Dental Follow-Up Visit SOAP Note: 30+ Ready-to-Copy Examples
A dental follow-up visit evaluates healing after a procedure, monitors pain, infection, and functional status, and plans …
A second-opinion dental consultation SOAP note documents a focused evaluation requested by another clinician or the patient to clarify diagnosis or treatment options. Unlike a routine exam, it centers on the specific concern, includes the referring clinician’s question, and records the opinion, alternative plans, and communication back to the referrer. The first fully populated example note below demonstrates how to capture all required elements concisely and clinically.
Post-Operative Complications
Smoker, Day 3 After Lower Molar Extraction
- Subjective
- 44-year-old male, smoker 5 cigarettes/day, on low-dose aspirin, NKDA; CC: “I’m still feeling a lot of pain and swelling after the extraction”; HPI: pain 7/10, worsening with heat, no trismus; PMH: smoking, aspirin; allergies: NKDA.
- Objective
- Extraoral: mild swelling at right mandibular angle, no erythema, no lymphadenopathy; Intraoral: socket closed with dry pink flap, no drainage, mild tenderness; Probing: socket depth 3 mm, no bleeding on probing; PA radiograph: normal bone, no fracture; Vitals: 98.6 °F, afebrile.
- Assessment
- Post-operative pain and mild edema after lower molar extraction, consistent with findings of mild swelling, socket closure, and pain severity.
- Plan
- Re-educated on pain control; instructed to use ice packs every 20 minutes for 24 hours; advised gentle oral hygiene with rinses; no medication prescribed; next visit in 7 days for reassessment.
Post-Op Day 7, Persistent Pain
- Subjective
- 63-year-old female, no significant medical history, allergic to penicillin (rash); CC: “I still have a lot of pain and the area is swollen”; HPI: pain persists 7 days post-extraction of #14, throbbing, 6/10, worsens with chewing; no trismus, temperature 99.1 °F; PMH: none; medications: none; allergies: penicillin rash; social: none.
- Objective
- Extraoral: moderate swelling left maxillary region, no erythema, no lymphadenopathy; Intraoral: extraction socket #14 closed with pink flap, mild tenderness, no drainage; Probing: socket depth 4 mm, slight bleeding on probing; Radiograph: PA of #14 shows normal bone, no fracture; Temperature 99.1 °F; Pain 6/10, throbbing, worse with chewing; No trismus.
- Assessment
- Post-operative pain and swelling after upper molar extraction, consistent with expected healing phase and mild inflammatory response; no signs of infection or mechanical complication.
- Plan
- Advised ice packs to the left maxillary area, soft diet, oral hygiene with chlorhexidine 0.12% rinse 15 mL twice daily; instructed to monitor temperature and swelling, report fever >100.4 °F or increasing pain; no medication prescribed; next visit scheduled in 14 days for reevaluation.
Post-Op Day 14, Implant Failure
- Subjective
- 78-year-old former smoker, NKDA, reports “The implant site is still mobile and painful”; pain 5/10, dull, persistent.
- Objective
- Extraoral: no swelling, no erythema; intraoral: implant in #18 shows slight mobility (Miller grade 1), mild tenderness, socket closed with pink flap; probing depth 2 mm, no BOP; PA radiograph: implant present, surrounding bone radiolucency 3 mm diameter; temp 98.4 °F, no trismus.
- Assessment
- Implant failure with peri-implantitis, supported by mobility, tenderness, 2 mm probing depth, and radiolucent bone area.
- Plan
- Scheduled surgical debridement and implant removal; discussed options for new implant or fixed bridge; no medications prescribed; instructed to keep site clean, avoid trauma, and return for surgery.
Post-Op Day 2, Severe Post-Extraction Pain
- Subjective
- 64-year-old female, asthma, NKDA, reports “I have severe pain after the extraction and it’s not going away”; pain 9/10, throbbing, worse with heat and chewing, trismus 30 mm; temperature 100.2 °F.
- Objective
- Extraoral marked swelling at right mandibular angle, slight erythema, no lymphadenopathy; intraoral extraction socket of #32 closed with pink flap, severe tenderness, no drainage; probing depth 5 mm, bleeding on probing; PA radiograph shows normal bone, no fracture; no spreading swelling.
- Assessment
- Acute post-extraction pain with possible early infection supported by fever, trismus, socket tenderness, bleeding on probing.
- Plan
- Administered ibuprofen 400 mg PO q6 h PRN up to 3 days; instructed to apply ice packs to the angle, maintain oral hygiene, and return if pain worsens or swelling spreads.
Post-Op Day 5, Persistent Swelling
- Subjective
- 27-year-old male, controlled hypertension on lisinopril, NKDA, reports “the swelling around the extraction site is still there” after #15 removal; pain 4/10 dull, persistent, no trismus.
- Objective
- Extraoral shows moderate swelling left maxillary region, no erythema or lymphadenopathy; intraoral extraction socket closed with pink flap, mild tenderness, no drainage; socket depth 3 mm, no bleeding on probing; PA radiograph normal bone, no fracture; temperature 98.7 °F.
- Assessment
- Post-operative swelling after upper molar extraction, with no infection or systemic signs.
- Plan
- Advised ice packs 15 min every 2 hrs, soft diet, chlorhexidine 0.12% rinse 15 mL twice daily; no medication prescribed; instructed to return if swelling increases, pain >6/10, or fever develops.
Post-Op Day 10, Implant Mobility
- Subjective
- 79-year-old male, NKDA, reports “the implant feels loose and I’m still in pain” (6/10 throbbing, persistent); no fever, trismus, or swelling.
- Objective
- Extraoral exam shows no erythema or swelling; intraoral implant site in #19 has mild tenderness, socket closed with pink flap, Miller grade 2 mobility; probing depth 3 mm, no bleeding on probing; PA radiograph reveals a 4 mm radiolucent area around the implant indicating bone loss; temperature 98.5 °F.
- Assessment
- Implant mobility with peri-implantitis, supported by Miller grade 2 mobility, 3 mm probing depth, and 4 mm radiolucent bone loss on PA.
- Plan
- Scheduled implant removal and bone grafting; discussed future restoration options; no drugs administered; instructed to keep the area clean, avoid chewing on the site, and return for graft assessment in 2 weeks.
Post-Op Day 3, Persistent Pain After Endodontic Retreatment
- Subjective
- 77-year-old male, type 2 diabetes on metformin, NKDA, reports persistent dull pain after endodontic retreatment of tooth #25, pain 5/10, no trismus.
- Objective
- Extraoral mild swelling right mandibular region, no erythema, no lymphadenopathy; intraoral post-retreatment site pink, mild tenderness, no drainage, socket closed; probing 2 mm, no bleeding; PA radiograph shows 4 mm periapical radiolucency, no fracture; temperature 98.9 °F.
- Assessment
- Persistent pain after endodontic retreatment with chronic apical periodontitis, supported by periapical radiolucency and lingering tenderness.
- Plan
- Advised continuation of ibuprofen 400 mg q6 h PRN up to 3 days, maintain oral hygiene, next visit in 2 weeks.
Post-Op Day 4, Persistent Bleeding After Extraction
- Subjective
- 24-year-old female, hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “I’m still bleeding after the extraction”; HPI: bleeding from #20 socket since extraction, pain 3/10, no swelling, no trismus; PMH: levothyroxine; no other medications.
- Objective
- Extraoral: no swelling or erythema; Intraoral: extraction socket of #20 shows active bleeding, no clot; probing depth 1 mm, bleeding on probing; PA of #20: normal bone, no fracture; T 98.6 °F; pain 3/10, mild, not worsening.
- Assessment
- Post-operative bleeding after lower left premolar extraction, supported by active bleeding, absence of clot, and normal radiograph.
- Plan
- Applied gauze pressure, instructed patient to bite on gauze for 20 min; advised to avoid alcohol and NSAIDs for 24 h; no medication prescribed; instructed to return if bleeding persists or pain increases.
Follow-Up, Persistent Post-Extraction Swelling
- Subjective
- 54-year-old male, smoker, NKDA, reports “the swelling after the extraction is still there” (HPI). History: extraction of #16 performed 7 days ago; pain 4/10, dull, persistent, no trismus.
- Objective
- Extraoral: moderate swelling left maxillary region, no erythema, no lymphadenopathy. Intraoral: socket closed with pink flap, mild tenderness, no drainage, probing 3 mm, no bleeding. PA radiograph: normal bone, no fracture. Temperature 98.8 °F.
- Assessment
- Post-operative swelling after upper molar extraction, likely inflammatory edema without infection.
- Plan
- Advised ice packs to the left maxillary area, soft diet, chlorhexidine 0.12% rinse 15 mL twice daily for 7 days. No medication prescribed. Patient instructed to return if swelling worsens, pain increases, or drainage develops.
Second Opinion for Systemic Conditions
Diabetic, HbA1c 9.2, Uncontrolled Pain
- Subjective
- 73-year-old female, type 2 diabetes on metformin, seasonal allergies, NKDA; chief complaint: “I have been having uncontrolled pain in my lower right molars for the past two weeks.” HPI: pain constant, throbbing, radiating to adjacent teeth, not relieved by OTC analgesics.
- Objective
- Extraoral: facial symmetry WNL, no cervical lymphadenopathy. Intraoral: deep caries with pulpal exposure on tooth #30, mild buccal mucosal swelling, no trismus. Radiograph: periapical radiolucency extending to the apex of #30, no other significant findings.
- Assessment
- Pulp necrosis with acute apical abscess of tooth #30, complicated by uncontrolled diabetes increasing risk of infection spread.
- Plan
- Recommend endodontic therapy for #30; discuss infection risks due to diabetes, obtain informed consent, schedule referral to endodontist within 7 days. No medications prescribed today.
Elderly, Osteoporosis, Bone Loss Concern
- Subjective
- 43-year-old female, takes daily low-dose aspirin, NKDA, reports a “persistent sore spot” on the lower right first molar that has not healed; she denies pain, swelling, or systemic symptoms.
- Objective
- Extraoral exam shows no swelling or enlarged lymph nodes; intraoral exam reveals a 5 mm ulcerated lesion on the buccal surface of tooth #30 with an indurated base; radiograph demonstrates mild bone loss around #30 and no periapical radiolucency.
- Assessment
- Chronic apical periodontitis of tooth #30 with secondary ulceration, supported by the ulcerated buccal lesion, mild bone loss, and absence of periapical pathology.
- Plan
- Discussed treatment options of root canal therapy versus extraction; advised continuation of aspirin therapy; no antibiotics prescribed due to lack of systemic signs; scheduled definitive treatment (root canal or extraction) in 10 days.
Allergy to Latex, Referred for Anesthesia
- Subjective
- 46-year-old male, “I need anesthesia for a dental procedure but I’m allergic to latex.” PMH: no significant medical history; latex allergy confirmed.
- Objective
- Extraoral: facial symmetry, normal TMJ, no lymphadenopathy. Intraoral: mucosa intact, no lesions or caries; no active pathology noted.
- Assessment
- Latex allergy confirmed; no systemic signs.
- Plan
- Recommend latex-free instruments and gloves. Administer 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), infiltration at the planned site. Discuss alternative anesthetics if needed. Plan procedure in 5 days.
Elderly, Cognitive Decline, Uncooperative
- Subjective
- 28-year-old female, former smoker, NKDA; CC: “I can’t sit still during appointments; I feel confused and sometimes forget what the dentist says.” HPI: reports difficulty staying still, confusion, occasional memory lapses; medical history unchanged.
- Objective
- Extraoral: no facial asymmetry; Intraoral: mild gingival recession on tooth #8, no caries; Radiograph: mild bone loss around #8, no periapical pathology; periodontal assessment: stage I, grade A.
- Assessment
- Cognitive decline with uncooperative behavior; periodontal stage I, grade A supported by mild recession and bone loss on #8.
- Plan
- Recommend short, focused appointments with clear instructions; consider sedation if necessary; no drugs prescribed; next visit in 4 weeks for periodontal maintenance.
Pregnancy, 34 Weeks, Amniotic Fluid Leak
- Subjective
- 69-year-old female, currently 34 weeks pregnant, reports a leaking amniotic fluid and asks whether dental treatment is safe; she has asthma managed with albuterol PRN and reports no known drug allergies. She denies pain, swelling, or other oral symptoms and states that her dental history is unremarkable, with no recent extractions or restorations.
- Objective
- Extraoral examination reveals no facial swelling, lymphadenopathy, or TMJ dysfunction; intraoral inspection shows healthy gingiva, intact mucosa, no caries, abscesses, or ulcerations; caries risk appears low; periodontal probing shows no bleeding on probing and pocket depths within normal limits.
- Assessment
- Pregnancy, 34 weeks, amniotic fluid leak with dental status within normal limits; no urgent dental pathology identified; systemic signs are absent, and the patient is otherwise medically stable.
- Plan
- Counsel patient to postpone non-essential dental work until after delivery; if urgent care is required (e.g., acute pain, infection), proceed with local anesthesia only, avoid systemic antibiotics unless a true infection is present; provide written instructions on oral hygiene, schedule a follow-up appointment for 6–8 weeks postpartum to reassess dental needs and overall health.
Allergy to Aspirin, Referred for Anticoagulation
- Subjective
- 52-year-old male, controlled hypertension on lisinopril, allergic to aspirin (rash); CC: “I have a painful tooth and I can’t take aspirin for pain relief.” O: extraoral normal; intraoral deep caries on #16 with pulpal exposure and mild buccal mucosal swelling; PA radiograph shows periapical radiolucency around #16, no other findings. A: pulp necrosis with acute apical abscess of tooth #16, evidenced by pulpal exposure, buccal swelling, and periapical radiolucency. P: recommend endodontic therapy for #16; prescribe ibuprofen 400 mg PO q6h PRN for 5 days for pain; continue lisinopril; no antibiotic indicated; schedule definitive treatment in 7 days.
Elderly, Renal Failure, Medication Review
- Subjective
- 80-year-old male, NKDA, reports a persistent sore spot in the lower right molar area, saying “I have been having a persistent sore spot in my lower right molar area.” HPI: pain intermittent, dull, not triggered by chewing, no swelling or fever.
- Objective
- Extraoral: facial symmetry WNL. Intraoral: periodontal stage III, grade B on tooth #30; mobility grade 1; bleeding on probing 30%; periapical radiolucency 3 mm; mild bone loss around #30; no other lesions.
- Assessment
- Chronic apical periodontitis of tooth #30 with periodontal stage III, grade B, supported by radiolucency, probing depth, and bleeding on probing.
- Plan
- Recommend endodontic therapy for tooth #30; discuss adjustment of renal-failure medications with nephrology; no local anesthesia given; schedule follow-up in 4 weeks.
Elderly, Osteopenia, Bone Loss After Extraction
- Subjective
- 34-year-old female, type 2 diabetes on metformin, NKDA; chief complaint: “My lower right first molar site still looks raw and feels sore after the extraction six months ago.” HPI: socket remains raw, sore, no swelling or infection. O: extraoral normal; intraoral: extraction socket #30 shows delayed healing, raw mucosa; periapical radiograph: 5 mm radiolucent area, reduced bone density; systemic: HbA1c 6.8 %, well controlled. A: delayed bone healing post-extraction with osteopenia contributing to poor osseointegration, evidenced by radiolucent area and low bone density. P: recommend bone grafting material placement at socket; advise strict glycemic control; refer to periodontist for surgical management; no medication prescribed; schedule follow-up in 6 weeks.
Pregnancy, 18 Weeks, Dental Pain
- Subjective
- 39-year-old female, pregnant, hypothyroid on levothyroxine, allergic to penicillin (rash); chief complaint: “My upper left canine hurts when I bite down and feels hot to the touch.” O: Deep caries to outer dentin on the occlusal surface of tooth #11; pulpal exposure noted; no swelling, trismus, or fever; temperature normal; no systemic signs. A: Symptomatic irreversible pulpitis of tooth #11, evidenced by deep caries, pulpal exposure, biting pain, and heat sensitivity. P: Root canal therapy performed under 4% articaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration; discussed postoperative care; prescribed ibuprofen 400 mg PO q6h PRN; scheduled obturation appointment in 2 weeks.
Second Opinion, Recurrent Apical Periodontitis
- Subjective
- 76-year-old female, smoker 5 cigarettes/day, NKDA, reports “pain in my lower right molar keeps coming back after the root canal I had last year.” HPI: recurrent pain localized to tooth #30, no trismus, mild gingival swelling, temperature 99.5 °F.
- Objective
- Periapical radiolucency 6 mm around #30; mild adjacent gingival swelling; bleeding on probing 20%; temperature 99.5 °F; no trismus.
- Assessment
- Recurrent apical periodontitis of tooth #30, evidenced by 6 mm periapical radiolucency, BOP 20%, and low-grade fever.
- Plan
- Endodontic retreatment of tooth #30 performed; patient counseled on smoking cessation; prescribed amoxicillin 500 mg PO q8h and ibuprofen 400 mg PO q6h PRN; instructed on oral hygiene and infection signs; scheduled follow-up in 1 month.
Second Opinion, Unexplained Jaw Pain After Orthognathic Surgery
- Subjective
- 25-year-old female patient, seasonal allergies, NKDA, reports a dull ache on the right side of her jaw despite orthognathic surgery performed a year ago.
- Objective
- TMJ examination normal, no clicking or deviation; no swelling or redness; pain localized to right mandibular angle on palpation; panoramic radiograph shows no pathology; no intraoral lesions.
- Assessment
- Post-surgical myofascial pain of the right mandibular angle, supported by localized tenderness and normal TMJ/jaw structures.
- Plan
- Referred to physiotherapy for myofascial release; prescribed ibuprofen 400 mg PO q6h PRN for pain control; scheduled reassessment in 4 weeks.
Second Opinion, Persistent Halitosis in Diabetic Patient
- Subjective
- 50-year-old male with type 2 diabetes on metformin, low-dose aspirin, NKDA, reports persistent halitosis despite brushing and flossing; he has no other systemic complaints. O: Extraoral exam shows no facial asymmetry or lymphadenopathy; intraoral exam reveals generalized gingival inflammation with bleeding on probing 40 % of sites, plaque index ≥3, no caries or restorations, and periodontal probing depths consistent with Stage II, Grade A disease; radiographs show no bone loss beyond normal for periodontitis; HbA1c 6.5 % confirms good glycemic control. A: Periodontal disease contributing to halitosis, evidenced by high BOP, plaque accumulation, and periodontal staging. P: Performed full-mouth scaling and root planing; provided detailed oral hygiene instruction; prescribed chlorhexidine gluconate 0.12 % rinse, 15 mL, 30 s, BID for 4 weeks; discussed probiotic supplement to support microbiome balance; no anesthesia was required; scheduled follow-up in 3 months to reassess periodontal status and odor improvement.
Allergy & Medication Management
Allergy to Penicillin, Referred for Antibiotic Selection
- Subjective
- 22-year-old male, no significant medical history, allergic to penicillin (rash); chief complaint: “I have a toothache and I’m worried about antibiotics because I had a rash to penicillin.” HPI: pain localized to right mandibular molar region, mild swelling on buccal mucosa, no exposed bone.
- Objective
- Intraoral: mild buccal swelling, periodontal probing depth 3 mm on tooth #30; radiograph: periapical radiolucency around #30 consistent with acute apical abscess; vital signs: 98.6 °F, 78 bpm, afebrile; no systemic signs.
- Assessment
- Pulp necrosis with acute apical abscess of tooth #30, supported by radiolucency, probing depth, and localized swelling.
- Plan
- Discussed definitive endodontic treatment; patient declined immediate root canal due to anxiety. Referred to endodontist for evaluation. Advised non-antibiotic pain control (NSAID) and strict oral hygiene; no antibiotics prescribed given lack of systemic involvement. Next visit: follow-up after endodontist assessment.
Allergy to Clindamycin, Referred for Antibiotic Choice
- Subjective
- 61-year-old male, former smoker, allergic to clindamycin (rash); chief complaint: “My upper left canine hurts when I bite down and I’m scared of antibiotics because of a rash to clindamycin”; medical history: none other than former smoker; medications: none; allergies: clindamycin rash.
- Objective
- Intraoral exam shows deep caries on mesial surface of tooth #11 extending into dentin; tenderness to percussion; periodontal probing depth 4 mm; periapical radiograph reveals periapical radiolucency consistent with chronic apical periodontitis; vital signs: temperature 98.4 °F; no lymphadenopathy; anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), buccal infiltration.
- Assessment
- Symptomatic irreversible pulpitis of tooth #11 with chronic apical periodontitis, supported by deep dentin caries, percussion tenderness, 4 mm probing depth, and periapical radiolucency.
- Plan
- Performed pulpotomy with calcium hydroxide and temporary restoration; discussed definitive root canal therapy in 2 weeks; no antibiotics indicated; prescribed chlorhexidine gluconate 0.12% mouthwash, 15 mL twice daily; advised to return for definitive RCT.
Allergy to Amoxicillin, Referred for Antibiotic Choice
- Subjective
- 41-year-old female, asthma, allergic to amoxicillin (rash); CC: “My upper right first molar is painful and I can’t eat because of the pain. I’m worried about antibiotics because I had a rash to amoxicillin.” HPI: pain on #3, difficulty chewing, no fever. PMH: asthma, albuterol PRN.
- Objective
- Intraoral: extensive occlusal caries on #3 extending into dentin, tenderness to percussion, 3 mm periodontal probing depth; mild buccal mucosal swelling adjacent to #3; PA shows periapical radiolucency consistent with acute apical abscess; vital signs normal (98.7 °F, no lymphadenopathy).
- Assessment
- Pulp necrosis with acute apical abscess of tooth #3, supported by caries, percussion tenderness, radiolucency, and localized swelling.
- Plan
- 4% articaine with 1:100,000 epinephrine, 1.8 mL infiltration administered; placed temporary restoration; prescribed ibuprofen 400 mg PO q6h PRN up to 3 days; chlorhexidine 0.12% rinse 15 mL for 30 s twice daily; no antibiotics given due to lack of systemic infection; discussed doxycycline as alternative if future antibiotic needed; referred to endodontist for definitive RCT; next visit to assess pain control.
Orthodontic and Periodontal Referrals
Teenager, Orthodontic Relapse
- Subjective
- 68-year-old male, controlled hypertension, NKDA, CC: “My braces came back into place after the last adjustment.” HPI: mild relapse of lower incisors, no pain.
- Objective
- Extraoral normal; intraoral: mild overjet 3 mm, mild crowding of #15-#16, no caries, probing 1-2 mm, no BOP, occlusal contacts slight relapse; PAN shows no root resorption.
- Assessment
- Orthodontic relapse based on overjet, crowding, and occlusal contact changes.
- Plan
- Discussed re-treatment options with orthodontist; referred for orthodontic evaluation and possible re-adjustment or re-bonding; advised strict oral hygiene and avoidance of premature contacts; no drugs prescribed.
Smoker, Chronic Periodontitis, Referred for Surgical Plan
- Subjective
- 75-year-old male, smoker 5 cigarettes/day, NKDA, reports “my gums bleed a lot when I brush.” HPI: chronic bleeding with no pain, no systemic symptoms.
- Objective
- Deep pockets 6–8 mm on buccal and lingual surfaces of #30 and #31; BOP present at all sites; CAL 5 mm (#30), 4 mm (#31); PA shows horizontal bone loss 30 % of root length; no swelling or trismus; IANB 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
- Assessment
- Chronic periodontitis, stage III, grade B, supported by deep pockets, CAL, BOP, and radiographic bone loss.
- Plan
- Scaling and root planing performed; plan periodontal flap surgery discussed with periodontist; reinforce oral hygiene, schedule postoperative follow-up in 2 weeks.
Teenager, Bruxism, Tooth Wear
- Subjective
- 36-year-old male, type 2 diabetes on metformin, NKDA. Chief complaint: “My front teeth look worn and I grind them at night.” History: nocturnal grinding, no pain, HbA1c 6.8%, no other systemic signs.
- Objective
- Attrition 2 mm on incisal edges of #7 and #8; no caries or restorations; probing depths 1 mm, no bleeding on probing; premature occlusal contacts on #7 and #8; panoramic radiograph shows no root resorption; periodontal status within normal limits.
- Assessment
- Bruxism with tooth wear, evidenced by 2 mm incisal attrition, premature contacts, nocturnal grinding, and absence of caries or periodontal disease.
- Plan
- No anesthesia used. Fluoride varnish applied to worn surfaces. Referred for custom night guard fabrication. Counselled on stress management, avoidance of hard foods, and scheduled review in 3 months to assess wear progression.
Urgent, Pregnancy, and Sensitivity Presentations
Pregnant, 28 Weeks, Recurrent Canker Sores
- Subjective
- 49-year-old female, pregnant 28 weeks, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “I have a sore spot on my lower right back tooth that’s been burning for the last week.”
- Objective
- Tooth #30 shows deep dentin caries with pulpal exposure, 4 mm deep; PA shows no periapical radiolucency; BOP present, PD 6 mm; extraoral: no swelling, no trismus, temperature 37.0 °C, no lymphadenopathy.
- Assessment
- Symptomatic irreversible pulpitis of tooth #30, supported by pulpal exposure, deep caries, pain, BOP, and PD ≥6 mm.
- Plan
- Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; placed calcium hydroxide dressing; prescribed ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days; instructed on oral hygiene, advised to avoid hot foods, and scheduled for root canal therapy next visit.
Pregnancy, 12 Weeks, Acute Gingivitis
- Subjective
- 23-year-old pregnant female, 12 weeks, smoker 5 cigarettes/day, NKDA. CC: “My upper left canine hurts when I bite down and it’s swollen.” HPI: acute pain on biting, swelling noted, no other symptoms. PMH: pregnancy, smoking; no medications, no allergies.
- Objective
- Tooth #11 shows moderate gingival inflammation, BOP, PD 5 mm; no caries, no periapical radiolucency. Extraoral exam: no swelling, no trismus, temp 36.8 °C, no lymphadenopathy. Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration, aspiration negative.
- Assessment
- Acute gingivitis of the maxillary left canine area, supported by BOP, PD 5 mm, inflammation, no radiolucency.
- Plan
- Performed professional scaling and root planing of #11, instructed on oral hygiene, prescribed chlorhexidine gluconate 0.12% rinse 15 mL, 30 s, twice daily for 7 days. Advised patient on safe use during pregnancy, smoking cessation, and scheduled follow-up in 2 weeks to reassess gingival health.
Pregnancy, 20 Weeks, Dental Trauma
- Subjective
- 67-year-old pregnant female, seasonal allergies, NKDA, reports “I fell and the front tooth on my lower left side is knocked out”; no pain, swelling, or trismus noted.
- Objective
- PA shows traumatic avulsion of tooth #23, no periodontal ligament space, no periapical radiolucency; extraoral exam normal, temperature 36.9 °C, no lymphadenopathy.
- Assessment
- Traumatic avulsion of tooth #23, confirmed by PA and clinical exam.
- Plan
- Re-implantation performed with 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; splinting with composite resin; ibuprofen 400 mg PO q6h PRN for 3 days; oral hygiene and pain control instructions given; next visit in 48 h.
First-Visit, Acute Mandibular Pain with Fever
- Subjective
- 30-year-old female, daily low-dose aspirin, NKDA, reports “sharp pain in lower left front tooth and feverish feeling”; history of acute onset, pain worsens with biting, relieved only by rest; no trismus, no lymphadenopathy.
- Objective
- Tooth #23 shows deep caries with pulpal exposure, 5 mm deep, periapical radiolucency 4 mm; BOP on #23, PD 7 mm; swelling of lower left buccal mucosa 2 cm; temperature 38.2 °C; extraoral exam normal; infiltration anesthesia 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
- Assessment
- Acute apical abscess of tooth #23, supported by pulpal exposure, periapical radiolucency, BOP, PD 7 mm, swelling, fever.
- Plan
- Incision and drainage performed, calcium hydroxide dressing placed; amoxicillin 500 mg PO q8h for 7 days, ibuprofen 400 mg PO q6h PRN up to 3 days; instructed on oral hygiene, pain control, avoid hot foods; scheduled for root canal therapy next visit.
Emergency, Traumatic Avulsion of Incisor
- Subjective
- 72-year-old female, allergic to penicillin, reports “My upper right canine is completely knocked out”; no medical history, no systemic signs, temperature 36.7 °C, no lymphadenopathy.
- Objective
- Tooth #6 avulsed, displaced, no periodontal ligament space on PA, no periapical radiolucency, no swelling, no trismus; infiltration anesthesia 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
- Assessment
- Traumatic avulsion of tooth #6, confirmed by PA and clinical findings.
- Plan
- Re-implantation performed with 2% lidocaine infiltration; composite resin splint applied; patient instructed on oral hygiene, ibuprofen 400 mg q6h PRN up to 3 days; follow-up scheduled in 48 h.
First-Visit, Severe Tooth Sensitivity Post-Whitening
- Subjective
- 51-year-old female, former smoker, NKDA; CC: “After my whitening last week, this tooth hurts every time I drink cold”; HPI: sensitivity to cold on tooth #30, no other pain; PMH: none; medications: none; allergies: none.
- Objective
- Extraoral: symmetrical, no lymphadenopathy; Intraoral: tooth #30 post-whitening sensitivity, no caries, no periapical radiolucency; BOP absent, PD 2 mm; no swelling, no trismus; temperature 36.8 °C; no other findings.
- Assessment
- Severe tooth sensitivity post-whitening of tooth #30, supported by cold-induced pain, normal periodontal probing, and absence of decay or infection.
- Plan
- IANB with 2% lidocaine 1:100,000, 1.8 mL (1 cartridge), aspiration negative; applied desensitizing fluoride varnish to tooth #30; instructed to avoid extreme temperatures, use desensitizing toothpaste, and maintain good oral hygiene; no prescription drugs; scheduled follow-up in 2 weeks.
Emergency, Fractured Mandibular Incisor
- Subjective
- 60-year-old female, asthma (albuterol PRN), NKDA, reports “My lower right molar is fractured and I can’t bite down”; fever 38.0 °C, swelling 1.5 cm buccal, no trismus, no lymphadenopathy.
- Objective
- Tooth #30 shows fractured crown with exposed pulp, 3 mm deep; periapical radiolucency 3 mm; BOP present, PD 6 mm; swelling of lower right buccal mucosa 1.5 cm; temperature 38.0 °C; IANB with 2% lidocaine + 1:100,000 epinephrine, 1.8 mL, aspiration negative.
- Assessment
- Fractured mandibular incisor with acute apical abscess of tooth #30, supported by exposed pulp, periapical radiolucency, BOP, deep probing depth, swelling and fever.
- Plan
- Administered local anesthesia, performed pulpal extirpation, placed calcium hydroxide dressing; prescribed amoxicillin 500 mg q8h for 7 days and ibuprofen 400 mg q6h PRN up to 3 days; instructed on oral hygiene, pain control, and scheduled root canal therapy next visit.
Follow-Up After Treatment
Follow-Up, Post-RCT Pain in Tooth 47
- Subjective
- 45-year-old female, controlled hypertension on lisinopril, NKDA, reports “I’m still having pain after the root canal on tooth 30.” HPI: pain persists post-RCT, no fever or systemic symptoms.
- Objective
- Extraoral: no facial swelling or lymphadenopathy. Intraoral: slight erythema over the tooth 30 site; palpation of the lower right second molar shows mild tenderness. Periapical radiograph: radiolucency reduced compared to pre-treatment, no new bone loss.
- Assessment
- Symptomatic apical periodontitis of tooth #30, supported by persistent tenderness, mild mucosal erythema, and residual periapical radiolucency.
- Plan
- Prescribed ibuprofen 400 mg PO q6h PRN for 5 days; instructed to monitor pain, maintain oral hygiene, and return in 2 weeks if symptoms persist or worsen. No anesthesia administered.
Follow-Up, Implant Peri-Implantitis
- Subjective
- 33-year-old male, NKDA, reports “the implant site is still red and painful.” HPI: persistent erythema and discomfort at #28 since last procedure.
- Objective
- peri-implant mucosa erythematous, swollen, bleeding on probing; probing depth 6 mm mesial and distal; implant immobile; PA shows 2 mm bone loss, no radiolucent lesion; extraoral: no facial swelling or lymphadenopathy.
- Assessment
- peri-implantitis of implant at tooth #28, evidenced by erythema, BOP, 6 mm probing depth, and 2 mm bone loss.
- Plan
- Debridement performed; chlorhexidine 0.12% rinse 15 mL for 30 sec twice daily; amoxicillin 500 mg PO TID for 7 days prescribed; instructed on oral hygiene and to return in 4 weeks for reassessment.
Oral Cancer Screening and Chronic Conditions
Smoker, Chronic Halitosis
- Subjective
- 74-year-old female, smoker 5 cigarettes/day, type 2 diabetes on metformin, NKDA, complaints “bad breath for months, want to rule out serious issue.”
- Objective
- Extraoral: facial symmetry WNL, no cervical nodes, TMJ normal. Intraoral: mild erythema left buccal mucosa, 5 mm flat non-ulcerated lesion, no tongue or palate ulceration. Periodontal: PSR 1 all teeth, BOP 10 %, PD 3 mm avg, no recession. Radiographs: full-mouth series, no periapical radiolucencies, bone levels WNL.
- Assessment
- Chronic halitosis secondary to smoking; oral cancer screening negative.
- Plan
- Reassure patient, advise smoking cessation counseling, schedule routine recall in 6 months, provide written oral hygiene and diet instructions. No drugs or anesthesia administered.
Smoker, Chronic Halitosis, Referred for Oral Cancer Screening
- Subjective
- 40-year-old female smoker, 5 cigarettes/day, hypothyroidism on levothyroxine 75 µg; CC: “I’ve noticed a small sore on my tongue for a week and I’m worried it might be cancer because I smoke.” O: extraoral: no lymphadenopathy, TMJ normal; intraoral: 4 mm ulcerated lesion on ventral tongue, indurated base, 2 mm margin, no surrounding induration, no other lesions; periodontal: PSR 2 all teeth, BOP 15 %, PD 4 mm avg, mild lower incisor recession; no radiographs taken. A: suspected oral cancer in smoker; biopsy indicated. P: discussed biopsy options, referred to oral medicine specialist, provided written instructions to avoid irritants and maintain oral hygiene; no drugs prescribed; scheduled follow-up in 2 weeks to review referral status.
Referral, Suspected Oral Cancer in Smokers
- Subjective
- 31-year-old male, smoker 5 cigarettes/day, NKDA, reports a sore on his cheek that has persisted for a few days and is not healing; he fears it could be cancer.
- Objective
- Extraoral exam shows no cervical lymphadenopathy and normal TMJ; intraoral exam reveals a 6 mm ulcerated lesion on the left buccal mucosa with an indurated base and 1 mm margin, no induration of surrounding mucosa, and no other lesions; periodontal status PSR 1 on all teeth, BOP 8%, PD 3 mm average, no recession; no radiographs were taken as the clinical exam was deemed sufficient.
- Assessment
- Suspected oral cancer in a smoker; referral for biopsy.
- Plan
- Explained the need for biopsy and referred to oral medicine; advised tobacco cessation and provided written oral hygiene instructions; scheduled a follow-up in 2 weeks to confirm referral completion.
Documenting a Differential Diagnosis in a Second-Opinion Context
- List potential diagnoses in order of likelihood, each on a separate line, e.g., “Reversible pulpitis – tooth #15,” “Chronic apical periodontitis – tooth #30,” “Periapical abscess – tooth #30.”
- Provide a concise rationale for each item immediately after the diagnosis, using objective findings: “sharp, throbbing pain on biting, radiolucency at apex of #30” or “BOP and 4 mm PD at #15, no radiolucency.”
- Cite the original recommendation by referencing the referring clinician’s note or prior diagnosis: “Original diagnosis: symptomatic irreversible pulpitis – confirmed/modified after examination.”
- Note any new findings that shift priority: “New periapical radiolucency on PA of #30 increases likelihood of apical periodontitis above reversible pulpitis.”
- End the differential with a brief statement of the most likely diagnosis to guide the plan: “Most likely diagnosis: chronic apical periodontitis – tooth #30.”
Key Distinctions Between a Second-Opinion SOAP Note and a Routine Exam Note
| Element | Second-Opinion SOAP Note | Routine Exam Note |
|---|---|---|
| Referral source | Records referring clinician and contact details. | Typically internal or patient-initiated; source not specified. |
| Chief complaint | Focused on the specific issue asked by referrer (e.g., “Is extraction necessary?”). | General or multiple complaints; not tied to a question. |
| Reason for second opinion | Explicit statement of the question or uncertainty (e.g., “Confirm diagnosis of apical periodontitis”). | Not recorded; exam assumed to address all findings. |
| Comparison with original plan | Notes original recommendation, compares findings, and documents whether it is confirmed, modified, or rejected. | Original plan only referenced if it is a follow-up; no systematic comparison. |
| Alternative options | Lists at least two clinically relevant alternatives, risks, benefits, and patient preference. | Alternatives may be mentioned but not systematically documented. |
| Communication back to referrer | Includes a brief summary of findings, opinion, and recommended next steps sent to referrer. | No formal communication record required. |
| Documentation timing | Must be contemporaneous with the consultation and signed by the reviewing clinician. | Same requirement, but routine exams may be less time-critical. |
| Scope of exam | Limited to the area or problem requested; may omit routine screening unless relevant. | Comprehensive or periodic; includes full charting and screening. |
| Legal emphasis | Higher emphasis on informed consent for the opinion and discussion of alternatives. | Standard consent for routine care. |
Structured Data Tagging for Automated Retrieval of Second-Opinion Notes
Use a concise metadata block at the start of the note.
{
"note_type":"second_opinion",
"visit_reason":"confirm extraction necessity",
"provider_role":"consulting dentist",
"referral_source":"referring clinician",
"patient_age":45,
"medical_history":"diabetes, hypertension",
"allergies":"{allergy list}"
}
Alternatively XML:
<Note>
<Type>second_opinion</Type>
<Reason>confirm extraction necessity</Reason>
<ProviderRole>consulting dentist</ProviderRole>
<Referral>referring clinician</Referral>
<PatientAge>45</PatientAge>
<PMH>diabetes, hypertension</PMH>
<Allergies>{allergy list}</Allergies>
</Note>
These tags index the note in the EHR, enable automated search by question, provider, or patient risk, and allow quick comparison of similar second-opinion cases across the practice.
These examples show structure and wording only. Record what you actually found and did, and follow your practice’s documentation requirements.
