” History: day-2 post-endodontic surgery, no systemic symptoms.
Objective: extraoral: no facial swelling, lymph nodes not enlarged; intraoral: surgical site healing, mild erythema, mild swelling in vestibule, mild pain on biting; radiograph: periapical shows healing, no new radiolucency.
Assessment: acute apical abscess – supported by mild vestibular swelling, pain on biting, and periapical radiograph showing healing without new radiolucency.
Plan: reassure patient, reinforce oral hygiene, no medication prescribed; next visit scheduled in 7 days.

S: 82-year-old male, smoker, type 2 diabetic on metformin, NKDA; chief complaint: “I’m here for my follow-up after the surgery on my upper right canine.” History: day-2 post-endodontic surgery, no systemic symptoms.
O: extraoral: no facial swelling, lymph nodes not enlarged; intraoral: surgical site healing, mild erythema, mild swelling in vestibule, mild pain on biting; radiograph: periapical shows healing, no new radiolucency.
A: acute apical abscess – supported by mild vestibular swelling, pain on biting, and periapical radiograph showing healing without new radiolucency.
P: reassure patient, reinforce oral hygiene, no medication prescribed; next visit scheduled in 7 days.

Allergic to Penicillin, Day 3 After Endodontic Surgery

SOAP note

Subjective: 60-year-old female, asthma controlled with albuterol PRN, allergic to penicillin (rash). Chief complaint: “I’m here for my follow-up after the surgery on my upper left canine.” History: day-3 post-endodontic surgery, no systemic symptoms. PMH: asthma; medications: albuterol inhaler PRN.
Objective: Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: surgical site #11 shows mild erythema, mild swelling in vestibule, mild pain on biting. Radiograph: periapical shows healing, no new radiolucency.
Assessment: Acute apical abscess of tooth #11, supported by mild swelling, erythema, and pain on biting with radiographic healing.
Plan: Reassured patient, reinforced oral hygiene instructions, advised to avoid hard foods and maintain gentle rinsing. No medication prescribed. Scheduled next visit in 7 days for restoration placement.

S: 60-year-old female, asthma controlled with albuterol PRN, allergic to penicillin (rash). Chief complaint: “I’m here for my follow-up after the surgery on my upper left canine.” History: day-3 post-endodontic surgery, no systemic symptoms. PMH: asthma; medications: albuterol inhaler PRN.
O: Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: surgical site #11 shows mild erythema, mild swelling in vestibule, mild pain on biting. Radiograph: periapical shows healing, no new radiolucency.
A: Acute apical abscess of tooth #11, supported by mild swelling, erythema, and pain on biting with radiographic healing.
P: Reassured patient, reinforced oral hygiene instructions, advised to avoid hard foods and maintain gentle rinsing. No medication prescribed. Scheduled next visit in 7 days for restoration placement.

Implant Placement Follow-Up

Smoker, Day 7 After Sinus Lift and Implant Placement

SOAP note

Subjective: 47-year-old male, former smoker, NKDA, presents for Day 7 follow-up after sinus lift and implant placement in the maxillary right first molar (#14). He reports “I feel fine, just a little soreness in the upper back”; he denies pain, trismus, or bleeding, and notes only mild discomfort that has not worsened since the procedure.
Objective: Extraoral examination shows no facial swelling or lymphadenopathy. Intraoral inspection reveals a healing implant site with mild mucosal edema and no erythema, ulceration, or suppuration. The implant is stable on percussion and palpation. Periapical radiograph demonstrates well-integrated graft material in the sinus floor and proper implant positioning without radiolucency or perforation.
Assessment: Implant placement with graft integration, healing, no infection.
Plan: No medications prescribed; postoperative instructions regarding oral hygiene, diet, and activity were reiterated verbally and given in writing. The patient was advised to avoid smoking and to report any new pain, swelling, or bleeding immediately. Next visit scheduled for Day 30 for final prosthesis placement.

S: 47-year-old male, former smoker, NKDA, presents for Day 7 follow-up after sinus lift and implant placement in the maxillary right first molar (#14). He reports “I feel fine, just a little soreness in the upper back”; he denies pain, trismus, or bleeding, and notes only mild discomfort that has not worsened since the procedure.
O: Extraoral examination shows no facial swelling or lymphadenopathy. Intraoral inspection reveals a healing implant site with mild mucosal edema and no erythema, ulceration, or suppuration. The implant is stable on percussion and palpation. Periapical radiograph demonstrates well-integrated graft material in the sinus floor and proper implant positioning without radiolucency or perforation.
A: Implant placement with graft integration, healing, no infection.
P: No medications prescribed; postoperative instructions regarding oral hygiene, diet, and activity were reiterated verbally and given in writing. The patient was advised to avoid smoking and to report any new pain, swelling, or bleeding immediately. Next visit scheduled for Day 30 for final prosthesis placement.

Smoker, Day 4 After Implant Placement

SOAP note

Subjective: 76-year-old female smoker, 5 cigarettes/day, on low-dose aspirin, NKDA, reports “my lower molar feels a bit sore but nothing serious” since implant placement; no systemic symptoms.
Objective: Implant site in tooth #17 shows slight swelling, no pain or drainage; percussion stable; periapical radiograph confirms implant in place, no radiolucency; overall healing within expected limits.
Assessment: Implant placement, healing, no infection; stable implant with normal postoperative findings.
Plan: No medication prescribed; postoperative instructions reviewed (avoid hard foods, maintain oral hygiene, monitor for swelling or pain); next visit scheduled for Day 14 to reassess healing.

S: 76-year-old female smoker, 5 cigarettes/day, on low-dose aspirin, NKDA, reports “my lower molar feels a bit sore but nothing serious” since implant placement; no systemic symptoms.
O: Implant site in tooth #17 shows slight swelling, no pain or drainage; percussion stable; periapical radiograph confirms implant in place, no radiolucency; overall healing within expected limits.
A: Implant placement, healing, no infection; stable implant with normal postoperative findings.
P: No medication prescribed; postoperative instructions reviewed (avoid hard foods, maintain oral hygiene, monitor for swelling or pain); next visit scheduled for Day 14 to reassess healing.

Pregnancy, Day 8 After Implant Placement in the Maxillary Anterior Region

SOAP note

Subjective: 28-year-old pregnant female, controlled hypertension on lisinopril, NKDA; chief complaint: “I have a little soreness in the upper canine area”; no systemic symptoms, no pain reported.
Objective: Implant site #6 shows mild mucosal erythema, no pain; implant stable on percussion; periapical radiograph confirms implant placement with no radiolucency; extraoral and intraoral findings otherwise within normal limits.
Assessment: Implant placement, healing, no infection; findings of stable implant and absence of radiolucency support this assessment.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; post-operative instructions given regarding oral hygiene, diet, and activity restrictions; no medications prescribed; next visit scheduled for Day 30 for final prosthesis placement.

S: 28-year-old pregnant female, controlled hypertension on lisinopril, NKDA; chief complaint: “I have a little soreness in the upper canine area”; no systemic symptoms, no pain reported.
O: Implant site #6 shows mild mucosal erythema, no pain; implant stable on percussion; periapical radiograph confirms implant placement with no radiolucency; extraoral and intraoral findings otherwise within normal limits.
A: Implant placement, healing, no infection; findings of stable implant and absence of radiolucency support this assessment.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; post-operative instructions given regarding oral hygiene, diet, and activity restrictions; no medications prescribed; next visit scheduled for Day 30 for final prosthesis placement.

Non-smoker, Day 7 After Implant Placement with Immediate Loading

SOAP note

Subjective: 52-year-old female, 5 cigarettes/day, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “The new crown feels a bit tight but no pain”; HPI: day-7 post-implant placement with immediate loading, reports tight fit, no pain; PMH: hypothyroidism, no other meds.
Objective: Extraoral: slight swelling at #30 site, no erythema; Intraoral: prosthesis seated, implant stable on percussion; Periodontal: no BOP; Radiograph: implant and crown in place, no radiolucency; Periapical view WNL.
Assessment: Implant placement with immediate loading, healing, no infection; supported by stable percussion, absence of pain, normal radiograph.
Plan: No drugs prescribed; postoperative instructions given: avoid hard foods, maintain oral hygiene, report swelling or pain; next visit scheduled for Day 30 for final prosthesis adjustment.

S: 52-year-old female, 5 cigarettes/day, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “The new crown feels a bit tight but no pain”; HPI: day-7 post-implant placement with immediate loading, reports tight fit, no pain; PMH: hypothyroidism, no other meds.
O: Extraoral: slight swelling at #30 site, no erythema; Intraoral: prosthesis seated, implant stable on percussion; Periodontal: no BOP; Radiograph: implant and crown in place, no radiolucency; Periapical view WNL.
A: Implant placement with immediate loading, healing, no infection; supported by stable percussion, absence of pain, normal radiograph.
P: No drugs prescribed; postoperative instructions given: avoid hard foods, maintain oral hygiene, report swelling or pain; next visit scheduled for Day 30 for final prosthesis adjustment.

Pregnancy, Day 3 After Implant Placement in the Maxillary Posterior

SOAP note

Subjective: 42-year-old pregnant female, smoker, NKDA, reports “I feel a little sore in the back of my upper jaw”; history: implant placed in tooth #3, 3 days ago, no pain or drainage.
Objective: Extraoral: mild edema at implant site, no erythema; Intraoral: closed mucosa, no ulceration; Periodontal: implant stable on percussion, no mobility; Radiograph: periapical shows implant in place, no radiolucency; Vital signs WNL.
Assessment: Implant placement, healing, no infection.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; postoperative instructions given (avoid smoking, maintain oral hygiene, soft diet); next visit Day 14 for healing assessment.

S: 42-year-old pregnant female, smoker, NKDA, reports “I feel a little sore in the back of my upper jaw”; history: implant placed in tooth #3, 3 days ago, no pain or drainage.
O: Extraoral: mild edema at implant site, no erythema; Intraoral: closed mucosa, no ulceration; Periodontal: implant stable on percussion, no mobility; Radiograph: periapical shows implant in place, no radiolucency; Vital signs WNL.
A: Implant placement, healing, no infection.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; postoperative instructions given (avoid smoking, maintain oral hygiene, soft diet); next visit Day 14 for healing assessment.

Pediatric, Day 7 After Sealant Placement

SOAP note

Subjective: 8-year-old male, no significant medical history; allergic to penicillin (rash). Chief complaint: “I don’t have any pain, just a little sore spot.” HPI: reports mild soreness at the sealant site, no swelling or erythema. PMH: none.
Objective: Intraoral exam shows sealant intact on buccal surface of tooth #5, no caries, no sensitivity. No swelling, erythema, or other abnormalities noted. Extraoral exam WNL.
Assessment: Sealant placement with normal healing; no complications.
Plan: No medication prescribed. Post-operative instructions given verbally: keep the area clean, avoid hard foods for 24 h, use gentle brushing. Next visit scheduled for Day 30 for routine check.

S: 8-year-old male, no significant medical history; allergic to penicillin (rash). Chief complaint: “I don’t have any pain, just a little sore spot.” HPI: reports mild soreness at the sealant site, no swelling or erythema. PMH: none.
O: Intraoral exam shows sealant intact on buccal surface of tooth #5, no caries, no sensitivity. No swelling, erythema, or other abnormalities noted. Extraoral exam WNL.
A: Sealant placement with normal healing; no complications.
P: No medication prescribed. Post-operative instructions given verbally: keep the area clean, avoid hard foods for 24 h, use gentle brushing. Next visit scheduled for Day 30 for routine check.

Prosthetic & Restorative Follow-Up

Elderly, Day 2 After Implant Placement

SOAP note

Subjective: 54-year-old female, NKDA, comes for day-2 implant follow-up; says “I’m here for my follow-up after the implant placement.” HPI: no pain, no swelling, normal healing.
Objective: Implant site shows slight pink mucosa, 2 mm probing depth, no bleeding on probing. Periapical radiograph confirms implant in place, no radiolucency.
Assessment: Implant placement, healing; findings of normal soft tissue, shallow probing, and radiographic stability support this.
Plan: No drug administered. Post-operative instructions given verbally and in writing: keep site clean, avoid hard foods, resume normal diet gradually. Patient advised to return in 7 days for next visit.

S: 54-year-old female, NKDA, comes for day-2 implant follow-up; says “I’m here for my follow-up after the implant placement.” HPI: no pain, no swelling, normal healing.
O: Implant site shows slight pink mucosa, 2 mm probing depth, no bleeding on probing. Periapical radiograph confirms implant in place, no radiolucency.
A: Implant placement, healing; findings of normal soft tissue, shallow probing, and radiographic stability support this.
P: No drug administered. Post-operative instructions given verbally and in writing: keep site clean, avoid hard foods, resume normal diet gradually. Patient advised to return in 7 days for next visit.

Pediatric, Day 4 After Stainless-Steel Crown Placement

SOAP note

Subjective: 6-year-old male, NKDA, reports “little sore after the crown was put on”; no significant medical history; parent notes mild discomfort during chewing.
Objective: Crown on tooth K seated properly, no leakage; mild gingival inflammation at margin, probing depth 1 mm, no bleeding on probing; periapical radiograph shows no radiolucency; child reports no pain; extraoral exam shows no facial swelling or lymphadenopathy; intraoral soft tissues appear healthy; adjacent teeth exhibit normal enamel surfaces.
Assessment: Stainless-steel crown placement with normal healing; mild gingival inflammation around margin likely post-operative irritation.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration used for the procedure; fluoride varnish applied to adjacent teeth #K-1 and #K-2; parent instructed on gentle brushing with a soft-bristle brush, use of fluoride toothpaste, and avoidance of hard foods for 48 h; advised to rinse with 0.12% chlorhexidine for 30 s twice daily; no medication prescribed; next visit scheduled in 7 days for a check-up and to assess gingival healing.

S: 6-year-old male, NKDA, reports “little sore after the crown was put on”; no significant medical history; parent notes mild discomfort during chewing.
O: Crown on tooth K seated properly, no leakage; mild gingival inflammation at margin, probing depth 1 mm, no bleeding on probing; periapical radiograph shows no radiolucency; child reports no pain; extraoral exam shows no facial swelling or lymphadenopathy; intraoral soft tissues appear healthy; adjacent teeth exhibit normal enamel surfaces.
A: Stainless-steel crown placement with normal healing; mild gingival inflammation around margin likely post-operative irritation.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration used for the procedure; fluoride varnish applied to adjacent teeth #K-1 and #K-2; parent instructed on gentle brushing with a soft-bristle brush, use of fluoride toothpaste, and avoidance of hard foods for 48 h; advised to rinse with 0.12% chlorhexidine for 30 s twice daily; no medication prescribed; next visit scheduled in 7 days for a check-up and to assess gingival healing.

Elderly, Day 4 After Crown Removal

SOAP note

Subjective: 70-year-old female, type 2 diabetic on metformin, NKDA; CC: “The tooth feels a bit sensitive after the crown was taken off”; HPI: sensitivity to air, no pain on palpation; PMH: diabetes, no systemic signs; no medications besides metformin.
Objective: Extraoral: no swelling or erythema; Intraoral: root surface of tooth #30 exposed, mild air sensitivity; Periodontal: PD 3 mm, no BOP; Radiograph: periapical radiograph shows no pathology; Tests: none.
Assessment: Crown removal with exposed root, healing without pathology; root planing performed, fluoride varnish applied.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB administered; root planing and fluoride varnish applied; POI: use desensitizing toothpaste, avoid hot foods; next visit in 7 days to evaluate sensitivity.

S: 70-year-old female, type 2 diabetic on metformin, NKDA; CC: “The tooth feels a bit sensitive after the crown was taken off”; HPI: sensitivity to air, no pain on palpation; PMH: diabetes, no systemic signs; no medications besides metformin.
O: Extraoral: no swelling or erythema; Intraoral: root surface of tooth #30 exposed, mild air sensitivity; Periodontal: PD 3 mm, no BOP; Radiograph: periapical radiograph shows no pathology; Tests: none.
A: Crown removal with exposed root, healing without pathology; root planing performed, fluoride varnish applied.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB administered; root planing and fluoride varnish applied; POI: use desensitizing toothpaste, avoid hot foods; next visit in 7 days to evaluate sensitivity.

Pregnancy, Day 3 After Dental Implant Surgery

SOAP note

Subjective: 32-year-old pregnant female reports “I’m here to check on the implant after the surgery.” She has asthma, uses albuterol PRN, NKDA, and is on no other medications. HPI: mild soreness at implant site, no fever, no pain or swelling.
Objective: Extraoral: mild edema, pink mucosa. Intraoral: implant site with 2 mm probing depth, no bleeding on probing. Radiograph: implant in place, no radiolucency. No systemic signs noted.
Assessment: Implant placement, healing; findings of mild edema, 2 mm probing depth, and radiographic stability support this.
Plan: No drugs prescribed. Post-operative instructions: soft diet, chlorhexidine 0.12% rinse 15 mL for 30 s twice daily, avoid smoking. Patient advised to return in 7 days for follow-up.

S: 32-year-old pregnant female reports “I’m here to check on the implant after the surgery.” She has asthma, uses albuterol PRN, NKDA, and is on no other medications. HPI: mild soreness at implant site, no fever, no pain or swelling.
O: Extraoral: mild edema, pink mucosa. Intraoral: implant site with 2 mm probing depth, no bleeding on probing. Radiograph: implant in place, no radiolucency. No systemic signs noted.
A: Implant placement, healing; findings of mild edema, 2 mm probing depth, and radiographic stability support this.
P: No drugs prescribed. Post-operative instructions: soft diet, chlorhexidine 0.12% rinse 15 mL for 30 s twice daily, avoid smoking. Patient advised to return in 7 days for follow-up.

Elderly, Day 14 After Crown & Bridge Placement

SOAP note

Subjective: 80-year-old male, former smoker, NKDA, reports “I’m here for the follow-up after the bridge was placed.” No pain or sensitivity; history of crown & bridge placement on tooth #14.
Objective: Bridge seated correctly, no leakage. Mild gingival recession at margin; probing depth 2 mm, no bleeding on probing. Periapical radiograph shows restoration in place, no periapical pathology. Extraoral and intraoral findings otherwise WNL.
Assessment: Crown & bridge placement, healing; mild overbite contributing to marginal recession.
Plan: Occlusal adjustment performed to relieve mild overbite; fluoride varnish applied to tooth #14 and adjacent teeth. Patient instructed to maintain oral hygiene, avoid hard foods for 24 h. Next visit scheduled in 30 days for final check.

S: 80-year-old male, former smoker, NKDA, reports “I’m here for the follow-up after the bridge was placed.” No pain or sensitivity; history of crown & bridge placement on tooth #14.
O: Bridge seated correctly, no leakage. Mild gingival recession at margin; probing depth 2 mm, no bleeding on probing. Periapical radiograph shows restoration in place, no periapical pathology. Extraoral and intraoral findings otherwise WNL.
A: Crown & bridge placement, healing; mild overbite contributing to marginal recession.
P: Occlusal adjustment performed to relieve mild overbite; fluoride varnish applied to tooth #14 and adjacent teeth. Patient instructed to maintain oral hygiene, avoid hard foods for 24 h. Next visit scheduled in 30 days for final check.

Elderly, Day 7 After Crown & Bridge Placement on the Maxillary Arch

SOAP note

Subjective: 45-year-old female patient, daily low-dose aspirin, NKDA, presents for her routine Day 7 follow-up after a crown-and-bridge was placed on the maxillary arch; she reports “I’m here for my follow-up after the bridge was placed” and notes mild sensitivity to cold but no pain.
Objective: Extraoral exam shows no swelling or lymphadenopathy. Intraoral findings reveal the bridge seated properly with no evidence of leakage or marginal discrepancy. Probing depth at the abutment tooth #6 is 2 mm, with no bleeding on probing. Periapical radiograph demonstrates the restoration in place, with no periapical pathology or radiolucency. The patient reports mild sensitivity to cold stimuli but denies any discomfort or pain.
Assessment: Crown-and-bridge placement, healing; the abutment tooth exhibits normal periodontal status and no signs of postoperative complications.
Plan: A desensitizing agent was applied to tooth #6; the patient was instructed to avoid very hot foods and drinks, to maintain meticulous oral hygiene, and to rinse with 0.12% chlorhexidine twice daily. No medications were prescribed. The next visit is scheduled in 14 days for a final adjustment and to reassess sensitivity.

S: 45-year-old female patient, daily low-dose aspirin, NKDA, presents for her routine Day 7 follow-up after a crown-and-bridge was placed on the maxillary arch; she reports “I’m here for my follow-up after the bridge was placed” and notes mild sensitivity to cold but no pain.
O: Extraoral exam shows no swelling or lymphadenopathy. Intraoral findings reveal the bridge seated properly with no evidence of leakage or marginal discrepancy. Probing depth at the abutment tooth #6 is 2 mm, with no bleeding on probing. Periapical radiograph demonstrates the restoration in place, with no periapical pathology or radiolucency. The patient reports mild sensitivity to cold stimuli but denies any discomfort or pain.
A: Crown-and-bridge placement, healing; the abutment tooth exhibits normal periodontal status and no signs of postoperative complications.
P: A desensitizing agent was applied to tooth #6; the patient was instructed to avoid very hot foods and drinks, to maintain meticulous oral hygiene, and to rinse with 0.12% chlorhexidine twice daily. No medications were prescribed. The next visit is scheduled in 14 days for a final adjustment and to reassess sensitivity.

Pediatric, Day 6 After Composite Restoration of a Primary Tooth

SOAP note

Subjective: 6-year-old male, no significant medical history, NKDA, reports “Just here for my check-up after the filling.” He has no pain, no sensitivity to cold or biting, and no other complaints.
Objective: The composite restoration on the buccal surface of tooth K appears intact with no marginal discoloration. The gingiva surrounding tooth K is pink, healthy, and shows no bleeding on probing. Probing depths are 1–2 mm and there are no periodontal pockets. A periapical radiograph demonstrates no caries, no restoration overhang, and no periapical pathology.
Assessment: Composite restoration, no complications.
Plan: Reviewed the restoration with the patient and caregiver, confirming that the restoration is stable and that the patient understands the importance of maintaining good oral hygiene. Reinforced instructions to brush twice daily with fluoride toothpaste, floss around the tooth, and avoid hard foods for 24 h to protect the new restoration. No medication was prescribed. The next visit is scheduled for a routine check-up in 4 weeks to monitor the restoration and overall oral health.

S: 6-year-old male, no significant medical history, NKDA, reports “Just here for my check-up after the filling.” He has no pain, no sensitivity to cold or biting, and no other complaints.
O: The composite restoration on the buccal surface of tooth K appears intact with no marginal discoloration. The gingiva surrounding tooth K is pink, healthy, and shows no bleeding on probing. Probing depths are 1–2 mm and there are no periodontal pockets. A periapical radiograph demonstrates no caries, no restoration overhang, and no periapical pathology.
A: Composite restoration, no complications.
P: Reviewed the restoration with the patient and caregiver, confirming that the restoration is stable and that the patient understands the importance of maintaining good oral hygiene. Reinforced instructions to brush twice daily with fluoride toothpaste, floss around the tooth, and avoid hard foods for 24 h to protect the new restoration. No medication was prescribed. The next visit is scheduled for a routine check-up in 4 weeks to monitor the restoration and overall oral health.

Elderly, Day 5 After Crown Placement on a Single Tooth

SOAP note

Subjective: 62-year-old female, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: "I'm here to see how the crown is doing"; HPI: no pain, no sensitivity, no swelling; PMH: hypothyroidism; allergy: penicillin rash.
Objective: Full-coverage crown on #30 seated, margins smooth, no overhangs; Pericervical gingiva pink, no recession, no bleeding on probing; Probing depths 1–2 mm, no periodontal pockets; Radiograph shows no crown or root fracture, no periapical radiolucency; no systemic signs.
Assessment: Crown placement on #30, no complications.
Plan: Reinforced oral hygiene instructions, advised to avoid chewing hard foods for 24 h; no medications prescribed; next recall scheduled in 6 months.

S: 62-year-old female, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: "I'm here to see how the crown is doing"; HPI: no pain, no sensitivity, no swelling; PMH: hypothyroidism; allergy: penicillin rash.
O: Full-coverage crown on #30 seated, margins smooth, no overhangs; Pericervical gingiva pink, no recession, no bleeding on probing; Probing depths 1–2 mm, no periodontal pockets; Radiograph shows no crown or root fracture, no periapical radiolucency; no systemic signs.
A: Crown placement on #30, no complications.
P: Reinforced oral hygiene instructions, advised to avoid chewing hard foods for 24 h; no medications prescribed; next recall scheduled in 6 months.

Pediatric, Day 3 After Composite Restoration of a Permanent First Molar

SOAP note

Subjective: 9-year-old female, no significant medical history, NKDA. Chief complaint: “Just checking on my filling.” The patient reports no pain, no sensitivity to cold or biting, and no recent trauma. No systemic signs noted.
Objective: Composite on the mesio-occlusal surface of tooth #14 is intact with no marginal breakdown. Gingiva around #14 is pink and healthy; probing reveals 1–2 mm depths with no bleeding on probing. No periodontal pockets are present. Bite-wing radiograph shows no caries extension, no periapical radiolucency, and the restoration margins are well-contoured. Extraoral examination is unremarkable.
Assessment: Composite restoration, no complications.
Plan: Reviewed the restoration with the patient, reinforced proper brushing technique and fluoride use, and advised avoidance of sticky foods for 24 h to protect the new composite. No medications were prescribed. The patient was instructed to maintain regular oral hygiene and to report any new symptoms immediately. A routine recall is scheduled in 6 months to reassess restoration integrity and oral health.

S: 9-year-old female, no significant medical history, NKDA. Chief complaint: “Just checking on my filling.” The patient reports no pain, no sensitivity to cold or biting, and no recent trauma. No systemic signs noted.
O: Composite on the mesio-occlusal surface of tooth #14 is intact with no marginal breakdown. Gingiva around #14 is pink and healthy; probing reveals 1–2 mm depths with no bleeding on probing. No periodontal pockets are present. Bite-wing radiograph shows no caries extension, no periapical radiolucency, and the restoration margins are well-contoured. Extraoral examination is unremarkable.
A: Composite restoration, no complications.
P: Reviewed the restoration with the patient, reinforced proper brushing technique and fluoride use, and advised avoidance of sticky foods for 24 h to protect the new composite. No medications were prescribed. The patient was instructed to maintain regular oral hygiene and to report any new symptoms immediately. A routine recall is scheduled in 6 months to reassess restoration integrity and oral health.

Elderly, Day 2 After Placement of a Partial Denture

SOAP note

Subjective: 68-year-old male, NKDA, presents on Day 2 after placement of a partial denture for a routine check-in. He reports “I’m here to see how the denture feels.” He denies pain, swelling, or any discomfort while chewing or speaking, and reports no systemic symptoms or medication changes since the procedure.
Objective: Clinical exam shows the partial denture seated correctly on abutments #15 and #18 with no sore spots or mucosal ulceration. The gingiva surrounding the abutment teeth is pink, healthy, and exhibits no bleeding on probing. Probing depths around the abutments are 1–2 mm, with no periodontal pockets or signs of inflammation. Intraoral radiograph demonstrates intact roots, no root resorption, and no periapical pathology. Extraoral findings are unremarkable.
Assessment: Partial denture, no complications.
Plan: Confirmed proper fit and occlusion of the partial denture. Instructed the patient on daily denture cleaning techniques and oral hygiene around the abutment sites, emphasizing the importance of maintaining plaque control to prevent future periodontal issues. No medications were prescribed. Scheduled next adjustment visit in 4 weeks for routine follow-up and fit reassessment.

S: 68-year-old male, NKDA, presents on Day 2 after placement of a partial denture for a routine check-in. He reports “I’m here to see how the denture feels.” He denies pain, swelling, or any discomfort while chewing or speaking, and reports no systemic symptoms or medication changes since the procedure.
O: Clinical exam shows the partial denture seated correctly on abutments #15 and #18 with no sore spots or mucosal ulceration. The gingiva surrounding the abutment teeth is pink, healthy, and exhibits no bleeding on probing. Probing depths around the abutments are 1–2 mm, with no periodontal pockets or signs of inflammation. Intraoral radiograph demonstrates intact roots, no root resorption, and no periapical pathology. Extraoral findings are unremarkable.
A: Partial denture, no complications.
P: Confirmed proper fit and occlusion of the partial denture. Instructed the patient on daily denture cleaning techniques and oral hygiene around the abutment sites, emphasizing the importance of maintaining plaque control to prevent future periodontal issues. No medications were prescribed. Scheduled next adjustment visit in 4 weeks for routine follow-up and fit reassessment.

Pediatric, Day 4 After Stainless-Steel Crown

SOAP note

Subjective: 4-year-old female, NKDA, “Just here to see how the crown is doing”; the child reports no pain, no sensitivity to cold or biting, and no discomfort while chewing.
Objective: Stainless-steel crown on tooth K is seated properly, with smooth margins and no overhangs. Gingiva surrounding the crown is pink, healthy, and exhibits no bleeding on probing. Probing depths around the tooth are 1–2 mm, indicating no periodontal pockets. Periapical radiograph shows the crown intact, no fracture of the crown or root, and no periapical radiolucency.
Assessment: Stainless-steel crown, no complications.
Plan: Reinforced oral hygiene instructions were given, emphasizing brushing with a soft-bristle brush and flossing around the crown twice daily. The child was advised to avoid hard foods for 24 hours to allow the crown to settle. No medication was prescribed. A follow-up recall is scheduled in 6 months to reassess fit, occlusion, and oral hygiene status.

S: 4-year-old female, NKDA, “Just here to see how the crown is doing”; the child reports no pain, no sensitivity to cold or biting, and no discomfort while chewing.
O: Stainless-steel crown on tooth K is seated properly, with smooth margins and no overhangs. Gingiva surrounding the crown is pink, healthy, and exhibits no bleeding on probing. Probing depths around the tooth are 1–2 mm, indicating no periodontal pockets. Periapical radiograph shows the crown intact, no fracture of the crown or root, and no periapical radiolucency.
A: Stainless-steel crown, no complications.
P: Reinforced oral hygiene instructions were given, emphasizing brushing with a soft-bristle brush and flossing around the crown twice daily. The child was advised to avoid hard foods for 24 hours to allow the crown to settle. No medication was prescribed. A follow-up recall is scheduled in 6 months to reassess fit, occlusion, and oral hygiene status.

Pediatric, Day 2 After Composite Restoration

SOAP note

Subjective: 8-year-old male, seasonal allergies, NKDA; CC: “I’m here to check my filling”; HPI: no pain, no sensitivity to cold or biting; PMH: none.
Objective: Composite on buccal surface of tooth #19 intact, no marginal discoloration; gingiva pink, healthy, no bleeding on probing; probing depths 1–2 mm, no periodontal pockets; radiograph shows no caries or periapical pathology; no systemic signs.
Assessment: Composite restoration, no complications.
Plan: Reviewed restoration, reinforced brushing technique, advised to avoid sticky foods for 24 h; no medication prescribed; next visit in 6 months for routine check.

S: 8-year-old male, seasonal allergies, NKDA; CC: “I’m here to check my filling”; HPI: no pain, no sensitivity to cold or biting; PMH: none.
O: Composite on buccal surface of tooth #19 intact, no marginal discoloration; gingiva pink, healthy, no bleeding on probing; probing depths 1–2 mm, no periodontal pockets; radiograph shows no caries or periapical pathology; no systemic signs.
A: Composite restoration, no complications.
P: Reviewed restoration, reinforced brushing technique, advised to avoid sticky foods for 24 h; no medication prescribed; next visit in 6 months for routine check.

Periodontal Surgery Follow-Up

Diabetic, Day 30 After Periodontal Surgery

SOAP note

Subjective: 24-year-old male, type 2 diabetic on metformin, NKDA, reports “I’m here for my 30-day follow-up after the flap surgery. I feel fine, just a little sore around the flap.”
Objective: Flap healed with minimal erythema, no exudate; probing depth at tooth #30 is 3 mm, BOP negative; gingival recession 1 mm; no suppuration or swelling; radiograph shows bone fill at the surgical site, no radiolucency.
Assessment: Stage I, Grade A periodontal disease – post-operative healing, supported by shallow probing depth, absence of bleeding, and radiographic bone fill.
Plan: Reviewed postoperative instructions, reinforced oral hygiene, advised avoidance of hot foods for 48 h; no medications prescribed. Next visit: routine recall in 6 months.

S: 24-year-old male, type 2 diabetic on metformin, NKDA, reports “I’m here for my 30-day follow-up after the flap surgery. I feel fine, just a little sore around the flap.”
O: Flap healed with minimal erythema, no exudate; probing depth at tooth #30 is 3 mm, BOP negative; gingival recession 1 mm; no suppuration or swelling; radiograph shows bone fill at the surgical site, no radiolucency.
A: Stage I, Grade A periodontal disease – post-operative healing, supported by shallow probing depth, absence of bleeding, and radiographic bone fill.
P: Reviewed postoperative instructions, reinforced oral hygiene, advised avoidance of hot foods for 48 h; no medications prescribed. Next visit: routine recall in 6 months.

Non-smoker, Day 4 After Periodontal Flap Surgery for Recession on the Mandible

SOAP note

Subjective: 69-year-old female, non-smoker, presents on day 4 after periodontal flap surgery for recession on tooth #27; reports “area feels a bit tender but it’s healing.” Medical history: asthma, albuterol PRN, NKDA.
Objective: Flap margins intact, slight erythema; probing depth at #27 is 4 mm with BOP positive; gingival recession 2 mm; no swelling or suppuration; radiograph shows bone remodeling, no pathology.
Assessment: Stage I, Grade A periodontal disease – early post-operative healing with mild inflammation.
Plan: No medication prescribed; patient counseled on smoking cessation impact on healing, reinforced chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily, and scheduled next visit in 2 weeks for reassessment.

S: 69-year-old female, non-smoker, presents on day 4 after periodontal flap surgery for recession on tooth #27; reports “area feels a bit tender but it’s healing.” Medical history: asthma, albuterol PRN, NKDA.
O: Flap margins intact, slight erythema; probing depth at #27 is 4 mm with BOP positive; gingival recession 2 mm; no swelling or suppuration; radiograph shows bone remodeling, no pathology.
A: Stage I, Grade A periodontal disease – early post-operative healing with mild inflammation.
P: No medication prescribed; patient counseled on smoking cessation impact on healing, reinforced chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily, and scheduled next visit in 2 weeks for reassessment.

Diabetic, Day 1 After Periodontal Flap Surgery for a Mandibular Molar

SOAP note

Subjective: 31-year-old male, type 2 diabetes on metformin, former smoker, NKDA; chief complaint: “I’m here the day after the flap surgery. The flap is a bit sore but I can still eat.”
Objective: Flap edges neat with slight pinkness; probing depth #31 5 mm, BOP negative; gingival recession 1.5 mm; no swelling or drainage; panoramic radiograph shows bone fill at the surgical site, no radiolucency.
Assessment: Stage I, Grade A periodontal disease – immediate post-operative healing, supported by stable probing depth, absence of BOP, and radiographic bone fill.
Plan: Reviewed postoperative care instructions, advised soft toothbrush use, no medications prescribed; scheduled next visit in 7 days for healing assessment.

S: 31-year-old male, type 2 diabetes on metformin, former smoker, NKDA; chief complaint: “I’m here the day after the flap surgery. The flap is a bit sore but I can still eat.”
O: Flap edges neat with slight pinkness; probing depth #31 5 mm, BOP negative; gingival recession 1.5 mm; no swelling or drainage; panoramic radiograph shows bone fill at the surgical site, no radiolucency.
A: Stage I, Grade A periodontal disease – immediate post-operative healing, supported by stable probing depth, absence of BOP, and radiographic bone fill.
P: Reviewed postoperative care instructions, advised soft toothbrush use, no medications prescribed; scheduled next visit in 7 days for healing assessment.

Diabetic, Day 3 After Periodontal Flap Surgery for Gingival Recession

SOAP note

Subjective: 57-year-old male, type 2 diabetes on metformin, daily low-dose aspirin, NKDA; CC: “I’m back for my 3-day check-up after the flap. The flap is a bit red but I don’t have any pain.”; HPI: no pain, mild erythema, normal healing; PMH: diabetes, aspirin.
Objective: Flap margins intact, mild erythema; Probing depth at tooth #28 4 mm, BOP positive; Gingival recession 2 mm; No swelling or drainage; Radiograph shows bone remodeling, no pathology; systemic signs none.
Assessment: Stage I, Grade A periodontal disease – early post-operative healing with mild inflammation.
Plan: Advised on aspirin use and wound care; reinforced chlorhexidine 0.12% rinse twice daily; no drugs prescribed; next visit scheduled in 2 weeks.

S: 57-year-old male, type 2 diabetes on metformin, daily low-dose aspirin, NKDA; CC: “I’m back for my 3-day check-up after the flap. The flap is a bit red but I don’t have any pain.”; HPI: no pain, mild erythema, normal healing; PMH: diabetes, aspirin.
O: Flap margins intact, mild erythema; Probing depth at tooth #28 4 mm, BOP positive; Gingival recession 2 mm; No swelling or drainage; Radiograph shows bone remodeling, no pathology; systemic signs none.
A: Stage I, Grade A periodontal disease – early post-operative healing with mild inflammation.
P: Advised on aspirin use and wound care; reinforced chlorhexidine 0.12% rinse twice daily; no drugs prescribed; next visit scheduled in 2 weeks.

What Is a Dental Follow-Up Visit?

A dental follow-up visit is scheduled after a specific procedure to monitor healing, assess pain, and evaluate treatment progress. The visit differs from a routine exam, which reviews overall oral health without a recent intervention, and from an emergency follow-up, which addresses acute complications or unexpected events. The goal is to document how the site is healing, whether pain or swelling is resolving, and whether the patient is complying with postoperative instructions. The SOAP structure is adapted to these objectives: Subjective captures the patient’s pain level and functional status; Objective records clinical findings such as swelling, wound appearance, and vital signs; Assessment summarizes healing status and any concerns; Plan outlines next steps, medications, and the date of the next visit.

SOAP Structure & Key Follow-Up Data Points

Subjective (S)

Chief complaint (CC) in the patient’s own words, including pain location, onset, and character.
Numeric pain rating 0–10, triggers, relief, and effect on sleep or function.
Medical history updates: current medications, anticoagulants, antiplatelets, bisphosphonates, denosumab, and allergies.
Medication adherence and any new prescriptions taken since the last visit.
Review of postoperative instructions followed, signs of infection (redness, swelling, drainage), and any adverse events.

Objective (O)

Vital signs when indicated: blood pressure, pulse; temperature if infection suspected.
Extraoral findings: facial symmetry, lymphadenopathy, TMJ function.
Intraoral examination: wound appearance, drainage, bleeding, swelling, edema, palpation of the surgical site.
Probing of adjacent teeth: BOP, PD, CAL if relevant.
Radiographic findings: PA or BWX taken for the postoperative site, noting healing status or complications.
Local anesthetic details: agent, concentration, vasoconstrictor, volume, technique, and aspiration result.

Assessment (A)

Healing status relative to expected timeline (e.g., “wound healing within normal limits, no infection”).
Pain level and control adequacy.
Any complications: infection, delayed healing, bleeding, adverse medication reaction.
Summary diagnosis or clinical impression that guides the next step.

Plan (P)

Medications prescribed or reinforced (e.g., NSAID, antibiotic if indicated).
Postoperative instructions reiterated verbally and in writing.
Follow-up appointment date and purpose (e.g., suture removal, implant integration check).
Referrals or additional diagnostics if complications noted.

Differentiating Follow-Up from Routine and Emergency Notes & Customizing for Patient Populations

Follow-up SOAP notes focus on healing status, pain resolution, and compliance with postoperative instructions, unlike routine exam notes that assess baseline oral health without recent intervention, or emergency follow-ups that document acute complications and immediate management. In a follow-up, the Subjective section records pain level and functional impact, the Objective section documents wound appearance, swelling, and vital signs, the Assessment summarizes healing progress or concerns, and the Plan outlines next steps such as medication adjustments or next appointment. When tailoring the template, use a child-friendly pain scale (e.g., “0–10” with pictorial anchors) and keep language simple. For pregnant patients, avoid bisphosphonates and note fetal safety in the medication list. Diabetic patients require glucose monitoring prompts and a note on infection risk. Anticoagulated patients need explicit documentation of bleeding control measures, INR checks, and a plan for continuation or adjustment of therapy. Adjust the wording of instructions and the frequency of follow-up visits to reflect these population-specific considerations.

Copying, Pasting, and Inserting Notes into Charting Systems

Copying the Note

Select the entire SOAP block with a tap-and-hold, drag the handles to include all lines, then tap Copy. Open the charting system, navigate to the follow-up visit section, tap the text field, and choose Paste. Use the system’s “Keep line breaks” option or paste as plain text to preserve the S:, O:, A:, P: layout. Verify that the note lands in the correct encounter tab and that the line breaks align with the system’s formatting rules. Adjust spacing if needed, but avoid re-typing the content.

Emergency Follow-Up SOAP Note Examples

Emergency follow-up SOAP notes capture acute complications that arise after a dental procedure. The examples below cover the most common scenarios: post-trauma assessment, post-surgical infection evaluation, and medication reaction documentation. Each note is fully populated with S:, O:, A:, and P: sections and is ready to copy into any charting system. Use the template that matches the patient’s presentation—trauma, infection, or drug reaction—and paste it directly into the encounter. The ready-to-copy format saves time and ensures consistent, compliant documentation for every emergency follow-up visit.

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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Dental Follow-Up Visit SOAP Note: 30+ Ready-to-Copy Examples

Extraction Follow-Up Visits

Smoker, Day 3 After Lower Molar Extraction

Pregnant, Day 7 After Upper Incisor Extraction

Non-smoker, Day 10 After Extraction of Third Molar

Geriatric, Day 1 After Crown & Bridge Placement

Smoker, Day 1 After Extraction of Impacted Tooth

Diabetic, Day 7 After Extraction of Tooth 18

Elderly, Day 3 After Extraction of a Mandibular Incisor with Anticoagulant Therapy

Smoker, Day 1 After Molar Extraction with Graft

Non-smoker, Day 1 After Extraction of an Impacted Third Molar With Graft

Pregnancy, Day 14 After Wisdom Tooth Extraction

Root Canal & Endodontic Follow-Up

Diabetic, Day 5 After Root Canal Therapy

Non-smoker, Day 6 After Root Canal Therapy

Diabetic, Day 2 After Endodontic Surgery

Pregnancy, Day 10 After Root Canal Therapy

Non-smoker, Day 3 After Root Canal of a Mandibular Premolar

Pregnant, Day 5 After Endodontic Surgery of a Maxillary Incisor

Non-smoker, Day 2 After Endodontic Surgery for a Maxillary Canine

Allergic to Penicillin, Day 3 After Endodontic Surgery

Implant Placement Follow-Up

Smoker, Day 7 After Sinus Lift and Implant Placement

Smoker, Day 4 After Implant Placement

Pregnancy, Day 8 After Implant Placement in the Maxillary Anterior Region

Non-smoker, Day 7 After Implant Placement with Immediate Loading

Pregnancy, Day 3 After Implant Placement in the Maxillary Posterior

Pediatric, Day 7 After Sealant Placement

Prosthetic & Restorative Follow-Up

Elderly, Day 2 After Implant Placement

Pediatric, Day 4 After Stainless-Steel Crown Placement

Elderly, Day 4 After Crown Removal

Pregnancy, Day 3 After Dental Implant Surgery

Elderly, Day 14 After Crown & Bridge Placement

Elderly, Day 7 After Crown & Bridge Placement on the Maxillary Arch

Pediatric, Day 6 After Composite Restoration of a Primary Tooth

Elderly, Day 5 After Crown Placement on a Single Tooth

Pediatric, Day 3 After Composite Restoration of a Permanent First Molar

Elderly, Day 2 After Placement of a Partial Denture

Pediatric, Day 4 After Stainless-Steel Crown

Pediatric, Day 2 After Composite Restoration

Periodontal Surgery Follow-Up

Diabetic, Day 30 After Periodontal Surgery

Non-smoker, Day 4 After Periodontal Flap Surgery for Recession on the Mandible

Diabetic, Day 1 After Periodontal Flap Surgery for a Mandibular Molar

Diabetic, Day 3 After Periodontal Flap Surgery for Gingival Recession

What Is a Dental Follow-Up Visit?

SOAP Structure & Key Follow-Up Data Points

Subjective (S)

Objective (O)

Assessment (A)

Plan (P)

Differentiating Follow-Up from Routine and Emergency Notes & Customizing for Patient Populations

Copying, Pasting, and Inserting Notes into Charting Systems

Copying the Note

Emergency Follow-Up SOAP Note Examples

Stop retyping your templates

More Dental SOAP Notes

Dental Postoperative Examination SOAP Note: A Ready-to-Copy Guide

Dental Radiographic Examination SOAP Note: Quick-Copy Examples & Guidance

Dental Treatment Planning SOAP Note: Complete Copy-Ready Examples & Documentation Guidance

Extraoral Examination SOAP Note: Ready-Made Templates for Clinical Use

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