Limited Dental Exam SOAP Note: Quick-Copy Templates & Comparison to Emergency Exams

A limited dental exam focuses on a single chief complaint, documenting only the pertinent history, focused intra-oral findings, and a targeted plan. The note excludes full charting and routine screenings unless clinically indicated. The first example below is a concise, copy-ready SOAP note that fits on a phone screen. The page offers many more templates and a side-by-side comparison with emergency exams.

SSubjective

45-y-o male, CC: “tooth pain on #30 since yesterday.” HPI: sharp, 8/10, relieved by cold. PMH: HTN, NKDA.

OObjective

Extraoral: no swelling. Intraoral: #30 shows 1-mm deep enamel caries, no bleeding. Temperature 98.6°F.

AAssessment

Symptomatic irreversible pulpitis, tooth #30.

PPlan

RCT indicated; explain risks, alternatives. Prescribe ibuprofen 400 mg PO q6h PRN. Schedule appointment 7 days for RCT.

Diabetes Post-Extraction Follow-Up

Diabetic, Post-Extraction, 1 Week Follow-Up

SSubjective

43-year-old female, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “I still have a little swelling and a dull ache in the back of my mouth”; HPI: one week post-extraction of tooth #30, reports persistent mild swelling and dull ache; PMH: type 2 diabetes, hypertension; medications: metformin, lisinopril; allergies: NKDA.

OObjective

Extraoral: mild swelling of the right mandibular angle, no lymphadenopathy; Intraoral: extraction socket of #30 healed, slight erythema, no drainage; Probing: 3 mm depth at #30, no BOP; Radiograph: periapical PA of #30 shows normal healing, no radiolucency; systemic signs: none.

AAssessment

Symptomatic apical periodontitis of tooth #30, evidenced by persistent swelling, dull ache, 3 mm probing depth, and normal radiographic healing without radiolucency.

PPlan

No anesthesia or medications administered; instructed to continue chlorhexidine 0.12% rinse twice daily, maintain oral hygiene, avoid hard foods for 3 days; scheduled return visit in 2 weeks for reassessment of healing and glycemic control.

Diabetic, 2-Day Post-Extraction

SSubjective

65-year-old female, type 2 diabetes on metformin, seasonal allergies, NKDA; CC: “The pain is getting worse and I feel a bit feverish”; HPI: 2-day post-extraction of upper left molar #14, reports increasing discomfort and low-grade fever; PMH: type 2 diabetes, metformin; no known drug allergies.

OObjective

Extraoral: mild swelling of the left mandibular angle, no lymphadenopathy; Intraoral: extraction socket of upper left molar #14 shows slight drainage, erythema; Probing depth 4 mm at #14 with BOP; PA radiograph of #14 reveals a small radiolucent area at the apex; systemic: temperature 99.6 °F.

AAssessment

Acute apical abscess of upper left molar #14, supported by socket drainage, erythema, 4 mm probing depth with BOP, radiolucent apex, and low-grade fever.

PPlan

Prescribed amoxicillin 500 mg PO q8h for 7 days; ibuprofen 400 mg PO q6h PRN for pain; instructed to maintain oral hygiene, monitor swelling, report any worsening or high fever; next visit in 7 days for reassessment.

Diabetic, 2-Week Post-Extraction, Complication

SSubjective

73-year-old male, type 2 diabetes on metformin, NKDA; CC: “The socket is still red and I have a bad taste in my mouth”; HPI: 2-week post-extraction of lower left molar #19, reports persistent redness, foul taste, mild fever; PMH: diabetes, no other meds; allergies: NKDA.

OObjective

Extraoral: moderate swelling of left mandibular angle, tender cervical lymph nodes; Intraoral: extraction socket of #19 shows purulent drainage, erythema, no clot; Probing: 5 mm depth at #19, BOP present; Radiograph: PA of #19 shows a 4 mm radiolucent lesion extending to the root apex; systemic: fever 100.4°F, malaise.

AAssessment

Acute apical abscess of #19 with spreading cellulitis, supported by purulent drainage, erythema, 5 mm probing depth, BOP, radiolucent lesion, fever, and cervical lymphadenopathy.

PPlan

Advised immediate return for incision and drainage; prescribed clindamycin 300 mg PO q8h for 7 days; instructed warm saline rinses, maintain glycemic control, monitor temperature, and report worsening symptoms; next visit: incision and drainage procedure.

Diabetic, 1-Day Post-Extraction, Infection Alert

SSubjective

75-year-old male, type 2 diabetes on metformin, former smoker, NKDA, CC “I feel a sharp pain when I bite down and my mouth feels hot”; HPI: pain began 24 h post-extraction of #28, associated with heat sensation; PMH: diabetes, smoking history; no systemic symptoms.

OObjective

Extraoral: swelling of right mandibular angle, no lymphadenopathy; Intraoral: extraction socket of #28 shows slight bleeding, erythema; Probing depth 4 mm at socket, BOP present; Radiograph: periapical PA of #28 reveals a 3 mm radiolucent area at the apex; all other findings within normal limits.

AAssessment

Symptomatic apical periodontitis of tooth #28, supported by socket erythema, bleeding, BOP, 4 mm probing depth, and a 3 mm periapical radiolucency.

PPlan

Instructed patient to maintain oral hygiene, avoid chewing on the extraction side, and take ibuprofen 400 mg PO q6h PRN for pain; advised to monitor for fever or increased swelling and return if symptoms worsen.

Diabetic, 2-Month Post-Extraction, Re-evaluation

SSubjective

51-year-old male, type 2 diabetes on metformin, smoker 5 cig/day, NKDA, CC: “My extraction site looks fine, but I still have a slight sensitivity.” HPI: 2 months post-extraction of tooth #30, reports mild sensitivity but no pain or swelling.

OObjective

Extraoral: no swelling, no lymphadenopathy. Intraoral: socket of #30 fully healed, no erythema, probing depth 2 mm, no BOP. Radiograph: periapical PA of #30 shows normal bone density, no radiolucency.

AAssessment

Normal healing of extraction site #30; no infection or pathology noted.

PPlan

Reassured patient, advised to maintain routine oral hygiene, no medication prescribed. Next visit: routine check-up in 3 months.

Diabetic, 3-Day Post-Extraction, Mild Fever

SSubjective

50-year-old female, type 2 diabetes on metformin, NKDA, presents 3-day post-extraction of upper left first molar (#14) with low fever and mild ache around the socket. HPI: “I have a low fever and a mild ache around the extraction.”

OObjective

Extraoral: mild swelling of the left mandibular angle, no lymphadenopathy. Intraoral: extraction socket of #14 shows slight erythema, no drainage; probing depth 3 mm, BOP present. Radiograph: periapical PA of #14 shows a small radiolucent area at the apex.

AAssessment

Symptomatic apical periodontitis of #14, supported by socket erythema, BOP, 3 mm probing depth, radiolucent apex, and low fever 99.8 °F.

PPlan

Prescribed amoxicillin 500 mg PO q8h for 7 days, ibuprofen 400 mg PO q6h PRN for pain, instructed to use warm saline rinses twice daily; advised to monitor temperature and report worsening swelling or drainage; next visit in 1 week for reassessment.

Hypertension Post-Extraction Follow-Up

Hypertensive, 2-Week Post-Extraction

SSubjective

34-year-old male, on daily low-dose aspirin, NKDA, presents for 2-week post-extraction follow-up after tooth #15 extraction; reports no pain or swelling.

OObjective

Extraoral: no facial swelling, lymph nodes not enlarged. Intraoral: extraction site shows mild erythema, clot intact, no drainage. Probing depth 2 mm, no bleeding on probing. Radiograph: periapical radiograph shows no radiolucency. Soft tissue healing within expected limits.

AAssessment

Normal healing of extraction site, supported by intact clot, absence of drainage, 2 mm probing depth without bleeding, and radiographic absence of periapical pathology.

PPlan

No additional treatment performed. Post-operative instructions given verbally and in writing: maintain oral hygiene, avoid hard foods, and return in 4 weeks for final assessment. No medications prescribed.

Hypertensive, 1-Month Post-Extraction, Medication Review

SSubjective

66-year-old male, no significant medical history, allergic to penicillin (rash), presents for a one-month post-extraction check-up after tooth #12 extraction; states “I’m here for my one-month check-up after the extraction.” O: Extraction site shows well-formed scar tissue, no swelling or drainage; probing depth 1 mm, no bleeding on probing; periapical radiograph shows complete bone fill; soft tissue appears healthy, no ulceration. A: Normal healing of extraction site, supported by scar tissue, 1 mm probing depth, no bleeding, and complete bone fill on radiograph. P: Reviewed current medications, advised to continue aspirin as prescribed, no changes recommended; postoperative instructions reiterated; next visit scheduled in 3 months for routine recall.

Hypertensive, 2-Week Post-Extraction, Hemostasis Check

SSubjective

82-year-old female, hypothyroid on levothyroxine, allergic to penicillin (rash), reports “I’m here to check the bleeding after my extraction.”

OObjective

Extraction site #28 shows a stable clot, no oozing, soft-tissue margin intact, mild erythema, no swelling; probing depth 2 mm, no bleeding on probing; periapical radiograph shows no pathology.

AAssessment

Adequate hemostasis, supported by intact clot, absence of bleeding on probing, and normal radiograph.

PPlan

Reinforced hemostasis instructions given; patient advised to avoid vigorous rinsing, use gauze pad for 30 min, and no medications prescribed. Next visit scheduled in 4 weeks for final healing assessment.

Hypertensive, 3-Day Post-Extraction, Anticoagulant Review

SSubjective

56-year-old female, asthma on albuterol inhaler PRN, NKDA, chief complaint: "I'm here for my follow-up after the extraction." O: Extraction site shows mild swelling, clot intact, probing depth 1 mm, no bleeding on probing, periapical radiograph shows no radiolucency, soft tissue healing within expected limits, no systemic signs. A: Normal healing of extraction site, supported by intact clot, shallow probing depth, absence of radiolucency, and lack of bleeding. P: Reviewed inhaler use; patient advised to continue albuterol PRN and avoid strenuous activity that could increase bleeding risk. Post-operative instructions reiterated; next visit scheduled in 2 weeks.

Hypertensive, 1-Month Post-Extraction, Hemostasis Check

SSubjective

47-year-old male, controlled hypertension on lisinopril, NKDA, CC: “I’m here to make sure the extraction site is healing properly,” HPI: 1-month post-extraction of tooth #30, no complaints of pain or bleeding.

OObjective

Extraction site shows no bleeding, mild scar tissue, no swelling; probing depth 1 mm, no bleeding on probing; periapical radiograph shows complete bone fill; soft tissue appears healthy; extraoral exam normal.

AAssessment

Adequate hemostasis, complete bone fill, and healthy soft tissue indicate successful healing of extraction site #30.

PPlan

Reinforced postoperative care instructions; advised to maintain oral hygiene and avoid hard foods; no medications prescribed; next visit scheduled in 6 weeks for final assessment.

Hypertensive, 1-Week Post-Extraction, Antihypertensive Adjustment

SSubjective

32-year-old female, seasonal allergies, NKDA, presents for her one-week post-extraction check-up after removal of tooth #19; she reports no pain, no swelling, and is satisfied with healing. HPI: the patient has no new complaints and is compliant with postoperative care, noting that she has been monitoring her home blood pressure as advised during the last visit.

OObjective

Extraoral and intraoral examination shows a stable clot at the extraction site with mild erythema and no active bleeding; probing depth measures 2 mm with no bleeding on probing. Periapical radiograph of #19 reveals no pathology or radiolucency. Vital signs: blood pressure recorded at 145/90 mmHg, which is elevated for her age and sex; heart rate and temperature are within normal limits.

AAssessment

Adequate hemostasis achieved; blood pressure remains elevated, suggesting the need for antihypertensive reassessment.

PPlan

No new medication was prescribed. The patient was counseled to continue home blood pressure monitoring, to record any readings exceeding 160/100 mmHg, and to contact the office immediately if such readings occur. Post-operative instructions regarding wound care, diet, and activity were reiterated verbally and in writing. The next appointment is scheduled in two weeks to reassess blood pressure control and evaluate the extraction site for complete healing.

Asthma Post-Extraction Follow-Up

Asthma, 1-Day Post-Extraction

SSubjective

57-year-old female, NKDA, reports “I have a little pain and some swelling around the extraction site”; mild wheezing on exertion but no current respiratory symptoms.

OObjective

Extraction site #30 shows mild erythema, 1 mm soft tissue swelling, no drainage; socket tender on palpation, no fluctuation; temperature 98.6 °F; no lymphadenopathy.

AAssessment

Normal healing of #30 extraction site, supported by erythema, minimal swelling, absence of drainage or systemic signs.

PPlan

Reviewed postoperative instructions; advised to keep area clean, use ice packs, and avoid smoking; no drugs prescribed; next visit scheduled in 7 days for healing assessment.

Asthma, 3-Day Post-Extraction, Respiratory Check

SSubjective

55-year-old male, former smoker, NKDA, presents 3 days post-extraction of tooth #14 with complaint “The area is still a bit sore and I feel a little cough.” HPI: mild swelling, 2 mm erythema, tender socket, no drainage, temperature 98.7 °F, no lymphadenopathy, occasional dry cough, no shortness of breath.

OObjective

Extraoral: mild swelling, 2 mm erythema, no drainage. Intraoral: socket tender, no fluctuation. Periodontal: none noted. Radiographic: none taken. Tests: respiratory exam—no wheeze, normal breath sounds.

AAssessment

Normal healing of extraction site #14; no evidence of infection or respiratory compromise.

PPlan

Reviewed postoperative instructions; advised to monitor breathing and report any wheezing. No medications prescribed. Next visit scheduled in 7 days for healing assessment.

Asthma, 2-Day Post-Extraction, Respiratory Monitoring

SSubjective

39-year-old female, smoker 5 cigarettes/day, NKDA, chief complaint “I have a sore spot and a mild cough that started after the extraction.” HPI: soreness at #19 extraction, mild cough began 2 days ago.

OObjective

Extraction site shows mild swelling, 1.5 mm erythema, no drainage; socket tender, no fluctuation. Temperature 98.5 °F, no lymphadenopathy. Respiratory exam: mild cough on deep breath, no wheeze, normal breath sounds; patient continues smoking.

AAssessment

Normal healing of #19 extraction site; no infection or respiratory compromise noted.

PPlan

Reviewed postoperative instructions; advised smoking reduction, use of ice packs, and site cleanliness. Prescribed ibuprofen 400 mg PO every 6 hours PRN, up to 3 days for pain. Next visit scheduled in 5 days for healing assessment.

Asthma, 4-Day Post-Extraction, Local Anesthetic Allergy

SSubjective

69-year-old female, type 2 diabetes on metformin, allergic to local anesthetic (rash); CC: “I had a rash around the extraction site after the anesthetic was given.” HPI: rash appeared 30 min after anesthetic, 4 days post-extraction of tooth #28; PMH: diabetes, asthma; medications: metformin.

OObjective

Extraction site: mild swelling, 2 mm erythema, no drainage; socket tender on palpation, no fluctuation; temp 98.4 °F; no lymphadenopathy; maculopapular rash noted; respiratory exam: normal breath sounds, no wheeze.

AAssessment

Normal healing of #28 extraction site with allergic reaction to local anesthetic; no systemic involvement.

PPlan

Advised avoidance of local anesthetic in future; prescribed ibuprofen 400 mg PO q6 h PRN for up to 3 days for pain; instructed to seek allergist evaluation; reviewed POI; scheduled RTC in 7 days for healing assessment.

Allergy Post-Extraction Follow-Up

Allergic to Penicillin, 2-Day Post-Root Canal

SSubjective

64-year-old male, daily low-dose aspirin, allergic to penicillin (rash). Chief complaint: “I have a sore spot near the back of my mouth that feels tender when I bite down.” History: 2-day post-root canal on tooth #14. PMH: aspirin; no other systemic signs.

OObjective

Intraoral: mild buccal swelling adjacent to #14, 2 mm erythema. Probing: 3 mm pocket depth distal to #14, no BOP. Periapical radiograph: radiolucency around #14 consistent with apical periodontitis. Temperature 98.6 °F; no lymphadenopathy.

AAssessment

Symptomatic apical periodontitis of tooth #14, supported by radiolucency, pocket depth, and tenderness on bite.

PPlan

Root canal therapy completed, temporary restoration placed. Instructed on meticulous oral hygiene, use of pain control without NSAIDs, avoid chewing on the area, apply cold compresses, and return in 7 days for final restoration.

Allergy to NSAIDs, 3-Day Post-Extraction

SSubjective

79-year-old male, no significant medical history, allergic to penicillin (rash) and NSAIDs (rash); chief complaint: “My extraction site feels sore and I can’t eat without pain.” O: Intraoral exam shows 4 mm soft tissue healing, mild erythema, 2 mm probing depth buccally, no BOP; PA radiograph confirms complete socket healing, no residual pathology; temperature 98.4 °F, no extraoral swelling or lymphadenopathy. A: Normal healing of #30 extraction site, supported by soft tissue assessment and radiographic findings. P: Reviewed postoperative instructions, reinforced gentle 0.12% chlorhexidine rinses and soft diet; prescribed acetaminophen 400 mg PO q6 h PRN, up to 3 days; instructed to return if pain worsens or new symptoms appear.

Allergy to NSAIDs, 1-Week Post-Extraction, Pain Management

SSubjective

68-year-old male, hypothyroid on levothyroxine, allergic to penicillin and NSAIDs; chief complaint: “I still feel a dull ache around the extraction area and it’s getting harder to chew”; no systemic symptoms, temperature 98.7 °F.

OObjective

Intraoral: extraction socket of #19 shows 5 mm soft-tissue healing, mild erythema; probing 3 mm depth buccally, no BOP; periapical radiograph: socket fully healed, no residual pathology; no extraoral swelling or lymphadenopathy.

AAssessment

Normal healing of #19 extraction site, supported by 5 mm soft-tissue healing, 3 mm probing depth, and radiographic evidence of complete socket closure.

PPlan

Discussed pain control; prescribed acetaminophen 500 mg PO q6h PRN for 3 days; instructed to use only acetaminophen due to NSAID allergy, report any worsening pain or signs of infection, and return if symptoms persist.

Pregnancy Dental Visits

Pregnant, First Trimester, Routine Check-In

SSubjective

45-year-old female, pregnant, asthma (albuterol PRN), NKDA, presents for routine check-in; states “just want to make sure everything’s fine.”

OObjective

Extraoral shows facial symmetry, no lymphadenopathy; intraoral gingiva pink, no ulcerations, BOP 0%; periodontal PSR 0 on all teeth; PA of tooth #15 shows no caries or periapical pathology; no restorations noted.

AAssessment

Normal periodontal health; no pulpal or periapical disease.

PPlan

Reinforced oral hygiene instructions; fluoride varnish applied to all teeth; no medication prescribed; patient advised to continue albuterol PRN and to report any new symptoms; next visit scheduled in 6 months for routine check-in.

Pregnancy, 3rd Trimester, Tooth Pain

SSubjective

49-year-old female, pregnant, controlled hypertension on lisinopril, NKDA; CC: “My lower right first molar hurts when I bite down, especially on the left side.” HPI: pain on biting, no swelling, no systemic symptoms.

OObjective

Extraoral: no swelling, no lymphadenopathy. Intraoral: tooth #30 shows deep mesial caries extending into dentin, no pulpal exposure. Periodontal: PSR 1 on #30. Radiograph: PA of #30 shows deep caries, no periapical radiolucency.

AAssessment

Symptomatic irreversible pulpitis of tooth #30; normal apical tissues, supported by deep dentin caries and absence of periapical pathology.

PPlan

Pulpectomy performed; calcium hydroxide apexification placed, temporary restoration. Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB. Medications: Ibuprofen 400 mg q6h PRN up to 3 days; Acetaminophen 500 mg q6h PRN up to 3 days. POI: keep mouth clean, avoid hard foods, monitor pain. Next visit: RTC in 2 weeks for interim restoration.

Pregnancy, 2nd Trimester, Routine Check-In

SSubjective

80-year-old pregnant patient, seasonal allergies, NKDA; CC: “Just a quick check-up, nothing else.” HPI: patient reports no pain or swelling; PMH: pregnancy, seasonal allergies; medications: none; allergies: none.

OObjective

Extraoral: facial symmetry, no lymphadenopathy; Intraoral: gingiva pink, BOP 0%; Periodontal: PSR 0 on all teeth; Restorations: composite on #19, amalgam on #30; Radiographs: PA of #19 shows no periapical pathology, PA of #30 shows mild periapical radiolucency; Caries risk moderate.

AAssessment

Chronic apical periodontitis of tooth #30; normal periodontal health.

PPlan

No anesthesia used; scheduled root-canal therapy for #30 at next visit; reinforced oral hygiene instructions; no medications prescribed; patient advised to maintain regular prenatal care and report any new symptoms.

Pregnancy, 1st Trimester, Tooth Pain

SSubjective

20-year-old pregnant female; CC: “My upper left first molar hurts when I chew, especially on the right side.” HPI: pain localized to chewing, no swelling, no lymphadenopathy; PMH: pregnancy, NKDA.

OObjective

Extraoral: no swelling, no lymphadenopathy. Intraoral: tooth #14 shows deep caries on distal surface, no pulpal exposure. Periodontal: PSR 1 on #14. Radiograph PA of #14: deep caries, no periapical radiolucency.

AAssessment

Symptomatic irreversible pulpitis of tooth #14 with normal apical tissues, supported by deep caries, pain on chewing, and lack of periapical pathology.

PPlan

Pulpectomy performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; calcium hydroxide apexification placed, temporary restoration placed. Prescribed Ibuprofen 400 mg q6h PRN up to 3 days and Acetaminophen 500 mg q6h PRN up to 3 days. Instructed on oral hygiene, avoidance of hard foods, and to return if pain worsens or swelling develops.

Pregnancy, 4th Trimester, Routine Check-In

SSubjective

48-year-old female patient, pregnant, former smoker, NKDA; CC: “Just a routine check-up, no problems.” HPI: denies pain or swelling; PMH: pregnancy; meds: none.

OObjective

Extraoral: facial symmetry, no lymphadenopathy; Intraoral: gingiva pink, BOP 0%; Periodontal: PSR 0 on all teeth; Restorations: none; PA of #15 shows no caries, no periapical pathology.

AAssessment

Normal periodontal health; no pulpal or periapical disease, consistent with PSR 0 and clear PA.

PPlan

Reinforced oral hygiene instructions; fluoride varnish applied to all teeth; no drugs prescribed; advised to maintain hydration and balanced diet; next visit scheduled in 3 months for routine check-in.

Pregnancy, 2nd Trimester, Tooth Pain

SSubjective

26-year-old female, pregnant, smoker, NKDA, reports “upper right canine hurts when I bite down, especially on the left side.” HPI: pain on biting, no swelling or systemic symptoms.

OObjective

Extraoral: no swelling, no lymphadenopathy. Intraoral: deep caries on the mesial surface of tooth #6 extending into dentin, no pulpal exposure; periodontal: PSR 1 on #6; PA of #6 shows deep caries, no periapical radiolucency.

AAssessment

Symptomatic irreversible pulpitis of tooth #6 with normal apical tissues, supported by deep dentin caries, pain on biting, and lack of periapical pathology.

PPlan

Pulpectomy performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; calcium hydroxide apexification placed; temporary restoration placed. Prescribed ibuprofen 400 mg PO q6 h PRN up to 3 days and acetaminophen 500 mg PO q6 h PRN up to 3 days. Instructed on pain management, oral hygiene, and to return in 3 days for interim review.

Pregnancy, 2nd Trimester, Limited Exam, Tooth Mobility

SSubjective

28-year-old female, pregnant, type 2 diabetic on metformin, NKDA, presents for a limited exam with chief complaint: “My lower right molar feels a bit loose when I chew.” She reports no pain, no swelling, and denies recent trauma or changes in her oral hygiene routine. She is in her second trimester and has no systemic symptoms such as fever or malaise.

OObjective

Extraoral examination reveals facial symmetry with no cervical or submandibular lymphadenopathy. Intraoral soft tissues are pink and healthy, with no ulceration or erythema. Tooth #30 exhibits mild mobility, classified as Miller grade 1, with a probing depth of 3 mm; there is no bleeding on probing, no caries, and no existing restoration. Periodontal assessment shows no other sites with increased probing depths or bleeding, and the overall gingival condition is consistent with pregnancy-associated gingival changes.

AAssessment

Mild periodontal mobility of tooth #30 secondary to pregnancy-associated gingival changes.

PPlan

Reinforced oral hygiene instruction emphasizing gentle brushing, interdental cleaning, and the use of a soft-bristled brush; advised to avoid hard foods that may exacerbate mobility. Discussed safe home care practices during pregnancy and the importance of maintaining glycemic control for periodontal health. No anesthesia or medication was required. Scheduled a follow-up in 4 weeks for reassessment of tooth mobility and periodontal status.

Pregnancy, 3rd Trimester, Limited Exam, Tooth Pain

SSubjective

24-year-old pregnant female, CC “My upper left first molar hurts when I bite down.” HPI: pain on biting, sensitivity to cold, no swelling. PMH: pregnancy, daily low-dose aspirin, NKDA.

OObjective

Tooth #14 shows deep caries in outer dentin, no restoration. Sensitivity to cold and pain on biting. No BOP, no swelling. Extraoral: facial symmetry, no lymphadenopathy. Intraoral: gingiva pink, no lesions.

AAssessment

Symptomatic irreversible pulpitis of tooth #14; no apical involvement, supported by deep caries, biting pain, cold sensitivity, and absence of swelling or BOP.

PPlan

Prescribed ibuprofen 400 mg PO q6 h PRN for pain, max 3 days. Advised avoidance of hard foods, maintain oral hygiene, and refer for endodontic treatment. Next visit: endodontic appointment.

Pregnancy, 1st Trimester, Limited Exam, Tooth Mobility

SSubjective

21-year-old female, pregnant, allergic to penicillin (rash); CC: “My lower left first molar feels a little loose when I chew”; HPI: mild mobility noticed during chewing, no pain or swelling; PMH: pregnancy; allergy: penicillin; no other drug allergies.

OObjective

Extraoral: facial symmetry, no lymphadenopathy; Intraoral: gingiva pink, no swelling; Tooth #19: mild mobility, Miller grade 1; probing depth 3 mm, no BOP; no caries or restoration; periodontal assessment shows pregnancy-associated gingival changes.

AAssessment

Mild periodontal mobility of tooth #19 with pregnancy-associated gingival changes, supported by Miller 1 mobility, 3 mm probing depth, and healthy gingiva.

PPlan

No anesthesia or drugs administered; oral hygiene instruction and home care tips for pregnancy given; patient advised to return in 4 weeks for reassessment.

Pregnancy, 2nd Trimester, Limited Exam, Tooth Sensitivity

SSubjective

61-year-old female, pregnant, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “My lower right molar hurts when I drink hot coffee”; HPI: sensitivity to hot liquids, no pain on biting, no swelling, no BOP; PMH: hypothyroidism; no other medications listed.

OObjective

Extraoral: facial symmetry, no lymphadenopathy; Intraoral: gingiva pink, no lesions; Tooth #30: enamel caries class I, no restoration, sensitivity to hot liquids, no pain on biting, no swelling, no BOP; no extra findings.

AAssessment

Reversible pulpitis of tooth #30; no apical involvement, supported by sensitivity to hot liquids, absence of pain on biting, lack of swelling or BOP.

PPlan

Applied fluoride varnish to tooth #30; instructed oral hygiene and to avoid very hot drinks; no drugs prescribed; advised to return if pain worsens or new symptoms develop.

Pregnancy, 3rd Trimester, Limited Exam, Tooth Sensitivity

SSubjective

41-year-old pregnant female, chief complaint: “My upper right canine hurts when I bite down on cold food.” HPI: sensitivity to cold and pain on biting, no swelling, no bleeding on probing. PMH: pregnancy, asthma, albuterol PRN, NKDA.

OObjective

Tooth #6 shows deep caries in outer dentin, no restoration. Sensitivity to cold, pain on biting; extraoral symmetry, no lymphadenopathy. Intraoral gingiva pink, no lesions, BOP negative.

AAssessment

Symptomatic irreversible pulpitis of tooth #6; no apical involvement, supported by deep outer dentin caries, cold sensitivity, biting pain, and absence of swelling or BOP.

PPlan

Prescribed ibuprofen 400 mg PO q6 h PRN for pain, up to 3 days; advised to avoid hard foods and to continue albuterol as needed. Referred for endodontic treatment; instructed to return if pain worsens or persists beyond 3 days.

Elderly Limited Exams

Elderly, 80, New Patient, Limited Exam

SSubjective

80-year-old male, controlled hypertension on lisinopril, NKDA, reports “my molars hurt when I chew.” History of present illness: pain localized to #30, no swelling or fever.

OObjective

Extraoral: facial symmetry, no lymphadenopathy, TMJ normal. Intraoral: tooth #30 shows buccal and lingual probing depth 4 mm, bleeding on probing; no caries, no restorations, no mobility. Periodontal: all other teeth within normal limits. No extraoral or intraoral lesions noted.

AAssessment

Mild periodontal disease, stage I, supported by 4 mm probing depth with bleeding on #30 and otherwise healthy periodontium.

PPlan

Provided oral hygiene instruction and applied fluoride varnish to #30. No anesthesia used. Advised to maintain daily brushing with fluoride toothpaste, use interdental brushes, and schedule recall in 3 months.

Elderly, 75, Limited Exam, Dental Trauma

SSubjective

75-year-old female with seasonal allergies, NKDA, reports “My front tooth chipped when I fell.” HPI: fall caused a chipped front tooth; no pain, no swelling, no difficulty chewing.

OObjective

Extraoral normal. Intraoral: fractured enamel on mesial surface of tooth #9; no mobility, no tenderness on palpation. Periodontal: healthy gingiva, no bleeding on probing. Radiograph: periapical PA shows no radiolucency, no caries or restoration.

AAssessment

Enamel fracture of tooth #9, supported by visible enamel break on mesial surface and absence of pulpal or periapical pathology.

PPlan

Composite resin restoration of tooth #9 performed under local conditions; no anesthesia used. Postoperative instructions: avoid hard foods for 24 h, maintain oral hygiene, report any sensitivity. Recall in 6 weeks for restoration evaluation.

Elderly, 80, Limited Exam, Xerostomia

SSubjective

80-year-old male patient, no significant medical history, NKDA, presents with chief complaint “My mouth feels dry all the time” for the past six months; patient reports that the dryness is constant and worsens in the evening, and he has tried drinking water with limited relief.

OObjective

Unstimulated salivary flow measured at 0.3 mL/min; extraoral examination shows no facial asymmetry or lymphadenopathy; intraoral examination reveals no caries, no periodontal pockets, no ulcerations, and no mucosal lesions; patient has no swelling or pain in the salivary glands.

AAssessment

Xerostomia, evidenced by the markedly reduced unstimulated salivary flow rate of 0.3 mL/min and the patient’s six-month history of persistent dry mouth without associated systemic findings.

PPlan

Prescribed a saliva substitute to be used as needed; instructed the patient to increase oral fluid intake to at least 150 mL per hour during the day, chew sugar-free gum for 15 minutes every two hours, and use a humidifier at night; advised to schedule a follow-up in four weeks to reassess symptoms and consider ENT referral if dryness persists.

Elderly, 78, Limited Exam, Post-Extraction Pain

SSubjective

78-year-old female, former smoker, NKDA, reports “pain after my wisdom tooth was removed.” HPI: pain localized to extraction site of tooth #32, onset immediately post-surgery, mild, relieved by rest, no aggravating factors noted. Medical history: no current medications, no systemic disease, temperature 98.6 °F.

OObjective

Extraoral: facial symmetry intact, no cervical lymphadenopathy. Intraoral: extraction socket of #32 shows healing tissue, mild swelling confined to socket, tenderness to palpation, no purulent drainage, no trismus. Periodontal: surrounding tissues appear healthy, no gingival erythema. Radiograph: none taken this visit. Tests: none performed.

AAssessment

Post-extraction pain, supported by healing socket with mild swelling and tenderness, no signs of infection or systemic involvement.

PPlan

Ibuprofen 400 mg PO every 6 hours as needed, up to 3 days. Postoperative instructions: keep head elevated, apply ice packs, maintain oral hygiene, avoid smoking. Follow-up in 48 hours to reassess pain and healing.

Elderly, 70, Limited Exam, Post-Traumatic Pain

SSubjective

70-year-old female, smoker 5 cigarettes/day, NKDA, reports “my molar hurts after a fall.” HPI: pain localized to tooth #30, onset immediately post-fall, throbbing, worsens with chewing, no swelling or trismus. PMH: none relevant.

OObjective

Extraoral: normal. Intraoral: fractured cusp on occlusal surface of #30 with pulpal exposure; probing depth 3 mm, no BOP. Periodontal: healthy. Radiograph: periapical PA shows no radiolucency.

AAssessment

Symptomatic irreversible pulpitis of tooth #30, supported by exposed pulp, pain on function, and normal periapical radiograph.

PPlan

Referred for root canal therapy. Prescribed ibuprofen 400 mg PO q6h PRN, up to 3 days. POI: maintain oral hygiene, avoid hard foods, apply cold compress, report worsening pain or swelling. Next visit: RTC for endodontic treatment.

Smoking-Related Visits

Smoker, Day 3 After Lower Molar Extraction

SSubjective

74-year-old female, smoker 5 cigarettes/day, type 2 diabetes on metformin, NKDA; CC: “I’m here for a quick check-up and to talk about quitting smoking”; HPI: no pain, routine follow-up after lower molar extraction; PMH: diabetes, smoking; medications: metformin; allergies: NKDA.

OObjective

Extraoral: facial symmetry normal, no cervical lymphadenopathy, TMJ sounds normal, maximum opening 35 mm; Intraoral soft tissue: mild gingival erythema on buccal surfaces of lower molars, no ulcerations; Hard tissue: no caries, no restorations, no fractures; Periodontal: PSR code 1 (mild plaque) on all teeth, no mobility; Oral cancer screening: no suspicious lesions, tongue, buccal mucosa, floor of mouth, palate, gingiva all within normal limits; Radiographs: PA of lower molars #30-32 shows no periapical pathology, bone levels within normal limits.

AAssessment

Mild periodontal disease, stage I; smoking-related gingival inflammation, supported by PSR 1, mild gingival erythema, and normal bone levels.

PPlan

Discussed smoking cessation resources, provided written materials on benefits of quitting, and referred to primary care for counseling; advised to maintain oral hygiene and schedule next limited exam in 6 months; no drugs administered.

Smoking Cessation, 5-Year History, Follow-Up

SSubjective

27-year-old male, smokes ~5 cigarettes/day, takes low-dose aspirin, NKDA, CC: “I want to quit smoking and get a quick check-up,” HPI: no pain, seeks cessation advice.

OObjective

Extraoral: facial symmetry WNL, no lymphadenopathy, TMJ normal, opening 38 mm; Intraoral: mild gingival redness on lower molars, no ulcerations; Hard tissue: no caries, restorations, fractures; Periodontal: PSR code 1 on all teeth, no mobility; Oral cancer screening: no lesions; PA of #30-32: no periapical pathology, bone levels normal.

AAssessment

Mild periodontal disease, stage I; smoking-related gingival inflammation, supported by PSR 1 and gingival redness.

PPlan

Counseling on smoking cessation provided; nicotine patch trial offered; oral hygiene instructions given; no drugs prescribed; next visit scheduled in 3 months for reassessment.

Smoking Cessation, 1-Month Follow-Up

SSubjective

81-year-old male, smoker 5 cigarettes/day, allergic to penicillin (rash), presents for a quick check-up and to discuss quitting smoking.

OObjective

Extraoral: facial symmetry normal, no cervical lymphadenopathy, TMJ normal, opening 34 mm. Intraoral soft tissue: mild gingival erythema on lower molars, no ulcerations or lesions. Hard tissue: no caries, restorations, or fractures. Periodontal: PSR code 1 on all teeth, no mobility. Oral cancer screening: no suspicious lesions; tongue, buccal mucosa, floor of mouth, palate, gingiva normal. Radiographs: PA of lower molars #30-32 shows no periapical pathology; bone levels normal.

AAssessment

Mild periodontal disease, stage I; smoking-related gingival inflammation, supported by PSR 1, gingival erythema, and normal bone levels.

PPlan

Counseled on smoking cessation, provided written resources, advised to maintain oral hygiene; no drugs prescribed; next visit scheduled in 6 months.

Smoking Cessation, 6-Month Follow-Up, Oral Cancer Screening

SSubjective

72-year-old male, smoker 5 cigarettes/day, hypothyroidism on levothyroxine; chief complaint: “I’m here for a quick check-up and to talk about quitting smoking.”

OObjective

Extraoral: facial symmetry normal, no cervical lymphadenopathy, TMJ normal, maximum opening 36 mm. Intraoral soft tissue: mild gingival erythema on lower molars, no ulcerations or lesions. Hard tissue: no caries, no restorations, no fractures. Periodontal: PSR code 1 on all teeth, no mobility. Oral cancer screening: no suspicious lesions; tongue, buccal mucosa, floor of mouth, palate, gingiva normal. Radiographs: PA of lower molars #30-32 show no periapical pathology, bone levels normal.

AAssessment

Mild periodontal disease, stage I; smoking-related gingival inflammation, supported by PSR 1, mild erythema, and normal bone levels.

PPlan

Discussed smoking cessation strategies, provided written materials, advised on oral hygiene; no drugs prescribed; scheduled follow-up in 3 months.

SOAP Structure for a Limited Exam

Subjective

Record the chief complaint verbatim, then the HPI with onset, character, triggers, relief, and intensity on a 0-10 scale. Include PMH, current meds, allergies, tobacco/alcohol use, and pregnancy status if relevant. Example: “CC: ‘tooth pain on #30 since yesterday.’ HPI: sharp, 8/10, relieved by cold, no swelling.”

Objective

Document vital signs when indicated, extraoral findings, and focused intraoral exam. Note tooth number, surface, depth, and any bleeding or mobility. Include radiographic findings and any procedural details such as local anesthesia. Example: “O: Extraoral: no swelling. Intraoral: #30 shows 1-mm deep enamel caries, no bleeding. 0-10 °F.”

Assessment

State the clinical impression using standard terminology. Keep it concise and directly tied to the findings. Example: “A: Symptomatic irreversible pulpitis, tooth #30.”

Plan

Outline the immediate treatment, postoperative instructions, prescriptions, referrals, and next visit. Use clear, actionable language. Example: “P: RCT indicated; explain risks, alternatives. Prescribe ibuprofen 400 mg PO q6h PRN. Schedule appointment 7 days for RCT.”

Exam Content and Omissions

1. Extraoral: facial symmetry, lymph nodes, TMJ sounds, maximum opening, masticatory muscle bulk.
2. Intraoral soft tissue: lips, buccal and labial mucosa, tongue (dorsal, ventral, lateral borders), floor of mouth, hard and soft palate, oropharynx, gingiva.
3. Hard tissue: existing restorations, caries by tooth and surface, fractures, wear, missing teeth.
4. Periodontal screening: PSR code with * for furcation, mobility, mucogingival problems or recession.
5. Functional tests: bite force assessment, occlusal contacts on the affected quadrant, percussion and palpation of the involved tooth or area.

• Full periodontal charting (probing depths, BOP, CAL).
• Comprehensive occlusion evaluation (Angle classification, overjet/overbite, crossbites, wear facets).
• Panoramic or CBCT imaging unless clinically indicated.
• Extensive medical history updates beyond the current issue.
• Detailed oral cancer screening beyond the focused area.

Emergency Dental Exam SOAP Note – Side-by-Side Comparison

Emergency exams document a patient’s acute presentation, requiring vital signs, a full extraoral assessment, emergency radiographs, and triage notes, all in one concise SOAP. The limited exam records only the chief complaint, focused intra-oral findings, and a targeted plan; it omits vital signs, comprehensive extraoral findings, and emergency imaging unless indicated. In an emergency note, include BP, pulse, temperature, and a note on airway, breathing, and circulation status. Add a triage comment such as “patient stable, pain 9/10, no trismus.” Record emergency radiographs (PA, BWX) and any urgent findings. Example:

SSubjective

45-y-o male, CC: “severe pain in lower right molar #30, swelling, fever.” HPI: sudden onset, 9/10, worsens with heat. PMH: HTN, NKDA. O: BP 158/96, pulse 102, temp 101.2°F. Extraoral: left submandibular lymphadenopathy, 2 cm, tender. Intraoral: #30 exposed, purulent exudate, buccal mucosa erythematous. PA: periapical abscess. A: Acute apical abscess with cellulitis. P: Administer 2% lidocaine with 1:100,000 epinephrine, IANB, 1.8 mL. Prescribe amoxicillin 500 mg PO q8h for 7 days. Instruct to apply ice, take ibuprofen 400 mg q6h PRN. Schedule follow-up in 24 h.

Quick Reference – Copy-Paste Ready Templates

SSubjective

{patient name}, {date}, CC: “{chief complaint}”, HPI: {description}, PMH: {medical history}, NKDA. O: Extraoral: {findings}. Intraoral: {findings}. A: {assessment}. P: {plan}.

The page offers 30-40 full examples for various scenarios.

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