Periodic Oral Evaluation SOAP Note: Complete Ready-to-Copy Examples

Dr. Rahul Joshi

Nov 07, 2026 - Updated Nov 09, 2026 - 57 Min read

Routine Baseline Check-ups

30-Year-Old Male, No Complaints, First Recall

SOAP note

Subjective: 30-year-old male presents for his first recall appointment, stating “I’m here for my routine check-up.” He reports no pain, no swelling, no recent dental visits, and no medical conditions or medications. Past medical history is unremarkable; he has no known drug allergies (NKDA).
Objective: Extraoral examination shows facial symmetry, no cervical or submandibular lymphadenopathy, and a normal temporomandibular joint assessment. Intraoral inspection reveals all natural teeth present, no carious lesions, no restorations, and no visible soft-tissue abnormalities. Periodontal screening demonstrates PSR 0 on every tooth, indicating healthy gingiva with no bleeding on probing and probing depths ≤3 mm. No periapical or bite-wing radiographs were taken during this visit.
Assessment: Diagnosis is normal periodontal health, confirmed by the absence of caries, restorations, and the PSR 0 findings across the dentition.
Plan: Full-mouth prophylaxis was completed with standard polishing and fluoride varnish application; no local anesthesia was required. Comprehensive oral hygiene instruction was provided, emphasizing proper brushing technique, interdental cleaning, and the importance of regular recalls. The patient was advised to schedule his next routine check-up in 12 months.

S: 30-year-old male presents for his first recall appointment, stating “I’m here for my routine check-up.” He reports no pain, no swelling, no recent dental visits, and no medical conditions or medications. Past medical history is unremarkable; he has no known drug allergies (NKDA).
O: Extraoral examination shows facial symmetry, no cervical or submandibular lymphadenopathy, and a normal temporomandibular joint assessment. Intraoral inspection reveals all natural teeth present, no carious lesions, no restorations, and no visible soft-tissue abnormalities. Periodontal screening demonstrates PSR 0 on every tooth, indicating healthy gingiva with no bleeding on probing and probing depths ≤3 mm. No periapical or bite-wing radiographs were taken during this visit.
A: Diagnosis is normal periodontal health, confirmed by the absence of caries, restorations, and the PSR 0 findings across the dentition.
P: Full-mouth prophylaxis was completed with standard polishing and fluoride varnish application; no local anesthesia was required. Comprehensive oral hygiene instruction was provided, emphasizing proper brushing technique, interdental cleaning, and the importance of regular recalls. The patient was advised to schedule his next routine check-up in 12 months.

28-Year-Old Male, Routine Checkup, No Radiographs

SOAP note

Subjective: 28-year-old male, “Just a quick cleaning,” reports no pain or swelling, and is otherwise healthy. He has hypothyroidism controlled with levothyroxine and is allergic to penicillin, presenting a rash when exposed; no other drug allergies. He has no significant medical history beyond his thyroid condition and reports good compliance with medication. The patient denies any recent dental issues and is comfortable with routine care.
Objective: Extraoral examination shows facial symmetry, no cervical lymphadenopathy, and no swelling; intraoral surfaces are free of caries, restorations, or lesions. Periodontal assessment reveals PSR 1 on tooth #15 and #16, indicating mild gingival inflammation without bleeding on probing. No prosthetic appliances are present, and the patient’s oral mucosa appears healthy. No radiographs were taken for this visit as the clinical findings were sufficient for assessment.
Assessment: Early gingivitis is diagnosed on tooth #15 and #16, supported by the PSR 1 scores and the absence of caries or restorative work. The diagnosis aligns with the patient’s routine maintenance needs and his current medication profile.
Plan: Prophylaxis was performed, including scaling of #15 and #16 and polishing of adjacent surfaces. Oral hygiene instruction was reinforced, emphasizing twice-daily brushing, interdental cleaning, and the importance of regular check-ups. No medications were prescribed today. The next appointment is scheduled for six months from now for a routine recall and evaluation.

S: 28-year-old male, “Just a quick cleaning,” reports no pain or swelling, and is otherwise healthy. He has hypothyroidism controlled with levothyroxine and is allergic to penicillin, presenting a rash when exposed; no other drug allergies. He has no significant medical history beyond his thyroid condition and reports good compliance with medication. The patient denies any recent dental issues and is comfortable with routine care.
O: Extraoral examination shows facial symmetry, no cervical lymphadenopathy, and no swelling; intraoral surfaces are free of caries, restorations, or lesions. Periodontal assessment reveals PSR 1 on tooth #15 and #16, indicating mild gingival inflammation without bleeding on probing. No prosthetic appliances are present, and the patient’s oral mucosa appears healthy. No radiographs were taken for this visit as the clinical findings were sufficient for assessment.
A: Early gingivitis is diagnosed on tooth #15 and #16, supported by the PSR 1 scores and the absence of caries or restorative work. The diagnosis aligns with the patient’s routine maintenance needs and his current medication profile.
P: Prophylaxis was performed, including scaling of #15 and #16 and polishing of adjacent surfaces. Oral hygiene instruction was reinforced, emphasizing twice-daily brushing, interdental cleaning, and the importance of regular check-ups. No medications were prescribed today. The next appointment is scheduled for six months from now for a routine recall and evaluation.

48-Year-Old Male, Orthodontic Retainer Check

SOAP note

Subjective: 48-year-old male with controlled hypertension on lisinopril, NKDA, reports “my retainer feels loose” and has had no other complaints; he has no systemic signs.
Objective: Extraoral exam shows no swelling or asymmetry. Intraoral exam reveals a fixed retainer on the upper right canine, intact with no fracture. Periodontal screening shows PSR 0, and the retainer is in place with no periodontal compromise. No radiographs were taken.
Assessment: Retainer loose, no periodontal compromise, supported by intact retainer, PSR 0 and absence of fracture.
Plan: Re-bonded the retainer with no anesthesia; instructed the patient on proper retainer hygiene and to return in 6 months for routine check-up.

S: 48-year-old male with controlled hypertension on lisinopril, NKDA, reports “my retainer feels loose” and has had no other complaints; he has no systemic signs.
O: Extraoral exam shows no swelling or asymmetry. Intraoral exam reveals a fixed retainer on the upper right canine, intact with no fracture. Periodontal screening shows PSR 0, and the retainer is in place with no periodontal compromise. No radiographs were taken.
A: Retainer loose, no periodontal compromise, supported by intact retainer, PSR 0 and absence of fracture.
P: Re-bonded the retainer with no anesthesia; instructed the patient on proper retainer hygiene and to return in 6 months for routine check-up.

27-Year-Old Female, New Tooth, Routine Checkup

SOAP note

Subjective: 27-year-old female, smoker 5 cigarettes/day, NKDA, states “just a routine visit” and reports no pain, swelling, or bleeding; she has been compliant with her biannual cleanings and has not noticed any new symptoms since her last visit.
Objective: Extraoral examination reveals symmetrical facial features, no palpable submandibular or cervical lymph nodes, and a normal range of mandibular motion; intraoral inspection shows healthy mucosa, no carious lesions, no existing restorations, and no visible plaque accumulation beyond a mild supragingival deposit; periodontal screening indicates a PSR 1 on tooth #22 with no bleeding on probing, probing depths within normal limits, and no recession; prosthetic evaluation shows no crowns or bridges present; no radiographs were taken as the clinical findings were adequate for assessment; no adjunctive tests were performed.
Assessment: Diagnosis of early gingivitis localized to tooth #22, evidenced by PSR 1 classification and the absence of caries or restorative work, consistent with the patient’s smoking habit and mild plaque accumulation.
Plan: Completed a full prophylaxis with ultrasonic scaling and polishing of tooth #22; no local anesthesia was required; provided comprehensive smoking cessation counseling, including written resources and a referral to a cessation program; instructed the patient to maintain twice-daily brushing with fluoride toothpaste, interdental cleaning, and to schedule her next routine check-up in 6 months for ongoing periodontal monitoring and preventive care.

S: 27-year-old female, smoker 5 cigarettes/day, NKDA, states “just a routine visit” and reports no pain, swelling, or bleeding; she has been compliant with her biannual cleanings and has not noticed any new symptoms since her last visit.
O: Extraoral examination reveals symmetrical facial features, no palpable submandibular or cervical lymph nodes, and a normal range of mandibular motion; intraoral inspection shows healthy mucosa, no carious lesions, no existing restorations, and no visible plaque accumulation beyond a mild supragingival deposit; periodontal screening indicates a PSR 1 on tooth #22 with no bleeding on probing, probing depths within normal limits, and no recession; prosthetic evaluation shows no crowns or bridges present; no radiographs were taken as the clinical findings were adequate for assessment; no adjunctive tests were performed.
A: Diagnosis of early gingivitis localized to tooth #22, evidenced by PSR 1 classification and the absence of caries or restorative work, consistent with the patient’s smoking habit and mild plaque accumulation.
P: Completed a full prophylaxis with ultrasonic scaling and polishing of tooth #22; no local anesthesia was required; provided comprehensive smoking cessation counseling, including written resources and a referral to a cessation program; instructed the patient to maintain twice-daily brushing with fluoride toothpaste, interdental cleaning, and to schedule her next routine check-up in 6 months for ongoing periodontal monitoring and preventive care.

60-Year-Old Male, Orthodontic Retainer, Routine Checkup

SOAP note

Subjective: 60-year-old male with type 2 diabetes on metformin, NKDA, reports that his orthodontic retainer feels tight; no pain or swelling.
Objective: Extraoral: no swelling, facial symmetry intact; Intraoral: fixed lower left canine retainer present, no fracture; Periodontal: PSR 0, no gingival inflammation; Prosthetics: retainer in place, functional.
Assessment: Retainer tightness with no periodontal pathology, consistent with PSR 0 and intact gingiva.
Plan: Re-adjusted lower left canine retainer to relieve tightness; provided oral hygiene instruction focusing on interdental cleaning around the retainer; no medication prescribed; scheduled next routine check-up in 12 months.

S: 60-year-old male with type 2 diabetes on metformin, NKDA, reports that his orthodontic retainer feels tight; no pain or swelling.
O: Extraoral: no swelling, facial symmetry intact; Intraoral: fixed lower left canine retainer present, no fracture; Periodontal: PSR 0, no gingival inflammation; Prosthetics: retainer in place, functional.
A: Retainer tightness with no periodontal pathology, consistent with PSR 0 and intact gingiva.
P: Re-adjusted lower left canine retainer to relieve tightness; provided oral hygiene instruction focusing on interdental cleaning around the retainer; no medication prescribed; scheduled next routine check-up in 12 months.

58-Year-Old Female, Chronic Pain, Routine Exam

SOAP note

Subjective: 58-year-old female reports chronic jaw pain, “I’ve had this ache for months, especially when chewing.” She denies swelling, trismus or recent trauma. PMH non-contributory; allergic to penicillin (rash); NKDA for other drugs.
Objective: Extraoral: facial symmetry intact, no cervical lymphadenopathy, TMJ normal on palpation and range of motion. Intraoral: no caries or restorations noted; periodontal screening shows PSR 2 on tooth #30. No other periodontal or restorative findings.
Assessment: Chronic periodontitis stage I on tooth #30, evidenced by PSR 2 and localized attachment loss without mobility.
Plan: Prophylaxis performed; scaling of tooth #30 completed. Oral hygiene instruction provided, including proper brushing technique and interdental cleaning. No medication prescribed. Next visit scheduled in 6 months for routine recall.

S: 58-year-old female reports chronic jaw pain, “I’ve had this ache for months, especially when chewing.” She denies swelling, trismus or recent trauma. PMH non-contributory; allergic to penicillin (rash); NKDA for other drugs.
O: Extraoral: facial symmetry intact, no cervical lymphadenopathy, TMJ normal on palpation and range of motion. Intraoral: no caries or restorations noted; periodontal screening shows PSR 2 on tooth #30. No other periodontal or restorative findings.
A: Chronic periodontitis stage I on tooth #30, evidenced by PSR 2 and localized attachment loss without mobility.
P: Prophylaxis performed; scaling of tooth #30 completed. Oral hygiene instruction provided, including proper brushing technique and interdental cleaning. No medication prescribed. Next visit scheduled in 6 months for routine recall.

30-Year-Old Male, Latex Allergy, Routine Exam

SOAP note

Subjective: 30-year-old male, reports “I have a latex allergy, just here for a check-up.” HPI: no pain, no new symptoms. PMH: takes low-dose aspirin daily, NKDA.
Objective: Extraoral: no swelling, facial symmetry normal. Intraoral: no caries, no restorations. Periodontal: PSR 0, gingiva healthy, no bleeding on probing. Radiographs: none taken. Tests: none performed.
Assessment: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
Plan: Full-mouth prophylaxis performed; oral hygiene instruction given, emphasizing latex-free instruments and hand-rubbers. No anesthesia used. Patient advised to maintain twice-daily brushing and flossing. Next visit scheduled in 12 months for routine recall.

S: 30-year-old male, reports “I have a latex allergy, just here for a check-up.”  HPI: no pain, no new symptoms.  PMH: takes low-dose aspirin daily, NKDA.
O: Extraoral: no swelling, facial symmetry normal.  Intraoral: no caries, no restorations.  Periodontal: PSR 0, gingiva healthy, no bleeding on probing.  Radiographs: none taken.  Tests: none performed.
A: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
P: Full-mouth prophylaxis performed; oral hygiene instruction given, emphasizing latex-free instruments and hand-rubbers.  No anesthesia used.  Patient advised to maintain twice-daily brushing and flossing.  Next visit scheduled in 12 months for routine recall.

48-Year-Old Female, Post-Extraction Healing, Follow-up

SOAP note

Subjective: 48-year-old female, seasonal allergies, NKDA, reports “healing after my extraction”; no pain, no swelling, no discharge.
Objective: Extraoral: facial symmetry, no lymphadenopathy, no swelling. Intraoral: extraction site #19 shows complete soft tissue closure, no erythema or purulent drainage. Periodontal: PSR 0. No radiographs taken.
Assessment: Healing extraction site #19, supported by closed wound, absence of infection or inflammation.
Plan: No intervention performed. Oral hygiene instruction given: gentle brushing, interdental flossing, avoid irritants. Next visit scheduled for routine recall in 6 months.

S: 48-year-old female, seasonal allergies, NKDA, reports “healing after my extraction”; no pain, no swelling, no discharge.
O: Extraoral: facial symmetry, no lymphadenopathy, no swelling. Intraoral: extraction site #19 shows complete soft tissue closure, no erythema or purulent drainage. Periodontal: PSR 0. No radiographs taken.
A: Healing extraction site #19, supported by closed wound, absence of infection or inflammation.
P: No intervention performed. Oral hygiene instruction given: gentle brushing, interdental flossing, avoid irritants. Next visit scheduled for routine recall in 6 months.

45-Year-Old Female, Mild Periodontitis, Second Recall

SOAP note

Subjective: 45-year-old female, former smoker, NKDA, reports “just a routine visit.” No pain, no swelling, no new symptoms. HPI: routine recall, last visit 6 months ago, no changes noted.
Objective: Extraoral: facial symmetry, no lymphadenopathy. Intraoral: no caries, no restorations, healthy mucosa. Periodontal: PSR 2 on teeth #15 and #16. Prosthetics: none.
Assessment: Mild periodontitis, stage I on teeth #15 and #16, supported by PSR 2 findings and absence of deeper pathology.
Plan: Prophylaxis performed; scaling of teeth #15 and #16 completed. Oral hygiene instruction reinforced, including proper brushing and interdental cleaning. No anesthesia required. Next recall scheduled in 6 months for routine maintenance.

S: 45-year-old female, former smoker, NKDA, reports “just a routine visit.” No pain, no swelling, no new symptoms. HPI: routine recall, last visit 6 months ago, no changes noted.
O: Extraoral: facial symmetry, no lymphadenopathy. Intraoral: no caries, no restorations, healthy mucosa. Periodontal: PSR 2 on teeth #15 and #16. Prosthetics: none.
A: Mild periodontitis, stage I on teeth #15 and #16, supported by PSR 2 findings and absence of deeper pathology.
P: Prophylaxis performed; scaling of teeth #15 and #16 completed. Oral hygiene instruction reinforced, including proper brushing and interdental cleaning. No anesthesia required. Next recall scheduled in 6 months for routine maintenance.

60-Year-Old Male, New Crown, Annual Checkup

SOAP note

Subjective: 60-year-old male, asthma on albuterol, NKDA, reports “new crown on tooth #30 looks fine.” HPI: crown placed 2 weeks ago, no pain or sensitivity. PMH: asthma, no other meds.
Objective: Extraoral: no swelling, facial symmetry normal. Intraoral: new crown on tooth #30, no caries, no restoration fracture. Periodontal: PSR 0, gingiva healthy. Prosthetics: crown in place, margins smooth, occlusion acceptable. No radiographs taken.
Assessment: Crown in place, no complications; periodontal health excellent (PSR 0).
Plan: Checked crown fit, occlusion, margin integrity; no anesthesia needed. Instructed patient on brushing technique around crown, flossing, and to report any sensitivity. Advised routine recall in 12 months for periodic evaluation.

S: 60-year-old male, asthma on albuterol, NKDA, reports “new crown on tooth #30 looks fine.” HPI: crown placed 2 weeks ago, no pain or sensitivity. PMH: asthma, no other meds.
O: Extraoral: no swelling, facial symmetry normal. Intraoral: new crown on tooth #30, no caries, no restoration fracture. Periodontal: PSR 0, gingiva healthy. Prosthetics: crown in place, margins smooth, occlusion acceptable. No radiographs taken.
A: Crown in place, no complications; periodontal health excellent (PSR 0).
P: Checked crown fit, occlusion, margin integrity; no anesthesia needed. Instructed patient on brushing technique around crown, flossing, and to report any sensitivity. Advised routine recall in 12 months for periodic evaluation.

25-Year-Old Pregnant Female, Routine Checkup

SOAP note

Subjective: 25-year-old pregnant female presents for a routine check-up with no complaints, stating “just a routine visit.” She reports no pain or discomfort, has no significant medical history, is on no medications, and is NKDA. She is currently in the second trimester and has no pregnancy-related complications noted on history.
Objective: Extraoral examination reveals no swelling or asymmetry; intraoral surfaces are smooth with no caries, restorations, or visible lesions. Periodontal screening shows PSR 0, indicating healthy gingiva and no pocketing. Prosthetic appliances are absent. No radiographs were taken as the clinical findings are within normal limits.
Assessment: The patient has normal periodontal health, evidenced by PSR 0 and the absence of carious lesions or restorative work.
Plan: Full-mouth prophylaxis was completed without local anesthesia. Oral hygiene instruction emphasized proper brushing technique, flossing twice daily, and the use of an antimicrobial mouth rinse when recommended. The patient was advised to schedule her next routine check-up in 12 months and to contact the office early if any new symptoms arise.

S: 25-year-old pregnant female presents for a routine check-up with no complaints, stating “just a routine visit.” She reports no pain or discomfort, has no significant medical history, is on no medications, and is NKDA. She is currently in the second trimester and has no pregnancy-related complications noted on history.
O: Extraoral examination reveals no swelling or asymmetry; intraoral surfaces are smooth with no caries, restorations, or visible lesions. Periodontal screening shows PSR 0, indicating healthy gingiva and no pocketing. Prosthetic appliances are absent. No radiographs were taken as the clinical findings are within normal limits.
A: The patient has normal periodontal health, evidenced by PSR 0 and the absence of carious lesions or restorative work.
P: Full-mouth prophylaxis was completed without local anesthesia. Oral hygiene instruction emphasized proper brushing technique, flossing twice daily, and the use of an antimicrobial mouth rinse when recommended. The patient was advised to schedule her next routine check-up in 12 months and to contact the office early if any new symptoms arise.

50-Year-Old Smoker, No Symptoms, Recall

SOAP note

Subjective: 50-year-old male smoker, “just a routine visit,” reports no pain or discomfort; history shows regular smoking of 1 pack/day for 25 years, no new habits; past medical history includes hypothyroidism managed with levothyroxine, allergic to penicillin (rash); no other medications or known drug allergies.
Objective: Extraoral examination reveals symmetrical facial musculature, no cervical lymphadenopathy, TMJ without audible clicks or deviation; intraoral inspection shows healthy mucosa, no lesions, and no restorations or carious lesions; periodontal assessment shows PSR 1 on tooth #22 with mild gingival inflammation, no bleeding on probing; prosthetic evaluation shows no crowns, bridges or removable appliances; radiographs were not indicated or taken for this recall.
Assessment: Early gingivitis localized to tooth #22, evidenced by PSR 1 and mild gingival inflammation without caries or restorations, consistent with the patient's smoking habit and lack of oral hygiene reinforcement.
Plan: Completed a thorough prophylaxis with ultrasonic scaling of tooth #22, performed without local anesthesia; provided detailed oral hygiene instructions emphasizing brushing technique, interdental cleaning, and cessation of smoking; advised a follow-up recall in 6 months to reassess periodontal status and reinforce preventive care.

S: 50-year-old male smoker, “just a routine visit,” reports no pain or discomfort; history shows regular smoking of 1 pack/day for 25 years, no new habits; past medical history includes hypothyroidism managed with levothyroxine, allergic to penicillin (rash); no other medications or known drug allergies.
O: Extraoral examination reveals symmetrical facial musculature, no cervical lymphadenopathy, TMJ without audible clicks or deviation; intraoral inspection shows healthy mucosa, no lesions, and no restorations or carious lesions; periodontal assessment shows PSR 1 on tooth #22 with mild gingival inflammation, no bleeding on probing; prosthetic evaluation shows no crowns, bridges or removable appliances; radiographs were not indicated or taken for this recall.
A: Early gingivitis localized to tooth #22, evidenced by PSR 1 and mild gingival inflammation without caries or restorations, consistent with the patient's smoking habit and lack of oral hygiene reinforcement.
P: Completed a thorough prophylaxis with ultrasonic scaling of tooth #22, performed without local anesthesia; provided detailed oral hygiene instructions emphasizing brushing technique, interdental cleaning, and cessation of smoking; advised a follow-up recall in 6 months to reassess periodontal status and reinforce preventive care.

70-Year-Old Male, Edentulous, Prosthesis Check

SOAP note

Subjective: 70-year-old male, “I’d like to check my denture fit,” reports no pain or discomfort; medical history includes controlled hypertension on lisinopril, NKDA, no other complaints.
Objective: Extraoral exam shows no swelling or asymmetry; intraoral exam reveals complete denture in place with no sore spots; periodontal screening shows PSR 0; no radiographs taken; no tests performed.
Assessment: Denture fit acceptable, supported by intact denture, absence of sore spots, and PSR 0 indicating healthy mucosa.
Plan: Adjusted denture seating as needed; instructed patient on proper cleaning technique with denture brush and daily soaking; advised to return for routine check-up in 6 months for fit reassessment.

S: 70-year-old male, “I’d like to check my denture fit,” reports no pain or discomfort; medical history includes controlled hypertension on lisinopril, NKDA, no other complaints.
O: Extraoral exam shows no swelling or asymmetry; intraoral exam reveals complete denture in place with no sore spots; periodontal screening shows PSR 0; no radiographs taken; no tests performed.
A: Denture fit acceptable, supported by intact denture, absence of sore spots, and PSR 0 indicating healthy mucosa.
P: Adjusted denture seating as needed; instructed patient on proper cleaning technique with denture brush and daily soaking; advised to return for routine check-up in 6 months for fit reassessment.

35-Year-Old Female, New Filling, Recall

SOAP note

Subjective: 35-year-old female, smoker 5 cigarettes/day, NKDA, reports “new filling on tooth 12” and no pain or sensitivity. O: Extraoral shows no swelling, intraoral reveals a composite restoration on tooth #12 with no caries or defects, periodontal screening PSR 0, no prosthetics. A: Filling in place, no complications, supported by intact restoration and PSR 0. P: No anesthesia required; inspected restoration, reinforced oral hygiene instruction focusing on interdental flossing, and advised to quit smoking; next recall scheduled in 12 months.

S: 35-year-old female, smoker 5 cigarettes/day, NKDA, reports “new filling on tooth 12” and no pain or sensitivity. O: Extraoral shows no swelling, intraoral reveals a composite restoration on tooth #12 with no caries or defects, periodontal screening PSR 0, no prosthetics. A: Filling in place, no complications, supported by intact restoration and PSR 0. P: No anesthesia required; inspected restoration, reinforced oral hygiene instruction focusing on interdental flossing, and advised to quit smoking; next recall scheduled in 12 months.

42-Year-Old Female, Periodontal Screening, Recall

SOAP note

Subjective: 42-year-old female, type 2 diabetes on metformin, NKDA, presents for routine recall; says “just a regular check-up.” No pain or swelling reported. HPI: last visit 6 months ago, no changes since.
Objective: Extraoral: no swelling, facial symmetry normal. Intraoral: no caries, no restorations noted. Periodontal: PSR 1 on tooth #15, mild erythema, no BOP. Prosthetics: none present.
Assessment: Early gingivitis on tooth #15, supported by PSR 1 and gingival erythema.
Plan: Prophylaxis performed; scaling of tooth #15 completed without anesthesia. Oral hygiene instruction reinforced; patient advised to brush twice daily with fluoridated toothpaste and floss nightly. Next recall scheduled in 6 months.

S: 42-year-old female, type 2 diabetes on metformin, NKDA, presents for routine recall; says “just a regular check-up.” No pain or swelling reported. HPI: last visit 6 months ago, no changes since.
O: Extraoral: no swelling, facial symmetry normal. Intraoral: no caries, no restorations noted. Periodontal: PSR 1 on tooth #15, mild erythema, no BOP. Prosthetics: none present.
A: Early gingivitis on tooth #15, supported by PSR 1 and gingival erythema.
P: Prophylaxis performed; scaling of tooth #15 completed without anesthesia. Oral hygiene instruction reinforced; patient advised to brush twice daily with fluoridated toothpaste and floss nightly. Next recall scheduled in 6 months.

55-Year-Old Male, Low Caries Risk, Routine Exam

SOAP note

Subjective: 55-year-old male, reports “just a routine check-up,” no complaints, no pain; PMH: none, NKDA; no medications.
Objective: Extraoral: facial symmetry, no swelling, lymph nodes non-tender; Intraoral: no caries, no restorations, soft tissues intact; Periodontal: PSR 0, no BOP; Radiographs: none taken; Tests: none performed.
Assessment: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
Plan: Full-mouth prophylaxis performed; oral hygiene instruction on brushing technique, interdental cleaning, and fluoride use given; no anesthesia required; patient advised to return in 12 months for routine recall.

S: 55-year-old male, reports “just a routine check-up,” no complaints, no pain; PMH: none, NKDA; no medications.
O: Extraoral: facial symmetry, no swelling, lymph nodes non-tender; Intraoral: no caries, no restorations, soft tissues intact; Periodontal: PSR 0, no BOP; Radiographs: none taken; Tests: none performed.
A: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
P: Full-mouth prophylaxis performed; oral hygiene instruction on brushing technique, interdental cleaning, and fluoride use given; no anesthesia required; patient advised to return in 12 months for routine recall.

38-Year-Old Female, High Caries Risk, Recall

SOAP note

Subjective: 38-year-old female, reports no current dental complaints, states she has been taking low-dose aspirin daily for hypertension, NKDA, and has no other significant medical history.
Objective: Extraoral examination shows facial symmetry with no swelling or lymphadenopathy; intraoral surfaces are smooth, no caries or restorations noted, periodontal probing reveals PSR 0 with healthy gingiva, and no prosthetic devices are present.
Assessment: High caries risk with no active lesions; this assessment is based on the patient’s aspirin therapy, age, and the absence of decay or periodontal pathology.
Plan: Applied topical fluoride varnish to all tooth surfaces; no local anesthesia was required. Instructed on twice-daily fluoride toothpaste use, daily flossing, limiting sugary snacks, and maintaining regular dental visits. Advised to schedule the next recall in 6 months for a routine check-up.

S: 38-year-old female, reports no current dental complaints, states she has been taking low-dose aspirin daily for hypertension, NKDA, and has no other significant medical history.
O: Extraoral examination shows facial symmetry with no swelling or lymphadenopathy; intraoral surfaces are smooth, no caries or restorations noted, periodontal probing reveals PSR 0 with healthy gingiva, and no prosthetic devices are present.
A: High caries risk with no active lesions; this assessment is based on the patient’s aspirin therapy, age, and the absence of decay or periodontal pathology.
P: Applied topical fluoride varnish to all tooth surfaces; no local anesthesia was required. Instructed on twice-daily fluoride toothpaste use, daily flossing, limiting sugary snacks, and maintaining regular dental visits. Advised to schedule the next recall in 6 months for a routine check-up.

62-Year-Old Female, Implant Maintenance, Recall

SOAP note

Subjective: 62-year-old female with seasonal allergies, NKDA, reports “no problems, just routine implant maintenance.” She has had the implant in place for 3 years, notes no pain or swelling, and wants a check-up.
Objective: Extraoral examination shows no swelling or asymmetry. Intraoral exam reveals implant site #30 stable, abutment intact, no peri-implantitis. Periodontal screening (PSR) is 0. No radiographs were taken this visit.
Assessment: Implant stable, no peri-implantitis; findings: intact abutment, PSR 0, absence of swelling or infection.
Plan: Prophylaxis performed around implant #30. Oral hygiene instruction reinforced, focusing on interdental cleaning around the implant. No anesthesia required. Next recall scheduled in 6 months for routine maintenance.

S: 62-year-old female with seasonal allergies, NKDA, reports “no problems, just routine implant maintenance.” She has had the implant in place for 3 years, notes no pain or swelling, and wants a check-up.
O: Extraoral examination shows no swelling or asymmetry. Intraoral exam reveals implant site #30 stable, abutment intact, no peri-implantitis. Periodontal screening (PSR) is 0. No radiographs were taken this visit.
A: Implant stable, no peri-implantitis; findings: intact abutment, PSR 0, absence of swelling or infection.
P: Prophylaxis performed around implant #30. Oral hygiene instruction reinforced, focusing on interdental cleaning around the implant. No anesthesia required. Next recall scheduled in 6 months for routine maintenance.

30-Year-Old Male, Allergy to Penicillin, Recall

SOAP note

Subjective: 30-year-old male, reports “allergy to penicillin, just a routine visit.” He has no current complaints, is a former smoker, and has no known drug allergies or chronic medications. He denies pain, swelling, or recent dental problems and confirms his penicillin allergy with no reaction history beyond a mild rash in childhood.
Objective: Extraoral examination reveals no facial asymmetry, no cervical lymphadenopathy, and no swelling; intraoral surfaces are smooth, with no caries, restorations, or visible lesions. Periodontal probing shows a PSR score of 0 across all sextants, indicating healthy gingival tissues and no attachment loss; no prosthetic devices are present. No radiographs were taken this visit.
Assessment: Diagnosis is normal periodontal health, as evidenced by PSR 0, absence of caries or restorations, and healthy gingival tissues on examination.
Plan: Full-mouth prophylaxis was performed with a rubber cup and prophylaxis paste; no local anesthesia was required. Oral hygiene instruction was reinforced, emphasizing proper brushing technique, interdental cleaning, and the importance of regular recall visits. The patient was advised to return in six months for the next routine check-up.

S: 30-year-old male, reports “allergy to penicillin, just a routine visit.” He has no current complaints, is a former smoker, and has no known drug allergies or chronic medications. He denies pain, swelling, or recent dental problems and confirms his penicillin allergy with no reaction history beyond a mild rash in childhood.
O: Extraoral examination reveals no facial asymmetry, no cervical lymphadenopathy, and no swelling; intraoral surfaces are smooth, with no caries, restorations, or visible lesions. Periodontal probing shows a PSR score of 0 across all sextants, indicating healthy gingival tissues and no attachment loss; no prosthetic devices are present. No radiographs were taken this visit.
A: Diagnosis is normal periodontal health, as evidenced by PSR 0, absence of caries or restorations, and healthy gingival tissues on examination.
P: Full-mouth prophylaxis was performed with a rubber cup and prophylaxis paste; no local anesthesia was required. Oral hygiene instruction was reinforced, emphasizing proper brushing technique, interdental cleaning, and the importance of regular recall visits. The patient was advised to return in six months for the next routine check-up.

52-Year-Old Male, Chronic Pain, Recall

SOAP note

Subjective: 52-year-old male presents for a routine recall, stating “I’ve had chronic jaw pain for years, but today I’m just here for a check-up.” He reports no new symptoms, no swelling, and no recent changes in pain intensity; his asthma is well controlled with albuterol as needed, and he has no known drug allergies (NKDA).
Objective: Extraoral examination reveals facial symmetry, no cervical lymphadenopathy, and a normal range of motion of the TMJ. Intraoral inspection shows no caries, no existing restorations, and healthy mucosa; periodontal charting indicates PSR 1 on tooth #30 with no bleeding on probing. No prosthetic appliances are present and no radiographs were taken during this visit.
Assessment: Chronic periodontitis, stage I on tooth #30, is diagnosed based on the PSR 1 finding and the absence of caries or restorative work, indicating early periodontal involvement that requires routine maintenance.
Plan: Prophylaxis was performed with polishing and fluoride application; scaling of tooth #30 was completed without local anesthesia. Comprehensive oral hygiene instruction was provided, emphasizing proper brushing technique, interdental cleaning, and the importance of regular recalls. The patient was advised to schedule his next routine check-up in six months.

S: 52-year-old male presents for a routine recall, stating “I’ve had chronic jaw pain for years, but today I’m just here for a check-up.” He reports no new symptoms, no swelling, and no recent changes in pain intensity; his asthma is well controlled with albuterol as needed, and he has no known drug allergies (NKDA).
O: Extraoral examination reveals facial symmetry, no cervical lymphadenopathy, and a normal range of motion of the TMJ. Intraoral inspection shows no caries, no existing restorations, and healthy mucosa; periodontal charting indicates PSR 1 on tooth #30 with no bleeding on probing. No prosthetic appliances are present and no radiographs were taken during this visit.
A: Chronic periodontitis, stage I on tooth #30, is diagnosed based on the PSR 1 finding and the absence of caries or restorative work, indicating early periodontal involvement that requires routine maintenance.
P: Prophylaxis was performed with polishing and fluoride application; scaling of tooth #30 was completed without local anesthesia. Comprehensive oral hygiene instruction was provided, emphasizing proper brushing technique, interdental cleaning, and the importance of regular recalls. The patient was advised to schedule his next routine check-up in six months.

40-Year-Old Female, Dental Anxiety, Recall

SOAP note

Subjective: 40-year-old female, no significant medical history, NKDA, presents for a routine recall. She reports “I’m a bit nervous about the visit” and has no dental complaints; she wishes to maintain her oral health and keep her routine appointments on schedule.
Objective: Extraoral examination reveals facial symmetry, no cervical or submandibular lymphadenopathy, and no swelling or tenderness. Intraoral inspection shows no carious lesions, no existing restorations, and healthy gingival tissues with no bleeding on probing. Periodontal screening yields PSR 0 across all sextants, indicating clinically healthy periodontium. No prosthetic appliances are present. Radiographic assessment was not performed this visit as no pathology was suspected.
Assessment: Diagnosis is normal periodontal health, confirmed by PSR 0 and the absence of caries or restorative work.
Plan: Full-mouth prophylaxis was completed without local anesthesia. Oral hygiene instruction emphasized correct brushing technique, use of a soft-bristle brush, interdental cleaning with floss or interdental brushes, and the importance of regular recalls every 12 months. The patient was advised to return in one year for her next routine check-up.

S: 40-year-old female, no significant medical history, NKDA, presents for a routine recall. She reports “I’m a bit nervous about the visit” and has no dental complaints; she wishes to maintain her oral health and keep her routine appointments on schedule.
O: Extraoral examination reveals facial symmetry, no cervical or submandibular lymphadenopathy, and no swelling or tenderness. Intraoral inspection shows no carious lesions, no existing restorations, and healthy gingival tissues with no bleeding on probing. Periodontal screening yields PSR 0 across all sextants, indicating clinically healthy periodontium. No prosthetic appliances are present. Radiographic assessment was not performed this visit as no pathology was suspected.
A: Diagnosis is normal periodontal health, confirmed by PSR 0 and the absence of caries or restorative work.
P: Full-mouth prophylaxis was completed without local anesthesia. Oral hygiene instruction emphasized correct brushing technique, use of a soft-bristle brush, interdental cleaning with floss or interdental brushes, and the importance of regular recalls every 12 months. The patient was advised to return in one year for her next routine check-up.

65-Year-Old Male, Medication-Induced Dry Mouth, Recall

SOAP note

Subjective: 65-year-old male reports “dry mouth” due to his levothyroxine; no pain or other symptoms. History: hypothyroidism, levothyroxine 75 µg daily; NKDA otherwise.
Objective: Extraoral: no swelling, normal facial symmetry. Intraoral: xerostomia noted, mucosa dry, no caries or lesions. Periodontal: PSR 0, full gingival health. No radiographs taken.
Assessment: Dry mouth, medication-induced; supported by xerostomia and absence of active lesions.
Plan: Advised saliva substitute (artificial saliva, 5 mL every 2–3 h as needed); instructed on oral hygiene with gentle brushing, fluoride gel 2 % nightly, and adequate hydration. No anesthesia used. Next recall in 6 months for routine check-up.

S: 65-year-old male reports “dry mouth” due to his levothyroxine; no pain or other symptoms. History: hypothyroidism, levothyroxine 75 µg daily; NKDA otherwise.
O: Extraoral: no swelling, normal facial symmetry. Intraoral: xerostomia noted, mucosa dry, no caries or lesions. Periodontal: PSR 0, full gingival health. No radiographs taken.
A: Dry mouth, medication-induced; supported by xerostomia and absence of active lesions.
P: Advised saliva substitute (artificial saliva, 5 mL every 2–3 h as needed); instructed on oral hygiene with gentle brushing, fluoride gel 2 % nightly, and adequate hydration. No anesthesia used. Next recall in 6 months for routine check-up.

32-Year-Old Male, Smoking Cessation, Routine Exam

SOAP note

Subjective: 32-year-old male, reports “I want to quit smoking, just a routine visit.” No other complaints. PMH: controlled hypertension on lisinopril. NKDA.
Objective: Extraoral: no swelling, symmetrical facial profile. Intraoral: no caries, no restorations. Periodontal: PSR 1 on tooth #22. Prosthetics: none.
Assessment: Early gingivitis on tooth #22, supported by PSR 1 and absence of caries or restorations.
Plan: Prophylaxis performed; scaling of tooth #22 completed. No anesthesia used. Counseling on smoking cessation provided, including benefits of quitting and resources. Patient instructed to maintain oral hygiene and avoid tobacco. Next visit scheduled in 6 months for routine check-up.

S: 32-year-old male, reports “I want to quit smoking, just a routine visit.” No other complaints. PMH: controlled hypertension on lisinopril. NKDA.
O: Extraoral: no swelling, symmetrical facial profile. Intraoral: no caries, no restorations. Periodontal: PSR 1 on tooth #22. Prosthetics: none.
A: Early gingivitis on tooth #22, supported by PSR 1 and absence of caries or restorations.
P: Prophylaxis performed; scaling of tooth #22 completed. No anesthesia used. Counseling on smoking cessation provided, including benefits of quitting and resources. Patient instructed to maintain oral hygiene and avoid tobacco. Next visit scheduled in 6 months for routine check-up.

50-Year-Old Female, Diabetes, Recall

SOAP note

Subjective: 50-year-old female, smoker 5 cigarettes/day, reports “just a routine visit” and that she has diabetes; no other complaints. She has type 2 diabetes mellitus, well controlled on metformin, and reports no known drug allergies. She has no history of significant dental problems and has been compliant with her annual check-ups.
Objective: Extraoral: facial symmetry preserved, no cervical lymphadenopathy, TMJ sounds normal, maximum opening 40 mm. Intraoral: soft tissues pink and intact, no caries or restorations noted on any tooth; tooth #15 shows healthy gingiva with mild erythema and no plaque accumulation. Periodontal: PSR 1 on tooth #15, no bleeding on probing, probing depths 1–2 mm, no recession. Prosthetics: none present. No radiographs were taken during this visit.
Assessment: Early gingivitis on tooth #15, indicated by PSR 1, mild gingival erythema, and absence of caries or restorations.
Plan: Prophylaxis performed with ultrasonic scaling and polishing of tooth #15; no local anesthesia required. Oral hygiene instruction emphasized twice-daily brushing with fluoride toothpaste, interdental cleaning, and the importance of smoking cessation and glycemic control for periodontal health. Patient expressed willingness to adopt a daily chlorhexidine rinse if needed. Next recall scheduled for 6 months to monitor periodontal status and reinforce preventive measures.

S: 50-year-old female, smoker 5 cigarettes/day, reports “just a routine visit” and that she has diabetes; no other complaints. She has type 2 diabetes mellitus, well controlled on metformin, and reports no known drug allergies. She has no history of significant dental problems and has been compliant with her annual check-ups.
O: Extraoral: facial symmetry preserved, no cervical lymphadenopathy, TMJ sounds normal, maximum opening 40 mm. Intraoral: soft tissues pink and intact, no caries or restorations noted on any tooth; tooth #15 shows healthy gingiva with mild erythema and no plaque accumulation. Periodontal: PSR 1 on tooth #15, no bleeding on probing, probing depths 1–2 mm, no recession. Prosthetics: none present. No radiographs were taken during this visit.
A: Early gingivitis on tooth #15, indicated by PSR 1, mild gingival erythema, and absence of caries or restorations.
P: Prophylaxis performed with ultrasonic scaling and polishing of tooth #15; no local anesthesia required. Oral hygiene instruction emphasized twice-daily brushing with fluoride toothpaste, interdental cleaning, and the importance of smoking cessation and glycemic control for periodontal health. Patient expressed willingness to adopt a daily chlorhexidine rinse if needed. Next recall scheduled for 6 months to monitor periodontal status and reinforce preventive measures.

29-Year-Old Male, Allergic to Latex, Routine Checkup

SOAP note

Subjective: 29-year-old male presents for a routine check-up, stating “I’m allergic to latex, just a routine visit.” He has type 2 diabetes managed with metformin, reports no pain or other complaints, and has no known drug allergies (NKDA).
Objective: Extraoral examination shows no swelling or asymmetry; intraoral surfaces are free of caries or restorations, with healthy gingiva and no periodontal pockets. Periodontal screening reveals PSR 0 across all sextants. No prosthetic appliances are present, and the patient declined radiographs at this visit.
Assessment: Diagnosis is normal periodontal health, confirmed by the absence of caries, restorations, periodontal pockets, and a PSR 0 score.
Plan: Full-mouth prophylaxis was completed without local anesthesia. Post-operative instructions included use of a latex-free toothbrush, daily fluoride toothpaste, and a 0.12 % chlorhexidine rinse twice daily for 30 seconds. The patient was advised to maintain regular brushing and flossing, and to return for the next routine check-up in 12 months.

S: 29-year-old male presents for a routine check-up, stating “I’m allergic to latex, just a routine visit.” He has type 2 diabetes managed with metformin, reports no pain or other complaints, and has no known drug allergies (NKDA).
O: Extraoral examination shows no swelling or asymmetry; intraoral surfaces are free of caries or restorations, with healthy gingiva and no periodontal pockets. Periodontal screening reveals PSR 0 across all sextants. No prosthetic appliances are present, and the patient declined radiographs at this visit.
A: Diagnosis is normal periodontal health, confirmed by the absence of caries, restorations, periodontal pockets, and a PSR 0 score.
P: Full-mouth prophylaxis was completed without local anesthesia. Post-operative instructions included use of a latex-free toothbrush, daily fluoride toothpaste, and a 0.12 % chlorhexidine rinse twice daily for 30 seconds. The patient was advised to maintain regular brushing and flossing, and to return for the next routine check-up in 12 months.

57-Year-Old Female, Medically Complex, Recall

SOAP note

Subjective: 57-year-old female, no complaints, reports routine check-up; medical history unremarkable, allergic to penicillin (rash), NKDA otherwise.
Objective: Extraoral: no swelling, facial symmetry intact. Intraoral: no caries, no restorations, gingiva healthy, no BOP. Periodontal: PSR 0. Radiographs: none taken.
Assessment: Normal periodontal health, supported by PSR 0 and absence of clinical pathology.
Plan: Full mouth prophylaxis performed; oral hygiene instruction reinforced; no anesthesia used. Patient advised to maintain twice-daily brushing, flossing, and quarterly cleanings; next recall scheduled in 6 months.

S: 57-year-old female, no complaints, reports routine check-up; medical history unremarkable, allergic to penicillin (rash), NKDA otherwise.
O: Extraoral: no swelling, facial symmetry intact. Intraoral: no caries, no restorations, gingiva healthy, no BOP. Periodontal: PSR 0. Radiographs: none taken.
A: Normal periodontal health, supported by PSR 0 and absence of clinical pathology.
P: Full mouth prophylaxis performed; oral hygiene instruction reinforced; no anesthesia used. Patient advised to maintain twice-daily brushing, flossing, and quarterly cleanings; next recall scheduled in 6 months.

45-Year-Old Male, Low Risk, Routine Exam

SOAP note

Subjective: 45-year-old male, reports “just a routine visit,” no complaints; history negative for pain or swelling; past medical history includes daily low-dose aspirin; no known drug allergies (NKDA).
Objective: Extraoral: facial symmetry, no swelling; Intraoral: no caries, no restorations; Periodontal: PSR 0; Prosthetics: none; Radiographs: none taken; Tests: none.
Assessment: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
Plan: Full-mouth prophylaxis performed without anesthesia; oral hygiene instruction reinforced, including brushing twice daily, flossing, and low-dose aspirin impact on bleeding risk; patient advised to return in 12 months for routine check-up.

S: 45-year-old male, reports “just a routine visit,” no complaints; history negative for pain or swelling; past medical history includes daily low-dose aspirin; no known drug allergies (NKDA).
O: Extraoral: facial symmetry, no swelling; Intraoral: no caries, no restorations; Periodontal: PSR 0; Prosthetics: none; Radiographs: none taken; Tests: none.
A: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
P: Full-mouth prophylaxis performed without anesthesia; oral hygiene instruction reinforced, including brushing twice daily, flossing, and low-dose aspirin impact on bleeding risk; patient advised to return in 12 months for routine check-up.

31-Year-Old Female, Pregnancy, Recall

SOAP note

Subjective: 31-year-old female, pregnant, states she is here for a routine recall; no pain, no swelling, no dental complaints. HPI: “Just a routine visit, nothing else.” Medical history: seasonal allergies, NKDA. The patient reports being in her second trimester and wants to ensure her oral health remains optimal during pregnancy. She has no history of systemic disease and is not taking any medications.
Objective: Extraoral: no swelling, symmetrical facial profile, no lymphadenopathy. Intraoral: soft tissues intact, no lesions, no caries, no restorations. Periodontal: PSR 0, probing depths within normal limits, no bleeding on probing. Prosthetics: none. No radiographs were taken this visit.
Assessment: Normal periodontal health, supported by PSR 0, absence of caries or restorations, and overall healthy oral tissues.
Plan: Full-mouth prophylaxis performed with no anesthesia. Oral hygiene instruction reinforced, emphasizing fluoride toothpaste, proper brushing technique, and interdental cleaning; patient was advised to use a 0.12% chlorhexidine rinse twice daily for one week. Patient was reminded to maintain regular prenatal care and to return in 6 months for the next recall.

S: 31-year-old female, pregnant, states she is here for a routine recall; no pain, no swelling, no dental complaints. HPI: “Just a routine visit, nothing else.” Medical history: seasonal allergies, NKDA. The patient reports being in her second trimester and wants to ensure her oral health remains optimal during pregnancy. She has no history of systemic disease and is not taking any medications.
O: Extraoral: no swelling, symmetrical facial profile, no lymphadenopathy. Intraoral: soft tissues intact, no lesions, no caries, no restorations. Periodontal: PSR 0, probing depths within normal limits, no bleeding on probing. Prosthetics: none. No radiographs were taken this visit.
A: Normal periodontal health, supported by PSR 0, absence of caries or restorations, and overall healthy oral tissues.
P: Full-mouth prophylaxis performed with no anesthesia. Oral hygiene instruction reinforced, emphasizing fluoride toothpaste, proper brushing technique, and interdental cleaning; patient was advised to use a 0.12% chlorhexidine rinse twice daily for one week. Patient was reminded to maintain regular prenatal care and to return in 6 months for the next recall.

26-Year-Old Female, New Crown, Recall

SOAP note

Subjective: 26-year-old female, former smoker, NKDA. Chief complaint: “I have a new crown on tooth #12.” She reports no pain or sensitivity and no functional issues. Medical history reviewed; no systemic conditions noted.
Objective: Extraoral: no swelling, facial symmetry normal. Intraoral: crown on tooth #12, no caries or restoration defects. Periodontal: PSR 0, healthy gingiva. Prosthetic: crown in place, well-fitted, no occlusal contacts.
Assessment: Crown in place, no complications; findings support a stable, uncomplicated restoration.
Plan: Checked crown fit and occlusion; no anesthesia required. Provided oral hygiene instruction focused on interdental cleaning around the crown. Advised next recall in 12 months for routine check-up.

S: 26-year-old female, former smoker, NKDA. Chief complaint: “I have a new crown on tooth #12.” She reports no pain or sensitivity and no functional issues. Medical history reviewed; no systemic conditions noted.
O: Extraoral: no swelling, facial symmetry normal. Intraoral: crown on tooth #12, no caries or restoration defects. Periodontal: PSR 0, healthy gingiva. Prosthetic: crown in place, well-fitted, no occlusal contacts.
A: Crown in place, no complications; findings support a stable, uncomplicated restoration.
P: Checked crown fit and occlusion; no anesthesia required. Provided oral hygiene instruction focused on interdental cleaning around the crown. Advised next recall in 12 months for routine check-up.

43-Year-Old Male, Periodontal Disease, Recall

SOAP note

Subjective: 43-year-old male, asthma on albuterol, NKDA, states “just a routine visit” for periodontal disease; he reports no pain, no swelling, no bleeding, and has not noticed any changes in his gums since his last check-up.
Objective: Extraoral examination shows facial symmetry, no cervical or submandibular lymphadenopathy, and no TMJ tenderness; intraoral assessment reveals healthy mucosa, no carious lesions, no restorations, and no visible prosthetic components. Periodontal charting demonstrates a PSR 3 score on tooth #30, with probing depths of 5 mm, bleeding on probing present, and no furcation involvement; radiographs are not indicated at this visit.
Assessment: Periodontitis stage II on tooth #30, based on PSR 3 findings, moderate probing depths, and clinical attachment loss, with no systemic or acute inflammatory signs.
Plan: Prophylaxis completed with a 15-minute pumice rinse and scaling of tooth #30 performed under local anesthesia (none required); oral hygiene instruction emphasized proper brushing technique, interdental cleaning, and the importance of regular recall visits; patient scheduled for a maintenance recall in 6 months.

S: 43-year-old male, asthma on albuterol, NKDA, states “just a routine visit” for periodontal disease; he reports no pain, no swelling, no bleeding, and has not noticed any changes in his gums since his last check-up.
O: Extraoral examination shows facial symmetry, no cervical or submandibular lymphadenopathy, and no TMJ tenderness; intraoral assessment reveals healthy mucosa, no carious lesions, no restorations, and no visible prosthetic components. Periodontal charting demonstrates a PSR 3 score on tooth #30, with probing depths of 5 mm, bleeding on probing present, and no furcation involvement; radiographs are not indicated at this visit.
A: Periodontitis stage II on tooth #30, based on PSR 3 findings, moderate probing depths, and clinical attachment loss, with no systemic or acute inflammatory signs.
P: Prophylaxis completed with a 15-minute pumice rinse and scaling of tooth #30 performed under local anesthesia (none required); oral hygiene instruction emphasized proper brushing technique, interdental cleaning, and the importance of regular recall visits; patient scheduled for a maintenance recall in 6 months.

54-Year-Old Female, Low Caries Risk, Routine Exam

SOAP note

Subjective: 54-year-old female, no complaints, states she only wants a routine check-up to keep her low caries risk; PMH non-contributory, NKDA, no current medications; she reports no pain, no sensitivity, and no recent changes in oral hygiene habits.
Objective: Extraoral: facial symmetry, no swelling, lymph nodes not enlarged; Intraoral soft tissues intact, no lesions; teeth: no caries, no restorations, smooth surfaces, no attrition; periodontal: PSR 0, no bleeding on probing, probing depths 1-2 mm, no recession; prosthetics: none; radiographs: none taken, patient declined.
Assessment: Normal periodontal health, evidenced by PSR 0, absence of caries or restorations, and healthy gingival tissues with no bleeding on probing.
Plan: Full-mouth prophylaxis completed with ultrasonic scaling and polishing; patient received verbal and written oral hygiene instruction emphasizing twice-daily brushing with fluoride toothpaste, interdental cleaning, and regular flossing; advised to maintain current routine and return in 12 months for a routine recall.

S: 54-year-old female, no complaints, states she only wants a routine check-up to keep her low caries risk; PMH non-contributory, NKDA, no current medications; she reports no pain, no sensitivity, and no recent changes in oral hygiene habits.
O: Extraoral: facial symmetry, no swelling, lymph nodes not enlarged; Intraoral soft tissues intact, no lesions; teeth: no caries, no restorations, smooth surfaces, no attrition; periodontal: PSR 0, no bleeding on probing, probing depths 1-2 mm, no recession; prosthetics: none; radiographs: none taken, patient declined.
A: Normal periodontal health, evidenced by PSR 0, absence of caries or restorations, and healthy gingival tissues with no bleeding on probing.
P: Full-mouth prophylaxis completed with ultrasonic scaling and polishing; patient received verbal and written oral hygiene instruction emphasizing twice-daily brushing with fluoride toothpaste, interdental cleaning, and regular flossing; advised to maintain current routine and return in 12 months for a routine recall.

39-Year-Old Male, High Caries Risk, Recall

SOAP note

Subjective: 39-year-old male with hypothyroidism on levothyroxine, reports “just a routine visit, high caries risk.” No pain or other complaints; medication list includes levothyroxine; NKDA.
Objective: Extraoral exam shows no swelling or asymmetry. Intraoral exam reveals no caries or restorations; periodontal screening code 0 (PSR 0); no prosthetic appliances present. Radiographs were not taken.
Assessment: High caries risk, no active lesions; supported by absence of caries, PSR 0, and medical history of hypothyroidism.
Plan: Applied fluoride varnish; provided oral hygiene instruction focusing on brushing technique and fluoride use; no anesthesia administered. Scheduled next recall in 6 months.

S: 39-year-old male with hypothyroidism on levothyroxine, reports “just a routine visit, high caries risk.” No pain or other complaints; medication list includes levothyroxine; NKDA.
O: Extraoral exam shows no swelling or asymmetry. Intraoral exam reveals no caries or restorations; periodontal screening code 0 (PSR 0); no prosthetic appliances present. Radiographs were not taken.
A: High caries risk, no active lesions; supported by absence of caries, PSR 0, and medical history of hypothyroidism.
P: Applied fluoride varnish; provided oral hygiene instruction focusing on brushing technique and fluoride use; no anesthesia administered. Scheduled next recall in 6 months.

47-Year-Old Female, Implant, Routine Checkup

SOAP note

Subjective: 47-year-old female with controlled hypertension on lisinopril reports no concerns, stating her implant on tooth #30 feels stable and pain free. She denies swelling, bleeding, or discomfort. Past medical history includes hypertension; medications are lisinopril; NKDA.
Objective: Extraoral exam shows no facial asymmetry or lymphadenopathy. Intraoral exam reveals implant site at #30 with stable abutment, no peri-implantitis, and healthy surrounding tissues. Periodontal screening returns PSR 0. No radiographs were taken this visit.
Assessment: Implant on #30 is stable with no peri-implantitis, supported by absence of swelling, normal PSR 0, and stable abutment on intraoral inspection.
Plan: Prophylaxis performed around implant site; patient instructed on implant-specific hygiene and to avoid hard foods. No anesthesia used. Follow-up scheduled in 12 months for routine implant maintenance.

S: 47-year-old female with controlled hypertension on lisinopril reports no concerns, stating her implant on tooth #30 feels stable and pain free. She denies swelling, bleeding, or discomfort. Past medical history includes hypertension; medications are lisinopril; NKDA.
O: Extraoral exam shows no facial asymmetry or lymphadenopathy. Intraoral exam reveals implant site at #30 with stable abutment, no peri-implantitis, and healthy surrounding tissues. Periodontal screening returns PSR 0. No radiographs were taken this visit.
A: Implant on #30 is stable with no peri-implantitis, supported by absence of swelling, normal PSR 0, and stable abutment on intraoral inspection.
P: Prophylaxis performed around implant site; patient instructed on implant-specific hygiene and to avoid hard foods. No anesthesia used. Follow-up scheduled in 12 months for routine implant maintenance.

34-Year-Old Male, Allergy to Aspirin, Recall

SOAP note

Subjective: 34-year-old male, smoker 5 cigarettes/day, reports no dental complaints; states “just a routine visit” and notes known aspirin allergy, NKDA otherwise.
Objective: Extraoral exam shows facial symmetry, no swelling; intraoral surfaces smooth, no caries or restorations; periodontal screening (PSR) code 0, healthy gingiva; no radiographs taken; all tests within normal limits.
Assessment: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
Plan: Full-mouth prophylaxis performed with no anesthesia; oral hygiene instruction given, emphasizing smoking cessation and proper brushing technique; patient advised to return in 12 months for routine check-up.

S: 34-year-old male, smoker 5 cigarettes/day, reports no dental complaints; states “just a routine visit” and notes known aspirin allergy, NKDA otherwise.
O: Extraoral exam shows facial symmetry, no swelling; intraoral surfaces smooth, no caries or restorations; periodontal screening (PSR) code 0, healthy gingiva; no radiographs taken; all tests within normal limits.
A: Normal periodontal health, supported by PSR 0 and absence of caries or restorations.
P: Full-mouth prophylaxis performed with no anesthesia; oral hygiene instruction given, emphasizing smoking cessation and proper brushing technique; patient advised to return in 12 months for routine check-up.

41-Year-Old Male, Smoking, Routine Checkup

SOAP note

Subjective: 41-year-old male, smoker, reports “just a routine visit” and no complaints; history of type 2 diabetes on metformin, NKDA.
Objective: Extraoral: no swelling, intraoral: no caries, no restorations; periodontal: PSR 1 on tooth #15; prosthetics: none; radiographs: none taken.
Assessment: Early gingivitis on tooth #15, supported by PSR 1 and absence of caries or restorations.
Plan: Prophylaxis performed; scaling of tooth #15 completed; no anesthesia used. Smoking cessation counseling provided, with written resources and recommendation for nicotine patch trial. Patient instructed to maintain twice-daily brushing, flossing; next visit scheduled in 6 months for routine check-up.

S: 41-year-old male, smoker, reports “just a routine visit” and no complaints; history of type 2 diabetes on metformin, NKDA.
O: Extraoral: no swelling, intraoral: no caries, no restorations; periodontal: PSR 1 on tooth #15; prosthetics: none; radiographs: none taken.
A: Early gingivitis on tooth #15, supported by PSR 1 and absence of caries or restorations.
P: Prophylaxis performed; scaling of tooth #15 completed; no anesthesia used. Smoking cessation counseling provided, with written resources and recommendation for nicotine patch trial. Patient instructed to maintain twice-daily brushing, flossing; next visit scheduled in 6 months for routine check-up.

63-Year-Old Male, COPD, Recall

SOAP note

Subjective: 63-year-old male, COPD, “just a routine visit” and no other complaints; he reports no pain, no bleeding, no sensitivity, and no changes in his oral habits; PMH non-contributory, NKDA, no current medications, no recent dental visits beyond this recall.
Objective: Extraoral: facial symmetry intact, no cervical or submandibular lymphadenopathy, TMJ normal, no trismus; Intraoral: mucosa pink, no lesions, no caries, no restorations, no missing teeth; Periodontal: probing depths 0–2 mm, no bleeding on probing, PSR 0; Prosthetics: none present; Radiographs: none taken this visit; Tests: none performed.
Assessment: Normal periodontal health, evidenced by PSR 0, absence of caries or restorations, and normal probing depths; no signs of disease or pathology.
Plan: Full-mouth prophylaxis completed with polishing and fluoride varnish application; oral hygiene instruction reinforced with emphasis on proper brushing technique, interdental cleaning, and smoking cessation benefits for COPD; no anesthesia required; scheduled next recall in 12 months.

S: 63-year-old male, COPD, “just a routine visit” and no other complaints; he reports no pain, no bleeding, no sensitivity, and no changes in his oral habits; PMH non-contributory, NKDA, no current medications, no recent dental visits beyond this recall.
O: Extraoral: facial symmetry intact, no cervical or submandibular lymphadenopathy, TMJ normal, no trismus; Intraoral: mucosa pink, no lesions, no caries, no restorations, no missing teeth; Periodontal: probing depths 0–2 mm, no bleeding on probing, PSR 0; Prosthetics: none present; Radiographs: none taken this visit; Tests: none performed.
A: Normal periodontal health, evidenced by PSR 0, absence of caries or restorations, and normal probing depths; no signs of disease or pathology.
P: Full-mouth prophylaxis completed with polishing and fluoride varnish application; oral hygiene instruction reinforced with emphasis on proper brushing technique, interdental cleaning, and smoking cessation benefits for COPD; no anesthesia required; scheduled next recall in 12 months.

55-Year-Old Male, Recurrent Halitosis, Recall

SOAP note

Subjective: 55-year-old male, reports recurrent halitosis, says it has persisted for several months despite brushing twice daily; no pain, no swelling; PMH: takes low-dose aspirin daily; NKDA.
Objective: Extraoral: no swelling, facial symmetry normal; Intraoral: no caries, no restorations; Periodontal: PSR 0; Prosthetics: none; Radiographs: none taken; Tests: none.
Assessment: Halitosis likely due to inadequate oral hygiene, supported by absence of caries, restorations, periodontal disease, and normal intraoral findings.
Plan: Oral hygiene instruction emphasized twice-daily brushing, interdental cleaning, tongue cleaning, and diet modifications; fluoride varnish applied to all teeth; patient advised to maintain current aspirin regimen and to return in 6 months for routine recall.

S: 55-year-old male, reports recurrent halitosis, says it has persisted for several months despite brushing twice daily; no pain, no swelling; PMH: takes low-dose aspirin daily; NKDA.
O: Extraoral: no swelling, facial symmetry normal; Intraoral: no caries, no restorations; Periodontal: PSR 0; Prosthetics: none; Radiographs: none taken; Tests: none.
A: Halitosis likely due to inadequate oral hygiene, supported by absence of caries, restorations, periodontal disease, and normal intraoral findings.
P: Oral hygiene instruction emphasized twice-daily brushing, interdental cleaning, tongue cleaning, and diet modifications; fluoride varnish applied to all teeth; patient advised to maintain current aspirin regimen and to return in 6 months for routine recall.

36-Year-Old Male, Dental Trauma, Emergency Visit

SOAP note

Subjective: 36-year-old male, seasonal allergies, NKDA, reports “I fell on my face and the upper right canine looks cracked.” HPI: trauma to tooth #12, swelling present, no pain.
Objective: Extraoral: swelling of the upper right canine region; Intraoral: fractured crown on tooth #12, no pulpal exposure; Periodontal: PSR 0; Prosthetics: none; Radiographs: none taken.
Assessment: Fractured crown on tooth #12, no pulpal involvement, supported by intact pulp and absence of exposure.
Plan: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), maxillary infiltration, aspiration negative. Performed crown repair with composite resin; instructed patient on gentle brushing, use of a mouthguard during sports, and to return in 2 weeks for follow-up.

S: 36-year-old male, seasonal allergies, NKDA, reports “I fell on my face and the upper right canine looks cracked.” HPI: trauma to tooth #12, swelling present, no pain.
O: Extraoral: swelling of the upper right canine region; Intraoral: fractured crown on tooth #12, no pulpal exposure; Periodontal: PSR 0; Prosthetics: none; Radiographs: none taken.
A: Fractured crown on tooth #12, no pulpal involvement, supported by intact pulp and absence of exposure.
P: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), maxillary infiltration, aspiration negative. Performed crown repair with composite resin; instructed patient on gentle brushing, use of a mouthguard during sports, and to return in 2 weeks for follow-up.

62-Year-Old Female, Medication-Induced Gingival Hyperplasia, Recall

SOAP note

Subjective: 62-year-old female, former smoker, NKDA, reports “I have a bit of gum swelling around my upper left front teeth, but nothing else.” History: medication-induced gingival hyperplasia noted on previous recall; no pain, no bleeding, no systemic symptoms.
Objective: Extraoral: facial symmetry, no lymphadenopathy. Intraoral: diffuse gingival enlargement on teeth #15 and #16, soft, non-ulcerated. Periodontal: PSR 2 on #15 and #16, no BOP, probing depths within normal limits. Prosthetics: none.
Assessment: Medication-induced gingival hyperplasia stage I, supported by diffuse gingival enlargement on #15-#16 and PSR 2 findings.
Plan: Reviewed current medications with patient; performed scaling of #15 and #16; instructed on gentle brushing and interdental cleaning, advised to maintain oral hygiene and report any increase in swelling; no anesthesia used. Follow-up recall in 3 months.

S: 62-year-old female, former smoker, NKDA, reports “I have a bit of gum swelling around my upper left front teeth, but nothing else.” History: medication-induced gingival hyperplasia noted on previous recall; no pain, no bleeding, no systemic symptoms.
O: Extraoral: facial symmetry, no lymphadenopathy. Intraoral: diffuse gingival enlargement on teeth #15 and #16, soft, non-ulcerated. Periodontal: PSR 2 on #15 and #16, no BOP, probing depths within normal limits. Prosthetics: none.
A: Medication-induced gingival hyperplasia stage I, supported by diffuse gingival enlargement on #15-#16 and PSR 2 findings.
P: Reviewed current medications with patient; performed scaling of #15 and #16; instructed on gentle brushing and interdental cleaning, advised to maintain oral hygiene and report any increase in swelling; no anesthesia used. Follow-up recall in 3 months.

29-Year-Old Male, First-Time Implant Placement, New Patient

SOAP note

Subjective: 29-year-old male, asthma on albuterol, NKDA, presents for first-time implant placement; “I need a replacement for the missing tooth.” No medical or dental complaints beyond the missing tooth.
Objective: Extraoral examination shows no swelling or asymmetry. Intraoral exam reveals missing tooth #30, bone sufficient for implant; periodontal screening shows PSR 0, no probing depths or BOP. No prosthetics present.
Assessment: Indication for implant placement supported by missing tooth #30 with adequate bone and healthy periodontal status (PSR 0).
Plan: Discussed implant placement plan, risks, benefits, and alternatives; obtained verbal consent. No anesthesia used today. Provided oral hygiene instruction focusing on peri-implant care and scheduled implant placement appointment in 4 weeks.

S: 29-year-old male, asthma on albuterol, NKDA, presents for first-time implant placement; “I need a replacement for the missing tooth.” No medical or dental complaints beyond the missing tooth.
O: Extraoral examination shows no swelling or asymmetry. Intraoral exam reveals missing tooth #30, bone sufficient for implant; periodontal screening shows PSR 0, no probing depths or BOP. No prosthetics present.
A: Indication for implant placement supported by missing tooth #30 with adequate bone and healthy periodontal status (PSR 0).
P: Discussed implant placement plan, risks, benefits, and alternatives; obtained verbal consent. No anesthesia used today. Provided oral hygiene instruction focusing on peri-implant care and scheduled implant placement appointment in 4 weeks.

Definition and Scope of a Periodic Oral Evaluation SOAP Note

A periodic oral evaluation is a routine recall exam for an established patient, focused on updating history, re-examining, screening for caries and periodontal disease, and providing preventive instructions. The exam is shorter than a comprehensive exam, which includes a full charting and extensive radiographs, and it differs from a limited exam that targets a single problem. Key components:

History update: chief complaint, HPI, medical and dental history, allergies, medications.
Re-examination: extraoral and intraoral findings, plaque index, BOP, periodontal screening (PSR).
Preventive instructions: oral hygiene reinforcement, fluoride recommendations, dietary counseling.
Radiographic protocol: bitewing or periapical films as indicated by caries risk.

These elements form the backbone of the SOAP structure that follows.

Full SOAP Structure and Customization for Variations

Subjective

Record the patient’s chief complaint verbatim, followed by a concise history of present illness that notes onset, character, duration, aggravating and relieving factors, and any numeric pain rating. Update medical and dental history, allergies, current medications, tobacco and alcohol use, and pregnancy status. Mandatory elements: CC, HPI, PMH, allergies, medications. Example:

SOAP note

Subjective: 45-year-old female, “no pain,” NKDA, PMH: HTN on lisinopril.

S: 45-year-old female, “no pain,” NKDA, PMH: HTN on lisinopril.

Objective

Document extraoral findings, intraoral examination, plaque index, bleeding on probing (BOP), periodontal screening code (PSR), and any carious lesions or restorations. Include vital signs if indicated and note radiographic findings with type and indication. Mandatory elements: extraoral, intraoral, plaque/BOP/PSR, radiographs. Example:

SOAP note

Objective: Extraoral WNL. Intraoral: plaque 2/5, BOP 0%. PSR 1. No caries. BP 128/78.

O: Extraoral WNL. Intraoral: plaque 2/5, BOP 0%. PSR 1. No caries. BP 128/78.

Assessment

State the clinical impression or diagnosis derived from subjective and objective data. Use standardized terminology (e.g., “periodic recall, low caries risk”) and note any changes from the previous visit. Mandatory element: a clear, concise assessment. Example:

SOAP note

Assessment: Periodic recall, low caries risk.

A: Periodic recall, low caries risk.

Plan

Outline instructions given, preventive measures, any prescriptions, referrals, and the next recall date. Include oral hygiene reinforcement, fluoride recommendations, and any follow-up imaging if warranted. Mandatory element: next recall date and purpose. Example:

SOAP note

Plan: Reinforce oral hygiene, fluoride toothpaste, next recall in 12 months.

P: Reinforce oral hygiene, fluoride toothpaste, next recall in 12 months.

Orthodontic Recall

Add a section on appliance integrity, bracket/retainer fit, and any occlusal adjustments. Record patient-reported comfort or appliance issues. Include a brief periodontal assessment around brackets and a note on orthodontic-specific prophylaxis. Example:

SOAP note

Objective: Retainer intact, no mucosal irritation. PSR 0 around brackets.

O: Retainer intact, no mucosal irritation. PSR 0 around brackets.

Implant Maintenance

Include implant site evaluation: probing depths, bleeding, mobility, peri-implant mucosa color, and any radiographic assessment of bone levels. Document cleaning protocol and any adjunctive therapy (laser, ultrasound). Example:

SOAP note

Objective: Implant #35, PD 3 mm, no BOP, radiograph shows stable bone.

O: Implant #35, PD 3 mm, no BOP, radiograph shows stable bone.

Special-Needs Patient

Document functional status, communication aids, and any medical or behavioral considerations that influence care. Note adaptations used (e.g., modified instruments, sedation level). Include a brief safety plan for emergencies and any caregiver instructions. Example:

SOAP note

Objective: Patient uses wheelchair, requires verbal cues, sedation planned for anxiety.

O: Patient uses wheelchair, requires verbal cues, sedation planned for anxiety.

Checklist of Mandatory Documentation Items

Patient demographics: name, age, gender, DOB, contact information
Chief complaint (CC) in patient’s words
History of present illness (HPI) with onset, duration, character, and numeric pain rating if applicable
Updated past medical history (PMH) with current medications, anticoagulants, bisphosphonates, etc.
Allergies and reaction details (e.g., latex)
Tobacco, alcohol, and pregnancy status
Extraoral examination: facial symmetry, lymph nodes, TMJ function, lip and skin findings
Intraoral soft-tissue examination: lips, buccal/labial mucosa, tongue, floor of mouth, hard/soft palate, oral cancer screening
Hard-tissue findings: existing restorations, caries (tooth and surface), fractures, missing teeth
Periodontal screening: plaque index, bleeding on probing (BOP), periodontal screening code (PSR)
Vital signs if indicated (BP, pulse, temperature)
Radiographic findings: type (PA, BWX, PAN), indication, and key observations
Caries risk assessment (low, moderate, high)
Preventive instructions given (oral hygiene reinforcement, fluoride recommendations, diet counseling)
Treatment performed during the visit (e.g., prophylaxis, polishing, extractions)
Post-operative instructions (POI) provided verbally or in writing
Prescriptions written (medication name, dose, frequency, duration)
Referrals made (specialist, laboratory)
Next recall date and purpose (RTC)

Common Pitfalls and How to Avoid Them

Vague subjective statements – write the chief complaint in the patient’s exact words and follow with a concise history of present illness that notes onset, character, duration, and any numeric pain rating.
Missing objective measurements – always include plaque index, bleeding on probing, and periodontal screening code (PSR); if a finding is normal, state “WNL” or “no BOP.”
No documentation of patient instructions – record every preventive instruction given, e.g., “reinforce oral hygiene, fluoride toothpaste, next recall in 12 months.”
Incomplete risk assessment – state the caries risk level (low, moderate, high) explicitly in the assessment or plan.
Failure to record radiographs – note the type, indication, and key findings; if no radiograph was taken, record the patient’s refusal or the clinical reason for omission.

Radiographic Protocol for Routine Check-Ups

Radiographs for a routine periodic oral evaluation follow a risk-based approach. For a low-risk adult with no new complaints, a single bitewing series (BWX) covering the posterior quadrants is sufficient; periapical (PA) films are added only if a restoration, fracture, or suspected pathology is noted. In patients with moderate to high caries risk—history of decay, poor oral hygiene, or recent orthodontic treatment—full-mouth PA series or a CBCT of the region of interest may be justified, documenting bone levels or impacted teeth. Findings are recorded as “BWX: no caries, PA: intact” or “CBCT: no pathology, bone loss 1 mm.” Radiographs may be omitted when the clinical exam is normal, the patient declines, or prior recent imaging provides adequate information; note the reason for deferral.

Caries Risk Assessment and Preventive Instructions

Caries risk assessment begins with a structured history: smoking, diet, fluoride exposure, salivary flow, previous caries, and oral hygiene habits. Observe plaque index, BOP, and any untreated cavities. Classify risk:

Low – good hygiene, no recent decay, regular fluoride use.
Moderate – occasional plaque, recent restorations, or dietary sugars.
High – poor hygiene, frequent sugary snacks, xerostomia, or multiple untreated lesions.

Document the category in the Assessment and tailor preventive instructions:

Low risk
- Reinforce daily brushing with fluoride toothpaste.
- Use interdental brushes or floss daily.
- Schedule next recall in 12 months; no radiographs unless indicated.
Moderate risk
- Recommend 0.12 % chlorhexidine rinse twice daily for 30 s.
- Discuss fluoride varnish at each visit.
- Consider bitewing radiographs; schedule next recall in 6 months.
High risk
- Apply fluoride varnish or sealants at each visit.
- Provide a 5 % sodium fluoride rinse 4 × daily.
- Order full-mouth bitewing series; schedule next recall in 3 months.

Record each instruction verbatim under Plan, noting patient acceptance or refusal.

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

About the author

Dr. Rahul Joshi

Specialist Orthodontist

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

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

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Periodic Oral Evaluation SOAP Note: Complete Ready-to-Copy Examples

Routine Baseline Check-ups

30-Year-Old Male, No Complaints, First Recall

28-Year-Old Male, Routine Checkup, No Radiographs

48-Year-Old Male, Orthodontic Retainer Check

27-Year-Old Female, New Tooth, Routine Checkup

60-Year-Old Male, Orthodontic Retainer, Routine Checkup

58-Year-Old Female, Chronic Pain, Routine Exam

30-Year-Old Male, Latex Allergy, Routine Exam

48-Year-Old Female, Post-Extraction Healing, Follow-up

45-Year-Old Female, Mild Periodontitis, Second Recall

60-Year-Old Male, New Crown, Annual Checkup

25-Year-Old Pregnant Female, Routine Checkup

50-Year-Old Smoker, No Symptoms, Recall

70-Year-Old Male, Edentulous, Prosthesis Check

35-Year-Old Female, New Filling, Recall

42-Year-Old Female, Periodontal Screening, Recall

55-Year-Old Male, Low Caries Risk, Routine Exam

38-Year-Old Female, High Caries Risk, Recall

62-Year-Old Female, Implant Maintenance, Recall

30-Year-Old Male, Allergy to Penicillin, Recall

52-Year-Old Male, Chronic Pain, Recall

40-Year-Old Female, Dental Anxiety, Recall

65-Year-Old Male, Medication-Induced Dry Mouth, Recall

32-Year-Old Male, Smoking Cessation, Routine Exam

50-Year-Old Female, Diabetes, Recall

29-Year-Old Male, Allergic to Latex, Routine Checkup

57-Year-Old Female, Medically Complex, Recall

45-Year-Old Male, Low Risk, Routine Exam

31-Year-Old Female, Pregnancy, Recall

26-Year-Old Female, New Crown, Recall

43-Year-Old Male, Periodontal Disease, Recall

54-Year-Old Female, Low Caries Risk, Routine Exam

39-Year-Old Male, High Caries Risk, Recall

47-Year-Old Female, Implant, Routine Checkup

34-Year-Old Male, Allergy to Aspirin, Recall

41-Year-Old Male, Smoking, Routine Checkup

63-Year-Old Male, COPD, Recall

55-Year-Old Male, Recurrent Halitosis, Recall

36-Year-Old Male, Dental Trauma, Emergency Visit

62-Year-Old Female, Medication-Induced Gingival Hyperplasia, Recall

29-Year-Old Male, First-Time Implant Placement, New Patient

Definition and Scope of a Periodic Oral Evaluation SOAP Note

Full SOAP Structure and Customization for Variations

Subjective

Objective

Assessment

Plan

Orthodontic Recall

Implant Maintenance

Special-Needs Patient

Checklist of Mandatory Documentation Items

Common Pitfalls and How to Avoid Them

Radiographic Protocol for Routine Check-Ups

Caries Risk Assessment and Preventive Instructions

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More Dental SOAP Notes

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

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

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