Dental Hygiene Recall SOAP Note: Ready-to-Copy Examples & Customization Guide
Dental hygiene recall SOAP notes are ready-to-copy templates for routine recalls and no-complaint visits. Each note …
A fully populated, copy-ready SOAP note for periodontal maintenance visits is available here. It contains every essential element: patient demographics, objective periodontal findings, assessment, plan, follow-up, and documented patient education. Designed for hygienists and assistants, the template saves time while ensuring comprehensive, defensible documentation for each maintenance appointment.
Routine Maintenance Visits
Non-smoker, 55-year-old, 3-month maintenance visit
- Subjective
- 55-year-old male, smoker 5 cigarettes/day, presents for routine cleaning; says “Here for my cleaning.” No medical complaints; NKDA.
- Objective
- Probing depth 3 mm at all sites; BOP 5 %; plaque score 20 %; no calculus, suppuration, mobility, or furcation involvement.
- Assessment
- Stage I periodontitis, Grade A, supported by uniform 3 mm PD, low BOP, and plaque score.
- Plan
- Full-mouth prophylaxis performed with ultrasonic scaler and curettes; oral hygiene instruction reinforced; fluoride varnish 5 % sodium fluoride applied to all teeth. No anesthesia or medications used. Next maintenance visit scheduled in 3 months.
Maintenance, 40-year-old, 3-month visit, no changes
- Subjective
- 40-year-old female with type 2 diabetes on metformin, NKDA, presents for a routine periodontal maintenance visit and states “just a routine checkup.”
- Objective
- Extraoral examination is unremarkable. Intraoral probing shows uniform 3 mm depth at all sites, BOP at 4 % of sites, and a plaque score of 15 %. No calculus, no suppuration, no tooth mobility, and no furcation involvement are noted. Radiographs are not indicated at this visit.
- Assessment
- Stage I periodontitis, Grade A, is confirmed by the stable probing depths, low BOP, and good plaque control.
- Plan
- Full-mouth prophylaxis performed with ultrasonic scaler and hand curettes; no scaling required. Oral hygiene instruction reinforced, emphasizing proper brushing, interdental cleaning, and the importance of maintaining glycemic control for periodontal health. No medications prescribed. Patient advised to return for the next maintenance visit in 3 months.
Maintenance, 38-year-old, 3-month visit, improved plaque
- Subjective
- 38-year-old male, controlled hypertension on lisinopril, NKDA, reports “My plaque has gone down.”
- Objective
- Probing depth 3 mm at all sites, BOP 2 % of sites, plaque score 10 %, no calculus, no suppuration, no mobility, no furcation involvement.
- Assessment
- Stage I periodontitis, Grade A, supported by uniform 3 mm pockets, minimal BOP, low plaque score and absence of attachment loss.
- Plan
- Full-mouth prophylaxis performed with ultrasonic scaler and curettes; fluoride varnish 5 % sodium fluoride applied; oral hygiene instruction reinforced; next visit in 3 months for routine maintenance.
Maintenance, 40-year-old, 3-month visit, no plaque
- Subjective
- 40-year-old female, “I’m here for my cleaning.” No significant medical history, allergic to penicillin (rash).
- Objective
- Probing depth 3 mm at all sites, BOP 0 %, plaque score 5 %, no calculus, no suppuration, no mobility, no furcation involvement.
- Assessment
- Stage I periodontitis, Grade A, supported by uniform 3 mm PD, 0 % BOP, low plaque score and absence of attachment loss.
- Plan
- Full-mouth prophylaxis with ultrasonic scaler and curettes performed; oral hygiene instruction reinforced; 5 % sodium fluoride varnish applied; no medications prescribed; next maintenance visit scheduled in 3 months.
Maintenance with Medical Conditions
Smoker, 48-year-old, 6-month maintenance visit
- Subjective
- 48-year-old male, smoker 5 cigarettes/day, asthma on albuterol PRN, NKDA, chief complaint: “Here for my routine cleaning and check-up.” HPI: no pain, no bleeding, routine maintenance.
- Objective
- Extraoral: normal. Intraoral: plaque score 18%; PD 3 mm on all teeth; BOP 12% of sites; CAL 3 mm all teeth; no suppuration, mobility, or furcation involvement. Radiographs: none taken this visit.
- Assessment
- Stage I periodontitis, Grade C (smoking modifier) supported by uniform 3 mm PD, 12% BOP, and 18% plaque score.
- Plan
- Prophylaxis performed: full-mouth scaling and polishing, fluoride varnish 5 % sodium fluoride applied to all teeth, oral hygiene instruction reinforced, tobacco cessation counseling provided. No anesthesia used. Advised to maintain twice-daily brushing, interdental cleaning, and to return in 6 months for next maintenance visit.
Pregnant, 32-year-old, 3-month maintenance visit
- Subjective
- 32-year-old pregnant female, first trimester, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “Just a routine cleaning”; medical history: hypothyroidism, no other systemic signs; medications: levothyroxine; allergies: penicillin; no other drug allergies.
- Objective
- Extraoral: normal; intraoral: plaque score 15%; periodontal chart: PD 3 mm, BOP 10% of sites, CAL 3 mm, no suppuration, no mobility, no furcation involvement; radiographs: none taken; tests: none.
- Assessment
- Stage I periodontitis, Grade A, supported by PD 3 mm, BOP 10%, CAL 3 mm, plaque 15%, no attachment loss beyond mild.
- Plan
- Prophylaxis performed: scaling and polishing, oral hygiene instruction, review of pregnancy-safe oral care products, fluoride varnish 5% sodium fluoride applied to all teeth; no drugs prescribed; next visit scheduled in 3 months for maintenance.
Diabetic, 60-year-old, 4-month maintenance visit
- Subjective
- 60-year-old female with type 2 diabetes on metformin and low-dose aspirin, NKDA, reports “Cleaning today.”
- Objective
- Extraoral normal. Intraoral: plaque score 20%; probing depth 4 mm on 12 teeth, BOP 18 % of sites, CAL 4 mm on those teeth; no suppuration, mobility, or furcation involvement. Radiographs not taken.
- Assessment
- Stage II periodontitis, Grade C (HbA1c ≥ 7.0 % modifier) supported by PD 4 mm, BOP 18 %, CAL 4 mm on 12 teeth.
- Plan
- Full-mouth scaling and polishing performed; fluoride varnish 5 % sodium fluoride applied to all teeth; oral hygiene instruction reinforced; patient advised to maintain glycemic control; next maintenance visit scheduled in 4 months.
Maintenance, 35-year-old, 3-month visit, smoking
- Subjective
- 35-year-old male, smoker 5 cigarettes/day, seasonal allergies, NKDA; CC: “Cleaning”; HPI: routine 3-month periodontal maintenance; PMH: none; Meds: none; Allergies: NKDA.
- Objective
- Extraoral: normal; Intraoral: plaque score 17%; Periodontal chart: PD 3 mm, BOP 12 % of sites, CAL 3 mm, no suppuration, no mobility, no furcation involvement; Radiographs: none taken; Tests: none.
- Assessment
- Stage I periodontitis, Grade C (smoking modifier) supported by PD 3 mm, BOP 12 %, CAL 3 mm and smoking history.
- Plan
- Prophylaxis performed: scaling and polishing, fluoride varnish 5 % sodium fluoride applied to all teeth; oral hygiene instruction given; tobacco cessation counseling offered; no anesthesia; POI: maintain oral hygiene, avoid smoking; next visit: 3 months for maintenance.
Maintenance, 45-year-old, 3-month visit, smoking cessation
- Subjective
- 45-year-old male, smokes ~5 cigarettes/day, NKDA, presents for routine cleaning; reports “cleaning” only.
- Objective
- Extraoral normal. Intraoral: plaque score 15%, PD 3 mm, BOP 10% of sites, CAL 3 mm, no suppuration, no mobility, no furcation involvement.
- Assessment
- Stage I periodontitis, Grade C (smoking modifier) supported by PD ≤3 mm, BOP 10%, CAL 3 mm, no attachment loss beyond mild.
- Plan
- Prophylaxis performed: scaling, polishing, fluoride varnish 5 % sodium fluoride applied to all teeth; brief tobacco cessation counseling given; no anesthesia or medication prescribed. Next visit scheduled in 3 months for maintenance.
Maintenance, 60-year-old, 3-month visit, diabetes management
- Subjective
- 60-year-old male with type 2 diabetes on metformin, former smoker, NKDA, reports “Cleaning.” HPI: routine periodontal maintenance, no pain or bleeding complaints. Medical history: controlled diabetes, no systemic signs, no medication changes.
- Objective
- Extraoral: normal. Intraoral: plaque score 18%; probing depths 4 mm on 10 teeth, bleeding on probing 15% of sites, CAL 4 mm on those teeth, no suppuration, no mobility, no furcation involvement. Radiographs: none taken this visit.
- Assessment
- Stage II periodontitis, Grade C (HbA1c ≥7.0% modifier) supported by PD ≥4 mm, BOP 15%, CAL 4 mm on multiple teeth.
- Plan
- Prophylaxis performed with scaling and polishing; fluoride varnish 5% sodium fluoride applied to all teeth. Oral hygiene instruction emphasized glycemic control and daily brushing/flossing; patient advised to monitor blood glucose and schedule next maintenance in 3 months.
Maintenance, 47-year-old, 3-month visit, localized recession
- Subjective
- 47-year-old male, NKDA, presents for routine cleaning; says “Here for my cleaning.” No medical issues reported.
- Objective
- Extraoral normal. Intraoral: tooth #14 shows PD 3 mm mesial and distal, BOP 0%; buccal recession 1 mm, CAL 4 mm; plaque score 15%; no suppuration, mobility, or furcation involvement. Radiograph not taken.
- Assessment
- Stage I periodontitis, Grade A; supported by probing depths ≤3 mm, minimal recession, and low plaque index.
- Plan
- Scaling of supragingival plaque on #14, polishing, and OHI reinforcement performed. No local anesthesia used. Patient advised to maintain twice-daily brushing and interdental cleaning; next maintenance visit in 3 months.
Maintenance, 58-year-old, 3-month visit, medication change
- Subjective
- 58-year-old female, type 2 diabetes on metformin, NKDA, comes for routine cleaning and gum check; says “Cleaning and check for my gums.”
- Objective
- Extraoral normal. Intraoral: plaque score 20%; tooth #30 mesial PD 4 mm, distal 3 mm, BOP 10%; buccal recession 2 mm, CAL 6 mm; no suppuration, no mobility, no furcation involvement. Radiographs not taken this visit.
- Assessment
- Stage II periodontitis, Grade C (HbA1c ≥ 7.0 % modifier) – supported by PD ≥ 3 mm, BOP, CAL, and diabetes status.
- Plan
- Scaling of subgingival deposits at #30 mesial, polishing, OHI, advised to monitor glucose control; no drugs prescribed. Next maintenance visit in 3 months.
Maintenance, 57-year-old, 3-month visit, medication-induced gingival overgrowth
- Subjective
- 57-year-old female, controlled hypertension on lisinopril, NKDA, CC: “Just a routine cleaning.” HPI: no pain, no swelling, routine maintenance visit.
- Objective
- extraoral normal. Intraoral: tooth #3 mesial and distal PD 3 mm, BOP 5 %; buccal recession 1 mm, CAL 4 mm; plaque score 12 %; no suppuration, mobility, or furcation. Radiograph not taken.
- Assessment
- Stage I periodontitis, Grade A; findings support mild attachment loss with minimal inflammation.
- Plan
- Scaling of supragingival plaque on #3, polishing, OHI given; no anesthesia or drugs. Advised to maintain daily brushing and interdental cleaning; next maintenance in 3 months.
Maintenance, 52-year-old, 3-month visit, periodontal ligament hyperplasia
- Subjective
- 52-year-old male, “Cleaning and check for gum health.” No significant medical history; allergic to penicillin (rash).
- Objective
- Extraoral WNL. Intraoral: tooth #27 mesial PD 4 mm, distal 3 mm, BOP 15 %. Recession 2 mm buccal, CAL 6 mm buccal, plaque score 18 %. No suppuration, no mobility, no furcation.
- Assessment
- Stage II periodontitis, Grade C, supported by PD ≥ 3 mm, BOP > 10 %, CAL 6 mm, and plaque ≥ 15 %.
- Plan
- Scaling of subgingival deposits at #27 mesial, polishing, oral hygiene instruction. No antibiotics or anesthesia. Advised to maintain plaque control, re-visit in 3 months for maintenance.
Maintenance, 59-year-old, 3-month visit, chronic gingival bleeding after anticoagulant therapy
- Subjective
- 59-year-old male, chief complaint: “Cleaning and check my gums.” History: asthma, albuterol PRN, NKDA. HPI: reports regular bleeding from gums during brushing; denies pain or swelling.
- Objective
- Extraoral normal. Intraoral: tooth #19, PD 3 mm mesial and distal, BOP 20 %; buccal recession 1 mm, CAL 4 mm; plaque score 22 %; no suppuration, no mobility, no furcation involvement.
- Assessment
- Stage I periodontitis, Grade C (smoking modifier) supported by PD ≤3 mm, BOP 20 %, CAL 4 mm, and smoking history.
- Plan
- Prophylaxis performed—scaling of supragingival plaque on #19, polishing, and OHI. No anesthesia used. Discussed smoking cessation; patient agreed to quit. Next visit in 3 months for routine maintenance.
Maintenance, 43-year-old, 3-month visit, medication-induced gingival overgrowth after calcium channel blocker
- Subjective
- 43-year-old male, chief complaint: “Cleaning and check my gums.” He reports routine maintenance; no pain or swelling. Medical history: hypothyroidism on levothyroxine. O: Extraoral normal. Intraoral: tooth #11 mesial PD 4 mm, distal 3 mm, BOP 25 %. Recession 2 mm buccal, CAL 6 mm buccal, plaque score 25 %. No suppuration, no mobility, no furcation involvement. A: Stage II periodontitis, Grade C (smoking modifier); moderate pocket depths, significant BOP, and buccal recession support the diagnosis. P: Scaling of subgingival deposits at #11 mesial, polishing, and oral-hygiene instruction performed. Discussed smoking cessation and its impact on periodontal health. Next maintenance visit scheduled in 3 months.
Post-SRP / Re-evaluation Visits
Post-SRP, 30-year-old, 2-month re-evaluation visit
- Subjective
- 30-year-old male, takes daily low-dose aspirin, NKDA, reports “Here for my follow-up after the cleaning.”
- Objective
- PD 3 mm at tooth #30, BOP 0 %; plaque score 12 %; no suppuration; periapical radiograph shows no new bone loss.
- Assessment
- Stage I periodontitis, Grade A, supported by probing depths ≤3 mm, absence of bleeding, and stable radiographic findings.
- Plan
- Re-evaluation performed; no active therapy required. Advised to continue routine maintenance every 3 months, maintain oral hygiene, and report any new bleeding or discomfort. No medications prescribed. Next visit scheduled for 3-month maintenance.
Post-SRP, 45-year-old, 8-week re-evaluation visit
- Subjective
- 45-year-old male, seasonal allergies, NKDA, reports “Just checking in after my SRP.” He notes no pain or swelling and is compliant with home care.
- Objective
- Extraoral normal. Intraoral: PD 4 mm at tooth #3, 3 mm at #14; BOP 10%; plaque score 18%; no suppuration. Radiograph shows slight bone loss at #3; no other findings.
- Assessment
- Stage II periodontitis, Grade A, supported by PDs ≥3 mm, BOP, plaque, and radiographic bone loss at #3.
- Plan
- No anesthesia or drugs used. Reinforced oral hygiene instruction; scheduled periodontal maintenance in 3 months. No additional SRP indicated at this time.
Gross debridement, 70-year-old, 1-month follow-up visit
- Subjective
- 70-year-old male, smoker 5 cigarettes/day, NKDA, reports “I still have a lot of plaque buildup.”
- Objective
- Plaque score 35 %; BOP 25 %; PD 5 mm at #17, 4 mm at #18, 3 mm elsewhere; generalized bone loss on radiograph, no acute changes; no anesthesia used.
- Assessment
- Stage III periodontitis, Grade C (smoking modifier), supported by PD ≥5 mm, BOP 25 %, and generalized bone loss.
- Plan
- Full-mouth debridement performed; no drugs prescribed. Counselled on smoking cessation, reinforced OHI. Plan SRP in 4 weeks; next visit in 1 month for reassessment.
Maintenance, 55-year-old, 3-month visit, increased BOP
- Subjective
- 55-year-old female, former smoker, NKDA; CC: “My gums bleed more lately”; HPI: reports increased bleeding during brushing over past month; PMH: none; medications: none; allergies: NKDA.
- Objective
- Extraoral: normal; Intraoral: PD 4 mm at #27, BOP 30 % of sites, plaque score 20 %; Radiograph: stable bone levels, no suppuration noted; no adjunctive tests performed.
- Assessment
- Stage II periodontitis, Grade A, with increased BOP indicating active inflammation but no deep pockets or bone loss.
- Plan
- Re-evaluation performed; advised intensified plaque control with home-care instruction; no SRP indicated; next maintenance visit scheduled in 3 months; no drugs prescribed; anesthesia not required.
Maintenance, 50-year-old, 3-month visit, localized deep pocket
- Subjective
- 50-year-old female patient, NKDA, presents with chief complaint “I feel a deep pocket around my tooth.” She reports no pain, no systemic symptoms, and has no significant medical history; she is otherwise healthy and compliant with her routine dental care.
- Objective
- Extraoral exam is unremarkable. Intraoral findings reveal a localized deep pocket at tooth #19 with a probing depth of 6 mm, bleeding on probing of 20 %, and a plaque score of 15 %. Suppuration is noted at the margin of #19. Radiographic assessment shows localized bone loss at #19, with no other radiographic abnormalities.
- Assessment
- Diagnosis is Stage II periodontitis, Grade A, based on the 6 mm pocket depth, significant BOP, presence of suppuration, and localized radiographic bone loss at tooth #19.
- Plan
- Scaling and root planing was performed on tooth #19 with no local anesthesia. Post-procedure oral hygiene instruction was reinforced, emphasizing interdental cleaning and proper brushing technique. No medications were prescribed. The patient is scheduled for a re-evaluation in 4 weeks to assess pocket depth reduction and healing.
Maintenance, 60-year-old, 3-month visit, heavy plaque
- Subjective
- 60-year-old male, type 2 diabetes on metformin, NKDA, reports “teeth feel dirty and I have a bad taste.” HPI: heavy plaque accumulation, no pain or bleeding complaints. PMH: diabetes, no other systemic disease.
- Objective
- Plaque score 40 %; BOP 35 %; PD 4 mm at tooth #12, 3 mm elsewhere; radiograph shows moderate bone loss, no acute changes; extraoral and intraoral exams within normal limits.
- Assessment
- Stage II periodontitis, Grade C (HbA1c ≥ 7.0 %) supported by 40 % plaque, 35 % BOP, 4 mm pocket at #12 and moderate bone loss.
- Plan
- Full-mouth debridement performed; no anesthesia used. Discussed importance of glycemic control and oral hygiene; instructed to maintain regular flossing. Next maintenance scheduled in 3 months.
Maintenance, 55-year-old, 3-month visit, periodontal abscess
- Subjective
- 55-year-old male, controlled hypertension on lisinopril, NKDA, CC: “I have a painful swelling near my molar.” HPI: swelling noted 3 days ago, throbbing, no fever, denies trismus.
- Objective
- Extraoral: buccal mucosa swelling adjacent to #30. Intraoral: #30, PD 7 mm, BOP 40 %, suppuration, no mobility. Periodontal chart: Stage II periodontitis, Grade A. Radiograph: localized bone loss, no sinus tract. Temperature 98.6 °F.
- Assessment
- Acute apical abscess on #30, Stage II periodontitis, Grade A; supported by 7 mm pocket, suppuration, BOP 40 %, localized bone loss.
- Plan
- Incision and drainage of abscess at #30, SRP performed on #30, no anesthesia used. POI: apply warm compress, maintain oral hygiene, avoid hard foods for 24 h, report increased pain or fever. Next visit: 4-week re-evaluation to assess healing and pocket depth.
Maintenance, 48-year-old, 3-month visit, deep pocket in molar
- Subjective
- 48-year-old male, no significant medical history, allergic to penicillin (rash), presents for routine check-up and cleaning; reports no pain or discomfort.
- Objective
- Extraoral normal. Intraoral: PD 4 mm mesial, 5 mm distal, 4 mm buccal, 4 mm lingual, 4 mm mesiolingual, 4 mm distolingual at tooth #30; BOP 20 % of sites at #30; CAL 5 mm distal; plaque score 35 %; radiograph shows mild bone loss around #30, no furcation; no suppuration, no mobility.
- Assessment
- Stage II periodontitis, Grade A, based on probing depths ≥5 mm, CAL 5 mm, bone loss, and BOP >20 %.
- Plan
- Scaling and root planing of #30 performed with ultrasonic scalers and hand curettes; polishing completed; fluoride varnish 5 % sodium fluoride applied to all teeth; oral hygiene instruction reinforced; no medications prescribed; next maintenance visit scheduled in 3 months.
Maintenance, 62-year-old, 3-month visit, periodontal disease progression
- Subjective
- 62-year-old female, asthma, NKDA, reports soreness around molars; no systemic symptoms; history of periodontal maintenance.
- Objective
- Extraoral normal. Intraoral: tooth #14 shows PD 6 mm mesial, 5 mm distal, buccal, lingual, mesiolingual, distolingual; BOP 30 % of sites; CAL 7 mm mesial; plaque score 40 %; radiograph: moderate bone loss at #14, slight furcation Grade I; no suppuration; mobility Miller I.
- Assessment
- Stage III periodontitis, Grade C, based on deep pockets, CAL, bone loss, and furcation involvement.
- Plan
- Deep scaling and root planing of #14 performed with ultrasonic scalers and hand curettes for furcation; oral hygiene instruction reinforced; chlorhexidine 0.12 % rinse 15 mL 30 sec twice daily prescribed; no drugs; next visit in 3 months for reassessment of pocket depths and BOP.
Maintenance, 63-year-old, 3-month visit, post-surgical healing
- Subjective
- 63-year-old female, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “My gums still feel a little tender”; HPI: post-surgical healing after SRP, reports mild tenderness; PMH: hypothyroidism, no other systemic signs.
- Objective
- Full mouth prophylaxis performed; plaque score 30%; PD 4 mm at all sites on tooth #27, BOP 15% of sites at #27, CAL 4 mm at all sites; no suppuration, mobility, or furcation involvement; slight bone loss on radiograph; no radiographic furcation.
- Assessment
- Stage I periodontitis, Grade A, based on PD ≤4 mm, BOP 15%, CAL 4 mm, and slight bone loss.
- Plan
- No anesthesia used; polishing and full-mouth prophylaxis completed; fluoride varnish 5 % sodium fluoride applied to all teeth; oral hygiene instruction reinforced; next visit in 3 months for maintenance and reassessment of pocket depths.
Maintenance, 37-year-old, 3-month visit, early onset periodontitis with rapid progression
- Subjective
- 37-year-old female, chief complaint: “My front teeth look a bit uneven.” She reports no pain; takes daily low-dose aspirin; NKDA.
- Objective
- Extraoral normal. Intraoral: tooth #7 shows PD 5 mm at all six sites; BOP 25 % of sites; CAL 6 mm mesial and distal; plaque score 45 %; mild bone loss on radiograph; no furcation involvement; mobility Miller I.
- Assessment
- Stage II periodontitis, Grade B, based on PD ≥5 mm, CAL ≥6 mm, 25 % BOP, and radiographic bone loss.
- Plan
- Scaling and root planing of #7 performed with ultrasonic scalers and hand curettes; oral hygiene instruction given; chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily prescribed; no medication; next maintenance visit in 3 months to reassess pocket depths and BOP.
Maintenance, 70-year-old, 3-month visit, post-surgical flap healing with residual pockets
- Subjective
- 70-year-old male, seasonal allergies, NKDA, complains “my molars feel a bit loose”; reports mild discomfort after recent SRP; no systemic symptoms.
- Objective
- Extraoral normal. Intraoral: #19 PD 6 mm all sites, BOP 35% of sites, CAL 8 mm mesial/distal, plaque 50%; radiograph shows moderate bone loss, furcation Grade I; suppuration at mesial site; mobility Miller 2, furcation Grade I.
- Assessment
- Stage III periodontitis, Grade C, with residual pockets and furcation involvement.
- Plan
- Completed deep scaling and root planing of #19 with hand curettes for furcation; prescribed chlorhexidine 0.12% rinse 15 mL 30 sec twice daily; reinforced oral hygiene instruction; scheduled flap surgery in 4 weeks; no medications prescribed.
Maintenance, 60-year-old, 3-month visit, peri-implantitis with suppuration
- Subjective
- 60-year-old female, smoker 5 cigarettes/day, NKDA, CC: “My implant site still has some swelling”; HPI: swelling noted for 3 months, no pain, no systemic symptoms.
- Objective
- Implant #3 probing depths 5 mm at all six sites, BOP 30% of sites, CAL 5 mm, plaque score 40%; radiograph shows 1.5 mm peri-implant bone loss, no radiolucency; suppuration at mesial site; no mobility or furcation involvement.
- Assessment
- Peri-implantitis, Stage II, Grade C, supported by uniform 5 mm pockets, BOP, plaque, bone loss and suppuration.
- Plan
- Scaling of implant surface with plastic curette performed; chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily prescribed; oral hygiene instruction reinforced; next implant maintenance visit scheduled in 4 weeks.
Implant Maintenance
Maintenance, 70-year-old, 3-month visit, implant maintenance
- Subjective
- 70-year-old male, former smoker, NKDA, presents for routine implant check-up, stating “Here for my routine implant check-up.” No medical complaints or systemic signs noted.
- Objective
- Implant #30 PD 3 mm, BOP 0 %, suppuration 0 %; plaque index 15 %; radiograph shows no bone loss, no peri-implant radiolucency.
- Assessment
- Implant maintenance, peri-implant mucositis, Stage I, Grade A, supported by 3 mm probing depth, 0 % BOP, and absence of bone loss.
- Plan
- Scaling of implant surface with ultrasonic scaler performed; oral hygiene instruction given; chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily prescribed; next visit in 3 months for routine maintenance.
Maintenance, 52-year-old, 3-month visit, peri-implant mucositis
- Subjective
- 52-year-old female, NKDA, reports “cleaning my implant, it feels a bit red.” History of implant #15 maintenance, no systemic symptoms.
- Objective
- Implant #15 probing depth 5 mm, BOP 30 %, no suppuration; plaque index 25 %; radiograph shows 0.5 mm radiolucency at crest; extraoral and intraoral otherwise normal.
- Assessment
- Peri-implant mucositis, Stage II, Grade B, supported by PD 5 mm, BOP 30 %, radiolucency 0.5 mm.
- Plan
- Manual debridement of implant surface and ultrasonic scaling performed; chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily prescribed; oral hygiene instruction given; next maintenance visit in 3 months.
Maintenance, 68-year-old, 3-month visit, peri-implant mucositis with bone loss
- Subjective
- 68-year-old female, type 2 diabetes on metformin, NKDA, reports “my implant looks swollen and I have a bad taste.”
- Objective
- Implant #22 shows PD 6 mm, BOP 40 %, 1 site of suppuration; plaque index 35 %; periapical radiograph reveals 1.5 mm bone loss at the apex; no systemic signs noted.
- Assessment
- Peri-implantitis, Stage III, Grade C, supported by deep probing, high BOP, suppuration, and radiographic bone loss.
- Plan
- Debridement of implant surface with ultrasonic scaler, removal of granulation tissue; prescribed chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily; provided oral hygiene instruction; discussed surgical options for next visit; no anesthesia or medications administered.
Orthodontic Appliance Maintenance
Maintenance, 30-year-old, 3-month visit, orthodontic appliance
- Subjective
- 30-year-old female, controlled hypertension on lisinopril, NKDA, comes for routine check-up and to clean braces; reports no pain or discomfort.
- Objective
- Brackets intact, no loose or broken components; ligature wires tight, no visible corrosion; oral hygiene adequate; plaque index 15%; no gingival inflammation around brackets; no inter-bracket calculus; no pain or discomfort reported.
- Assessment
- Orthodontic appliance maintenance, no complications, supported by intact brackets, tight ligatures, adequate plaque control and absence of inflammation.
- Plan
- Cleaned brackets with ultrasonic scaler and hand curette; reinforced ligature wires; instructed patient on proper flossing with orthodontic floss and daily interdental brush use; no medication prescribed; next maintenance visit in 3 months.
Maintenance, 39-year-old, 3-month visit, orthodontic relapse
- Subjective
- 39-year-old male, allergic to penicillin (rash); CC: “I’m here for my 3-month check-up and to get the braces cleaned.” HPI: reports occasional soreness after meals; no pain or swelling. O: extraoral normal; intraoral: brackets on #15-#16 intact, ligature wires tight, no corrosion; plaque index 20% inter-bracket; mild gingival erythema around #15-#16; no inter-bracket calculus; BOP none; PDs 3 mm at inter-bracket sites; no suppuration; radiographs not taken. A: Orthodontic relapse: mild inter-arch spacing on #15-#16; orthodontic appliance maintenance. P: Removed loose inter-bracket calculus with hand curette; tightened ligature wires; gentle scaling of inter-bracket areas; instructed on orthodontic floss and interdental brushes; no drugs; next maintenance in 3 months.
Maintenance, 45-year-old, 3-month visit, orthodontic appliance-related calculus
- Subjective
- 45-year-old female, asthma on albuterol PRN, NKDA, reports “I’m here for my routine cleaning and to check the braces.” HPI: no pain, routine maintenance visit.
- Objective
- Brackets on #24-#25 intact, ligature wires tight, no corrosion. Plaque index 18% on inter-bracket surfaces, moderate inter-bracket calculus on #24 and #25. Gingival inflammation present around #24-#25. No systemic signs.
- Assessment
- Orthodontic appliance maintenance with calculus accumulation; no active infection.
- Plan
- Removed inter-bracket calculus with hand curette, reinforced ligature wires, ultrasonic scaling of surrounding enamel. Instructed patient on improved interdental cleaning, advised softer brush for braces. No drugs prescribed. Next maintenance scheduled in 3 months.
Special Cases
Maintenance, 44-year-old, 3-month visit, acute pain
- Subjective
- 44-year-old female, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “I have a sharp pain in my lower right molar that started this morning.” History: pain started this morning, no fever or systemic symptoms. PMH: hypothyroidism; medications: levothyroxine.
- Objective
- Extraoral: swelling of lower right buccal mucosa; intraoral: PD #30 6 mm mesial, 5 mm distal, 5 mm buccal, 5 mm lingual; BOP 100 % of sites; suppuration mesially; CAL 8 mm; plaque score 45 %; radiograph PA #30 shows periapical radiolucency to the root apex; vital signs WNL.
- Assessment
- Acute apical abscess, Stage II periodontitis, Grade A – supported by deep pockets, 100 % BOP, suppuration, radiolucency, and clinical pain.
- Plan
- Incision and drainage of periapical abscess performed under 2 % lidocaine 1:100 000, 1.8 mL IANB; irrigated with sterile saline; oral hygiene instruction given; prescribed ibuprofen 400 mg PO q6 h PRN up to 3 days; advised to return if pain worsens or swelling increases.
Maintenance, 71-year-old, 3-month visit, dental implant fracture
- Subjective
- 71-year-old female, NKDA, reports “My implant in the lower right has cracked and is loose.” She takes low-dose aspirin daily. No systemic signs, temperature 98.4 °F.
- Objective
- Implant #30 shows 3 mm mobility, 2 mm peri-implant probing depth, BOP 50 %. Plaque score 30 %. PAN radiograph reveals a 4 mm fracture line extending apically. No extraoral findings noted.
- Assessment
- Implant fracture with peri-implant mucositis, Stage I, Grade A, supported by mobility, deep pocket, BOP, radiographic fracture line and plaque level.
- Plan
- Re-positioned implant, splinted with composite resin, temporary crown placed. Instructed to avoid hard foods and to use chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily. Next visit in 3 months for maintenance and healing assessment.
Maintenance, 36-year-old, 3-month visit, pregnancy-related gingival hyperplasia
- Subjective
- 36-year-old female patient, pregnant, seasonal allergies, NKDA; CC: “My gums look swollen and pink, especially around my front teeth.” HPI: reports generalized gingival swelling, no pain, normal temperature 98.7 °F.
- Objective
- Extraoral normal. Intraoral: generalized BOP 60 %; PD max 4 mm, CAL max 3 mm; gingival margin 1 mm recession on #7, #8; plaque score 55 %; PA radiograph shows no bone loss.
- Assessment
- Gingival hyperplasia, Stage I periodontitis, Grade A, supported by 60 % BOP, 4 mm PD, 3 mm CAL, 55 % plaque, and absence of bone loss.
- Plan
- Full-mouth prophylaxis performed; supragingival scaling completed; oral hygiene instruction reinforced; chlorhexidine 0.12 % rinse 15 mL BID for 7 days prescribed; next maintenance visit in 3 months.
Maintenance, 50-year-old, 3-month visit, dental anxiety
- Subjective
- 50-year-old male, smoker 5 cigarettes/day, NKDA, reports “I’m nervous about the cleaning; I don’t want to feel any pain.”
- Objective
- Extraoral WNL. Intraoral: tooth #11 PD 4 mm mesial, 3 mm distal, 4 mm buccal, 3 mm lingual; BOP 30 %; CAL 4 mm; plaque score 40 %; temperature 98.5 °F. No systemic signs noted.
- Assessment
- Localized Stage I periodontitis, Grade A, supported by PD ≤4 mm, BOP 30 %, CAL 4 mm, and plaque 40 %.
- Plan
- Prophylaxis with ultrasonic scaler performed under 2 % lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; aspiration negative. Offered nitrous oxide for anxiety management; patient declined. Oral hygiene instruction reinforced. No medications prescribed. Next visit in 3 months for routine maintenance.
Maintenance, 51-year-old, 3-month visit, pregnancy-related gingival inflammation
- Subjective
- 51-year-old female, pregnant, former smoker, NKDA; CC: “My gums feel sore and bleed when I brush.” HPI: reports generalized soreness and bleeding with brushing, no pain, no systemic symptoms. PMH: pregnancy; no medications.
- Objective
- Extraoral WNL. Intraoral: generalized BOP 70 %; PD max 5 mm; CAL max 4 mm; plaque score 60 %; PA radiograph shows no bone loss; temperature 98.6 °F.
- Assessment
- Gingival inflammation, Stage I periodontitis, Grade A—supported by generalized BOP 70 %, PD ≤5 mm, CAL ≤4 mm, no radiographic bone loss.
- Plan
- Full-mouth prophylaxis performed; supragingival plaque scaled; oral hygiene instruction reinforced; prescribed chlorhexidine gluconate 0.12 % rinse 15 mL BID for 7 days; instructed to rinse 30 s after brushing, avoid hard foods for 2 h; next visit in 3 months for maintenance.
Documenting Patient Education in the SOAP Note
Documenting patient education captures what was conveyed, how the patient reacted, and any written or visual aids given. Record the content in objective language, quote the patient’s exact words when they clarify understanding or express concern, and note the patient’s verbal or written acknowledgment of the instructions. Specify the medium used—hand-written handout, printed pamphlet, or digital link—and the patient’s response, such as “understands” or “needs clarification.” This level of detail protects the practitioner and demonstrates that care instructions were effectively communicated.
Education section template (insert after Plan)
- E: Education provided:
- - Discussed plaque control technique, emphasizing interdental brushing and chlorhexidine rinsing.
- - Reviewed risk of progression to periodontitis if compliance lapses.
- - Provided written handout (Plaque Control Guide) and demonstrated brushing on tooth #30.
- Patient response:
- - “I will start using the interdental brush tomorrow.”
- - “I understand the importance of the rinse.”
- Materials given:
- - Plaque Control Guide (PDF), chlorhexidine 0.12% rinse bottle, interdental brush.
Differentiating Maintenance SOAP Notes from Surgical Notes
Maintenance SOAP notes focus on routine periodontal surveillance, while surgical notes document operative interventions.
| Feature | Maintenance SOAP Note | Surgical SOAP Note |
|---|---|---|
| Objective data | PD, CAL, BOP, plaque score, mobility, furcation, radiographs | Same baseline data + flap design, bone level, defect size, regenerative materials, sutures, dressing |
| Tone | Descriptive, monitoring-oriented, concise | Procedural, detailed, technical |
| Required details | Probe depths, BOP %, plaque %; note changes from baseline | Flap type (coronal, supracrestal), osteotomy depth, graft type, barrier membrane, suture material, postoperative care |
| Omitted items | Flap design, regenerative materials, bone grafts, suturing technique | None of the routine monitoring data |
| Emphasis | Trend of periodontal health, risk factors, maintenance frequency | Surgical technique, intra-operative findings, immediate postoperative instructions |
Use this quick reference to keep maintenance documentation focused on periodontal status and avoid surgical jargon that belongs in the operative note.
Structuring the Note for Mobile Readability
Use short, capitalized headings—S, O, A, P—each followed by a single line of concise text. Keep each line under four lines of content and insert a line break after every heading. Bold or caps the headings so they stand out on a small screen. Arrange the note so the entire SOAP fits within one vertical scroll; avoid extra padding or long paragraphs that force extra scrolling. The layout lets a hygienist tap the heading, read the concise data, and quickly move to the next section without losing context. The result is a clean, mobile-friendly note that preserves detail while fitting on a single phone screen.
Assessment in a Periodontal Maintenance SOAP Note
Patient Demographics and Visit Context
Record age, sex, medical history, allergies, and tobacco use in a single line. Add visit frequency and reason (e.g., “3-month maintenance” or “post-SRP re-evaluation”). Keep the sentence short and factual:
Age 55, male, NKDA, non-smoker, 3-month maintenance visit.
Probing Depth, Attachment Loss, Bleeding Index, Plaque Score
Summarise the most critical periodontal metrics in order. Use the format:
PD: 3 mm; CAL: 1 mm; BOP %: 12 %; Plaque %: 18 %.
If any site exceeds thresholds, list the max depth and number of sites:
Max PD 5 mm at sites 15, 16; BOP % 20 %; Plaque % 22 %.
Other Objective Findings (Mobility, Furcation, Radiographs)
Include mobility grades, furcation involvement, and key radiographic observations in a single line. Example:
Mobility: Miller 0; Furcation: none; Radiograph: mild interproximal bone loss at 24, 25.
Plan in a Periodontal Maintenance SOAP Note
Scaling Frequency
Assign intervals based on max probing depth and BOP %.
- ≤3 mm, BOP ≤10 %: 3-month scaling.
- 4–5 mm or BOP 11–20 %: 2-month scaling.
- ≥6 mm or BOP >20 %: 1-month scaling. Document the interval and rationale in the note.
Oral Hygiene Instruction
Record the specific OHI delivered: “demonstrated interdental brushing, reinforced brushing technique, advised chlorhexidine 0.12 % rinse twice daily.” Note patient’s ability to perform the technique and any barriers observed.
Referrals and Adjunctive Care
If a site remains ≥5 mm after scaling or if the patient has uncontrolled systemic disease, add a referral to a periodontist. Document adjunctive measures: “prescribed chlorhexidine 0.12 % rinse, scheduled next visit in 4 weeks for reassessment.”
Documentation of Patient Education
Insert the education template:
- E: Education provided:
- - Discussed plaque control technique, emphasizing interdental brushing and chlorhexidine rinsing.
- - Reviewed risk of progression to periodontitis if compliance lapses.
- - Provided written handout (Plaque Control Guide) and demonstrated brushing on tooth #30.
- Patient response:
- - “I will start using the interdental brush tomorrow.”
- - “I understand the importance of the rinse.”
- Materials given:
- - Plaque Control Guide (PDF), chlorhexidine 0.12% rinse bottle, interdental brush.
Follow-Up in a Periodontal Maintenance SOAP Note
Next Appointment Date
Write the exact calendar date for the next visit, e.g., “Next appointment: 15-Oct-2025.” If the date is not yet decided, note “Next appointment: TBD.”
Monitoring Goals
Summarise the quantitative targets: “Maintain PD ≤ 3 mm; BOP ≤ 10 %; plaque ≤ 15 %.” If a site exceeds a threshold, note the specific max depth and number of sites, e.g., “Max PD 4 mm at 15, 16; BOP 12 %.”
Patient Response and Consent
Document the patient’s verbal or written acknowledgment of the plan:
- “Patient agrees to the 3-month interval and understands the goals.”
- If the patient refuses or requests a different interval, record the reason and obtain a signature if required.
- Plan
- Follow-up
- - Next appointment: 15-Oct-2025
- - Monitoring goals: PD ≤ 3 mm; BOP ≤ 10 %; plaque ≤ 15 %
- - Patient response: “I will attend on 15-Oct and understand the goals.” (verbal consent)
These examples show structure and wording only. Record what you actually found and did, and follow your practice’s documentation requirements.
