Periodontitis SOAP Note: Ready-to-Copy Bone Loss Cases
The collection presents 30-40 fully populated SOAP notes for periodontitis cases with bone loss, sorted by severity …
Dental hygiene recall SOAP notes are ready-to-copy templates for routine recalls and no-complaint visits. Each note includes complete S-O-A-P entries, from chief complaint to objective findings, assessment, and plan. A brief customization guide shows how to adjust age, medical history, or specific findings while keeping the format concise and clinically accurate.
Routine Cleanings and Fluoride
Routine 3-Month Recall – 45-Year-Old Male
- Subjective
- 45-year-old male with type 2 diabetes on metformin, NKDA, presents for routine cleaning; says “Here for my routine cleaning.” No complaints, systemic signs absent.
- Objective
- Plaque index 12%, calculus 8%, BOP 5%; probing depths 2 mm on all teeth; no caries, mobility, recession or suppuration noted.
- Assessment
- Gingival health, supported by light plaque, minimal calculus, low BOP, and shallow probing depths.
- Plan
- Prophylaxis performed: supragingival scaling, polishing, fluoride varnish 5 % applied to all teeth. No medication prescribed. Patient advised to maintain current oral hygiene routine and return in 3 months for next recall.
First Recall – 28-Year-Old Female, No Complaints
- Subjective
- 28-year-old female, controlled hypertension on lisinopril, NKDA, reports “I have no complaints, just a cleaning.”
- Objective
- Extraoral inspection shows no swelling or asymmetry; intraoral surfaces reveal plaque 15 %, calculus 10 %, bleeding on probing 8 %; probing depths uniformly 2 mm; no carious lesions, no mobility, no recession; periodontal charting confirms healthy gingival attachment; patient is in good general health with no systemic signs.
- Assessment
- Plaque-induced gingivitis, evidenced by BOP 8 % and plaque index 15 %, with normal probing depths and no attachment loss.
- Plan
- Full-mouth prophylaxis completed: scaling of all teeth, polishing with rubber cup and prophylaxis paste, and application of 5 % sodium fluoride varnish to all tooth surfaces. No medications prescribed. Patient educated on brushing technique, interdental cleaning, and diet; advised to return in 3 months for routine recall and to maintain oral hygiene.
Recall – 60-Year-Old Male, Mild Gingivitis
- Subjective
- 60-year-old male smoker, 5 cigarettes/day, NKDA, reports “Just a routine checkup”; no pain or swelling; medical history unchanged.
- Objective
- Extraoral normal; intraoral plaque 20%, calculus 15%; BOP 12%; PD 3 mm on all teeth; no caries, mobility, or recession.
- Assessment
- Stage I periodontitis, Grade C (smoking modifier) supported by PD ≤3 mm, BOP 12 %, plaque and calculus levels.
- Plan
- Full-mouth scaling, polishing, fluoride varnish 5 % applied to all teeth, tobacco cessation counseling; no medication prescribed; advised to maintain oral hygiene, avoid smoking, and return in 3 months for routine recall.
Recall – 35-Year-Old Pregnant Female, No Complaints
- Subjective
- 35-year-old pregnant female, former smoker, NKDA, states “Just a cleaning, no pain”; no new symptoms or concerns reported; medical history includes pregnancy, no other systemic conditions noted.
- Objective
- Extraoral exam shows no facial asymmetry or swelling; intraoral surfaces reveal plaque score 18 %, calculus 12 %; BOP 10 % across all sextants; probing depths uniformly 2 mm; no carious lesions, no tooth mobility, no recession; periodontal charting confirms stable attachment levels; oral hygiene aids are in place; no visible gingival inflammation beyond mild erythema.
- Assessment
- Diagnosis is gingival health per 2017 AAP/EFP criteria, supported by BOP ≤10 % and PD ≤2 mm with no attachment loss.
- Plan
- Prophylaxis performed: full-mouth scaling, hand polishing, fluoride varnish 5 % sodium fluoride applied to all tooth surfaces; patient received verbal and written instructions on maintaining plaque control, advised to continue daily brushing with fluoride toothpaste and interdental cleaning; no medication prescribed; next recall scheduled in 3 months.
Recall – 50-Year-Old Smoker, No Complaints
- Subjective
- 50-year-old female smoker, 5 cigarettes per day, allergic to penicillin (rash); chief complaint: “I just want my routine cleaning.” She reports no pain, no bleeding, and no new symptoms; medical history is unremarkable aside from her smoking habit.
- Objective
- Extraoral exam is normal. Intraoral findings show plaque accumulation of 22 % and calculus of 18 %, with bleeding on probing at 14 % of sites. Probing depths are 3 mm uniformly, with no carious lesions, no mobility, and no gingival recession. No abnormal swelling or suppuration noted.
- Assessment
- The periodontal diagnosis is Stage I periodontitis, Grade C, consistent with the smoking modifier, supported by the BOP of 14 % and uniform 3 mm probing depths.
- Plan
- Full-mouth prophylaxis performed: scaling and polishing of all teeth, fluoride varnish 5 % applied to every surface, and tobacco cessation counseling delivered. No medications were prescribed. The patient was instructed to maintain oral hygiene, avoid smoking, and return in 3 months for the next routine recall.
Recall – 22-Year-Old Student, No Complaints
- Subjective
- 22-year-old female, daily low-dose aspirin, NKDA, states “Just a cleaning, no issues.”
- Objective
- Extraoral examination shows no abnormalities. Intraoral findings include plaque 10 %, calculus 5 %, BOP 4 %, and probing depths of 2 mm throughout; no caries, mobility, or recession observed. Periodontal charting confirms a healthy periodontium with minimal gingival inflammation.
- Assessment
- Gingival health; plaque-induced gingivitis with BOP 4 % and PD 2 mm, consistent with a clinically healthy periodontium.
- Plan
- Prophylaxis performed: scaling, polishing, and fluoride varnish 5 % applied to all teeth; no anesthesia or medications administered. Post-operative instructions reviewed, patient advised to maintain twice-daily brushing and interdental cleaning; next recall scheduled in 3 months.
Recall – 40-Year-Old Male, No Complaints, Recent Fluoride Varnish
- Subjective
- 40-year-old male, seasonal allergies, NKDA; chief complaint: “Just a routine cleaning”; no pain, no medical issues; no medications.
- Objective
- Extraoral: normal. Intraoral: plaque 12 %, calculus 8 %, BOP 6 %; probing depths 2 mm all sites; no caries, no mobility, no recession. Radiographs: none taken.
- Assessment
- Gingival health; supported by plaque, calculus, BOP and probing depths all within healthy limits.
- Plan
- Prophylaxis performed: scaling, polishing, fluoride varnish 5 % sodium fluoride applied to all teeth; no anesthesia or drugs used. Patient advised to maintain daily brushing and flossing; next recall in 3 months.
Recall – 48-Year-Old Female, No Complaints, Recent Fluoride Varnish
- Subjective
- 48-year-old female, asthma (albuterol PRN), NKDA; CC: “Just a cleaning, no pain”; HPI: routine recall, no new complaints; PMH: asthma; meds: albuterol PRN; allergies: NKDA.
- Objective
- Extraoral: normal; Intraoral: plaque 14%, calculus 9%, BOP 7%; PD 2 mm; no caries, no mobility, no recession; Radiographs: none taken; Tests: none.
- Assessment
- Gingival health; supported by PD ≤2 mm, BOP 7 %, low plaque and calculus, no attachment loss.
- Plan
- Prophylaxis performed: scaling, polishing, fluoride varnish 5 % applied to all teeth; no drugs prescribed; patient advised to maintain oral hygiene, avoid sugary snacks, and return in 3 months for next recall.
Recall – 30-Year-Old Male, Post-Fluoride Varnish Follow-up
- Subjective
- 30-year-old male with hypothyroidism on levothyroxine, allergic to penicillin (rash), reports “just checking after the varnish”; no pain or other symptoms.
- Objective
- plaque 11 %, calculus 7 %, BOP 5 %; probing depths 2 mm; no caries, mobility, or recession; overall gingival health.
- Assessment
- Gingival health, supported by low plaque, calculus, BOP and shallow probing depths.
- Plan
- Re-applied 5 % fluoride varnish to all teeth; provided oral hygiene instruction; no medications prescribed; patient advised to maintain current brushing and flossing routine and return for next recall in 3 months.
Recall – 41-Year-Old Female, Post-Fluoride Varnish Follow-up
- Subjective
- 41-year-old female, NKDA, presents for a quick check after her recent fluoride varnish application. She reports no pain, sensitivity or new symptoms and states, “Just a quick check after my varnish.” Past medical history is unremarkable; no medications or allergies noted.
- Objective
- Extraoral exam shows no facial asymmetry or swelling. Intraoral findings reveal plaque accumulation at 13 % and calculus at 8 %. Bleeding on probing is 6 % across all sites, with all probing depths measuring 2 mm. There is no evidence of caries, tooth mobility, or gingival recession, and the gingival margin is level with the CEJ on all teeth.
- Assessment
- Diagnosis is gingival health, consistent with plaque-induced gingivitis (BOP ≤10 % and PD ≤3 mm, no attachment loss).
- Plan
- Re-application of 5 % fluoride varnish was performed on all tooth surfaces. Comprehensive oral hygiene instruction was reinforced, emphasizing interdental cleaning and proper brushing technique. No medications were prescribed. The patient was advised to maintain current oral hygiene habits and to return in 3 months for her routine recall.
Routine with Sealants and Oral Hygiene Instruction
Recall – 30-Year-Old Female, No Complaints, Recent Sealants
- Subjective
- 30-year-old female, type 2 diabetes on metformin, NKDA; CC: “Here for my routine cleaning and sealant check.” HPI: no complaints, routine recall. O: plaque index 12% all teeth; supragingival calculus 5%; no caries; sealants intact on #15 and #16, no marginal leakage; probing depths 2 mm all teeth; BOP 0%; PA of #15-#16 shows no pathology; BWX shows no new caries. A: Gingival health; plaque-induced gingivitis, Stage I, Grade A, supported by 2 mm probing depths, 0 % BOP, low plaque index. P: Prophylaxis performed with supragingival scaling; oral hygiene instruction reinforced with focus on interdental cleaning technique; sealant integrity confirmed; no medications prescribed; next RTC in 3 months.
Recall – 52-Year-Old Male, No Complaints, Recent OHI
- Subjective
- 52-year-old male, controlled hypertension on lisinopril, NKDA, presents for routine check-up, “Just a routine check-up, no problems.”
- Objective
- Plaque index 18% all teeth; calculus 12% subgingival on lower molars; probing depths 3 mm on lower molars, 2 mm elsewhere; BOP 5%; bitewing shows no caries; periapical of lower molars shows no pathology.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade B (moderate progression due to smoking 5 cigarettes/day).
- Plan
- Full-mouth scaling and polishing performed; oral hygiene instruction reinforced with emphasis on interdental cleaning technique; smoking cessation counseling provided; patient advised to maintain daily brushing and interdental cleaning, avoid tobacco, and return in 6 months for routine maintenance.
Recall – 33-Year-Old Female, No Complaints, Recent OHI
- Subjective
- 33-year-old female, smoker (5 cigarettes/day), NKDA, CC: “Just here for my regular cleaning.” HPI: no complaints, routine recall, PMH: smoking.
- Objective
- Plaque index 22% all teeth, calculus 15% subgingival on upper molars, PD 4 mm on upper molars, 3 mm elsewhere, BOP 10%; bitewing shows no caries, periapical of upper molars no pathology.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage II, Grade C (rapid progression due to smoking and poor OHI).
- Plan
- Full-mouth scaling and polishing performed; oral hygiene instruction focused on brushing technique, interdental cleaning; smoking cessation counseling given and referral to quitline; next visit in 3 months for maintenance.
Recall – 46-Year-Old Male, No Complaints, Recent Sealants
- Subjective
- 46-year-old male, former smoker, NKDA, reports “Just a routine check-up, no issues.” History: no systemic signs, no complaints.
- Objective
- Plaque index 14 % on all teeth; calculus 8 % subgingival on lower molars; periodontal probing depths 2 mm all teeth; BOP 0 %; sealants on #24 and #25 intact, no marginal leakage; bitewing shows no caries; PA of #24 and #25 shows no pathology.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade A, supported by 2 mm probing depths, 0 % BOP, and low plaque index.
- Plan
- Scaling of supragingival calculus performed; oral hygiene instruction reinforced with emphasis on interdental cleaning technique; sealant integrity confirmed; no restoration needed; next recall in 3 months.
Recall – 36-Year-Old Female, Post-Sealant Check
- Subjective
- 36-year-old female, PMH none; CC: “Just checking the sealants I had placed last month.” HPI: routine recall, no pain or discomfort.
- Objective
- Plaque index 10% all teeth, supragingival calculus 4%; probing depths 2 mm all sites, BOP 0%; sealants on #18 and #19 intact, no marginal leakage; bitewing and periapical radiographs of #18-#19 show no caries or pathology; extraoral and intraoral exams WNL.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade A, supported by PD 2 mm, BOP 0 %, plaque index 10 %.
- Plan
- Full-mouth prophylaxis performed; polishing with fluoride-enriched paste; oral hygiene instruction reinforced with emphasis on interdental cleaning technique; sealant integrity confirmed; no restoration indicated; next recall in 3 months.
Recall – 24-Year-Old Female, Post-OHI Reinforcement
- Subjective
- 24-year-old female, PMH: daily low-dose aspirin, NKDA; chief complaint: “Just here for my routine cleaning and to review my brushing.”
- Objective
- Plaque index 8% on all teeth; calculus 3% supragingival; probing depths 2 mm all teeth; BOP 0%; bitewing shows no caries; periapical radiographs show no pathology.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade A, supported by 8% plaque, 3% calculus, 2 mm probing depths and absent BOP.
- Plan
- Prophylaxis performed with scaling and polishing; oral hygiene instruction reinforced focusing on interdental cleaning and proper brushing technique; no medications prescribed; next visit scheduled in 3 months for routine maintenance.
Recall – 32-Year-Old Female, Post-Sealant Check with Marginal Leakage
- Subjective
- 32-year-old female, seasonal allergies, NKDA, states “I think the sealant on my molars might be leaking.”
- Objective
- plaque index 15% on all teeth; calculus 7% subgingival on lower molars; probing depths 3 mm on lower molars, 2 mm elsewhere; BOP 5%; sealants on #12 and #13 show marginal leakage buccally; PA of #12-#13 shows no pathology; bitewing shows no caries.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade A; marginal sealant leakage.
- Plan
- Prophylaxis with scaling and polishing performed; oral hygiene instruction reinforced, emphasizing interdental cleaning technique; sealant leakage noted; patient advised to return in 4 weeks for sealant re-application or restoration if leakage persists.
Routine with Tobacco Cessation Support
Recall – 38-Year-Old Female, No Complaints, Recent Tobacco Cessation
- Subjective
- 38-year-old female, asthma, NKDA, presents for routine cleaning and to discuss recent quit attempt; reports no pain or other complaints.
- Objective
- Plaque score 18% (O'Leary), light calculus on all teeth, BOP 8% of sites, PD 2 mm on all teeth; no caries, no pockets >3 mm, no recession, no mobility, no furcation involvement.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade A, supported by low PD, minimal BOP, and light calculus.
- Plan
- Prophylaxis performed: supragingival scaling, polishing, OHI reinforcement; brief tobacco cessation counseling, referral to quitline, patient expressed readiness to quit; no drugs prescribed; next recall in 3 months for maintenance and cessation follow-up.
Recall – 47-Year-Old Male, Tobacco Cessation Progress
- Subjective
- 47-year-old male, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “I’m here for my cleaning and want to review my quit progress”; HPI: no pain, wants to discuss smoking cessation; PMH: hypothyroidism; no systemic signs.
- Objective
- Plaque score 22 %; calculus moderate on #30-#32; BOP 12 % of sites; PD 3 mm on #30-#32; no caries, no pockets > 4 mm, no recession, no mobility, no furcation involvement; extraoral and intraoral otherwise normal.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade C (smoking modifier) supported by 22 % plaque, 12 % BOP, 3 mm PD, moderate calculus.
- Plan
- Prophylaxis performed: scaling of subgingival calculus on #30-#32, polishing, OHI reinforcement; tobacco cessation counseling: brief advice, motivational interviewing, referral to smoking cessation program; patient reported increased motivation; no drugs prescribed; next visit in 3 months for maintenance.
Recall – 50-Year-Old Male, Tobacco Cessation Progress, New Plaque Index
- Subjective
- 50-year-old male, NKDA, reports “I’m here for my cleaning and to check my plaque levels”; no medical issues, no pain.
- Objective
- Plaque score 30%; heavy calculus on #30-#32; BOP 15% of sites; PD 4 mm on #30-#31-#32; no caries, pockets ≤5 mm, no recession, mobility, or furcation involvement.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade B, supported by 30 % plaque, heavy calculus, 15 % BOP and 4 mm PD on the lower molars.
- Plan
- Full-mouth prophylaxis performed: subgingival scaling on #30-#32, polishing, OHI reinforcement; brief tobacco cessation counseling with quitline referral; patient willing to quit. No drugs used. Next visit in 3 months for periodontal maintenance and plaque reassessment.
Patients with Medical or Behavioral Conditions
Recall – 55-Year-Old Female, Diabetes Type II, No Complaints
- Subjective
- 55-year-old female, type 2 diabetes on metformin, NKDA, reports “Here for my routine cleaning.”
- Objective
- Plaque score 18 %; BOP 12 %; PD max 3 mm; CAL max 3 mm; no suppuration, mobility or furcation involvement; extraoral and intraoral otherwise within normal limits.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade C (smoking modifier) supported by BOP 12 % and PD ≤ 3 mm.
- Plan
- Full-mouth prophylaxis performed: scaling and polishing, OHI reinforcement, fluoride varnish 5 % applied to all teeth; no drugs or anesthesia used. Patient advised to maintain twice-daily brushing, interdental cleaning, and to monitor glycemic control; next recall scheduled in 3 months.
Recall – 55-Year-Old Female, Diabetes-Related Periodontitis
- Subjective
- 55-year-old female with type 2 diabetes on metformin and controlled hypertension on lisinopril, NKDA, reports “I’m here for my cleaning.”
- Objective
- plaque score 22 %, BOP 18 %, max probing depth 4 mm, max clinical attachment level 4 mm, no suppuration, no mobility, no furcation involvement.
- Assessment
- Periodontitis, Stage II, Grade C (diabetes modifier) based on PD ≤ 4 mm, CAL 4 mm, BOP > 10 %.
- Plan
- Scaling and root planing performed on quadrants 1 and 2; oral hygiene instruction provided; fluoride varnish 5 % applied to all teeth; next maintenance scheduled in 3 months.
Recall – 54-Year-Old Male, Diabetes-Related Periodontitis, HbA1c Check
- Subjective
- 54-year-old male, type 2 diabetes on metformin, smokes 5 cigarettes/day, NKDA, CC “Just a routine checkup”, HPI none, PMH diabetes, smoking, no systemic signs.
- Objective
- Plaque score 25 %; BOP 20 %; max PD 5 mm; max CAL 5 mm; no suppuration, mobility, or furcation involvement; extraoral normal; no radiographs taken today.
- Assessment
- Periodontitis, Stage III, Grade C (smoking and diabetes modifiers) supported by PD 5 mm, CAL 5 mm, BOP 20 % and plaque 25 %.
- Plan
- Scaling and root planing performed in quadrants 3 and 4; oral hygiene instruction given; fluoride varnish 5 % applied to all teeth; no anesthesia used; patient advised to monitor HbA1c; referred to periodontist for possible surgical therapy; next maintenance visit scheduled in 3 months.
Recall – 38-Year-Old Female, Post-OHI Reinforcement, Improved Technique
- Subjective
- 38-year-old female, former smoker, NKDA; CC: “I need a follow-up after my last OHI”; HPI: no pain, routine recall; PMH: none; allergies: NKDA.
- Objective
- Plaque score 12%; BOP 8%; PD 3 mm max; CAL 3 mm max; no suppuration, mobility or furcation involvement; extraoral and intraoral normal.
- Assessment
- Gingival health; plaque-induced gingivitis, Stage I, Grade A, supported by low plaque, limited BOP and shallow PDs.
- Plan
- Full-mouth scaling and polishing performed; fluoride varnish 5 % applied to all teeth; OHI reinforced with emphasis on improved brushing and interdental cleaning technique; no drugs; next maintenance visit scheduled in 3 months.
Periodontal Disease Management Follow-Ups
Recall – 70-Year-Old Male, Mild Periodontitis Stage I
- Subjective
- 70-year-old male, “Here for my routine cleaning and check of my gums.” No significant medical history; allergic to penicillin (rash).
- Objective
- Extraoral normal. Intraoral: PD 3 mm on all teeth, BOP 12 % of sites, CAL 1 mm on #15, #16, plaque score 18 %, no suppuration, no mobility, no furcation involvement.
- Assessment
- Periodontitis, Stage I, Grade A – supported by uniform 3 mm probing depths, 12 % BOP, 1 mm CAL on #15, #16, and 18 % plaque score.
- Plan
- Reinforced oral hygiene instruction; no scaling performed; scheduled periodontal maintenance in 3 months; no medications prescribed.
Recall – 58-Year-Old Male, Mild Periodontitis Stage II
- Subjective
- 58-year-old male, NKDA, takes low-dose aspirin, says “I want to make sure my gums are still healthy after the last cleaning.” HPI: no pain, no bleeding, routine recall. PMH: none.
- Objective
- PD 4 mm on #24, #25; BOP 18 % of sites; CAL 3 mm on #24, #25; plaque score 22 %; no suppuration, no mobility, no furcation involvement.
- Assessment
- Periodontitis, Stage II, Grade A, supported by PD 4 mm, BOP 18 %, CAL 3 mm and plaque score 22 %.
- Plan
- Scaling and root planing performed on #24 and #25; prescribed chlorhexidine 0.12 % rinse 15 mL for 30 seconds, twice daily; instructed on rinsing technique and to avoid brushing the treated sites for 24 h; next visit scheduled in 4 weeks for re-evaluation.
Recall – 68-Year-Old Male, Periodontal Abscess Management
- Subjective
- 68-year-old male, seasonal allergies, NKDA, reports “My lower right molar hurts and feels swollen.” History: acute pain, no fever, no trismus, no lymphadenopathy.
- Objective
- Extraoral: no facial swelling. Intraoral: tooth #30 shows PD 9 mm, BOP 100 %, suppuration present, no mobility, no furcation involvement. Radiograph: periapical radiolucency around #30. Temperature 98.6 °F.
- Assessment
- Periodontal abscess, acute, supported by deep pocket, bleeding, suppuration, radiolucency, and lack of systemic signs.
- Plan
- Incision and drainage of abscess performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB; irrigated with saline. Prescribed ibuprofen 400 mg PO q6h PRN. Instructed to apply warm compresses, maintain oral hygiene, and report worsening pain or swelling. Next visit: 2-week follow-up to assess healing.
Recall – 70-Year-Old Male, Periodontal Surgery Follow-up
- Subjective
- 70-year-old male, asthma (albuterol PRN), NKDA; CC: “My gums look better after the surgery, but I still have some discomfort.” HPI: post-flap surgery on tooth #12, reports mild soreness.
- Objective
- Post-surgical flap closed over #12; PD 3 mm, BOP 5 % on #12; no suppuration, no mobility, no furcation involvement; suture intact; radiograph shows bone fill in previous defect; temperature 98.4 °F, no fever, no trismus, no lymphadenopathy.
- Assessment
- Post-operative healing after flap surgery, supported by stable pocket depth, low BOP, radiographic bone fill, and absence of inflammation or suppuration.
- Plan
- 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration; chlorhexidine gluconate 0.12 % rinse 15 mL for 30 seconds, twice daily; advised to avoid brushing surgical site for 48 h; suture removal scheduled in 10 days; next visit in 4 weeks for healing assessment.
Recall – 57-Year-Old Male, Mild Periodontitis Stage I, Post-SRP Follow-up
- Subjective
- 57-year-old male, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “I’m here to check how my gums are healing after the last cleaning.” HPI: no pain, no swelling, no systemic symptoms. PMH: hypothyroidism; medications: levothyroxine.
- Objective
- Extraoral: normal. Intraoral: healthy mucosa. Periodontal charting: tooth #15 PD 3 mm, BOP 8 %, CAL 1 mm, plaque score 15 %; no suppuration, no mobility, no furcation involvement. Radiographs: none taken this visit.
- Assessment
- Periodontitis, Stage I, Grade A; supported by PD ≤3 mm, BOP 8 %, CAL 1 mm, plaque 15 %.
- Plan
- No anesthesia used. Reviewed healing status of tooth #15; reinforced oral-hygiene instructions; no medication prescribed. Scheduled next periodontal maintenance in 3 months.
Recall – 63-Year-Old Male, Periodontal Abscess Resolution
- Subjective
- 63-year-old male, NKDA, reports “My lower left molar feels fine now, but I want to make sure the swelling is gone.” No pain, no trismus, no lymphadenopathy, temperature 98.5 °F.
- Objective
- PD 4 mm on tooth #19, BOP 10 % on #19, no suppuration, no mobility, no furcation involvement; periapical radiograph shows resolution of the previous radiolucency.
- Assessment
- Resolved periodontal abscess, supported by absence of suppuration, normal mobility, and radiographic healing.
- Plan
- No additional treatment required; instructed to use chlorhexidine gluconate 0.12 % rinse 15 mL for 30 seconds twice daily; next periodontal maintenance scheduled in 3 months.
Recall – 29-Year-Old Female, Periodontal Surgery Follow-up
- Subjective
- 29-year-old female, type 2 diabetes on metformin, NKDA, reports “I’m here for my follow-up after the flap surgery.” HPI: no pain, no swelling, no bleeding since surgery. O: healing of flap edges, no suppuration; BOP 0%; PD 3 mm; CAL 4 mm; recession 1 mm on tooth #12; systemic signs none. A: Periodontitis, Stage II, Grade C (diabetes modifier) – supported by PD 3 mm, CAL 4 mm, and absence of BOP. P: No anesthesia needed; suture removal not required. Provided oral hygiene instruction and reinforced maintenance schedule; advised to return in 4 weeks for next follow-up.
Recall – 68-Year-Old Male, Periodontal Maintenance, New Radiograph
- Subjective
- 68-year-old male, controlled hypertension on lisinopril, NKDA, reports “Just a routine cleaning and check.” No pain or swelling noted.
- Objective
- Extraoral normal. Intraoral: PD max 4 mm, BOP 15 %, CAL 5 mm, plaque score 20 %. Panoramic radiograph shows 3 mm bone loss at molars. No signs of acute infection.
- Assessment
- Periodontitis, Stage III, Grade A – supported by PD ≤ 4 mm, CAL 5 mm, BOP 15 % and 3 mm bone loss on PAN.
- Plan
- Scaling and root planing performed on quadrant 4; oral hygiene instruction reinforced; no anesthesia or medications used. Next periodontal maintenance scheduled in 3 months.
Recall – 52-Year-Old Male, Periodontal Re-Evaluation Post-SRP
- Subjective
- 52-year-old male smoker, 5 cigarettes/day, NKDA; chief complaint: “Checking how the pockets are after SRP.” History: no systemic signs, no pain, no medication changes since last visit.
- Objective
- Extraoral: no swelling or asymmetry. Intraoral: tooth #15 shows PD 3 mm, BOP 10 %, CAL 4 mm, plaque score 25 %. Periodontal charting: all other teeth within normal limits, no suppuration or mobility. Radiographic: periapical radiograph of #15 shows no radiolucency, bone crest at expected level.
- Assessment
- Periodontitis, Stage II, Grade C (smoking modifier) – probing depths and bleeding on probing consistent with mild-moderate disease and a high risk of progression due to smoking.
- Plan
- Reviewed maintenance plan, reinforced oral hygiene instruction with emphasis on interdental cleaning and hand-brushing technique; no additional therapy or medication prescribed. Advised patient to continue daily chlorhexidine rinse 0.12 % for 30 s twice daily and to return for periodontal maintenance in 3 months.
Recall – 56-Year-Old Male, Moderate Periodontitis Stage II, Post-SRP Follow-up
- Subjective
- 56-year-old male, former smoker, NKDA, reports “Just a quick check after my SRP.” HPI: no pain, no swelling, routine follow-up after periodontal scaling and root planing. PMH: none, no systemic signs.
- Objective
- Extraoral: normal. Intraoral: plaque 30%, BOP 20%. Periodontal charting: tooth #30 PD 4 mm, CAL 6 mm. No radiographs taken.
- Assessment
- Periodontitis, Stage II, Grade B – moderate progression, supported by PD 4 mm, CAL 6 mm and BOP 20 %.
- Plan
- No anesthesia or drugs administered. Reinforced oral hygiene instructions, advised to maintain plaque control. Planned second SRP for quadrant 3, next visit scheduled in 3 months.
Recall – 43-Year-Old Female, Periodontal Abscess Resolution, New Radiograph
- Subjective
- 43-year-old female, no significant medical history, allergic to penicillin (rash). Chief complaint: “My molar hurts and there’s a swelling.” History: mild fever 99.5°F, no other symptoms.
- Objective
- Extraoral: mild facial swelling over #19. Intraoral: deep pocket 10 mm at #19, suppuration present, bleeding on probing 100 %. Periodontal chart: PD 10 mm, BOP 100 %. Radiographic: panoramic shows 4 mm periapical radiolucency at #19. No other findings.
- Assessment
- Periodontal abscess, acute, supported by 10 mm pocket, suppuration, BOP 100 % and periapical radiolucency.
- Plan
- 2 % lidocaine with 1:100 000 epinephrine, 1.8 mL, IANB administered. Incision and drainage of abscess performed. Prescribed chlorhexidine 0.12 % rinse 15 mL, 30 sec, twice daily for 7 days; clindamycin 300 mg QID for 7 days. Instructed to maintain oral hygiene, avoid chewing on the area, and report worsening pain or fever. Next visit: periodontal re-evaluation with new radiograph in 4 weeks.
Implant Maintenance and Radiographic Follow-Ups
Recall – 65-Year-Old Male, No Complaints, Recent Implant Maintenance
- Subjective
- 65-year-old male, takes low-dose aspirin, NKDA, reports “Here for my routine implant check and cleaning.”
- Objective
- Probing depth at implant #30: 3 mm, BOP: negative, suppuration: none; periapical radiograph shows bone level at implant shoulder, no radiolucency; plaque score 12%; no peri-implant mucositis noted.
- Assessment
- Implant maintenance, no peri-implant disease, supported by 3 mm probing depth, absence of BOP, suppuration, and radiolucency.
- Plan
- Prophylactic cleaning of implant surface with ultrasonic scaler and gentle curette, chlorhexidine 0.12% rinse 15 mL for 30 s, oral hygiene instruction; no drugs prescribed; next visit in 6 months for routine maintenance.
Recall – 42-Year-Old Female, Re-evaluation Post-Implant Placement
- Subjective
- 42-year-old female, seasonal allergies, NKDA; chief complaint: “Just checking the implant I had placed last month.” History: no pain, no swelling, no systemic symptoms.
- Objective
- Probing depth at implant #18: 2 mm, BOP: negative, suppuration: none; periapical radiograph: bone level stable, no radiolucency; plaque score: 8%; soft tissue around implant: healthy, pink, non-inflamed.
- Assessment
- Implant maintenance, no peri-implant disease – findings support healthy implant integration with stable bone levels and no inflammation.
- Plan
- Light curette cleaning of implant #18 performed; oral hygiene instruction reinforced; no medications prescribed; next recall scheduled in 6 months.
Recall – 62-Year-Old Male, Implant Maintenance with Radiograph
- Subjective
- 62-year-old male, asthma, NKDA, reports “I want to make sure my implant is still fine.” No pain, no swelling, no systemic symptoms.
- Objective
- Extraoral: normal. Intraoral: implant #31 with healthy mucosa, no recession. Periodontal: PD 3 mm, BOP negative, no suppuration. Radiograph: periapical film shows bone level at implant shoulder, slight 1 mm radiolucency apical to implant tip. Plaque score 15 %.
- Assessment
- Implant maintenance with early peri-implant bone loss, supported by 3 mm probing depth, radiolucency apical to implant tip, and 15 % plaque.
- Plan
- Prophylactic cleaning performed; chlorhexidine 0.12 % rinse prescribed, 15 mL for 30 s twice daily. Advised tighter plaque control and to return for repeat radiograph in 12 months. No medications or anesthesia used.
Recall – 44-Year-Old Female, Implant Maintenance with New Radiograph
- Subjective
- 44-year-old female with hypothyroidism on levothyroxine, allergic to penicillin (rash), reports “Just a quick check on my implant.” HPI: no pain, routine maintenance visit. PMH: hypothyroidism; allergy to penicillin.
- Objective
- Probing depth at implant #29: 4 mm, BOP positive at two sites, no suppuration. Periapical radiograph: bone level at implant shoulder, mild 2 mm apical radiolucency. Plaque score 20%; soft tissue shows mild erythema, no ulceration.
- Assessment
- Implant maintenance, peri-implant mucositis supported by 4 mm PD, BOP, mild radiolucency and plaque.
- Plan
- Deep cleaning of implant #29 with ultrasonic scaler, chlorhexidine 0.12% rinse, reinforce OHI, no drugs prescribed. Schedule next implant maintenance in 3 months.
Recall – 67-Year-Old Male, Implant Maintenance, New Radiograph
- Subjective
- 67-year-old male, NKDA, reports “Just here for my implant check.” No pain or swelling, medical history unremarkable.
- Objective
- Probing depth at implant #32 2 mm, BOP negative, no suppuration; periapical radiograph shows bone level at implant shoulder, no radiolucency; plaque score 10 %; soft tissue healthy, pink.
- Assessment
- Implant maintenance, no peri-implant disease, supported by 2 mm probing depth, absence of BOP, suppuration, radiolucency, and low plaque score.
- Plan
- Prophylactic cleaning performed; chlorhexidine 0.12 % rinse prescribed, 15 mL for 30 s twice daily; oral hygiene instruction reinforced; next recall scheduled in 6 months.
SOAP Structure Overview
- Subjective (S): Record the patient’s chief complaint in their own words, HPI, medical history, allergies, and any relevant psychosocial factors.
- Objective (O): Document vital signs, extraoral and intraoral findings, periodontal charting, radiographs, and any procedures performed, using clinical abbreviations.
- Assessment (A): Summarize periodontal status (e.g., “Gingivitis, Stage I, Grade A”), note any systemic implications, and provide a concise diagnosis that links findings to the plan.
- Plan (P): Outline today’s treatment, postoperative instructions, referrals, and next visit purpose, ensuring continuity of care.
The examples below follow this exact structure.
Customizing the Plan Section
Plan begins with a standard directive: “Perform routine prophylaxis, remove plaque and calculus, and apply fluoride varnish to all teeth.” Then append patient-specific instructions. For example, add “use interdental brushes twice daily” if the plaque score is >30 %. Include “advise 5 % potassium nitrate toothpaste for dentin hypersensitivity” when the patient reports sensitivity. If the patient smokes, insert “tobacco cessation counseling and referral to quitline.” For those with recent fluoride varnish, note “re-apply varnish in the next visit.” A concise list of common customizations:
- Interdental brush use
- Fluoride rinse or varnish
- Tobacco cessation referral
- Dentin hypersensitivity management
- Dietary counseling
- Recall interval adjustment based on plaque score or periodontal status
The base Plan line in each example is ready to copy; simply append the relevant customizations.
Objective Findings and Assessment Rationale
Objective findings in a recall include plaque index, gingival index, BOP %, and CAL. A plaque index ≤20 % and gingival index ≤1.0 indicate good plaque control and healthy gingiva. BOP % ≤10 % and CAL ≤1 mm are the thresholds for stable periodontal health. When these values fall within those limits, the assessment reads “stable periodontal health” or “gingival health.” Example notes record these exact figures, allowing the clinician to justify a routine recall or a minimal intervention plan.
Mobile-Friendly Copy-Paste Tips
Use plain text only; no tables or rich formatting. Start each heading (S:, O:, A:, P:) on a new line and insert a line break after each section. Keep objective findings in a simple bullet list—one finding per line—to preserve readability on small screens. Place the CC and HPI in the first line of S:, then list allergies and PMH. The examples below are already formatted for instant copy-paste; copy the block, paste into your chart, and edit only the patient-specific details. The layout guarantees that the note pastes cleanly into any EHR or mobile app.
These examples show structure and wording only. Record what you actually found and did, and follow your practice’s documentation requirements.
