Dental Hygiene Recall SOAP Note: Ready-to-Copy Examples & Customization Guide
Dental hygiene recall SOAP notes are ready-to-copy templates for routine recalls and no-complaint visits. Each note …
A copy-ready gingivitis SOAP note template is provided here, complete with all required S, O, A, P sections. Each section is fully populated to reflect a realistic clinical encounter, including chief complaint, objective findings, assessment, and plan. The template follows the 2017 AAP/EFP classification for gingivitis and incorporates standard periodontal charting. Copy the first example note below to use immediately in your charting workflow.
Routine Recall Baseline Gingivitis
Initial Gingivitis Diagnosis – 25-Year-Old Female
- Subjective
- 25-year-old female, “Here for my routine cleaning,” reports no pain or bleeding; medical history is unremarkable, NKDA, no medications.
- Objective
- Extraoral exam WNL. Intraoral: plaque score 35 %; CAL 1 mm on all teeth; BOP 12 % of sites; no calculus, recession, or mobility noted.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, based on BOP ≥10 % and PD ≤3 mm with no attachment loss.
- Plan
- Full-mouth prophylaxis performed with ultrasonic scaler and hand curettes; fluoride varnish 5 % sodium fluoride applied to all surfaces; oral hygiene instruction reinforced; next visit scheduled in 3 months for periodontal maintenance.
First-Time Visit – 35-Year-Old Male, Mild Gingivitis
- Subjective
- 35-year-old male, “Just a quick checkup and cleaning,” reports no pain or bleeding. PMH: low-dose aspirin daily, NKDA. HPI: routine recall, no recent changes in oral hygiene habits.
- Objective
- Extraoral WNL. Intraoral: plaque score 28%; CAL 1 mm; BOP 10 % of sites; no calculus, no recession, no mobility. No radiographs taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 28 % plaque, 1 mm CAL, 10 % BOP and absence of calculus or attachment loss.
- Plan
- Full-mouth prophylaxis performed; 5 % sodium fluoride varnish applied to all teeth. Patient instructed to brush twice daily, floss once daily, and return in 3 months for maintenance.
Allergic to Chlorhexidine, 28-Year-Old Female, Gingivitis
- Subjective
- 28-year-old female reports “mild gum bleed when I brush”; history of seasonal allergies; no known drug allergies; no current medications.
- Objective
- Extraoral: no swelling, extraoral lymph nodes not enlarged. Intraoral: gingival erythema, plaque score 40 %; periodontal: CAL 1 mm, BOP 15 % of sites, no calculus, no recession, no mobility; radiographs: none taken; all tests WNL.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A; supported by 40 % plaque, 15 % BOP, CAL 1 mm, and absence of calculus or attachment loss.
- Plan
- Full-mouth prophylaxis performed; fluoride varnish 5 % sodium fluoride applied; patient instructed to use chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily; no anesthesia used; next visit in 3 months for periodontal maintenance.
Gingivitis in a Child – 10-Year-Old Male
- Subjective
- 10-year-old male, former smoker, NKDA; reports “My gums bleed a little when I brush”; no other symptoms, no medical conditions.
- Objective
- Extraoral normal; intraoral plaque score 45%; CAL 1 mm; BOP 18 % of sites; no calculus, no recession, no mobility; radiographs not taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 45 % plaque, 18 % BOP, CAL 1 mm and absence of calculus or attachment loss.
- Plan
- Full-mouth prophylaxis performed; 5 % sodium fluoride varnish applied; oral hygiene instruction focused on proper brushing technique; no anesthesia used; next visit in 6 months for reassessment.
Gingivitis in a Teenager – 16-Year-Old Female, Heavy Sugar Intake
- Subjective
- 16-year-old female reports “My gums feel sore and bleed a bit” after brushing; she has hypothyroidism on levothyroxine, is allergic to penicillin (rash), and has no other drug allergies.
- Objective
- Extraoral: no swelling or asymmetry. Intraoral: gingival erythema, 50 % plaque score, no calculus, no recession, no mobility. Periodontal: CAL 1 mm, BOP 20 % of sites, probing depths ≤3 mm. Radiographs: none taken this visit.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 50 % plaque, 20 % BOP, 1 mm CAL, and absence of calculus or recession.
- Plan
- Full-mouth prophylaxis performed; fluoride varnish 5 % sodium fluoride applied; patient instructed to reduce sugary snacks, use 0.12 % chlorhexidine rinse twice daily, and schedule next prophylaxis in 3 months.
Gingivitis in a Post-Op Chemotherapy Patient – 62-Year-Old Female
- Subjective
- 62-year-old female, controlled hypertension on lisinopril, NKDA, reports “My gums bleed when I brush” for the past 4 weeks, no pain, no systemic symptoms.
- Objective
- Extraoral normal, intraoral soft tissue healthy, plaque score 38 %, CAL 1 mm, BOP 12 % of sites, no calculus, no recession, no mobility, radiographs not taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 38 % plaque, 12 % BOP, 1 mm CAL, no attachment loss.
- Plan
- Full-mouth prophylaxis performed, 5 % sodium fluoride varnish applied, oral hygiene instruction reinforced, no anesthesia used, next visit in 3 months for periodontal maintenance.
Gingivitis in a Post-Surgical Orthodontic Patient – 22-Year-Old Male
- Subjective
- 22-year-old male reports “My gums bleed a little when I brush.” He is post-surgical orthodontic patient, no other complaints. Medical history unremarkable; allergic to penicillin (rash). NKDA.
- Objective
- Extraoral: normal. Intraoral: plaque score 42 %; CAL 1 mm; BOP 14 % of sites; no calculus, no recession, no mobility. Radiographs: none taken today.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 42 % plaque, 14 % BOP, 1 mm CAL, and absence of calculus or recession.
- Plan
- Full-mouth prophylaxis performed; fluoride varnish 5 % sodium fluoride applied. Prescribed chlorhexidine 0.12 % rinse, 15 mL twice daily for 7 days. Advised to maintain brushing and interdental cleaning; next visit in 3 months for periodontal maintenance.
Gingivitis in a Post-Dental Extraction, 30-Year-Old Male
- Subjective
- 30-year-old male, type 2 diabetes on metformin, NKDA, reports “my gums bleed when I brush”; bleeding started about 3 weeks ago, no pain, no swelling.
- Objective
- Extraoral normal; intraoral: plaque score 48 %; periodontal: CAL 1 mm, BOP 16 % of sites, no calculus, no recession, no mobility; radiographs not taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 48 % plaque, 1 mm CAL, 16 % BOP.
- Plan
- Full-mouth prophylaxis performed, fluoride varnish 5 % sodium fluoride applied, oral hygiene instruction emphasizing reduced sugary drinks; no anesthesia used; next visit scheduled in 4 weeks for reassessment.
Gingivitis in a Patient with Alcohol Use Disorder – 52-Year-Old Male
- Subjective
- 52-year-old male, smoker 5 cigarettes/day, reports “My gums bleed a bit when I brush.” He has no known drug allergies, no medications, and no significant medical history.
- Objective
- Extraoral: no swelling or lymphadenopathy. Intraoral: gingival inflammation, no recession, no mobility. Periodontal: plaque score 55%; CAL 1 mm; BOP 18 % of sites; no calculus. Radiographs: none taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 55 % plaque, 18 % BOP, and 1 mm CAL.
- Plan
- Full-mouth prophylaxis performed under local anesthesia (none used). Fluoride varnish 5 % sodium fluoride applied. Advised smoking cessation and chlorhexidine 0.12 % rinse twice daily. Next visit scheduled in 3 months for periodontal maintenance.
Gingivitis in a Patient with Chronic Fatigue Syndrome – 30-Year-Old Female
- Subjective
- 30-year-old female, asthma (albuterol PRN), NKDA, reports “my gums bleed when I brush”; bleeding started 3 months ago, no pain.
- Objective
- Extraoral: facial symmetry, no lymphadenopathy. Intraoral: gingival inflammation, no recession, no mobility. Periodontal: plaque score 44 %, CAL 1 mm, BOP 13 % of sites, no calculus. Radiographs: none taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by plaque 44 %, BOP 13 %, CAL 1 mm, no attachment loss.
- Plan
- Full-mouth prophylaxis performed, no anesthesia used. Fluoride varnish 5 % sodium fluoride applied. Reinforced OHI, advised twice-daily brushing with soft-bristle brush, interdental cleaning, and avoidance of tobacco. Next visit: 4-week recall for re-evaluation.
Gingivitis in a Patient with Celiac Disease – 45-Year-Old Male
- Subjective
- 45-year-old male with celiac disease reports “my gums bleed a little when I brush.” He has no other medical issues, is NKDA, and has not taken any medications.
- Objective
- Extraoral exam shows no abnormalities. Intraoral: plaque score 39 %, BOP 11 % of sites, CAL 1 mm, no calculus, no recession, no mobility. Radiographs are not indicated.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by 39 % plaque, 11 % BOP, and 1 mm CAL with no attachment loss.
- Plan
- Full-mouth prophylaxis performed with no anesthesia. Fluoride varnish 5 % sodium fluoride applied. Advised to reduce sugary snacks and maintain twice-daily brushing with interdental cleaning. Next visit scheduled in 3 months for maintenance.
Gingivitis in a Patient on Bisphosphonates – 65-Year-Old Female
- Subjective
- 65-year-old female, chief complaint “My gums bleed when I brush”; reports bleeding for 2 weeks; PMH includes low-dose aspirin; NKDA; no other meds.
- Objective
- Extraoral normal; intraoral shows healthy mucosa; periodontal: plaque 47 %, CAL 1 mm, BOP 15 % of sites, no calculus, no recession, no mobility; radiographs not taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by plaque 47 %, BOP 15 %, CAL 1 mm, absence of calculus or attachment loss.
- Plan
- Full-mouth prophylaxis performed; fluoride varnish 5 % sodium fluoride applied; oral hygiene instruction reinforced; no anesthesia used; next visit in 3 months for maintenance.
Gingivitis in a Patient with Hypertension – 45-Year-Old Female
- Subjective
- 45-year-old female, seasonal allergies, NKDA, reports “My gums bleed a little when I brush”; bleeding noted for several months, no pain, no systemic symptoms.
- Objective
- Extraoral: symmetrical, no swelling. Intraoral: pink gingiva, no recession, no mobility. Periodontal: plaque score 41 %; CAL 1 mm; BOP 12 % of sites; no calculus, no gingival recession. Radiographs: none taken this visit.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by plaque score >40 %, BOP 12 %, CAL 1 mm and absence of attachment loss.
- Plan
- Full-mouth prophylaxis performed; fluoride varnish 5 % sodium fluoride applied; chlorhexidine 0.12 % rinse prescribed twice daily for 7 days; patient instructed on brushing technique and interdental cleaning; next visit scheduled in 3 months for maintenance.
Post-Procedure and First-Time Gingivitis
Post-Orthodontic Retainer, 18-Year-Old Female
- Subjective
- 18-year-old female, former smoker, NKDA, reports “my gums feel swollen and bleed when I brush.” She has been wearing a removable retainer since orthodontic treatment 4 weeks ago and has noticed increased bleeding during brushing. No pain, no systemic symptoms, no medications.
- Objective
- Extraoral: facial symmetry, no swelling. Intraoral: gingival inflammation, BOP 35 % of sites, PD max 3 mm, CAL 1 mm, plaque score 45 %, no calculus, no suppuration, no tooth mobility. Radiographs: none taken.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by BOP >10 %, PD ≤3 mm, no attachment loss, high plaque index.
- Plan
- Reinforced oral hygiene instruction focused on gentle brushing and flossing around the retainer. Applied 5 % fluoride varnish to all teeth. No anesthesia used. Advised to avoid smoking, schedule follow-up in 4 weeks to reassess gingival health.
Post-Extraction, 50-Year-Old Female, Gingival Inflammation
- Subjective
- 50-year-old female, chief complaint: “My gums are red and swollen around the extraction site.” She reports bleeding gums for 2 days post-extraction of tooth #16. PMH: hypothyroidism on levothyroxine; allergic to penicillin (rash); NKDA.
- Objective
- Extraoral: no facial swelling, extraoral lymph nodes not palpable. Intraoral: extraction socket on tooth #16 shows mild erythema, no suppuration, no mobility. Periodontal: BOP 40 % of sites, PD max 4 mm, CAL 2 mm, plaque score 50 %. Radiograph: periapical view of #16 shows no radiolucency.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by BOP ≥10 %, PD ≤4 mm, no attachment loss beyond 2 mm.
- Plan
- Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; aspiration negative. Prescribed chlorhexidine 0.12 % rinse 15 mL for 30 sec twice daily, fluoride varnish 5 % on all teeth. Advised soft diet, oral hygiene instruction, and return in 2 weeks for healing assessment.
Post-Surgical Healing, 42-Year-Old Male, Gingival Inflammation
- Subjective
- 42-year-old male, controlled hypertension on lisinopril, NKDA, reports “lower right molars feel sore and the gums look inflamed” since extraction of tooth #30; no pain beyond soreness, no trismus, no systemic symptoms.
- Objective
- Extraoral: mild facial edema, no lymphadenopathy. Intraoral: surgical site on #30 shows mild edema, no suppuration, no mobility. Periodontal: BOP 30 % of sites, PD max 3.5 mm, CAL 1.5 mm, plaque score 40 %. Radiographs: periapical of #30 shows healing socket, no pathology.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by BOP 30 %, PD ≤3.5 mm, CAL 1.5 mm, and absence of suppuration or mobility.
- Plan
- Administered 4 % articaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Provided post-surgical hygiene instruction, chlorhexidine 0.12 % rinse 15 mL for 30 sec twice daily, fluoride varnish 5 % on all teeth, advised avoidance of hard foods for 48 hrs, and scheduled follow-up in 3 weeks.
Post-Dental Implant, 48-Year-Old Male, Gingival Inflammation
- Subjective
- 48-year-old male, no significant medical history, allergic to penicillin (rash), reports “the implant site looks red and a bit swollen.” He had a dental implant placed in tooth #26 two weeks ago; he denies pain, fever, or systemic symptoms.
- Objective
- Extraoral: no facial swelling or lymphadenopathy. Intraoral: implant site erythematous, mild edema, no suppuration, no mobility. Periodontal: BOP 25% of sites, PD max 3 mm, CAL 1 mm, plaque score 35%. Radiograph: periapical PA shows smooth implant surface, no peri-implant bone loss.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade A, supported by BOP ≥10%, PD ≤3 mm, CAL 1 mm, and absence of bone loss.
- Plan
- Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (IANB), aspiration negative. Instructed patient to rinse with 0.12% chlorhexidine, 15 mL for 30 sec twice daily, apply 5% fluoride varnish to all teeth, reinforce oral hygiene, and schedule follow-up in 4 weeks.
First-time Visit for Chronic Periodontitis
- Subjective
- 58-year-old female, type 2 diabetes on metformin, NKDA, reports “my gums bleed a lot and I feel a pocket around my molars.” HPI: bleeding with brushing, swelling around lower molars, no pain.
- Objective
- Extraoral normal. Intraoral: BOP 60 % of sites, PD 6 mm max, CAL 5 mm, plaque 70 %, suppuration on upper left premolar #13, no mobility. PAN shows mild bone loss around lower molars #12-15.
- Assessment
- Periodontitis, Stage II, Grade B, supported by BOP 60 %, PD 6 mm, CAL 5 mm, radiographic bone loss.
- Plan
- Scaling and root planing of lower posterior quadrant performed, no anesthesia used. Chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily, fluoride varnish 5 % on all teeth applied. Next periodontal maintenance in 3 months.
Risk Factor-Related Gingivitis
Pregnancy-Related Gingivitis – 30-Year-Old Mother-to-Be
- Subjective
- 30-year-old male presents for routine cleaning, reports “just a routine visit.” He smokes ~5 cigarettes/day; no medications, NKDA, ASA I.
- Objective
- Extraoral: no abnormalities. Intraoral: plaque on all surfaces, BOP 12 % of sites, PD ≤2 mm, no recession, no suppuration, no mobility. Plaque score 18 %, calculus light. Radiograph: full-mouth series shows no caries or bone loss. Vital signs BP 118/76, HR 72.
- Assessment
- Risk Factor-Related Gingivitis – Smoking; supported by 12 % BOP, plaque accumulation, and smoking history.
- Plan
- Prophylaxis performed: scaling and polishing of all tooth surfaces; oral hygiene instruction; tobacco cessation counseling; 5 % sodium fluoride varnish applied to all teeth. No anesthesia used. Patient advised to reduce smoking, maintain oral hygiene, and return in 3 months for maintenance.
Smoker, 45-Year-Old Male, Severe Gingivitis
- Subjective
- 45-year-old male smoker reports “I have been having a lot of bleeding gums lately.” He has asthma, uses albuterol inhaler PRN, NKDA, and has no other chronic illnesses.
- Objective
- Extraoral: normal. Intraoral: plaque and calculus on all teeth; BOP 25% of sites; PD 3 mm on maxillary molars, 2 mm elsewhere; no attachment loss, suppuration, or mobility; plaque score 22%; calculus score moderate; full-mouth radiographs show no bone loss. Vital signs: BP 122/78, HR 70; ASA II.
- Assessment
- Risk Factor-Related Gingivitis – asthma with inhaled steroids, supported by 25% BOP, moderate calculus, and absence of bone loss.
- Plan
- Scaling and polishing of all tooth surfaces performed; fluoride varnish 5% sodium fluoride applied to all teeth; oral hygiene instruction given, emphasizing proper brushing, interdental cleaning, and rinsing after inhaler use; patient advised to quit smoking and to return in 4 weeks for re-evaluation.
Gingivitis in a Patient with Chronic Obstructive Pulmonary Disease – 65-Year-Old Male
- Subjective
- 65-year-old male, “My gums bleed when I brush,” reports bleeding during brushing for 3 months; no other symptoms. Medical history unremarkable, NKDA, no medications.
- Objective
- Extraoral: normal. Intraoral: heavy plaque and calculus on all teeth; BOP 30 % of sites; PD 3 mm on molars, 2 mm on premolars, 1 mm on incisors; no attachment loss, no suppuration, no mobility; plaque score 28 %; calculus heavy; full-mouth radiographs show no bone loss. Vital signs BP 130/80 mm Hg, HR 68 bpm; ASA I.
- Assessment
- Risk Factor-Related Gingivitis – Chronic Obstructive Pulmonary Disease with reduced oral hygiene, supported by 30 % BOP, heavy plaque/calculus, and absence of periodontal attachment loss.
- Plan
- Prophylaxis performed with scaling and polishing of all tooth surfaces; fluoride varnish 5 % sodium fluoride applied to all teeth; oral hygiene instruction focused on brushing technique and interdental cleaning; referral to pulmonology for COPD management; next visit in 3 months for maintenance and reassessment.
Gingivitis in a Patient with Chronic Pain – 40-Year-Old Male
- Subjective
- 40-year-old male, NKDA, reports “My gums are red and bleed a lot”; has been taking low-dose aspirin daily for chronic pain.
- Objective
- Extraoral: no abnormalities. Intraoral: plaque and calculus on all teeth; BOP 20 % of sites; PD 2 mm all sites; no attachment loss, suppuration, or mobility; plaque score 20 %; calculus moderate; full-mouth radiographs show no bone loss. Vital signs: BP 115/70, HR 72; ASA II.
- Assessment
- Risk Factor-Related Gingivitis – chronic pain with daily aspirin use, supported by 20 % BOP, 2 mm PD, plaque/calculus burden, and absence of attachment loss.
- Plan
- Prophylaxis performed: scaling and polishing all tooth surfaces; fluoride varnish 5 % sodium fluoride applied to all teeth; oral hygiene instruction on brushing and interdental cleaning; advised patient to discuss aspirin regimen with primary care provider; next visit in 3 months for maintenance.
Diabetes-Related Gingivitis
Diabetic, 60-Year-Old Male, Recurrent Gingivitis
- Subjective
- 60-year-old male, seasonal allergies, NKDA, reports “I’ve had bleeding gums for the past few weeks and it’s getting worse.” He has no other medical issues and no medications.
- Objective
- Extraoral exam normal. Intraoral: soft tissue pink, no ulceration. Periodontal: BOP 25 % of sites, PD ≤3 mm everywhere, plaque index 40 %, no supragingival calculus beyond the gingival margin, no pockets >4 mm, no radiographic bone loss. No systemic signs of infection.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade C, supported by BOP 25 %, PD ≤3 mm, plaque index 40 %, no attachment loss or bone loss.
- Plan
- Applied 5 % sodium fluoride varnish to all teeth; instructed on interdental cleaning and proper brushing technique; advised monitoring blood glucose control; no anesthesia used; next visit in 4 weeks for reassessment of BOP and plaque control.
Gingivitis in a Patient with Diabetes Type 1 – 28-Year-Old Male
- Subjective
- 28-year-old male patient, former smoker, NKDA, reports “My gums bleed when I brush and I feel a bit swollen.” He has been brushing twice daily for 6 months, notes increased bleeding over the last 2 weeks, and denies pain or systemic symptoms.
- Objective
- Extraoral: no facial asymmetry, no lymphadenopathy. Intraoral: gingiva erythematous, mild edema, bleeding on probing 30 % of sites. Periodontal: all probing depths ≤3 mm, plaque index 45 %, no subgingival calculus, no radiographic bone loss on panoramic film. No suppuration, no systemic signs of infection.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade C, supported by BOP 30 %, PD ≤3 mm, high plaque index, and rapid progression modifier (former smoker, HbA1c not provided but grade C implied).
- Plan
- Applied 5 % sodium fluoride varnish to all teeth; instructed on proper brushing technique, interdental cleaning, and tight glycemic control; advised to quit smoking; next visit in 4 weeks for periodontal maintenance.
Post-Extraction Gingival Healing in a Diabetic Patient
- Subjective
- 81-year-old female with hypothyroidism on levothyroxine reports “I’m healing fine after the extraction but my gums are still a bit red and swollen.” She has a penicillin allergy (rash). No other medications or allergies noted.
- Objective
- Extraoral normal. Intraoral: extraction socket of tooth #16 closed with clot; BOP 20 % of surrounding sites; PD 3 mm around #16; plaque index 35 %. Radiograph shows no bone loss. No systemic signs of infection.
- Assessment
- Post-extraction gingival healing, Stage I, Grade A, supported by clot presence, mild BOP, shallow PD, and absence of radiographic bone loss.
- Plan
- Local anesthesia: 4 % articaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), infiltration. Prescribed chlorhexidine gluconate 0.12 % rinse, 15 mL for 30 s twice daily for 7 days. Instructed on oral hygiene for the extraction site, monitoring blood glucose and thyroid levels, and to return in 7 days for suture removal and healing assessment.
Systemic Chronic Disease Gingivitis
Gingivitis with Periodontal Abscess – 55-Year-Old Male
- Subjective
- 55-year-old male reports “My gums are swollen and bleed when I brush.” He has controlled hypertension on lisinopril, NKDA, and has noticed bleeding for the past month.
- Objective
- Extraoral exam normal. Intraoral: BOP 100% on #30, 80% on #31, 90% on #32; PD 5/4/5 mm, CAL 6/5/6 mm respectively. Radiograph shows mild bone loss around #30-#32, no periapical radiolucency. BP 138/84 mmHg, T 98.6 °F.
- Assessment
- Periodontitis, Stage II, Grade B, supported by PD ≥4 mm, CAL ≥5 mm, BOP >70 % and radiographic bone loss.
- Plan
- Full-mouth SRP performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge) IANB, aspiration negative. Patient instructed to use 0.12 % chlorhexidine rinse twice daily, brush with a soft-bristle brush, and schedule a follow-up in 4 weeks for re-evaluation.
Gingivitis in Elderly – 70-Year-Old Female, Cognitive Decline
- Subjective
- 70-year-old female with cognitive decline reports “I have trouble eating because my gums hurt”; history of present illness includes progressive pain over last 2 weeks; no significant medical history, NKDA, allergic to penicillin (rash).
- Objective
- Extraoral: normal. Intraoral: generalized plaque, BOP 90-100 %; Periodontal: #12 PD 6 mm buccal/5 mm lingual, CAL 7 mm, BOP 100 %; #13 PD 5 mm buccal/4 mm lingual, CAL 6 mm, BOP 90 %; #14 PD 6 mm buccal/5 mm lingual, CAL 7 mm, BOP 100 %; #15 PD 5 mm buccal/4 mm lingual, CAL 6 mm, BOP 80 %; Radiograph: generalized bone loss, no abscess; Temperature 98.4 °F.
- Assessment
- Periodontitis, Stage III, Grade C, supported by PDs ≥5 mm, CAL ≥6 mm, generalized bone loss, and 90-100 % BOP.
- Plan
- Quadrant SRP performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative; no drugs prescribed; instructed intensive OHI, 0.12 % chlorhexidine rinse twice daily, avoid brushing over treated sites for 24 h; next visit in 4 weeks for re-evaluation.
Gingivitis in a Patient on Anticoagulants – 68-Year-Old Male
- Subjective
- 68-year-old male reports “my gums bleed a lot and feel sore.” He has type 2 diabetes on metformin, NKDA, and is taking no anticoagulants. He has been experiencing bleeding for several weeks despite regular brushing and flossing.
- Objective
- Extraoral: no swelling, intraoral: erythematous gingiva, periodontal: PD 5/4 mm on #23–26, BOP 90/80 %, CAL 6/5 mm, radiograph: moderate bone loss, no periapical radiolucency, temperature 98.7 °F, HbA1c 7.2 %.
- Assessment
- Periodontitis, Stage II, Grade C, supported by PD ≥4 mm, CAL ≥5 mm, BOP >80 %, and HbA1c ≥7 %.
- Plan
- Full-mouth scaling and root planing performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Instructed on glycemic control, chlorhexidine 0.12 % rinse twice daily, and gentle brushing. Next visit in 4 weeks for re-evaluation.
Gingivitis with Systemic Lupus Erythematosus – 35-Year-Old Female
- Subjective
- 35-year-old female; CC “My gums are red and bleed when I floss”; HPI: bleeding for 2 weeks, no pain; PMH: smoker, 5 cigarettes/day; NKDA.
- Objective
- Extraoral: normal. Intraoral: generalized plaque, BOP 85% overall. Periodontal: #11 buccal PD 4 mm, lingual 3 mm, BOP 80%, CAL 5 mm; #12 buccal 5 mm, lingual 4 mm, BOP 90%, CAL 6 mm; #13 buccal 4 mm, lingual 3 mm, BOP 80%, CAL 5 mm; #14 buccal 5 mm, lingual 4 mm, BOP 90%, CAL 6 mm. Radiograph: mild bone loss, no abscess; Temp 98.5 °F.
- Assessment
- Periodontitis, Stage I, Grade C, supported by PD 4–5 mm, CAL 5–6 mm, BOP 80–90%, mild bone loss.
- Plan
- Quadrant SRP performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; patient advised smoking cessation, chlorhexidine 0.12% rinse twice daily for 2 weeks, and return in 4 weeks for re-evaluation.
Gingivitis in a Patient with Sjögren’s Syndrome – 50-Year-Old Female
- Subjective
- 50-year-old female reports “lower gums are swollen and bleed” for several weeks; she has asthma controlled with albuterol PRN, no other medications, NKDA.
- Objective
- Extraoral normal. Intraoral: generalized gingival swelling, BOP 90-100%; probing depths 4-5 mm on #17-20, CAL 5-6 mm; radiograph shows generalized bone loss, no abscess; temperature 98.4 °F.
- Assessment
- Periodontitis, Stage II, Grade B, supported by pocket depths ≥4 mm, CAL 5-6 mm, 90-100 % BOP and generalized bone loss.
- Plan
- Full-mouth scaling and root planing performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (IANB), aspiration negative. Patient instructed to use 0.12 % chlorhexidine rinse twice daily, maintain asthma control, and return in 4 weeks for re-evaluation.
Gingivitis in a Patient with HIV – 40-Year-Old Male
- Subjective
- 40-year-old male, no known drug allergies, reports “my gums bleed and feel tender” for the past week, no other medical conditions.
- Objective
- Extraoral normal. Intraoral: BOP 85% overall; PD 4–5 mm, CAL 5–6 mm on teeth #3-#6; mild bone loss on radiograph, no abscess; temperature 98.6 °F.
- Assessment
- Periodontitis, Stage I, Grade A, supported by PD 4–5 mm, CAL 5–6 mm, BOP >80 % and mild bone loss.
- Plan
- Quadrant scaling and root planing performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Advised chlorhexidine 0.12 % rinse twice daily, gentle brushing, flossing; next visit in 4 weeks for re-evaluation.
Gingivitis in a Patient with Chronic Kidney Disease – 55-Year-Old Female
- Subjective
- 55-year-old female reports “my gums are red and bleed when I brush”; bleeding has worsened over 3 months. She takes low-dose aspirin daily, NKDA, no other chronic illnesses.
- Objective
- Extraoral normal. Intraoral: generalized erythema, BOP 95% (100% on #27-#29, 90% on #28, #30). Periodontal chart: PD 5 mm buccal, 4 mm lingual on #27 (CAL 6 mm); PD 4/3 mm on #28 (CAL 5 mm); PD 5/4 mm on #29 (CAL 6 mm); PD 4/3 mm on #30 (CAL 5 mm). Radiograph shows generalized bone loss, no abscess. Temperature 98.5 °F.
- Assessment
- Periodontitis, Stage II, Grade B—generalized moderate attachment loss with BOP >90% and PD ≥4 mm.
- Plan
- Full-mouth scaling and root planing performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (IANB), aspiration negative. Instructed patient on aspirin precautions, advised chlorhexidine 0.12% rinse twice daily, and to return in 4 weeks for re-evaluation.
Gingivitis in a Patient with Rheumatoid Arthritis – 60-Year-Old Male
- Subjective
- 60-year-old male, seasonal allergies, NKDA, reports “My gums bleed and feel sore” for the last 2 weeks, no pain, no systemic symptoms.
- Objective
- Extraoral: normal. Intraoral: BOP 80–90 % on #1-#4, PD 4–5 mm buccally, 3–4 mm lingually, CAL 5–6 mm on all four teeth. Radiograph: mild bone loss, no abscess. Temperature 98.6 °F.
- Assessment
- Periodontitis, Stage I, Grade A; supported by PD 4–5 mm, BOP 80–90 %, CAL 5–6 mm, mild bone loss.
- Plan
- Quadrant SRP performed on #1-#4 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Post-op: chlorhexidine 0.12 % rinse twice daily for 2 weeks, gentle brushing, avoid flossing in treated sites for 48 h. Return to clinic in 4 weeks for re-evaluation.
Gingivitis in a Patient with Osteoporosis – 70-Year-Old Female
- Subjective
- 70-year-old female, former smoker, NKDA, reports “My gums are swollen and bleed when I floss.” She has had progressive gingival swelling for 3 months, with no pain or systemic symptoms.
- Objective
- Extraoral exam WNL. Intraoral: generalized erythema, 100 % BOP, pocket depths 4–5 mm, CAL 5–6 mm on teeth #15–#18. Panoramic radiograph shows generalized bone loss, no abscesses. Temperature 98.4 °F.
- Assessment
- Periodontitis, Stage II, Grade B, supported by generalized 4–5 mm pockets, 100 % BOP, CAL 5–6 mm, and radiographic bone loss.
- Plan
- Full-mouth scaling and root planing performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Post-operative instructions: use chlorhexidine 0.12 % rinse twice daily, gentle brushing, avoid flossing until next visit. Return in 4 weeks for re-evaluation.
Gingivitis in a Patient with Thyroid Disorder – 38-Year-Old Female
- Subjective
- 38-year-old female, hypothyroid on levothyroxine, reports “my gums bleed and feel tender” for the past 2 weeks; no other systemic complaints; allergic to penicillin (rash); NKDA otherwise.
- Objective
- Extraoral: normal. Intraoral: BOP 80-90 % on teeth #9-12; PD 4–5 mm, CAL 5–6 mm; radiograph: mild bone loss, no abscess; temperature 98.5 °F; aspiration negative.
- Assessment
- Periodontitis, Stage I, Grade A—supported by pocket depths 4–5 mm, CAL 5–6 mm, BOP >75 %, and mild radiographic bone loss.
- Plan
- Quadrant SRP performed on teeth #9-12 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge); patient instructed to use chlorhexidine 0.12 % rinse twice daily, maintain oral hygiene, avoid hard foods for 24 h; next visit in 4 weeks for re-evaluation.
Gingivitis in a Patient with Multiple Sclerosis – 55-Year-Old Female
- Subjective
- 55-year-old female, chief complaint “My gums bleed when I brush.” She reports bleeding since 2 weeks, denies pain. PMH: controlled hypertension on lisinopril, NKDA.
- Objective
- Extraoral WNL. Intraoral: generalized plaque, erythema. Periodontal: PD 5 mm buccal, 4 mm lingual on #21-#24; BOP 90-100 %; CAL 5-6 mm on all four teeth. Radiograph: generalized bone loss, no abscess. Temperature 98.6 °F.
- Assessment
- Periodontitis, Stage II, Grade B; generalized attachment loss with 90-100 % BOP supports diagnosis.
- Plan
- Full-mouth scaling and root planing performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Patient instructed to use chlorhexidine gluconate 0.12 % rinse twice daily for 30 s, maintain oral hygiene, avoid smoking. Next visit in 4 weeks for re-evaluation.
Gingivitis in a Patient with Chronic Anemia – 60-Year-Old Female
- Subjective
- 60-year-old female reports “my gums are red and bleed when I floss”; HPI: bleeding for 2 weeks, no pain; PMH: no significant disease; NKDA; no medications.
- Objective
- Extraoral: normal. Intraoral: generalized erythema; periodontal: #5 buccal 4 mm PD, lingual 3 mm, BOP 80 %, CAL 5 mm; #6 buccal 5 mm, lingual 4 mm, BOP 90 %, CAL 6 mm; #7 buccal 4 mm, lingual 3 mm, BOP 80 %, CAL 5 mm; #8 buccal 5 mm, lingual 4 mm, BOP 90 %, CAL 6 mm; radiograph: mild bone loss, no abscess; temp 98.5 °F.
- Assessment
- Periodontitis, Stage I, Grade A – localized interdental CAL 1–2 mm, BOP >10 %, probing depths ≤5 mm, mild bone loss.
- Plan
- Quadrant SRP performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Post-op: chlorhexidine 0.12 % rinse, 15 mL 30 s twice daily, avoid brushing the treated sites for 24 h; next visit in 4 weeks for re-evaluation.
Follow-up After Periodontal Surgery
- Subjective
- 47-year-old male, type 2 diabetes on metformin, NKDA, reports “my gums still feel sore but are healing” since surgery on teeth #30-#32.
- Objective
- Extraoral: normal. Intraoral: gingival margins stable, mild erythema, no suppuration. Periodontal: PD 4 mm buccal/3 mm lingual on #30-#32, BOP 20 % of sites, CAL 5 mm on each tooth. Radiograph: healing, no bone loss. Temperature 98.4 °F.
- Assessment
- Post-surgical healing, Stage I, Grade A, supported by stable margins, mild erythema, PD ≤4 mm, BOP 20 %, CAL 5 mm, no suppuration or bone loss.
- Plan
- No anesthesia administered. Patient instructed to continue chlorhexidine gluconate 0.12 % rinse, 15 mL, 30 seconds, twice daily, avoid brushing surgical sites, and return in 2 weeks for suture removal.
Special Situations
Re-evaluation After Scaling and Root Planing
- Subjective
- 54-year-old female smoker, 5 cigarettes/day, NKDA, reports “I’m here for my follow-up after the cleaning.”
- Objective
- Extraoral: normal. Intraoral: mild gingival inflammation, no ulceration. Periodontal: PD #30 3 mm, #31 3 mm, #32 2 mm; BOP 10% of sites; CAL #30 4 mm, #31 4 mm, #32 3 mm; plaque 15%; radiograph: no new bone loss; mobility Miller 0; furcation none.
- Assessment
- Periodontitis, Stage II, Grade B, supported by PD ≤3 mm with CAL 3–4 mm, BOP 10%, and stable radiographs.
- Plan
- No anesthesia used. Reinforced oral hygiene instruction, advised smoking cessation referral, scheduled periodontal maintenance in 3 months.
Emergency Visit for Acute Gingival Hemorrhage
- Subjective
- 45-year-old female, asthma, NKDA, reports “my gums are bleeding all over and I can’t stop it”; bleeding started this morning, no pain, no swelling, no systemic symptoms.
- Objective
- Extraoral normal; intraoral shows diffuse gingival bleeding, BOP 30% of sites, probing depths 3–4 mm throughout, no suppuration, plaque score 35%; radiograph shows no periapical pathology; mobility Miller 0; furcation none.
- Assessment
- Plaque-induced gingivitis, Stage I, Grade B, supported by BOP 30%, PD 3–4 mm, plaque 35%, no attachment loss.
- Plan
- No anesthesia used. Prescribed chlorhexidine gluconate 0.12% rinse 15 mL for 30 seconds, twice daily; reinforced oral hygiene instruction; scheduled follow-up in 1 week to reassess bleeding.
Documenting Oral Hygiene Routine and Probing Depth
- Brushing frequency: twice daily, 2 min each session.
- Brush type: soft-bristle manual brush, electric brush with gentle mode.
- Interdental aid: daily flossing, use of interdental brushes (size 1–2) for molars.
- Flossing technique: V-shaped wrap around each tooth, gentle horizontal motion, avoid snapping.
- Adjuncts: 0.12% chlorhexidine mouthwash, 0.05% fluoride toothpaste.
- Additional note: patient reports using a whitening strip once a week, no bleeding observed.
Probing depths ≤ 3 mm are considered normal in gingivitis because they indicate that the gingival sulcus is shallow and free of attachment loss. Depths beyond 3 mm suggest periodontal pocket formation, a hallmark of periodontitis, where connective tissue attachment has been lost and the pocket wall is at risk for bacterial colonization and further attachment breakdown.
Recording Follow-Up Recall Dates and Patient Education Steps
Plan checklist for follow-up recall and education
- Next recall: {Date of next visit} – 3-month interval for gingivitis maintenance.
- Purpose of visit: Re-evaluation of plaque control, probing depths ≤ 3 mm, and reassessment of bleeding on probing.
- Oral hygiene instructions given: Brush twice daily with a soft-bristle brush, floss daily, use interdental brushes (size 1–2) for molars, and rinse with 0.12 % chlorhexidine twice daily for 30 seconds.
- Written materials provided: Handout on proper brushing/flossing technique, schedule for future recalls, and a list of recommended oral care products.
- Patient’s verbal acknowledgment: Patient confirms understanding of instructions and agrees to return on the scheduled date.
- Referrals: If BOP > 10 % or PD > 3 mm, refer to periodontist for possible scaling and root planing.
Quick-Reference Table: Bleeding Gums in the Subjective Section
| Finding | Suggested Documentation |
|---|---|
| Bleeding on brushing | “Bleeding on brushing, noted during morning and evening routine.” |
| Spontaneous bleeding | “Spontaneous gingival bleeding reported, occurring without brushing.” |
| Bleeding after flossing | “Bleeding after flossing, especially between molars.” |
| Bleeding during dental visit | “Bleeding observed during professional cleaning, BOP present.” |
| Persistent gum swelling with bleeding | “Persistent gum swelling with occasional bleeding, especially in lower incisors.” |
Differentiating Gingivitis from Early Periodontitis & Documenting Modifiable Risk Factors
Gingivitis presents with probing depths ≤ 3 mm, no clinical attachment loss, and bleeding on probing (BOP) at 10 % of sites or more. Early periodontitis shows probing depths > 3 mm, clinical attachment loss of 1–2 mm, BOP > 10 %, and radiographic bone loss ≥ 15 % of root length. Systemic risk factors such as diabetes, smoking, or immunosuppression shift the diagnosis toward periodontitis. In the SOAP header, record the diagnosis as “Gingivitis – plaque-induced” or “Early Periodontitis – Stage I, Grade A” to reflect the clinical findings.
Risk factors that modify gingival inflammation should be captured in the HPI and Risk Factors sections.
- Tobacco use – “Smokes 10–15 cigarettes/day; last quit 2 years ago.”
- Pregnancy hormones – “Second trimester; reports increased gingival bleeding.”
- Poor oral hygiene – “Misses brushing > 1 day/week; reports plaque accumulation.”
- Medication side effects – “Takes amlodipine 10 mg daily; notes dry mouth.”
Record each as a separate sentence in the HPI, and summarize in the Risk Factors field with concise bullet points.
These examples show structure and wording only. Record what you actually found and did, and follow your practice’s documentation requirements.
