Nutritional Counseling Dental Hygiene SOAP Note: Ready-to-Copy Examples and Adaptation Guide
Ready-to-copy nutritional counseling SOAP notes for dental hygienists and students are available for immediate use. The …
Fully populated periodontal re-evaluation SOAP notes are available for every visit type. Each note is ready to copy and paste, grouped by routine maintenance, post-SRP with systemic conditions, anticoagulation, surgical follow-ups, graft and ridge preservation, Down syndrome, and cardiac follow-ups. The examples include complete S:, O:, A:, and P: sections with patient age, medical history, allergies, and all relevant periodontal findings.
Routine Maintenance
Routine Maintenance, 45-Year-Old Non-Smoker
- Subjective
- 45-year-old female, former smoker, NKDA, presents for routine cleaning, reports no pain or discomfort.
- Objective
- Plaque score 12%; light calculus present on all teeth; BOP 8% of sites; all probing depths 2–3 mm; no recession, suppuration, mobility or furcation involvement; OHI satisfactory; full-mouth series shows no caries or bone loss.
- Assessment
- Gingival health; plaque-induced gingivitis, supported by low plaque score, minimal BOP and shallow PDs.
- Plan
- Scaling of supragingival calculus, rubber-cup polishing with pumice, fluoride varnish 5% sodium fluoride applied to all teeth; no drugs prescribed; advised continued daily brushing and interdental cleaning; next routine maintenance in 3 months.
Routine Maintenance, 55-Year-Old Pregnant
- Subjective
- 55-year-old female, pregnant, controlled hypertension on lisinopril, NKDA; CC: “Just a routine checkup and cleaning”; HPI: no pain, no bleeding, routine visit; PMH: hypertension, pregnancy, no other meds; allergies: NKDA.
- Objective
- Extraoral: normal; Intraoral: plaque score 18 %, moderate calculus on lower molars, BOP 12 % of sites, probing depths 2–3 mm, no recession, no suppuration, no mobility, no furcation involvement; OHI adequate; Radiograph: full-mouth series shows no caries, no bone loss.
- Assessment
- Diagnosis: Gingival health; plaque-induced gingivitis, supported by 18 % plaque, 12 % BOP, shallow PDs, and absence of attachment loss.
- Plan
- Prophylaxis performed: hand curette scaling of subgingival calculus on lower molars, polishing, fluoride varnish 5 % sodium fluoride applied to all teeth; no drugs prescribed; instructed to maintain OHI, avoid smoking (none), continue prenatal care; next visit in 3 months for routine maintenance.
Relapse After Maintenance, 35-Year-Old Smoker
- Subjective
- 35-year-old male, 5 cigarettes/day, allergic to penicillin (rash). CC: “I feel some gum bleeding and a bit of discomfort around my lower right molars.” HPI: reports bleeding and discomfort; PMH: none.
- Objective
- Extraoral: normal. Intraoral: plaque 25%, heavy calculus on #30. Periodontal: BOP 30% sites, PD 4–5 mm, recession 1 mm buccal, suppuration buccal pocket, mobility Miller I, no furcation. Radiograph: PA of #30 shows 3 mm bone loss apical to CEJ.
- Assessment
- Stage II periodontitis, grade B, localized to tooth #30, supported by PD 4–5 mm, BOP 30%, bone loss 3 mm, suppuration.
- Plan
- Scaling and root planing of #30 with ultrasonic scaling, hand curette debridement, granulation tissue curette, saline irrigation; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB. Prescribed chlorhexidine 0.12% rinse 15 mL, 30 s, twice daily for 7 days. Advised oral hygiene instruction; next visit in 3 months for maintenance.
Post-SRP Re-Evaluation with Systemic Conditions
Post-SRP Re-Evaluation, 60-Year-Old Diabetic
- Subjective
- 60-year-old female, type 2 diabetes on metformin, smokes ~5 cigarettes/day, NKDA. Chief complaint: “I’m here for my follow-up after the cleaning.” HPI: routine post-SRP re-evaluation. PMH: diabetes, smoking; no systemic signs reported.
- Objective
- Extraoral: WNL. Intraoral: plaque score 25%. Periodontal chart: PD 4 mm at #15, 3 mm at #16; BOP 20% of sites; CAL 4 mm at #15, 3 mm at #16. Radiograph: mild bone loss around #15-16.
- Assessment
- Stage II periodontitis, grade B, localized to #15-16 – supported by PD, CAL, BOP, plaque score and radiographic bone loss.
- Plan
- No anesthesia used. Reinforced oral hygiene instruction. Scheduled periodontal maintenance in 3 months. No medication prescribed.
Post-SRP Re-Evaluation, 70-Year-Old with Diabetes and Hypertension
- Subjective
- 70-year-old male, type 2 diabetes on metformin, hypertension, NKDA; CC: “I have a sore spot in my lower right molar.” HPI: pain localized to #30, no systemic symptoms.
- Objective
- Extraoral: normal. Intraoral: plaque present, BOP 30% of sites. Periodontal: PD 5 mm at #30, CAL 6 mm, no furcation involvement. Radiograph: moderate bone loss at #30, no furcation. Tests: none.
- Assessment
- Stage III periodontitis, grade C, localized to #30, supported by PD 5 mm, CAL 6 mm, BOP 30% and radiographic bone loss.
- Plan
- 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Plan open flap debridement in 2 weeks. Prescribe chlorhexidine 0.12% rinse, 15 mL for 30 sec, twice daily for 2 weeks. Advise strict plaque control, monitor blood glucose, and schedule RTC in 2 weeks for surgical evaluation.
Post-SRP Re-Evaluation, 63-Year-Old with Chronic Kidney Disease
- Subjective
- 63-year-old male presents for a post-SRP re-evaluation, stating “Just checking how my gums are doing.” He reports no new symptoms; his medical history includes daily low-dose aspirin therapy and no known drug allergies.
- Objective
- Extraoral examination is within normal limits. Intraoral assessment reveals moderate plaque accumulation and bleeding on probing (BOP) at 25 % of sites. Periodontal charting shows probing depth (PD) of 4 mm at tooth #4 with a clinical attachment level (CAL) of 5 mm; radiographic analysis demonstrates mild alveolar bone loss around #4, with no furcation involvement.
- Assessment
- The findings are consistent with Stage II periodontitis, Grade B, generalized, as evidenced by the PD of 4 mm, CAL of 5 mm, BOP of 25 %, and radiographic bone loss.
- Plan
- No local anesthesia was required. Oral hygiene instruction was reinforced, emphasizing interdental cleaning and plaque control. The patient was scheduled for periodontal maintenance in 3 months, with no medications prescribed.
Re-Evaluation After Periodontal Surgery, 52-Year-Old with Diabetes Mellitus Type 1
- Subjective
- 52-year-old female, type 2 diabetes on metformin, NKDA, reports “My gums feel fine, just want to make sure the surgery healed.” HPI: routine post-surgical check after periodontal graft at tooth #19.
- Objective
- Extraoral normal. Intraoral: probing depth 2 mm at #19, bleeding on probing 5 % of sites, clinical attachment level 2 mm at #19. Radiograph: no bone loss, graft appears intact.
- Assessment
- Post-surgical healing, no active disease.
- Plan
- No anesthesia administered. Suture removal scheduled next visit; no medication prescribed. Advised to maintain oral hygiene, avoid trauma to the graft area, and report any pain, swelling or bleeding. Next visit in 4 weeks for suture removal.
Re-Evaluation After Periodontal Surgery, 60-Year-Old with Chronic Kidney Disease Stage 4
- Subjective
- 60-year-old female, NKDA, asthma controlled with albuterol PRN, reports “Just checking the healing after my gum surgery.”
- Objective
- Extraoral normal. Intraoral: #28 shows PD 3 mm, BOP 10 % of sites, CAL 3 mm. Radiograph of graft site stable, no bone loss. No swelling, erythema, or suppuration noted.
- Assessment
- Post-surgical healing, no active periodontal disease; findings consistent with successful graft integration and adequate plaque control.
- Plan
- No medication prescribed. Sutures to be removed at next visit. Instructed patient to maintain oral hygiene, avoid trauma to the site, and report any pain, swelling, or bleeding. Next appointment scheduled for suture removal and routine maintenance.
Re-Evaluation After Periodontal Surgery, CKD Patient
- Subjective
- 61-year-old male, seasonal allergies, NKDA, reports “I want to see how the surgery site is doing.”
- Objective
- PD 3 mm at tooth #11, BOP 8 % of sites, CAL 3 mm at #11; radiograph shows graft site intact, no bone loss; no anesthesia used; no medications prescribed.
- Assessment
- Post-surgical healing, no active disease, consistent with Stage I periodontitis remission and successful graft integration.
- Plan
- Sutures to be removed at next visit; patient instructed to maintain plaque control with daily brushing and interdental cleaning; next visit scheduled for suture removal and routine periodontal maintenance.
Re-Evaluation After Periodontal Graft, 39-Year-Old with Sjögren’s Syndrome
- Subjective
- 39-year-old female; CC: “Checking the graft site after my gum graft.” PMH: hypothyroidism on levothyroxine. No other systemic conditions.
- Objective
- PD 3 mm at tooth #12; BOP 12 % of sites; CAL 3 mm at #12; radiograph shows graft stable, no bone loss.
- Assessment
- Post-graft healing, graft stable, with mild gingival inflammation.
- Plan
- No anesthesia used. Prescribed chlorhexidine gluconate 0.12 % rinse, 15 mL for 30 sec, twice daily for 2 weeks. Instructed on proper rinsing technique, avoidance of hard foods for 24 h, and to return for suture removal and further evaluation in 2 weeks.
Post-SRP Re-Evaluation, 60-Year-Old with Antidepressant Therapy
- Subjective
- 60-year-old male, former smoker, NKDA, presents for a quick check after cleaning; reports no pain or bleeding.
- Objective
- Extraoral normal; intraoral: PD 4 mm at tooth #20, BOP 20 % of sites, CAL 4 mm at #20; radiograph shows mild bone loss, no furcation involvement; systemic signs none.
- Assessment
- Stage II periodontitis, grade B, localized to tooth #20, supported by PD 4 mm, BOP 20 %, CAL 4 mm and radiographic bone loss.
- Plan
- No anesthesia used; scheduled periodontal maintenance in 3 months; prescribed chlorhexidine gluconate 0.12 % rinse, 15 mL for 30 sec, twice daily for 2 weeks; instructed on proper rinsing technique and to report any adverse reaction.
Re-Evaluation After Periodontal Graft, 29-Year-Old with Allergic Rhinitis
- Subjective
- 29-year-old male, controlled hypertension on lisinopril, NKDA, CC: “Just here for the follow-up after my graft.” O: Extraoral exam shows no swelling or lymphadenopathy; intraoral surfaces smooth, no erythema; periodontal charting of tooth #12 reveals PD 3 mm, BOP 0 %, CAL 3 mm; graft site appears firm, pink, with no recession or suppuration; panoramic radiograph demonstrates complete graft integration, no radiolucency or bone loss; all other sites within normal limits. A: Post-graft healing with no active periodontal disease, evidenced by stable probing depths, absence of bleeding, and radiographic evidence of bone fill. P: Reviewed surgical site healing, reinforced meticulous oral hygiene instruction emphasizing interdental cleaning and chlorhexidine rinses, advised avoidance of hard foods for 48 hours, and scheduled next periodontal maintenance in 3 months; no medications prescribed, anesthesia not required.
Re-Evaluation After Periodontal Surgery, 55-Year-Old with Chronic Liver Disease
- Subjective
- 55-year-old female, medical history unremarkable, allergic to penicillin (rash); CC: “I’m here for my post-op check after the flap surgery.”
- Objective
- Probing depth on tooth #19 is 4 mm, bleeding on probing 10 %, clinical attachment level 5 mm; no suppuration noted; flap healing satisfactory; periapical radiograph shows no bone loss and no radiographic changes from baseline.
- Assessment
- Post-surgical healing with no active periodontal disease; pocket depths and attachment levels have stabilized within normal limits for this patient.
- Plan
- Continue routine periodontal maintenance; no medications prescribed; reinforce oral hygiene instructions and chlorhexidine 0.12 % rinse twice daily; schedule next maintenance visit in 4 weeks to reassess probing depths, plaque control, and flap integrity.
Re-Evaluation After Periodontal Graft, 42-Year-Old with Rheumatoid Arthritis
- Subjective
- 42-year-old male, smoker 5 cigarettes/day, NKDA, CC: “Just checking on my graft.” HPI: reports no pain, no swelling, routine follow-up after graft placed on tooth #28.
- Objective
- Extraoral: no facial swelling, intraoral: mucosa pink, no ulceration. Periodontal: PD at #28 3 mm, BOP 5 %, CAL 3 mm; graft appears stable, no recession noted. Radiographic: panoramic shows complete graft integration, bone fill evident, no radiolucency around #28.
- Assessment
- Post-graft healing with no active periodontal disease, evidenced by stable probing depths, minimal bleeding, and radiographic bone fill.
- Plan
- Reinforced oral hygiene instruction, emphasized interdental cleaning and chlorhexidine rinse as needed; no medications prescribed. Schedule next periodontal maintenance in 3 months, with emphasis on monitoring plaque control and graft integrity.
Re-Evaluation After Periodontal Surgery, 58-Year-Old with Bipolar Disorder
- Subjective
- 58-year-old female, type 2 diabetes on metformin, NKDA, states “I’m here for my follow-up after the surgery.” She reports no pain, no swelling, and feels comfortable with the healing site. HPI: She had periodontal surgery on tooth #30 six weeks ago and has been following oral hygiene instructions; no adverse events have occurred.
- Objective
- Extraoral exam shows no facial swelling or lymphadenopathy. Intraoral findings reveal a well-healed surgical flap over tooth #30 with intact mucogingival architecture. Periodontal charting shows probing depth 5 mm, bleeding on probing 15 %, clinical attachment level 6 mm; no suppuration noted. Radiographic assessment (PA of #30) demonstrates complete bone fill with no radiolucency or bone loss.
- Assessment
- Post-surgical healing without active disease is confirmed; the stability of PD, BOP, CAL, and radiographic bone integrity supports this assessment.
- Plan
- Continue periodontal maintenance protocol, emphasizing strict glycemic control and meticulous plaque control. No pharmacologic therapy is required at this time. Instruct patient to avoid smoking and maintain regular brushing and interdental cleaning. Schedule next maintenance visit in 4 weeks for re-evaluation and continued monitoring.
Re-Evaluation After Periodontal Surgery, 62-Year-Old Osteoporotic
- Subjective
- 62-year-old female, no known drug allergies, takes low-dose aspirin daily, presents for a post-op check, stating “Just here for my post-op check.”
- Objective
- Extraoral normal; intraoral surgical site on tooth #15 healing satisfactorily. Periodontal charting: PD 4 mm, BOP 10 %, CAL 5 mm. Periapical radiograph of #15 shows no bone loss. No other findings.
- Assessment
- Post-surgical healing with no active periodontal disease, supported by 4 mm probing depth, 10 % BOP, 5 mm CAL, and radiographic absence of bone loss.
- Plan
- Reinforced oral hygiene instruction; no medications prescribed. Scheduled next periodontal maintenance in 3 months.
Post-SRP Re-Evaluation, 48-Year-Old Pregnant
- Subjective
- 48-year-old female patient, pregnant, NKDA, presents for her post-SRP re-evaluation; she states, “I’m here for my post-SRP visit.” She reports no pain, no swelling, and is compliant with her prescribed oral hygiene routine. Her medical history is limited to pregnancy; she has no known drug allergies or systemic conditions that would affect periodontal healing.
- Objective
- Extraoral examination reveals no facial asymmetry or lymphadenopathy. Intraoral findings show healthy mucosa, no ulceration, and adequate salivary flow. Periodontal charting at tooth #20 shows a probing depth of 3 mm, bleeding on probing of 5 %, and a clinical attachment level of 3 mm; there is no gingival recession and the tissue appears well-healed. Panoramic radiograph demonstrates no radiographic bone loss around #20 or adjacent teeth, and the bone crest is at the expected level.
- Assessment
- Post-SRP healing with no active periodontal disease, confirmed by stable probing depths, low bleeding on probing, and absence of radiographic bone loss.
- Plan
- Reinforced comprehensive oral hygiene instruction, emphasizing safe brushing and interdental cleaning techniques suitable for pregnancy; advised use of a soft-bristle brush and fluoride mouth rinse. No medications were prescribed. The patient was scheduled for a follow-up re-evaluation in 4 weeks to monitor plaque control, bleeding, and overall periodontal stability.
Post-SRP Re-Evaluation, 57-Year-Old with Bisphosphonate Therapy
- Subjective
- 57-year-old male, asthma managed with albuterol as needed, NKDA, presents with the chief complaint “Just checking after my SRP.” He reports no pain, no swelling, and confirms that he has been following the oral hygiene routine discussed during his last visit.
- Objective
- Extraoral examination is within normal limits. Intraoral assessment shows tooth #11 with a probing depth of 4 mm and 10 % bleeding on probing; clinical attachment level is 5 mm. There is no suppuration, the surgical site appears healed, and the patient reports no discomfort. A periapical radiograph of the area shows no residual bone loss or radiolucency.
- Assessment
- Post-SRP healing with no active periodontal disease; periodontal status is stable and within acceptable limits for a patient on bisphosphonate therapy.
- Plan
- Reinforced oral hygiene instruction emphasizing interdental cleaning and chlorhexidine rinse; no medication was prescribed. Patient advised to maintain plaque control and to report any new symptoms immediately. Next periodontal maintenance appointment scheduled in 3 months.
Post-SRP Re-Evaluation, Hypothyroid Patient
- Subjective
- 53-year-old male patient with seasonal allergies, NKDA, presents for a scheduled post-SRP re-evaluation; patient states, “I’m here for my follow-up after SRP.” He reports no pain or swelling and is compliant with home care.
- Objective
- Extraoral examination is within normal limits. Intraoral findings include tooth #3 with a probing depth of 3 mm, bleeding on probing (BOP) of 5 %, and a clinical attachment level (CAL) of 3 mm; there is no gingival recession and the mucosa appears healed and pink. Panoramic radiograph shows no evidence of bone loss or radiographic pathology in the surrounding alveolar bone.
- Assessment
- Post-SRP healing with no active periodontal disease is confirmed, supported by probing depths ≤3 mm, minimal BOP, stable CAL, and a clear radiograph.
- Plan
- Reinforced oral hygiene instruction emphasizing proper brushing technique, interdental cleaning, and the importance of regular follow-ups; no medications were prescribed. The patient was advised to maintain current oral hygiene practices and to return in 4 weeks for the next maintenance visit.
Post-SRP Re-Evaluation with Anticoagulation
Post-SRP Re-Evaluation, 55-Year-Old Anticoagulated
- Subjective
- 55-year-old male, hypothyroid on levothyroxine, allergic to penicillin (rash); CC: “I’m here for my follow-up after the deep cleaning”; HPI: no pain, no swelling, no trismus; PMH: hypothyroidism, anticoagulation status noted;
- Objective
- Extraoral: no swelling, temperature 98.6 °F, BP 130/80 mmHg; Intraoral: PD 3 mm at #15 and #16, BOP 10% of sites, CAL 3 mm both teeth, plaque score 15%; Radiograph: full-mouth series, no new bone loss; No bleeding during prior SRP; Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
- Assessment
- Stage II periodontitis, grade B, localized to #15-16; supporting findings: PD 3 mm, CAL 3 mm, BOP 10%, no radiographic progression.
- Plan
- Post-SRP healing, no active disease; continue periodontal maintenance every 3 months; reinforce OHI; no medication prescribed; patient advised to monitor for bleeding and report immediately; next visit scheduled for maintenance in 3 months.
Post-SRP Re-Evaluation, 72-Year-Old with Anticoagulation Therapy
- Subjective
- 72-year-old male, former smoker, NKDA, CC: “Just checking in after my cleaning.”
- Objective
- PD #30 4 mm, #31 4 mm; BOP 20% of sites; CAL 4 mm both teeth; plaque score 25%; PA #30-31 shows no new bone loss; extraoral normal, temp 98.4 °F, BP 128/78 mmHg; no bleeding, swelling, or trismus.
- Assessment
- Stage III periodontitis, grade C, localized to #30-31, supported by PD 4 mm, BOP 20%, CAL 4 mm, and radiographic stability.
- Plan
- No active disease; recommend periodontal maintenance every 2 months; counsel on smoking cessation, reinforce oral hygiene; no medication prescribed; next visit in 2 months for maintenance.
Post-SRP Surgical Follow-Ups
Post-Surgical Healing, 50-Year-Old Non-Smoker
- Subjective
- 50-year-old female; “I’m here for my follow-up after the SRP and flap surgery on the upper right first molar.” Past medical history: controlled hypertension on lisinopril; smokes about 5 cigarettes a day; no known drug allergies.
- Objective
- Extraoral: normal. Intraoral: tooth #3 shows PD 3 mm at all sites, BOP 0 %; recession 0.5 mm, CAL 3.5 mm; mobility Miller 0; no suppuration. Radiograph: healed flap, no bone loss. Plaque score 12 %.
- Assessment
- Stage II periodontitis, grade B, localized to tooth #3; clinical findings show complete healing with no active disease.
- Plan
- Post-surgical healing observed; no active disease. Reinforce oral hygiene instruction. Schedule next maintenance visit in 3 months. No medications prescribed.
Re-Evaluation After Periodontal Graft, 28-Year-Old Non-Smoker
- Subjective
- 28-year-old male, smoker 5 cigarettes/day, allergic to penicillin (rash); CC: “I’m here to see how the graft on my lower left canine is healing.” HPI: no pain, no swelling, no bleeding; PMH: none else.
- Objective
- Extraoral: normal. Intraoral: tooth #22 shows PD 2 mm at all sites, BOP 0 %; Recession 0 mm, CAL 2 mm; graft stable, no mobility. Radiograph: graft integration, no bone loss. Plaque score 10 %.
- Assessment
- Post-graft healing, no active disease.
- Plan
- Continue periodontal maintenance; instruct patient to avoid trauma to graft site; no drugs prescribed. Schedule next visit in 4 weeks for reassessment.
Re-Evaluation After Ridge Preservation, 32-Year-Old Non-Smoker
- Subjective
- 32-year-old male, NKDA, smokes 5 cigarettes/day; CC: “I’m here for my follow-up after the ridge preservation on the lower right first molar.”
- Objective
- PD 3 mm at all sites, BOP 0 %; recession 0.5 mm, CAL 3.5 mm; plaque score 15 %; radiograph shows preserved ridge height, no dehiscence.
- Assessment
- Post-ridge preservation healing, no active disease, supported by stable PD, BOP, CAL and radiographic findings.
- Plan
- Maintain oral hygiene; no intervention required. Instructed to avoid smoking near the site, given plaque control instructions, and scheduled implant evaluation in 6 months.
Re-Evaluation After Periodontal Surgery, 48-Year-Old Non-Smoker
- Subjective
- 48-year-old male, non-smoker, type 2 diabetes on metformin, NKDA, reports “I’m here to check the flap surgery on my lower right second molar.”
- Objective
- Extraoral normal. Intraoral: tooth #31 shows PD 4 mm at all sites, BOP 0 %, recession 1 mm, CAL 5 mm, mobility Miller 0. Radiograph: healed flap, bone fill in socket. Plaque score 18 %.
- Assessment
- Post-surgical healing, no active disease, supported by stable PD, absence of BOP, and radiographic evidence of bone fill.
- Plan
- Continue periodontal maintenance. Reinforce oral hygiene instruction. No further surgical intervention. Schedule next visit in 3 months.
Re-Evaluation After Periodontal Abscess Drainage, 40-Year-Old Non-Smoker
- Subjective
- 40-year-old female, smoker 5 cigarettes/day, takes low-dose aspirin, NKDA; CC: “I’m here to see how the abscess drainage on my lower left second molar is healing”; HPI: presents 4 weeks post-SRP and abscess drainage, reports no pain or swelling; PMH: no systemic disease, no allergies.
- Objective
- Extraoral: normal; Intraoral: PD 3 mm at all sites on tooth #18, BOP 0%; Recession 0.5 mm, CAL 3.5 mm; no suppuration; Radiograph: resolved abscess, no bone loss; Plaque score 12 %.
- Assessment
- Post-abscess drainage healing, no active periodontal disease.
- Plan
- Maintain oral hygiene; no antibiotics or medications prescribed; patient instructed on proper brushing and flossing; next visit scheduled in 4 weeks for re-evaluation.
Re-Evaluation After Ridge Preservation, 29-Year-Old Smokers
- Subjective
- 29-year-old male, NKDA, smokes 5 cigarettes/day, CC: “I’m here for my follow-up after the ridge preservation on the lower left first molar.” HPI: routine post-SRP follow-up, no pain or swelling.
- Objective
- Extraoral WNL. Intraoral: tooth #19 shows PD 3 mm at all sites, BOP 0 %, recession 0.5 mm, CAL 3.5 mm. Radiograph: preserved ridge height, slight 1 mm bone loss apical to CEJ. Plaque score 20 %.
- Assessment
- Post-ridge preservation healing, no active periodontal disease.
- Plan
- Continue periodontal maintenance; advise smoking cessation. No medications. Next visit in 3 months.
Re-Evaluation After Periodontal Graft, 34-Year-Old with Periodontal Disease Relapse
- Subjective
- 34-year-old female, asthma, NKDA, CC: “I’m here for my follow-up after the graft.”
- Objective
- PD 5 mm, BOP 30 %, CAL 7 mm, recession 2 mm; graft stable, no suppuration; radiograph shows maintained bone level; plaque index 15 %; no mobility, no furcation.
- Assessment
- Stage III periodontitis, grade C, localized to tooth #12, supported by PD 5 mm, CAL 7 mm, BOP 30 %.
- Plan
- Evaluated graft stability, no medication prescribed; instructed to reinforce oral hygiene, plan second-stage regenerative therapy if pocket depths persist; next visit in 4 weeks.
Re-Evaluation After Periodontal Surgery, 45-Year-Old with Severe Periodontitis
- Subjective
- 45-year-old female patient with seasonal allergies, NKDA, presents for a routine check-in after her periodontal surgery; she reports no pain or discomfort and says, “Just checking in after my surgery.”
- Objective
- Extraoral examination is unremarkable. Intraoral findings show complete flap healing over tooth #19 with no evidence of suppuration or inflammation. Periodontal charting reveals a probing depth of 4 mm, bleeding on probing at 10 % of sites, and a clinical attachment level of 5 mm. Plaque index is 10 %, mobility is absent, and there is no furcation involvement. Panoramic radiograph demonstrates stable bone levels around #19 with no radiolucencies.
- Assessment
- The patient is diagnosed with Stage II periodontitis, Grade B, localized to tooth #19, as evidenced by the PD of 4 mm, CAL of 5 mm, and BOP of 10 %.
- Plan
- No medication is prescribed. Continue periodontal maintenance therapy; reinforce oral hygiene instructions and schedule the next maintenance visit in three months.
Post-SRP Re-Evaluation, 58-Year-Old with Chronic Obstructive Pulmonary Disease
- Subjective
- 58-year-old male, hypothyroid on levothyroxine, allergic to penicillin (rash), presents for post-SRP check-up; states “I’m back for my post-SRP checkup.”
- Objective
- Extraoral WNL. Intraoral: tooth #20 shows PD 6 mm, BOP 35 %, CAL 8 mm, recession 3 mm; no suppuration, no mobility, no furcation involvement. Plaque index 20 %. Radiograph: bone loss consistent with Stage III periodontitis.
- Assessment
- Stage III periodontitis, grade C, generalized – supported by PD 6 mm, CAL 8 mm, BOP 35 %, and radiographic bone loss.
- Plan
- Regenerative surgery planned. Administered 2 % lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Prescribed chlorhexidine gluconate 0.12 % rinse, 15 mL, 30 sec, twice daily for 7 days. Instructed on postoperative care and advised return in 4 weeks for healing assessment.
Post-SRP Re-Evaluation, 66-Year-Old with Hypothyroidism
- Subjective
- 66-year-old female, former smoker, NKDA, CC: “Just a routine follow-up.” HPI: post-SRP re-evaluation, no pain or swelling.
- Objective
- Extraoral WNL. Intraoral: plaque index 12%; periodontal charting: PD 5 mm, BOP 25%, CAL 6 mm on tooth #3, no suppuration, no mobility, no furcation involvement. Radiograph: stable bone.
- Assessment
- Stage II periodontitis, grade B, generalized – supported by PD ≥5 mm, CAL 6 mm, BOP 25 %.
- Plan
- Local anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative. Reinforced oral hygiene instruction; scheduled periodontal maintenance in 3 months.
Re-Evaluation After Periodontal Abscess Drainage, 52-Year-Old Anticoagulated
- Subjective
- 52-year-old male, controlled hypertension on lisinopril, NKDA, presents after periodontal abscess drainage on tooth #18.
- Objective
- Extraoral normal. Intraoral: flap healing complete, PD 4 mm, BOP 5 %, CAL 4 mm, plaque index 8 %. No suppuration, no mobility, no furcation involvement. Radiograph shows stable bone.
- Assessment
- Stage I periodontitis, grade A, localized – supported by PD ≤4 mm, BOP <10 %, CAL 4 mm, and radiographic stability.
- Plan
- No additional treatment required; continue monitoring healing. Informed the patient of signs of recurrence and advised routine oral hygiene. Scheduled next review in 6 weeks for re-evaluation.
Re-Evaluation After Ridge Preservation, 37-Year-Old with Osteopenia
- Subjective
- 37-year-old male, “Just checking on the ridge preservation,” no significant medical history, allergic to penicillin (rash).
- Objective
- Extraoral normal. Intraoral: tooth #30, PD 3 mm, BOP 5 %, CAL 3 mm, no recession, no mobility, no furcation. Radiograph: bone crest maintained. Plaque index 10 %.
- Assessment
- Gingival health, supported by PD ≤3 mm, BOP 5 %, CAL 3 mm, and maintained bone crest.
- Plan
- Routine periodontal maintenance performed with 2 % lidocaine 1:100,000, 1.8 mL IANB, aspiration negative; no drugs prescribed. POI: maintain oral hygiene, avoid hard foods for 24 h, return in 3 months for maintenance.
Graft and Ridge Preservation Follow-Ups
Re-Evaluation After Periodontal Abscess Drainage, 44-Year-Old with Lupus
- Subjective
- 44-year-old male, smoker 5 cigarettes/day, NKDA, CC: “I’m here for my follow-up after the abscess drainage.” HPI: abscess resolved, no swelling, no systemic signs.
- Objective
- PD 6 mm at #16, BOP 80 %, suppuration present, plaque score 25 %, no mobility, no furcation involvement; PA shows no periapical radiolucency.
- Assessment
- Stage II periodontitis, grade B, localized to #16; abscess resolved.
- Plan
- Infiltration with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL; continue periodontal maintenance, prescribe chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily; re-evaluate in 4 weeks.
Re-Evaluation After Periodontal Abscess Drainage, 50-Year-Old with Systemic Lupus Erythematosus
- Subjective
- 50-year-old male, type 2 diabetes on metformin, NKDA, reports “I’m here for my follow-up after the abscess drainage.”
- Objective
- Extraoral: mild buccal swelling; Intraoral: PD 7 mm at #30, BOP 70 %, suppuration present, plaque score 30 %; Radiograph: slight periapical radiolucency; No mobility, no furcation involvement.
- Assessment
- Stage III periodontitis, grade C, localized to tooth #30; abscess has resolved.
- Plan
- 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; prescribed amoxicillin 500 mg TID for 7 days, chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily; surgical referral scheduled in 2 weeks.
Re-Evaluation After Abscess Drainage, Anticoagulated
- Subjective
- 54-year-old female, NKDA, daily low-dose aspirin; CC: “I’m here for my follow-up after the abscess drainage.” HPI: presents 4 weeks post-abscess drainage of tooth #12, reports mild buccal swelling that has subsided. PMH: aspirin therapy only, no other systemic disease.
- Objective
- Extraoral: mild buccal mucosal swelling; Intraoral: PD 5 mm at #12, BOP 60 %, no suppuration, plaque score 20 %; Radiograph: no periapical radiolucency; Mobility: none; Furcation: none.
- Assessment
- Stage II periodontitis, grade B, localized to #12; abscess resolved, BOP high but no suppuration or radiolucency.
- Plan
- Infiltration with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL (1 cartridge); continue periodontal maintenance; prescribe chlorhexidine 0.12 % rinse 15 mL for 30 s twice daily; advise continuation of aspirin; next visit in 4 weeks for reassessment.
Down Syndrome Follow-Ups
Re-Evaluation After Ridge Preservation, 31-Year-Old with Down Syndrome
- Subjective
- 31-year-old female with Down syndrome, no significant medical history, NKDA; CC: “Here for my follow-up after ridge preservation”; HPI: patient reports no pain or swelling; caregiver present and notes good compliance with home care; PMH: none; Meds: none; allergies: NKDA.
- Objective
- Extraoral: normal; Intraoral: tooth #19 shows PD 3 mm at all sites, BOP 0%, CAL 3 mm, no suppuration; Radiograph: FMX shows stable bone fill at extraction site, no radiolucency; Tests: none.
- Assessment
- Post-ridge preservation healing, no active disease, supported by PD 3 mm, BOP 0%, stable bone fill on FMX.
- Plan
- Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; No drugs prescribed; Reinforced oral hygiene instruction with caregiver, emphasizing interdental cleaning and plaque control; Scheduled next periodontal maintenance in 6 months.
Re-Evaluation After Ridge Preservation, Down Syndrome
- Subjective
- 35-year-old female, asthma, NKDA, CC: “Here for my follow-up after ridge preservation.” HPI: no pain, no swelling, no trismus.
- Objective
- Extraoral: WNL. Intraoral: PD 4 mm at all sites, BOP 10%, CAL 4 mm, no suppuration. Radiograph: FMX shows slight radiolucency at extraction site, mild bone loss.
- Assessment
- Stage II periodontitis, grade B, localized to tooth #30, supported by PD 4 mm, CAL 4 mm, BOP 10 % and radiographic bone loss.
- Plan
- Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Treatment: continue periodontal maintenance; prescribe chlorhexidine gluconate 0.12 % rinse 15 mL for 30 s, twice daily, for 4 weeks; reinforce oral hygiene instruction; schedule next visit in 6 months.
Post-SRP Re-Evaluation General & Cardiac
Post-SRP Re-Evaluation, 70-Year-Old Non-Smoker
- Subjective
- 70-year-old male, smoker 5 cigarettes/day, seasonal allergies, NKDA, presents for routine follow-up after deep cleaning; says “Here for my routine follow-up after the deep cleaning.” No pain, swelling, or systemic symptoms noted.
- Objective
- PD 4 mm at #15 mesial and distal, 3 mm buccal and lingual; PD 4 mm at #16 mesial and distal, 3 mm buccal and lingual; BOP 30 % of sites; CAL 5 mm at #15, 4 mm at #16; plaque score 20 %; no suppuration; radiograph shows no bone loss beyond baseline; no mobility; no furcation involvement.
- Assessment
- Stage II periodontitis, grade B, localized to #15-16, supported by PD ≥4 mm, CAL 4-5 mm, BOP 30 %, plaque 20 %.
- Plan
- Schedule periodontal maintenance in 3 months; reinforce oral hygiene; apply 5 % sodium fluoride varnish to all teeth; advise smoking cessation; no surgical intervention; POI given; next visit in 3 months.
Post-SRP Re-Evaluation, 73-Year-Old with Chronic Heart Failure
- Subjective
- 73-year-old female, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “I’m here for my follow-up after the scaling”; PMH: hypothyroidism; medications: levothyroxine; no other allergies; no systemic signs.
- Objective
- Extraoral: normal. Intraoral: PD 5 mm at #30 mesial, distal, buccal, lingual; PD 5 mm at #31 mesial, distal, buccal, lingual; BOP 40 % of sites; CAL 7 mm at #30, 6 mm at #31; plaque score 25 %; no suppuration; radiograph: 1-mm bone loss at #30 and #31; no mobility; no furcation involvement.
- Assessment
- Stage III periodontitis, grade C, localized to #30-31, supported by PD ≥5 mm, CAL ≥6 mm, BOP 40 %, radiographic bone loss, and plaque score 25 %.
- Plan
- No anesthesia used. Plan periodontal maintenance in 3 months; reinforce oral hygiene; apply 5 % sodium fluoride varnish to all teeth; counsel on thyroid medication adherence; no antibiotics indicated.
Routine Maintenance Notes
Routine maintenance notes capture the assessment of a patient whose periodontal status is stable, with no recent therapy or acute findings. Quick copy-and-paste templates save time while ensuring all required SOAP elements are present. The three example labels provided are: Routine Maintenance, 45-Year-Old Non-Smoker; Routine Maintenance, 55-Year-Old Pregnant; and Relapse After Maintenance, 35-Year-Old Smoker.
Post-SRP Re-Evaluation (Systemic Conditions)
Post-SRP re-evaluations for patients with systemic disease focus on healing trajectories and risk modification. Each template bears a concise label that captures the patient’s systemic condition, the elapsed time since SRP, and the clinical emphasis of the visit.
- Post-SRP Re-Evaluation, 60-Year-Old Diabetic
- Post-SRP Re-Evaluation, 70-Year-Old with Diabetes and Hypertension
- Post-SRP Re-Evaluation, 63-Year-Old with Chronic Kidney Disease
- Re-Evaluation After Periodontal Surgery, 52-Year-Old with Diabetes Mellitus Type 1
- Re-Evaluation After Periodontal Surgery, 60-Year-Old with Chronic Kidney Disease Stage 4
- Re-Evaluation After Periodontal Surgery, CKD Patient
- Re-Evaluation After Periodontal Graft, 39-Year-Old with Sjögren’s Syndrome
- Post-SRP Re-Evaluation, 60-Year-Old with Antidepressant Therapy
- Re-Evaluation After Periodontal Graft, 29-Year-Old with Allergic Rhinitis
- Re-Evaluation After Periodontal Surgery, 55-Year-Old with Chronic Liver Disease
- Re-Evaluation After Periodontal Graft, 42-Year-Old with Rheumatoid Arthritis
- Re-Evaluation After Periodontal Surgery, 58-Year-Old with Bipolar Disorder
- Re-Evaluation After Periodontal Surgery, 62-Year-Old Osteoporotic
- Post-SRP Re-Evaluation, 48-Year-Old Pregnant
- Post-SRP Re-Evaluation, 57-Year-Old with Bisphosphonate Therapy
- Post-SRP Re-Evaluation, Hypothyroid Patient
Post-SRP Surgical Follow-Ups (General)
Post-SRP surgical follow-ups document the healing trajectory after periodontal procedures such as flap surgery, grafting, or abscess drainage. The label for each note identifies the specific surgical intervention, the elapsed time since surgery, and the primary focus of the visit. The twelve example labels are:
- Post-Surgical Healing, 50-Year-Old Non-Smoker
- Re-Evaluation After Periodontal Graft, 28-Year-Old Non-Smoker
- Re-Evaluation After Ridge Preservation, 32-Year-Old Non-Smoker
- Re-Evaluation After Periodontal Surgery, 48-Year-Old Non-Smoker
- Re-Evaluation After Periodontal Abscess Drainage, 40-Year-Old Non-Smoker
- Re-Evaluation After Ridge Preservation, 29-Year-Old Smokers
- Re-Evaluation After Periodontal Graft, 34-Year-Old with Periodontal Disease Relapse
- Re-Evaluation After Periodontal Surgery, 45-Year-Old with Severe Periodontitis
- Post-SRP Re-Evaluation, 58-Year-Old with Chronic Obstructive Pulmonary Disease
- Post-SRP Re-Evaluation, 66-Year-Old with Hypothyroidism
- Re-Evaluation After Periodontal Abscess Drainage, 52-Year-Old Anticoagulated
- Re-Evaluation After Ridge Preservation, 37-Year-Old with Osteopenia
Special Patient Group Follow-Ups
Post-SRP Re-Evaluation with Anticoagulation
- Post-SRP Re-Evaluation, 55-Year-Old Anticoagulated
- Post-SRP Re-Evaluation, 72-Year-Old with Anticoagulation Therapy
Post-SRP Surgical Follow-Ups (Graft/Ridge Preservation)
- Re-Evaluation After Periodontal Graft, 28-Year-Old Non-Smoker
- Re-Evaluation After Ridge Preservation, 32-Year-Old Non-Smoker
- Re-Evaluation After Periodontal Graft, 34-Year-Old with Periodontal Disease Relapse
- Re-Evaluation After Periodontal Graft, 39-Year-Old with Sjögren’s Syndrome
- Re-Evaluation After Ridge Preservation, 37-Year-Old with Osteopenia
- Re-Evaluation After Ridge Preservation, 31-Year-Old with Down Syndrome
- Re-Evaluation After Ridge Preservation, Down Syndrome
Down Syndrome Follow-Ups
- Re-Evaluation After Ridge Preservation, 31-Year-Old with Down Syndrome
- Re-Evaluation After Ridge Preservation, Down Syndrome
Post-SRP Re-Evaluation General & Cardiac
- Post-SRP Re-Evaluation, 70-Year-Old Non-Smoker
- Post-SRP Re-Evaluation, 73-Year-Old with Chronic Heart Failure
These examples show structure and wording only. Record what you actually found and did, and follow your practice’s documentation requirements.
