Surgical Extraction SOAP Note: Ready-to-Copy Template & Guidance

Nov 10, 2026 - 52 Min read

More like this in Tooth Extraction and Oral Surgery SOAP Notes

A fully populated surgical extraction SOAP note is available for immediate use, along with a fill-in template that preserves the standard S-O-A-P format. Each section—Subjective, Objective, Assessment, Plan—is annotated with concise explanations, so the clinician can copy, adapt, or reference the example without re-typing. Unlike a simple extraction note, this record includes flap design, bone removal, sectioning details, hemostasis, and postoperative instructions specific to surgical extractions.

Immediate Post-Op Visits (Day 1-3)

Smoker, Day 3 After Lower Molar Extraction

SOAP note

Subjective: 55-year-old male, smoker 5 cigarettes/day, takes low-dose aspirin, NKDA, reports “I still have a lot of pain and the socket feels raw”; pain 8/10, throbbing, radiating to ear.
Objective: Socket shows exposed bone with dry socket appearance; no active bleeding, soft tissue intact, no swelling, temp 98.6°F; pain 8/10.
Assessment: Alveolar osteitis (dry socket) confirmed by exposed bone and pain pattern.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; gentle saline irrigation, medicated dressing with 0.12% chlorhexidine; advised to avoid smoking, use ice packs; prescribed ibuprofen 400 mg q6h PRN up to 3 days and acetaminophen 500 mg q6h PRN up to 3 days; scheduled review in 2 days.

S: 55-year-old male, smoker 5 cigarettes/day, takes low-dose aspirin, NKDA, reports “I still have a lot of pain and the socket feels raw”; pain 8/10, throbbing, radiating to ear.
O: Socket shows exposed bone with dry socket appearance; no active bleeding, soft tissue intact, no swelling, temp 98.6°F; pain 8/10.
A: Alveolar osteitis (dry socket) confirmed by exposed bone and pain pattern.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; gentle saline irrigation, medicated dressing with 0.12% chlorhexidine; advised to avoid smoking, use ice packs; prescribed ibuprofen 400 mg q6h PRN up to 3 days and acetaminophen 500 mg q6h PRN up to 3 days; scheduled review in 2 days.

Smoker, Day 1 After Extraction, First Visit

SOAP note

Subjective: 78-year-old female, smoker, NKDA, reports “I feel a bit of bleeding and my mouth hurts”; history of bleeding stopped after gauze pressure, mild lower lip swelling, pain 4/10, temperature 98.4 °F.
Objective: Socket bleeding ceased, no active bleeding, mild lower lip swelling, pain 4/10, temperature 98.4 °F, no systemic signs.
Assessment: Post-operative bleeding, controlled, supported by cessation of bleeding after gauze pressure and absence of active bleeding.
Plan: 4% articaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; pressure gauze maintained 30 min; patient instructed to bite gauze 60 min, avoid spitting, rinsing, straws, smoking 24 h; use ice packs; ibuprofen 400 mg PRN, 4 mg every 6 h up to 3 days; next visit Day 3 for healing assessment.

S: 78-year-old female, smoker, NKDA, reports “I feel a bit of bleeding and my mouth hurts”; history of bleeding stopped after gauze pressure, mild lower lip swelling, pain 4/10, temperature 98.4 °F.
O: Socket bleeding ceased, no active bleeding, mild lower lip swelling, pain 4/10, temperature 98.4 °F, no systemic signs.
A: Post-operative bleeding, controlled, supported by cessation of bleeding after gauze pressure and absence of active bleeding.
P: 4% articaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; pressure gauze maintained 30 min; patient instructed to bite gauze 60 min, avoid spitting, rinsing, straws, smoking 24 h; use ice packs; ibuprofen 400 mg PRN, 4 mg every 6 h up to 3 days; next visit Day 3 for healing assessment.

Non-Smoker, Day 2 After Extraction, Dry Socket Suspected

SOAP note

Subjective: 69-year-old female, smokes 5 cigarettes daily, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “The pain is worse than before and I see bone in the socket”; medical history: hypothyroidism, smoking; medications: levothyroxine; allergies: penicillin.
Objective: Socket #28 shows exposed bone, empty socket, no bleeding; soft tissue intact; mild lower lip swelling; pain 7/10, throbbing; temperature 98.7°F; no systemic signs.
Assessment: Alveolar osteitis (dry socket) confirmed by exposed bone and pain pattern.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; gentle saline irrigation, medicated dressing with 0.12% chlorhexidine; instructed to avoid smoking, use ice packs; prescribed ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days; scheduled review in 2 days.

S: 69-year-old female, smokes 5 cigarettes daily, hypothyroidism on levothyroxine, allergic to penicillin (rash); chief complaint: “The pain is worse than before and I see bone in the socket”; medical history: hypothyroidism, smoking; medications: levothyroxine; allergies: penicillin.
O: Socket #28 shows exposed bone, empty socket, no bleeding; soft tissue intact; mild lower lip swelling; pain 7/10, throbbing; temperature 98.7°F; no systemic signs.
A: Alveolar osteitis (dry socket) confirmed by exposed bone and pain pattern.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; gentle saline irrigation, medicated dressing with 0.12% chlorhexidine; instructed to avoid smoking, use ice packs; prescribed ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days; scheduled review in 2 days.

Patient with Mild Asthma, Day 1 After Extraction, Post-Op Bleeding

SOAP note

Subjective: 58-year-old female, former smoker, NKDA, reports “I have a bit of bleeding and my mouth feels sore”; pain 5/10, dull; temperature 98.5 °F.
Objective: Socket bleeding controlled after gauze pressure; no active bleeding; mild lower lip swelling; pain 5/10; 4% articaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
Assessment: Post-operative bleeding, controlled, supported by resolved socket bleeding and absence of active hemorrhage.
Plan: Pressure gauze maintained 30 min; patient instructed to bite on gauze for 60 min, avoid spitting, rinsing, straws, and smoking for 24 h; advised ice packs and ibuprofen 400 mg PRN, 400 mg every 6 h as needed up to 3 days; next visit in 3 days for reassessment.

S: 58-year-old female, former smoker, NKDA, reports “I have a bit of bleeding and my mouth feels sore”; pain 5/10, dull; temperature 98.5 °F.
O: Socket bleeding controlled after gauze pressure; no active bleeding; mild lower lip swelling; pain 5/10; 4% articaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
A: Post-operative bleeding, controlled, supported by resolved socket bleeding and absence of active hemorrhage.
P: Pressure gauze maintained 30 min; patient instructed to bite on gauze for 60 min, avoid spitting, rinsing, straws, and smoking for 24 h; advised ice packs and ibuprofen 400 mg PRN, 400 mg every 6 h as needed up to 3 days; next visit in 3 days for reassessment.

Patient on Low-Dose Aspirin, Emergency Extraction, Immediate Hemostasis

SOAP note

Subjective: 77-year-old male, allergic to penicillin (rash), presents with “I need the tooth removed because it’s bleeding a lot”; no significant medical history; on low-dose aspirin.
Objective: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, IANB, aspiration negative; socket bleeding profuse, gauze pressure applied; after 10 min no active bleeding; soft tissue intact; pain 6/10 throbbing; temperature 98.4 °F; systemic signs none.
Assessment: Post-operative bleeding, uncontrolled initially, resolved with local measures.
Plan: Gauze pressure for 30 min, oxidized cellulose placed in socket; instructed to avoid smoking, spitting, rinsing, straws for 24 h; use ice packs; ibuprofen 400 mg PRN, up to 3 days; next visit in 3 days for reassessment.

S: 77-year-old male, allergic to penicillin (rash), presents with “I need the tooth removed because it’s bleeding a lot”; no significant medical history; on low-dose aspirin.
O: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, IANB, aspiration negative; socket bleeding profuse, gauze pressure applied; after 10 min no active bleeding; soft tissue intact; pain 6/10 throbbing; temperature 98.4 °F; systemic signs none.
A: Post-operative bleeding, uncontrolled initially, resolved with local measures.
P: Gauze pressure for 30 min, oxidized cellulose placed in socket; instructed to avoid smoking, spitting, rinsing, straws for 24 h; use ice packs; ibuprofen 400 mg PRN, up to 3 days; next visit in 3 days for reassessment.

Patient with Recent COVID-19, Day 3 After Extraction, Infection Signs

SOAP note

Subjective: 54-year-old female, type 2 diabetes on metformin, NKDA, reports “My mouth hurts and I feel a bad taste” on day 3 after extraction of tooth #16.
Objective: Socket shows exposed bone, mild swelling of upper lip, mild erythema; pain 6/10 throbbing; temperature 99.1 °F; soft tissue intact, no drainage; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
Assessment: Alveolar osteitis (dry socket) with early infection signs, supported by exposed bone, erythema, low-grade fever, and throbbing pain.
Plan: Gentle saline irrigation and medicated dressing with 0.12% chlorhexidine applied; patient advised to avoid smoking, use ice packs, and take ibuprofen 400 mg PRN (every 6 h up to 3 days); scheduled review in 2 days.

S: 54-year-old female, type 2 diabetes on metformin, NKDA, reports “My mouth hurts and I feel a bad taste” on day 3 after extraction of tooth #16.
O: Socket shows exposed bone, mild swelling of upper lip, mild erythema; pain 6/10 throbbing; temperature 99.1 °F; soft tissue intact, no drainage; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
A: Alveolar osteitis (dry socket) with early infection signs, supported by exposed bone, erythema, low-grade fever, and throbbing pain.
P: Gentle saline irrigation and medicated dressing with 0.12% chlorhexidine applied; patient advised to avoid smoking, use ice packs, and take ibuprofen 400 mg PRN (every 6 h up to 3 days); scheduled review in 2 days.

Patient with Chronic Kidney Disease, Day 1 After Extraction, NSAID Avoidance

SOAP note

Subjective: 40-year-old female, seasonal allergies, NKDA, reports “I have a lot of pain after the extraction” (pain 7/10, throbbing).
Objective: Socket bleeding ceased with gauze pressure; no active bleeding; mild lower-lip swelling; temperature 98.6 °F; IANB with 4% articaine 1:100,000, 1.8 mL, aspiration negative.
Assessment: Post-operative pain, controlled (no infection or systemic signs).
Plan: Instructed to avoid NSAIDs because of chronic kidney disease; prescribed acetaminophen 500 mg PO q6 h PRN, up to 3 days; advised ice packs, keep gauze in place for 60 min, return if pain >7/10 or swelling worsens.

S: 40-year-old female, seasonal allergies, NKDA, reports “I have a lot of pain after the extraction” (pain 7/10, throbbing).
O: Socket bleeding ceased with gauze pressure; no active bleeding; mild lower-lip swelling; temperature 98.6 °F; IANB with 4% articaine 1:100,000, 1.8 mL, aspiration negative.
A: Post-operative pain, controlled (no infection or systemic signs).
P: Instructed to avoid NSAIDs because of chronic kidney disease; prescribed acetaminophen 500 mg PO q6 h PRN, up to 3 days; advised ice packs, keep gauze in place for 60 min, return if pain >7/10 or swelling worsens.

Follow-Up Visits (Day 5 and beyond)

Non-Smoker, Day 5 After Extraction, Follow-Up

SOAP note

Subjective: 39-year-old female, non-smoker, NKDA, CC: “Just here for follow-up, no pain.” HPI: no pain, discomfort, or swelling since extraction of tooth #30.
Objective: Extraction site of tooth #30 shows complete healing of the socket; no swelling, erythema, or exposed bone; mouth opening normal, no trismus; no lymphadenopathy; temperature 98.6 °F (37 °C).
Assessment: Healing extraction site, supported by complete socket healing, absence of inflammation, and normal vital signs.
Plan: Reviewed healing status; advised continuation of postoperative instructions: soft diet, avoid smoking, use ice packs as needed, and maintain oral hygiene. No drugs prescribed. Scheduled next visit in 7 days for final assessment.

S: 39-year-old female, non-smoker, NKDA, CC: “Just here for follow-up, no pain.” HPI: no pain, discomfort, or swelling since extraction of tooth #30.
O: Extraction site of tooth #30 shows complete healing of the socket; no swelling, erythema, or exposed bone; mouth opening normal, no trismus; no lymphadenopathy; temperature 98.6 °F (37 °C).
A: Healing extraction site, supported by complete socket healing, absence of inflammation, and normal vital signs.
P: Reviewed healing status; advised continuation of postoperative instructions: soft diet, avoid smoking, use ice packs as needed, and maintain oral hygiene. No drugs prescribed. Scheduled next visit in 7 days for final assessment.

Patient with Osteoarthritis, Day 5 After Extraction, Suture Removal

SOAP note

Subjective: 65-year-old male, osteoarthritis, controlled hypertension on lisinopril, NKDA; chief complaint: “I’m here for suture removal.” O: Sutures removed from extraction site of tooth #19; socket shows good soft-tissue coverage, no exposed bone; mild discomfort, pain 2/10; no swelling, erythema, or drainage; mouth opening normal, no trismus; no lymphadenopathy; temperature 98.7 °F (37.1 °C). A: Healing extraction site, evidenced by complete soft-tissue coverage and absence of inflammation. P: Sutures removed; reinforced postoperative instructions to avoid hard foods, use ice packs, and maintain oral hygiene; no medications prescribed; advised return in 7 days for final check.

S: 65-year-old male, osteoarthritis, controlled hypertension on lisinopril, NKDA; chief complaint: “I’m here for suture removal.” O: Sutures removed from extraction site of tooth #19; socket shows good soft-tissue coverage, no exposed bone; mild discomfort, pain 2/10; no swelling, erythema, or drainage; mouth opening normal, no trismus; no lymphadenopathy; temperature 98.7 °F (37.1 °C). A: Healing extraction site, evidenced by complete soft-tissue coverage and absence of inflammation. P: Sutures removed; reinforced postoperative instructions to avoid hard foods, use ice packs, and maintain oral hygiene; no medications prescribed; advised return in 7 days for final check.

Patient with Recent Trauma, Day 4 After Extraction, Healing Assessment

SOAP note

Subjective: 21-year-old female, recent trauma to lower jaw, asthma (albuterol PRN), NKDA, chief complaint: “Just checking healing after trauma.”
Objective: Extraction site of tooth #28 shows partial healing with slight mucosal coverage; no exposed bone or drainage; mild swelling, not progressive; pain 3/10; mouth opening normal, no trismus; no lymphadenopathy; temperature 98.5 °F (37 °C).
Assessment: Healing extraction site, supported by mucosal coverage, absence of exposed bone, stable swelling, and normal vital signs.
Plan: Observed healing; no intervention performed. Advised to continue postoperative instructions: soft diet, ice packs, avoid smoking, maintain oral hygiene. No medications prescribed. Scheduled next visit in 7 days for final assessment.

S: 21-year-old female, recent trauma to lower jaw, asthma (albuterol PRN), NKDA, chief complaint: “Just checking healing after trauma.”
O: Extraction site of tooth #28 shows partial healing with slight mucosal coverage; no exposed bone or drainage; mild swelling, not progressive; pain 3/10; mouth opening normal, no trismus; no lymphadenopathy; temperature 98.5 °F (37 °C).
A: Healing extraction site, supported by mucosal coverage, absence of exposed bone, stable swelling, and normal vital signs.
P: Observed healing; no intervention performed. Advised to continue postoperative instructions: soft diet, ice packs, avoid smoking, maintain oral hygiene. No medications prescribed. Scheduled next visit in 7 days for final assessment.

Emergency Extractions

Pregnant, First Trimester, Emergency Extraction of Carious Mandibular First Molar

SOAP note

Subjective: 34-year-old female, pregnant first trimester, on low-dose aspirin, NKDA; CC: "I have a huge toothache and I can't eat"; HPI: deep caries on buccal surface of #30 with pulpal exposure; PMH: pregnancy, aspirin; no allergies.
Objective: Extraoral: moderate facial swelling in the lower right quadrant; intraoral: exposed pulp on #30, no trismus, no lymphadenopathy; periodontal: none; radiographic: periapical radiolucency on PA; tests: temperature 98.6 °F, aspiration negative.
Assessment: Pulp necrosis with acute apical abscess, evidenced by pulpal exposure, periapical radiolucency, and facial swelling.
Plan: Closed simple extraction of #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; socket curetted, irrigated with sterile saline, hemostasis with gauze pressure; no sutures; POI: ibuprofen 400 mg PO q6h PRN for pain; advise soft diet, avoid hot foods, monitor for infection; next visit: 7-day review.

S: 34-year-old female, pregnant first trimester, on low-dose aspirin, NKDA; CC: "I have a huge toothache and I can't eat"; HPI: deep caries on buccal surface of #30 with pulpal exposure; PMH: pregnancy, aspirin; no allergies.
O: Extraoral: moderate facial swelling in the lower right quadrant; intraoral: exposed pulp on #30, no trismus, no lymphadenopathy; periodontal: none; radiographic: periapical radiolucency on PA; tests: temperature 98.6 °F, aspiration negative.
A: Pulp necrosis with acute apical abscess, evidenced by pulpal exposure, periapical radiolucency, and facial swelling.
P: Closed simple extraction of #30 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; socket curetted, irrigated with sterile saline, hemostasis with gauze pressure; no sutures; POI: ibuprofen 400 mg PO q6h PRN for pain; advise soft diet, avoid hot foods, monitor for infection; next visit: 7-day review.

Pregnancy & Anticoagulation Cases

Anticoagulated, On Warfarin, Extraction of Mandibular First Molar

SOAP note

Subjective: 82-year-old female, on warfarin for atrial fibrillation, NKDA; CC: “My first molar is very painful and keeps throbbing”; HPI: grossly carious #30, non-restorable, throbbing pain, no swelling; PMH: atrial fibrillation, warfarin, INR 2.5; no systemic signs.
Objective: Extraoral: soft tissue healthy, no erythema or swelling; Intraoral: #30 grossly carious, non-restorable; Periodontal: advanced bone loss, no root fracture; Radiograph: periapical PA shows advanced periodontal bone loss, apical periodontitis; Tests: INR 2.5, aspiration negative.
Assessment: Non-restorable caries with advanced periodontal disease, pulpal necrosis, apical periodontitis—diagnosis supported by gross caries, advanced bone loss, and periapical radiolucency.
Plan: Extraction of #30 under IANB with 2% lidocaine 1:100,000, 1.8 mL; hemostasis achieved with gauze pressure and oxidized cellulose; POI: bite on gauze 30-60 min, no spitting, rinsing, or smoking 24 h; NSAID: ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days; advise monitoring INR and reporting any bleeding; next visit: follow-up in 7 days to assess healing.

S: 82-year-old female, on warfarin for atrial fibrillation, NKDA; CC: “My first molar is very painful and keeps throbbing”; HPI: grossly carious #30, non-restorable, throbbing pain, no swelling; PMH: atrial fibrillation, warfarin, INR 2.5; no systemic signs.
O: Extraoral: soft tissue healthy, no erythema or swelling; Intraoral: #30 grossly carious, non-restorable; Periodontal: advanced bone loss, no root fracture; Radiograph: periapical PA shows advanced periodontal bone loss, apical periodontitis; Tests: INR 2.5, aspiration negative.
A: Non-restorable caries with advanced periodontal disease, pulpal necrosis, apical periodontitis—diagnosis supported by gross caries, advanced bone loss, and periapical radiolucency.
P: Extraction of #30 under IANB with 2% lidocaine 1:100,000, 1.8 mL; hemostasis achieved with gauze pressure and oxidized cellulose; POI: bite on gauze 30-60 min, no spitting, rinsing, or smoking 24 h; NSAID: ibuprofen 400 mg q6h PRN up to 3 days, acetaminophen 500 mg q6h PRN up to 3 days; advise monitoring INR and reporting any bleeding; next visit: follow-up in 7 days to assess healing.

Elderly, Osteoporosis on Bisphosphonate, Extraction of Maxillary Third Molar

SOAP note

Subjective: 68-year-old female, osteoporosis on bisphosphonate therapy, chief complaint: “My wisdom tooth is stuck and hurts when I bite.”
Objective: Tooth #16 mesioangular impacted, deep bone; PAN shows close proximity to maxillary sinus; no root fracture; soft tissue healthy, no swelling or erythema; diagnosis: impacted third molar with periodontal disease.
Assessment: Impacted third molar with periodontal disease, supported by panoramic proximity to sinus and clinical findings of mesioangular impaction.
Plan: Surgical extraction performed with buccal infiltration of 4% articaine 1:100,000, 1.8 mL (1 cartridge); flap raised, bone removed, tooth sectioned; hemostasis achieved with gauze pressure and oxidized cellulose; POI: avoid hard foods, keep gauze for 30-60 min, no smoking, follow up in 7 days.

S: 68-year-old female, osteoporosis on bisphosphonate therapy, chief complaint: “My wisdom tooth is stuck and hurts when I bite.”
O: Tooth #16 mesioangular impacted, deep bone; PAN shows close proximity to maxillary sinus; no root fracture; soft tissue healthy, no swelling or erythema; diagnosis: impacted third molar with periodontal disease.
A: Impacted third molar with periodontal disease, supported by panoramic proximity to sinus and clinical findings of mesioangular impaction.
P: Surgical extraction performed with buccal infiltration of 4% articaine 1:100,000, 1.8 mL (1 cartridge); flap raised, bone removed, tooth sectioned; hemostasis achieved with gauze pressure and oxidized cellulose; POI: avoid hard foods, keep gauze for 30-60 min, no smoking, follow up in 7 days.

Pregnant, Second Trimester, Extraction of Mandibular Second Molar

SOAP note

Subjective: 27-year-old pregnant female, second trimester, former smoker, NKDA; CC: “My lower second molar is very painful and I can’t chew”; HPI: pain started 2 days ago, throbbing, worsens with chewing; PMH: none, no systemic signs.
Objective: extraoral: no swelling, erythema; intraoral: tooth #31 gross caries, pulpal necrosis; periodontal: soft tissue healthy; radiograph: periapical radiolucency at #31; tests: IANB aspiration negative.
Assessment: pulpal necrosis with chronic apical periodontitis of tooth #31, supported by gross caries, radiolucency, and absence of systemic infection.
Plan: extraction of #31 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; hemostasis with gauze pressure and oxidized cellulose; POI: bite on gauze 30-60 min, no chewing, soft diet, cold packs; medication: acetaminophen 500 mg PO q6h PRN up to 3 days; next visit: follow-up in 7 days for healing assessment.

S: 27-year-old pregnant female, second trimester, former smoker, NKDA; CC: “My lower second molar is very painful and I can’t chew”; HPI: pain started 2 days ago, throbbing, worsens with chewing; PMH: none, no systemic signs.
O: extraoral: no swelling, erythema; intraoral: tooth #31 gross caries, pulpal necrosis; periodontal: soft tissue healthy; radiograph: periapical radiolucency at #31; tests: IANB aspiration negative.
A: pulpal necrosis with chronic apical periodontitis of tooth #31, supported by gross caries, radiolucency, and absence of systemic infection.
P: extraction of #31 under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; hemostasis with gauze pressure and oxidized cellulose; POI: bite on gauze 30-60 min, no chewing, soft diet, cold packs; medication: acetaminophen 500 mg PO q6h PRN up to 3 days; next visit: follow-up in 7 days for healing assessment.

Patient on Clopidogrel, Extraction of Mandibular Third Molar

SOAP note

Subjective: 74-year-old female, allergic to penicillin, reports “my wisdom tooth is painful and I can’t open my mouth fully”; PMH non-significant, on clopidogrel.
Objective: Extraoral normal; intraoral shows tooth #32 mesioangular impacted, deep bone, no swelling or erythema. Periodontal: healthy soft tissue, no BOP. Radiograph: panoramic shows close proximity to inferior alveolar canal.
Assessment: Impacted third molar with periodontal disease, confirmed by panoramic findings of deep bone and canal proximity.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Surgical extraction performed with flap, bone removal, sectioning; hemostasis achieved with gauze pressure and oxidized cellulose. Post-operative instructions given regarding pain control, diet, and oral hygiene. No medications prescribed. RTC in 7 days for healing assessment.

S: 74-year-old female, allergic to penicillin, reports “my wisdom tooth is painful and I can’t open my mouth fully”; PMH non-significant, on clopidogrel.
O: Extraoral normal; intraoral shows tooth #32 mesioangular impacted, deep bone, no swelling or erythema. Periodontal: healthy soft tissue, no BOP. Radiograph: panoramic shows close proximity to inferior alveolar canal.
A: Impacted third molar with periodontal disease, confirmed by panoramic findings of deep bone and canal proximity.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative. Surgical extraction performed with flap, bone removal, sectioning; hemostasis achieved with gauze pressure and oxidized cellulose. Post-operative instructions given regarding pain control, diet, and oral hygiene. No medications prescribed. RTC in 7 days for healing assessment.

Systemic Disease Extractions

Diabetic, Poor Glycemic Control, Extraction of Maxillary Second Premolar

SOAP note

Subjective: 24-year-old female, type 2 diabetes on metformin, NKDA, reports “I have a painful tooth that won’t go away.” O: deep caries to outer dentin, pulpal involvement, periapical radiolucency on PA, 6 mm probing depth, bleeding on probing; no systemic signs. A: symptomatic irreversible pulpitis with acute apical periodontitis, evidenced by deep caries, pulpal involvement, radiolucency and BOP. P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; flap elevation, bone removal, tooth #12 sectioned, socket curetted and irrigated, gauze pressure hemostasis; POI: ibuprofen 400 mg q6 h PRN up to 3 days, strict glycemic control, soft diet, avoid smoking, follow-up in 7 days.

S: 24-year-old female, type 2 diabetes on metformin, NKDA, reports “I have a painful tooth that won’t go away.” O: deep caries to outer dentin, pulpal involvement, periapical radiolucency on PA, 6 mm probing depth, bleeding on probing; no systemic signs. A: symptomatic irreversible pulpitis with acute apical periodontitis, evidenced by deep caries, pulpal involvement, radiolucency and BOP. P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration; flap elevation, bone removal, tooth #12 sectioned, socket curetted and irrigated, gauze pressure hemostasis; POI: ibuprofen 400 mg q6 h PRN up to 3 days, strict glycemic control, soft diet, avoid smoking, follow-up in 7 days.

Patient with Hypertension, Extraction of Mandibular First Molar

SOAP note

Subjective: 47-year-old female, NKDA, seasonal allergies, says “My molar hurts when I bite”; history shows caries extending to pulp and a periapical radiolucency on PA.
Objective: Extraoral normal; intraoral shows moderate swelling, tooth #30 with 5 mm probing depth, bleeding on probing; PA radiograph confirms periapical radiolucency; no other findings.
Assessment: Symptomatic irreversible pulpitis with chronic apical periodontitis, supported by deep caries, radiolucency, probing depth, and bleeding.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis; prescribed ibuprofen 400 mg PO q6h PRN for 3 days; POI given, next visit in 7 days for healing assessment.

S: 47-year-old female, NKDA, seasonal allergies, says “My molar hurts when I bite”; history shows caries extending to pulp and a periapical radiolucency on PA.
O: Extraoral normal; intraoral shows moderate swelling, tooth #30 with 5 mm probing depth, bleeding on probing; PA radiograph confirms periapical radiolucency; no other findings.
A: Symptomatic irreversible pulpitis with chronic apical periodontitis, supported by deep caries, radiolucency, probing depth, and bleeding.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis; prescribed ibuprofen 400 mg PO q6h PRN for 3 days; POI given, next visit in 7 days for healing assessment.

Patient with Chronic Kidney Disease, Extraction of Maxillary Second Molar

SOAP note

Subjective: 60-year-old male, smoker 5 cigarettes/day, NKDA, reports “My tooth is loose and painful.” HPI: gradual loosening, increased pain, recent swelling of buccal mucosa.
Objective: Extraoral: mild buccal swelling. Intraoral: tooth #13 has root fracture, probing depth 7 mm, bleeding on probing. Periodontal: acute apical abscess evident on PA radiograph.
Assessment: Pulpal necrosis with acute apical abscess, supported by root fracture, deep probing, bleeding, and periapical radiolucency.
Plan: Performed surgical extraction with flap elevation, bone removal, sectioning, socket curettage and irrigation. Hemostasis achieved with gauze pressure. Prescribed ibuprofen 400 mg PO q6h PRN for 3 days, gave POI, advised soft diet, no smoking for 24 h, and to return if pain worsens.

S: 60-year-old male, smoker 5 cigarettes/day, NKDA, reports “My tooth is loose and painful.” HPI: gradual loosening, increased pain, recent swelling of buccal mucosa.
O: Extraoral: mild buccal swelling. Intraoral: tooth #13 has root fracture, probing depth 7 mm, bleeding on probing. Periodontal: acute apical abscess evident on PA radiograph.
A: Pulpal necrosis with acute apical abscess, supported by root fracture, deep probing, bleeding, and periapical radiolucency.
P: Performed surgical extraction with flap elevation, bone removal, sectioning, socket curettage and irrigation. Hemostasis achieved with gauze pressure. Prescribed ibuprofen 400 mg PO q6h PRN for 3 days, gave POI, advised soft diet, no smoking for 24 h, and to return if pain worsens.

Patient with Diabetes, Extraction of Mandibular Third Molar

SOAP note

Subjective: 50-year-old female, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “My wisdom tooth is swollen and painful”; HPI: swelling, pain, pericoronitis, periapical radiolucency on PA; PMH: diabetes, hypertension; no systemic signs.
Objective: Extraoral: no facial asymmetry; Intraoral: mesioangular impaction of #32, 4 mm probing depth, bleeding on probing; Periodontal: BOP present; Radiographic: PA shows periapical radiolucency; Tests: IANB 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
Assessment: Pericoronitis with symptomatic irreversible pulpitis, supported by swelling, pain, radiolucency, deep probing depth, and bleeding on probing.
Plan: Flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis; POI: bite on gauze 30-60 min, no spitting, rinsing, or smoking first 24 h, soft diet, cold packs, ibuprofen 400 mg PO q6h PRN up to 3 days; next visit: review healing and pain control.

S: 50-year-old female, type 2 diabetes on metformin, controlled hypertension on lisinopril, NKDA; CC: “My wisdom tooth is swollen and painful”; HPI: swelling, pain, pericoronitis, periapical radiolucency on PA; PMH: diabetes, hypertension; no systemic signs.
O: Extraoral: no facial asymmetry; Intraoral: mesioangular impaction of #32, 4 mm probing depth, bleeding on probing; Periodontal: BOP present; Radiographic: PA shows periapical radiolucency; Tests: IANB 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
A: Pericoronitis with symptomatic irreversible pulpitis, supported by swelling, pain, radiolucency, deep probing depth, and bleeding on probing.
P: Flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis; POI: bite on gauze 30-60 min, no spitting, rinsing, or smoking first 24 h, soft diet, cold packs, ibuprofen 400 mg PO q6h PRN up to 3 days; next visit: review healing and pain control.

Patient with Epilepsy, Extraction of Mandibular Second Molar

SOAP note

Subjective: 76-year-old female, chief complaint “My tooth hurts and I have a bad taste,” history of caries to pulp, periapical radiolucency on PA, probing depth 6 mm, bleeding on probing; medical history: asthma, albuterol PRN, NKDA.
Objective: Extraoral normal; intraoral: #31 exposed, severe pain, periodontal pocket 6 mm, BOP present; radiograph shows periapical radiolucency; no other findings.
Assessment: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by deep caries, radiolucency, deep probing depth and BOP.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis; prescribed ibuprofen 400 mg PO q6h PRN up to 3 days; POI: bite on gauze 30-60 min, avoid spitting, soft diet, cold packs, report bleeding or severe pain; next visit in 7 days for healing assessment.

S: 76-year-old female, chief complaint “My tooth hurts and I have a bad taste,” history of caries to pulp, periapical radiolucency on PA, probing depth 6 mm, bleeding on probing; medical history: asthma, albuterol PRN, NKDA.
O: Extraoral normal; intraoral: #31 exposed, severe pain, periodontal pocket 6 mm, BOP present; radiograph shows periapical radiolucency; no other findings.
A: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by deep caries, radiolucency, deep probing depth and BOP.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB; flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis; prescribed ibuprofen 400 mg PO q6h PRN up to 3 days; POI: bite on gauze 30-60 min, avoid spitting, soft diet, cold packs, report bleeding or severe pain; next visit in 7 days for healing assessment.

Patient with Hyperthyroidism, Extraction of Maxillary Second Molar

SOAP note

Subjective: 72-year-old female, chief complaint: “My molar is loose and painful.” History: deep caries, symptomatic irreversible pulpitis with chronic apical periodontitis, periapical radiolucency on PA, 5 mm probing depth, bleeding on probing. Medical history: low-dose aspirin daily, NKDA.
Objective: Extraoral: normal. Intraoral: tooth #3 mobile, carious, tender. Periodontal: PD 5 mm, BOP present. Radiographic: periapical radiolucency on PA.
Assessment: Symptomatic irreversible pulpitis with chronic apical periodontitis, supported by deep caries, periapical radiolucency, 5 mm probing depth, and bleeding on probing.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration anesthesia. Flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis. POI: ibuprofen 400 mg PO q6h PRN, up to 3 days; avoid NSAIDs beyond 3 days; maintain soft diet, avoid smoking; return in 7 days for healing assessment.

S: 72-year-old female, chief complaint: “My molar is loose and painful.” History: deep caries, symptomatic irreversible pulpitis with chronic apical periodontitis, periapical radiolucency on PA, 5 mm probing depth, bleeding on probing. Medical history: low-dose aspirin daily, NKDA.
O: Extraoral: normal. Intraoral: tooth #3 mobile, carious, tender. Periodontal: PD 5 mm, BOP present. Radiographic: periapical radiolucency on PA.
A: Symptomatic irreversible pulpitis with chronic apical periodontitis, supported by deep caries, periapical radiolucency, 5 mm probing depth, and bleeding on probing.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL infiltration anesthesia. Flap elevation, bone removal, tooth sectioned, socket curetted and irrigated, gauze pressure hemostasis. POI: ibuprofen 400 mg PO q6h PRN, up to 3 days; avoid NSAIDs beyond 3 days; maintain soft diet, avoid smoking; return in 7 days for healing assessment.

Patient with Sickle Cell Disease, Extraction of Mandibular First Molar

SOAP note

Subjective: 66-year-old female, chief complaint “My lower first molar is painful and swollen”; medical history: no significant medical history, NKDA.
Objective: Periapical radiograph shows radiolucency around #30 with deep occlusal caries extending into dentin; probing depth 5 mm, bleeding on probing present; mobility grade 1; no sinus tract noted.
Assessment: Pulp necrosis with chronic apical periodontitis.
Plan: Extraction of #30 under IANB with 2% lidocaine 1:100,000 epinephrine, 1.8 mL; socket curetted, irrigated with saline, gauze pressure applied until hemostasis; patient advised to keep area moist, avoid smoking; prescribed ibuprofen 400 mg PO q6h PRN for pain and chlorhexidine gluconate 0.12% 15 mL rinse 30 s twice daily.

S: 66-year-old female, chief complaint “My lower first molar is painful and swollen”; medical history: no significant medical history, NKDA.
O: Periapical radiograph shows radiolucency around #30 with deep occlusal caries extending into dentin; probing depth 5 mm, bleeding on probing present; mobility grade 1; no sinus tract noted.
A: Pulp necrosis with chronic apical periodontitis.
P: Extraction of #30 under IANB with 2% lidocaine 1:100,000 epinephrine, 1.8 mL; socket curetted, irrigated with saline, gauze pressure applied until hemostasis; patient advised to keep area moist, avoid smoking; prescribed ibuprofen 400 mg PO q6h PRN for pain and chlorhexidine gluconate 0.12% 15 mL rinse 30 s twice daily.

Patient with Allergic to Penicillin, Extraction of Maxillary Third Molar

SOAP note

Subjective: 32-year-old female with hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “My upper third molar is hurting and I can’t eat”; PMH: hypothyroidism, no other systemic disease.
Objective: PAN shows impacted #16 with pericoronitis, deep caries; PD 4 mm, BOP present; mobility grade 2; swelling upper left posterior; no sinus tract; 2% lidocaine 1:100,000, 1.8 mL buccal infiltration, aspiration negative.
Assessment: Pulp necrosis with acute apical abscess, confirmed by radiograph, probing and swelling.
Plan: Extraction of #16 under buccal infiltration; flap raised, bone removed, tooth sectioned, socket curetted and irrigated with saline; gauze pressure until hemostasis. Prescribed ibuprofen 400 mg PO q6h PRN for pain; chlorhexidine gluconate 0.12% 15 mL rinse 30 s twice daily. Advised to avoid smoking, keep area moist, and return if swelling or pain worsens.

S: 32-year-old female with hypothyroidism on levothyroxine, allergic to penicillin (rash); CC: “My upper third molar is hurting and I can’t eat”; PMH: hypothyroidism, no other systemic disease.
O: PAN shows impacted #16 with pericoronitis, deep caries; PD 4 mm, BOP present; mobility grade 2; swelling upper left posterior; no sinus tract; 2% lidocaine 1:100,000, 1.8 mL buccal infiltration, aspiration negative.
A: Pulp necrosis with acute apical abscess, confirmed by radiograph, probing and swelling.
P: Extraction of #16 under buccal infiltration; flap raised, bone removed, tooth sectioned, socket curetted and irrigated with saline; gauze pressure until hemostasis. Prescribed ibuprofen 400 mg PO q6h PRN for pain; chlorhexidine gluconate 0.12% 15 mL rinse 30 s twice daily. Advised to avoid smoking, keep area moist, and return if swelling or pain worsens.

Patient with Recent COVID-19 Infection, Extraction of Maxillary Second Molar

SOAP note

Subjective: 37-year-old male, former smoker, NKDA, reports “My upper second molar is very sore and I can’t chew”; history of deep occlusal caries with radiolucency on PA.
Objective: PA shows radiolucency around #15, deep occlusal caries extending into dentin; probing depth 6 mm, BOP present, mobility grade 1, no sinus tract; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
Assessment: Pulp necrosis with chronic apical periodontitis, confirmed by radiolucency and deep caries.
Plan: Extraction of #15 under buccal infiltration; socket curetted, irrigated with saline, gauze pressure until hemostasis; prescribed ibuprofen 400 mg PO q6h PRN for pain and chlorhexidine 0.12% rinse 15 mL 30 s twice daily; instructed to keep area moist, avoid smoking, and return if pain worsens.

S: 37-year-old male, former smoker, NKDA, reports “My upper second molar is very sore and I can’t chew”; history of deep occlusal caries with radiolucency on PA.
O: PA shows radiolucency around #15, deep occlusal caries extending into dentin; probing depth 6 mm, BOP present, mobility grade 1, no sinus tract; 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative.
A: Pulp necrosis with chronic apical periodontitis, confirmed by radiolucency and deep caries.
P: Extraction of #15 under buccal infiltration; socket curetted, irrigated with saline, gauze pressure until hemostasis; prescribed ibuprofen 400 mg PO q6h PRN for pain and chlorhexidine 0.12% rinse 15 mL 30 s twice daily; instructed to keep area moist, avoid smoking, and return if pain worsens.

Patient with Recent Stroke, Extraction of Mandibular First Molar

SOAP note

Subjective: 63-year-old male, “My lower first molar is painful and I can’t eat.” No significant medical history; allergic to penicillin (rash). O: PA shows radiolucency around #30, deep occlusal caries extending into dentin; probing depth 5 mm, bleeding on probing present; mobility grade 1; no sinus tract noted. A: Pulp necrosis with chronic apical periodontitis, evidenced by radiolucency, deep caries, and BOP. P: Extraction of #30 under IANB (2% lidocaine 1:100,000, 1.8 mL, aspiration negative); socket curetted, irrigated with saline, gauze pressure until hemostasis. POI: keep area moist, avoid smoking. Meds: ibuprofen 400 mg PO q6h PRN, chlorhexidine 0.12% 15 mL rinse 30 s twice daily. RTC: follow-up in 7 days for healing assessment.

S: 63-year-old male, “My lower first molar is painful and I can’t eat.” No significant medical history; allergic to penicillin (rash). O: PA shows radiolucency around #30, deep occlusal caries extending into dentin; probing depth 5 mm, bleeding on probing present; mobility grade 1; no sinus tract noted. A: Pulp necrosis with chronic apical periodontitis, evidenced by radiolucency, deep caries, and BOP. P: Extraction of #30 under IANB (2% lidocaine 1:100,000, 1.8 mL, aspiration negative); socket curetted, irrigated with saline, gauze pressure until hemostasis. POI: keep area moist, avoid smoking. Meds: ibuprofen 400 mg PO q6h PRN, chlorhexidine 0.12% 15 mL rinse 30 s twice daily. RTC: follow-up in 7 days for healing assessment.

Patient with Recent Dental Implant Failure, Extraction of Mandibular Third Molar

SOAP note

Subjective: 35-year-old female, type 2 diabetes on metformin, NKDA; CC: “My lower third molar is painful and I can’t sleep”; HPI: impacted #32 with pericoronitis, deep caries, swelling, no sinus tract; PMH: diabetes; no systemic signs.
Objective: PAN shows impacted #32 with pericoronitis, deep caries; PD 4 mm, BOP present; mobility grade 2; swelling lower right posterior; IANB 2% lidocaine 1:100,000, 1.8 mL, aspiration negative; no extraoral abnormalities.
Assessment: Pulp necrosis with acute apical abscess supported by pericoronitis, deep caries, swelling, BOP, and mobility grade 2.
Plan: Extraction of #32 under IANB; flap, bone removal, sectioning, curettage, saline irrigation; gauze pressure until hemostasis; advised moist wound care, avoid smoking; prescribed ibuprofen 400 mg PO q6h PRN for pain; chlorhexidine 0.12% 15 mL rinse 30 s twice daily; next visit for healing assessment.

S: 35-year-old female, type 2 diabetes on metformin, NKDA; CC: “My lower third molar is painful and I can’t sleep”; HPI: impacted #32 with pericoronitis, deep caries, swelling, no sinus tract; PMH: diabetes; no systemic signs.
O: PAN shows impacted #32 with pericoronitis, deep caries; PD 4 mm, BOP present; mobility grade 2; swelling lower right posterior; IANB 2% lidocaine 1:100,000, 1.8 mL, aspiration negative; no extraoral abnormalities.
A: Pulp necrosis with acute apical abscess supported by pericoronitis, deep caries, swelling, BOP, and mobility grade 2.
P: Extraction of #32 under IANB; flap, bone removal, sectioning, curettage, saline irrigation; gauze pressure until hemostasis; advised moist wound care, avoid smoking; prescribed ibuprofen 400 mg PO q6h PRN for pain; chlorhexidine 0.12% 15 mL rinse 30 s twice daily; next visit for healing assessment.

Patient with Asthma, Extraction of Maxillary Third Molar

SOAP note

Subjective: 81-year-old male, seasonal allergies, NKDA, says “My upper third molar is very painful and I can’t eat”; history of pericoronitis and deep caries on #16; no systemic signs.
Objective: PAN shows impacted #16 with pericoronitis; PD 4 mm, BOP present; mobility grade 2; swelling in upper left posterior region; no sinus tract; anesthesia 2% lidocaine 1:100,000, 1.8 mL buccal infiltration, aspiration negative.
Assessment: Pulp necrosis with acute apical abscess, supported by pericoronitis, deep caries, swelling, and radiographic findings.
Plan: Extraction of #16 under buccal infiltration; flap raised, bone removed, tooth sectioned, socket curetted and irrigated with saline; gauze pressure until hemostasis; prescribed ibuprofen 400 mg PO q6h PRN for pain and chlorhexidine 0.12% rinse 15 mL 30 s twice daily; advised to keep area moist, avoid smoking, and return if pain worsens.

S: 81-year-old male, seasonal allergies, NKDA, says “My upper third molar is very painful and I can’t eat”; history of pericoronitis and deep caries on #16; no systemic signs.
O: PAN shows impacted #16 with pericoronitis; PD 4 mm, BOP present; mobility grade 2; swelling in upper left posterior region; no sinus tract; anesthesia 2% lidocaine 1:100,000, 1.8 mL buccal infiltration, aspiration negative.
A: Pulp necrosis with acute apical abscess, supported by pericoronitis, deep caries, swelling, and radiographic findings.
P: Extraction of #16 under buccal infiltration; flap raised, bone removed, tooth sectioned, socket curetted and irrigated with saline; gauze pressure until hemostasis; prescribed ibuprofen 400 mg PO q6h PRN for pain and chlorhexidine 0.12% rinse 15 mL 30 s twice daily; advised to keep area moist, avoid smoking, and return if pain worsens.

MRONJ & Trauma Extractions

Patient with History of MRONJ, Extraction of Maxillary Third Molar

SOAP note

Subjective: 79-year-old female, smoker 5 cigarettes/day, NKDA, chief complaint “sore spot in my lower right back that’s been there for months and it’s been getting worse.” History: exposed bone >8 weeks in socket of #30, mild purulent exudate, soft tissue recession, mild discomfort, no fever.
Objective: Exposed bone >8 weeks, necrotic bone in socket, radiolucent area surrounding bone on PA, no periosteal reaction, no systemic infection signs, maxillary IANB 2% lidocaine with 1:100,000 epinephrine, 1.8 mL.
Assessment: Medication-related osteonecrosis of the jaw (MRONJ) stage II, supported by exposed bone >8 weeks, radiolucent area, purulent exudate, and lack of systemic infection.
Plan: Surgical removal of #30 with debridement of necrotic bone, curettage, collagen sponge placement, pressure gauze for 30 min. Prescribed amoxicillin 500 mg q8h for 5 days and ibuprofen 400 mg q6h PRN for 3 days. POI: avoid hard foods, maintain oral hygiene, report fever or increased pain. Next visit: follow-up in 1 week for healing assessment.

S: 79-year-old female, smoker 5 cigarettes/day, NKDA, chief complaint “sore spot in my lower right back that’s been there for months and it’s been getting worse.” History: exposed bone >8 weeks in socket of #30, mild purulent exudate, soft tissue recession, mild discomfort, no fever.
O: Exposed bone >8 weeks, necrotic bone in socket, radiolucent area surrounding bone on PA, no periosteal reaction, no systemic infection signs, maxillary IANB 2% lidocaine with 1:100,000 epinephrine, 1.8 mL.
A: Medication-related osteonecrosis of the jaw (MRONJ) stage II, supported by exposed bone >8 weeks, radiolucent area, purulent exudate, and lack of systemic infection.
P: Surgical removal of #30 with debridement of necrotic bone, curettage, collagen sponge placement, pressure gauze for 30 min. Prescribed amoxicillin 500 mg q8h for 5 days and ibuprofen 400 mg q6h PRN for 3 days. POI: avoid hard foods, maintain oral hygiene, report fever or increased pain. Next visit: follow-up in 1 week for healing assessment.

Patient with Recent Trauma, Extraction of Maxillary First Molar

SOAP note

Subjective: 52-year-old female, controlled hypertension on lisinopril, NKDA, reports “my upper left molar cracked after I fell and it’s been bleeding a lot.” She describes throbbing pain, 8/10, with low-grade fever (37.2 °C).
Objective: Fractured crown with exposed pulp, grade 1 mobility, periapical radiolucency 4 mm, swelling of upper left buccal mucosa. Vital signs: temperature 37.2 °C; pain 8/10; no other systemic findings.
Assessment: Pulp necrosis with acute apical abscess, supported by exposed pulp, radiolucency, swelling, fever, and pain.
Plan: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL maxillary buccal infiltration. Extracted tooth #16, curetted socket, placed oxidized cellulose, applied pressure gauze. Prescribed amoxicillin 500 mg q8h for 5 days and ibuprofen 400 mg q6h PRN for 3 days. Instructed on oral hygiene, soft diet, avoid smoking, and return if pain worsens or swelling increases.

S: 52-year-old female, controlled hypertension on lisinopril, NKDA, reports “my upper left molar cracked after I fell and it’s been bleeding a lot.” She describes throbbing pain, 8/10, with low-grade fever (37.2 °C).
O: Fractured crown with exposed pulp, grade 1 mobility, periapical radiolucency 4 mm, swelling of upper left buccal mucosa. Vital signs: temperature 37.2 °C; pain 8/10; no other systemic findings.
A: Pulp necrosis with acute apical abscess, supported by exposed pulp, radiolucency, swelling, fever, and pain.
P: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL maxillary buccal infiltration. Extracted tooth #16, curetted socket, placed oxidized cellulose, applied pressure gauze. Prescribed amoxicillin 500 mg q8h for 5 days and ibuprofen 400 mg q6h PRN for 3 days. Instructed on oral hygiene, soft diet, avoid smoking, and return if pain worsens or swelling increases.

Patient with History of MRONJ, Day 1 After Extraction, Protective Measures

SOAP note

Subjective: 51-year-old female, asthma, NKDA, reports “I’m still a bit sore but the bleeding stopped.” HPI: mild pain 3/10, no swelling, no exposed bone, no difficulty swallowing or breathing.
Objective: socket healing, no active bleeding, mild pain 3/10, no swelling, no exposed bone, patient reports no difficulty swallowing or breathing.
Assessment: Post-operative healing after extraction of tooth #30, supported by socket healing, absence of bleeding, and lack of exposed bone.
Plan: Ibuprofen 400 mg PO q6h PRN for 3 days; advised to avoid smoking, use ice packs, maintain soft diet, and refrain from spitting for 24 h; next visit in 7 days for healing assessment.

S: 51-year-old female, asthma, NKDA, reports “I’m still a bit sore but the bleeding stopped.” HPI: mild pain 3/10, no swelling, no exposed bone, no difficulty swallowing or breathing.
O: socket healing, no active bleeding, mild pain 3/10, no swelling, no exposed bone, patient reports no difficulty swallowing or breathing.
A: Post-operative healing after extraction of tooth #30, supported by socket healing, absence of bleeding, and lack of exposed bone.
P: Ibuprofen 400 mg PO q6h PRN for 3 days; advised to avoid smoking, use ice packs, maintain soft diet, and refrain from spitting for 24 h; next visit in 7 days for healing assessment.

Patient with Recent Dental Implant Failure, Re-Evaluation, Adjacent Tooth Extraction

SOAP note

Subjective: 64-year-old male, takes low-dose aspirin, NKDA; CC: “My lower right molar is loose and the tooth next to it hurts.” HPI: throbbing pain 7/10, 37.0 °C, no systemic signs.
Objective: implant exposed, peri-implantitis with 3 mm bone loss, deep caries on distal surface of #30, grade 2 mobility, periapical radiolucency of #30, radiolucent area around implant; temperature 37.0 °C; no extraoral swelling.
Assessment: Implant failure with peri-implantitis; pulpal necrosis of adjacent tooth #30, supported by deep caries, mobility, radiolucency, and pain.
Plan: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL maxillary IANB. Removed implant, extracted #30, curetted socket, placed collagen sponge, applied pressure gauze. Prescribed amoxicillin 500 mg q8h for 5 days and ibuprofen 400 mg q6h PRN for 3 days. Advised soft diet, avoid chewing on site, use ice packs, report any fever or worsening pain. Next visit in 7 days for healing assessment.

S: 64-year-old male, takes low-dose aspirin, NKDA; CC: “My lower right molar is loose and the tooth next to it hurts.” HPI: throbbing pain 7/10, 37.0 °C, no systemic signs.
O: implant exposed, peri-implantitis with 3 mm bone loss, deep caries on distal surface of #30, grade 2 mobility, periapical radiolucency of #30, radiolucent area around implant; temperature 37.0 °C; no extraoral swelling.
A: Implant failure with peri-implantitis; pulpal necrosis of adjacent tooth #30, supported by deep caries, mobility, radiolucency, and pain.
P: Administered 2% lidocaine with 1:100,000 epinephrine, 1.8 mL maxillary IANB. Removed implant, extracted #30, curetted socket, placed collagen sponge, applied pressure gauze. Prescribed amoxicillin 500 mg q8h for 5 days and ibuprofen 400 mg q6h PRN for 3 days. Advised soft diet, avoid chewing on site, use ice packs, report any fever or worsening pain. Next visit in 7 days for healing assessment.

Other Dental History Extractions

Patient with Allergic Rhinitis, Extraction of Mandibular Third Molar

SOAP note

Subjective: 62-year-old female, NKDA, reports “I have a painful tooth that’s been hurting for a week”; medical history includes allergic rhinitis, no other significant conditions. O: Tooth #30 shows non-restorable caries to outer dentin; radiograph reveals moderate periodontal bone loss, no root fracture; extraction socket intact, no retained root tips, no sinus communication; hemostasis achieved with gauze pressure and oxidized cellulose; no swelling or trismus. A: Non-restorable caries with advanced periodontal disease, pulpal necrosis, and apical periodontitis supported by caries depth, bone loss, and radiographic findings. P: Simple closed extraction of tooth #30 performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB; socket curetted and irrigated; gauze pressure for 30 min; patient instructed to avoid hard foods, use ice packs, take ibuprofen 400 mg PRN.

S: 62-year-old female, NKDA, reports “I have a painful tooth that’s been hurting for a week”; medical history includes allergic rhinitis, no other significant conditions. O: Tooth #30 shows non-restorable caries to outer dentin; radiograph reveals moderate periodontal bone loss, no root fracture; extraction socket intact, no retained root tips, no sinus communication; hemostasis achieved with gauze pressure and oxidized cellulose; no swelling or trismus. A: Non-restorable caries with advanced periodontal disease, pulpal necrosis, and apical periodontitis supported by caries depth, bone loss, and radiographic findings. P: Simple closed extraction of tooth #30 performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB; socket curetted and irrigated; gauze pressure for 30 min; patient instructed to avoid hard foods, use ice packs, take ibuprofen 400 mg PRN.

Patient with Osteoarthritis, Extraction of Maxillary First Molar

SOAP note

Subjective: 71-year-old female, hypothyroid on levothyroxine, allergic to penicillin (rash); chief complaint: “My molar is loose and hurts when I bite”; medical history: hypothyroidism, penicillin allergy; no other systemic signs.
Objective: Tooth #16 shows symptomatic irreversible pulpitis with acute apical periodontitis; periapical radiolucency and moderate bone loss on PA; no root fracture, socket clean, no swelling or trismus; buccal infiltration 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
Assessment: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by clinical pain on biting, radiographic radiolucency, and bone loss.
Plan: Simple closed extraction of tooth #16 performed; socket irrigated with saline, gauze pressure for 30 min; patient instructed to apply ice, maintain soft diet, take ibuprofen 400 mg PRN for pain; no medications prescribed; next visit for healing assessment.

S: 71-year-old female, hypothyroid on levothyroxine, allergic to penicillin (rash); chief complaint: “My molar is loose and hurts when I bite”; medical history: hypothyroidism, penicillin allergy; no other systemic signs.
O: Tooth #16 shows symptomatic irreversible pulpitis with acute apical periodontitis; periapical radiolucency and moderate bone loss on PA; no root fracture, socket clean, no swelling or trismus; buccal infiltration 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, aspiration negative.
A: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by clinical pain on biting, radiographic radiolucency, and bone loss.
P: Simple closed extraction of tooth #16 performed; socket irrigated with saline, gauze pressure for 30 min; patient instructed to apply ice, maintain soft diet, take ibuprofen 400 mg PRN for pain; no medications prescribed; next visit for healing assessment.

Patient with Anemia, Extraction of Maxillary Third Molar

SOAP note

Subjective: 68-year-old female, former smoker, NKDA, reports “My upper molar is painful and looks decayed”; pain 7/10, worsens with chewing, relieved by ice. O: Extraoral WNL; intraoral: tooth #3 with deep dentin caries, pulpal involvement, periapical radiolucency, mild bone loss on PA; no swelling or trismus. A: Pulpal necrosis with chronic apical periodontitis, evidenced by deep caries, radiolucency and clinical pain. P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative; simple closed extraction of #3, socket curetted and irrigated; gauze pressure 30 min; patient advised to avoid smoking 24 h, use ice, take ibuprofen 400 mg PRN.

S: 68-year-old female, former smoker, NKDA, reports “My upper molar is painful and looks decayed”; pain 7/10, worsens with chewing, relieved by ice. O: Extraoral WNL; intraoral: tooth #3 with deep dentin caries, pulpal involvement, periapical radiolucency, mild bone loss on PA; no swelling or trismus. A: Pulpal necrosis with chronic apical periodontitis, evidenced by deep caries, radiolucency and clinical pain. P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration, aspiration negative; simple closed extraction of #3, socket curetted and irrigated; gauze pressure 30 min; patient advised to avoid smoking 24 h, use ice, take ibuprofen 400 mg PRN.

Patient with Smoking Cessation Program, Extraction of Mandibular First Molar

SOAP note

Subjective: 59-year-old female, smoker 5 cigarettes/day, allergic to penicillin (rash); CC: "My lower first molar is loose and hurts when I chew"; HPI: pain worsens with chewing, no fever or swelling; PMH: smoking, penicillin allergy; no systemic signs.
Objective: Extraoral: no swelling, trismus WNL; Intraoral: tooth #19 symptomatic irreversible pulpitis with acute apical periodontitis; radiograph: periapical radiolucency, moderate bone loss, no root fracture; socket clean, no retained fragments; PA: periapical radiolucency; BOP absent; PD <4 mm; CAL 1–2 mm.
Assessment: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by pain on chewing, periapical radiolucency, and moderate bone loss.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative; simple closed extraction of #19; socket irrigated with saline; gauze pressure for 30 min; advised to avoid smoking 24 h, apply ice, take ibuprofen 400 mg PRN; no antibiotics; next visit in 7 days for healing assessment.

S: 59-year-old female, smoker 5 cigarettes/day, allergic to penicillin (rash); CC: "My lower first molar is loose and hurts when I chew"; HPI: pain worsens with chewing, no fever or swelling; PMH: smoking, penicillin allergy; no systemic signs.
O: Extraoral: no swelling, trismus WNL; Intraoral: tooth #19 symptomatic irreversible pulpitis with acute apical periodontitis; radiograph: periapical radiolucency, moderate bone loss, no root fracture; socket clean, no retained fragments; PA: periapical radiolucency; BOP absent; PD <4 mm; CAL 1–2 mm.
A: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by pain on chewing, periapical radiolucency, and moderate bone loss.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL IANB, aspiration negative; simple closed extraction of #19; socket irrigated with saline; gauze pressure for 30 min; advised to avoid smoking 24 h, apply ice, take ibuprofen 400 mg PRN; no antibiotics; next visit in 7 days for healing assessment.

Patient with COPD, Extraction of Mandibular Third Molar

SOAP note

Subjective: 45-year-old male, type 2 diabetes on metformin, NKDA, reports “my lower third molar is painful and swollen”; pain started 3 days ago, throbbing, worse with biting, 8/10 intensity, no fever.
Objective: Extraoral: mild swelling in lower buccal vestibule, no trismus. Intraoral: impacted mesioangular #32 with deep caries, pulpal necrosis; radiograph shows close proximity to the inferior alveolar canal, no root fracture. Periodontal: socket clean, no retained fragments. No extra findings.
Assessment: Symptomatic apical periodontitis of impacted #32, supported by deep caries, pulpal necrosis, radiographic proximity to the canal and clinical swelling.
Plan: Surgical extraction performed with IANB (2% lidocaine 1:100,000, 1.8 mL), flap elevation, bone removal, tooth sectioning; socket curetted, irrigated, oxidized cellulose placed, gauze pressure for 30 min. Advised ice packs, soft diet, avoid hard foods, take ibuprofen 400 mg PRN. Next visit in 7 days for healing assessment.

S: 45-year-old male, type 2 diabetes on metformin, NKDA, reports “my lower third molar is painful and swollen”; pain started 3 days ago, throbbing, worse with biting, 8/10 intensity, no fever.
O: Extraoral: mild swelling in lower buccal vestibule, no trismus. Intraoral: impacted mesioangular #32 with deep caries, pulpal necrosis; radiograph shows close proximity to the inferior alveolar canal, no root fracture. Periodontal: socket clean, no retained fragments. No extra findings.
A: Symptomatic apical periodontitis of impacted #32, supported by deep caries, pulpal necrosis, radiographic proximity to the canal and clinical swelling.
P: Surgical extraction performed with IANB (2% lidocaine 1:100,000, 1.8 mL), flap elevation, bone removal, tooth sectioning; socket curetted, irrigated, oxidized cellulose placed, gauze pressure for 30 min. Advised ice packs, soft diet, avoid hard foods, take ibuprofen 400 mg PRN. Next visit in 7 days for healing assessment.

Patient with History of Dry Socket, Extraction of Mandibular Third Molar

SOAP note

Subjective: 22-year-old male, seasonal allergies, NKDA, CC: “My lower third molar is painful and I can’t sleep,” HPI: impacted horizontal #30 with deep caries and pulpal necrosis, no systemic signs.
Objective: Extraoral: swelling in lower buccal vestibule, no trismus. Intraoral: impacted #30, deep caries, pulpal necrosis. Periodontal: socket clean, no retained fragments. Radiographic: close proximity to inferior alveolar canal, no root fracture.
Assessment: Symptomatic apical periodontitis of #30, supported by deep caries, pulpal necrosis, pain, radiographic periapical radiolucency and proximity to the canal.
Plan: Surgical extraction performed: flap raised, bone removed, tooth sectioned, socket curetted and irrigated; oxidized cellulose placed, gauze pressure for 30 min. Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, IANB, aspiration negative. POI: ice packs, avoid smoking, take ibuprofen 400 mg PRN, return if pain worsens or signs of infection.

S: 22-year-old male, seasonal allergies, NKDA, CC: “My lower third molar is painful and I can’t sleep,” HPI: impacted horizontal #30 with deep caries and pulpal necrosis, no systemic signs.
O: Extraoral: swelling in lower buccal vestibule, no trismus. Intraoral: impacted #30, deep caries, pulpal necrosis. Periodontal: socket clean, no retained fragments. Radiographic: close proximity to inferior alveolar canal, no root fracture.
A: Symptomatic apical periodontitis of #30, supported by deep caries, pulpal necrosis, pain, radiographic periapical radiolucency and proximity to the canal.
P: Surgical extraction performed: flap raised, bone removed, tooth sectioned, socket curetted and irrigated; oxidized cellulose placed, gauze pressure for 30 min. Anesthesia: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL, IANB, aspiration negative. POI: ice packs, avoid smoking, take ibuprofen 400 mg PRN, return if pain worsens or signs of infection.

Patient with History of Periodontitis, Extraction of Mandibular Third Molar

SOAP note

Subjective: 29-year-old male, smoker 5 cigarettes/day, NKDA, says “My lower third molar is painful and I can’t chew”; history of deep caries and pulpal necrosis.
Objective: #30 mesioangular impacted, deep caries, pulpal necrosis; PA shows close proximity to the inferior alveolar canal, no root fracture; buccal vestibule swelling, no trismus; IANB with 2% lidocaine 1:100,000, 1.8 mL, aspiration negative.
Assessment: Symptomatic apical periodontitis of #30, supported by deep caries, pulpal necrosis, radiographic proximity to the canal and clinical pain on chewing.
Plan: Surgical extraction performed with flap, bone removal, sectioning; socket curetted, irrigated, oxidized cellulose placed, gauze pressure for 30 min; patient instructed to use ice, avoid smoking, take ibuprofen 400 mg PRN, and return if pain worsens or swelling increases.

S: 29-year-old male, smoker 5 cigarettes/day, NKDA, says “My lower third molar is painful and I can’t chew”; history of deep caries and pulpal necrosis.
O: #30 mesioangular impacted, deep caries, pulpal necrosis; PA shows close proximity to the inferior alveolar canal, no root fracture; buccal vestibule swelling, no trismus; IANB with 2% lidocaine 1:100,000, 1.8 mL, aspiration negative.
A: Symptomatic apical periodontitis of #30, supported by deep caries, pulpal necrosis, radiographic proximity to the canal and clinical pain on chewing.
P: Surgical extraction performed with flap, bone removal, sectioning; socket curetted, irrigated, oxidized cellulose placed, gauze pressure for 30 min; patient instructed to use ice, avoid smoking, take ibuprofen 400 mg PRN, and return if pain worsens or swelling increases.

Patient with Recent Orthodontic Treatment, Extraction of Maxillary Second Molar

SOAP note

Subjective: 36-year-old male, controlled hypertension on lisinopril, NKDA, reports “My upper second molar is painful and swollen”; pain started 2 days ago, throbbing, worse with chewing, 8/10 intensity.
Objective: Extraoral normal; intraoral shows tooth #15 with symptomatic irreversible pulpitis, acute apical periodontitis, periapical radiolucency, moderate bone loss, no root fracture, socket clean, no swelling or trismus; radiograph PA confirms findings; no systemic signs.
Assessment: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by pain characteristics, radiographic radiolucency, and clinical findings.
Plan: Simple closed extraction of tooth #15 performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration; socket irrigated with saline, gauze pressure for 30 min; patient instructed to apply ice, take ibuprofen 400 mg PRN, avoid hard foods for 48 h, and return if pain exceeds 6/10 or swelling develops.

S: 36-year-old male, controlled hypertension on lisinopril, NKDA, reports “My upper second molar is painful and swollen”; pain started 2 days ago, throbbing, worse with chewing, 8/10 intensity.
O: Extraoral normal; intraoral shows tooth #15 with symptomatic irreversible pulpitis, acute apical periodontitis, periapical radiolucency, moderate bone loss, no root fracture, socket clean, no swelling or trismus; radiograph PA confirms findings; no systemic signs.
A: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by pain characteristics, radiographic radiolucency, and clinical findings.
P: Simple closed extraction of tooth #15 performed under 2% lidocaine with 1:100,000 epinephrine, 1.8 mL buccal infiltration; socket irrigated with saline, gauze pressure for 30 min; patient instructed to apply ice, take ibuprofen 400 mg PRN, avoid hard foods for 48 h, and return if pain exceeds 6/10 or swelling develops.

Patient with Recent Dental Trauma, Extraction of Mandibular First Molar

SOAP note

Subjective: 28-year-old male, asthma (albuterol PRN), NKDA, reports “My lower first molar is painful and I can’t chew”; pain started 2 days ago, throbbing, worsens with chewing, 8/10 intensity, no swelling or trismus.
Objective: Extraoral WNL; intraoral tooth #19 shows deep caries and pulpal exposure, BOP present, probing depths 6 mm, radiograph reveals periapical radiolucency, moderate bone loss, no root fracture; no retained fragments, socket clean.
Assessment: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by deep caries, pulpal exposure, periapical radiolucency and clinical pain.
Plan: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; simple closed extraction of #19 performed, socket irrigated with saline, gauze pressure for 30 min; patient instructed to apply ice, take ibuprofen 400 mg PRN, avoid hard foods, maintain oral hygiene, return if pain exceeds 6/10 or swelling develops.

S: 28-year-old male, asthma (albuterol PRN), NKDA, reports “My lower first molar is painful and I can’t chew”; pain started 2 days ago, throbbing, worsens with chewing, 8/10 intensity, no swelling or trismus.
O: Extraoral WNL; intraoral tooth #19 shows deep caries and pulpal exposure, BOP present, probing depths 6 mm, radiograph reveals periapical radiolucency, moderate bone loss, no root fracture; no retained fragments, socket clean.
A: Symptomatic irreversible pulpitis with acute apical periodontitis, supported by deep caries, pulpal exposure, periapical radiolucency and clinical pain.
P: 2% lidocaine with 1:100,000 epinephrine, 1.8 mL (1 cartridge), IANB, aspiration negative; simple closed extraction of #19 performed, socket irrigated with saline, gauze pressure for 30 min; patient instructed to apply ice, take ibuprofen 400 mg PRN, avoid hard foods, maintain oral hygiene, return if pain exceeds 6/10 or swelling develops.

Post-Operative Instructions and Follow-Up Plan

Post-operative care for a surgical extraction is straightforward.

Place gauze over the socket and instruct the patient to bite firmly for 30–60 minutes; replace gauze every 15–20 minutes until bleeding stops.
Advise a soft diet for 48 hours; no hard, crunchy, or sticky foods.
Instruct to avoid spitting, rinsing, using a straw, or smoking for 24 hours.
Recommend cold packs to the cheek for 15 minutes every 2 hours as needed for swelling.
Prescribe an analgesic regimen: ibuprofen 400 mg PO q6h PRN for pain, or acetaminophen 500 mg PO q6h if NSAID contraindicated.
Counsel to rinse gently with 0.12 % chlorhexidine 15 mL for 30 seconds twice daily starting day 2.
Warn that any sudden increase in pain, persistent bleeding, fever >38 °C, or signs of infection warrants immediate contact.

Follow-up schedule:

Day	Purpose	Notes
1–3	Early complication check	Evaluate bleeding, swelling, pain
5	Suture removal or healing assessment	Confirm socket closure, assess for dry socket
7–10	Final healing review	Ensure complete mucosal coverage, discuss next steps

Documenting Complications in a Surgical Extraction Note

Dry socket (alveolar osteitis) – O: empty socket, exposed bone, patient reports “sharp, throbbing pain radiating to ear”; A: note “dry socket suspected, empty socket, no clot”; P: “placed medicated dressing, prescribed ibuprofen 400 mg q6h PRN, scheduled review in 2 days.”
Post-operative bleeding – O: continuous oozing, gauze saturated, patient says “bleeding hard to stop”; A: record “bleeding >30 min, hemostasis achieved with gauze pressure, oxidized cellulose applied”; P: “advised to apply pressure, instructed on signs of rebleeding, no return visit unless bleeding persists.”
Nerve injury (inferior alveolar/lingual) – O: numbness of lower lip/mandibular buccal mucosa, patient reports “pins and needles”; A: note “temporary paresthesia, no facial asymmetry”; P: “reassured, scheduled follow-up in 1 week, prescribed gabapentin 300 mg PO q12h if pain.”
Infection – O: swelling, erythema, fever 38.2 °C, patient says “fever and pain”; A: record “purulent exudate, socket inflamed”; P: “prescribed amoxicillin 500 mg TID for 7 days, advised to monitor temperature.”
Exposed bone/MRONJ – O: exposed bone >8 weeks, patient reports “persistent pain, no healing”; A: note “exposed bone, no periosteal reaction on PAN”; P: “refer to oral surgeon, advise chlorhexidine rinse, no antibiotics unless systemic signs.”

Key Differences Between Surgical and Simple Extraction SOAP Notes

Surgical extraction SOAP notes extend simple extraction documentation by recording anesthesia details, surgical technique (flap design, bone removal, sectioning), intra-operative findings, hemostasis measures, postoperative instructions, and complication documentation.

Element	Simple Extraction	Surgical Extraction
Anesthesia	Not specified	Agent, volume, technique, aspiration result
Technique	Closed: forceps	Open: flap, bone removal, sectioning
Findings	Tooth removal intact	Root tips, bone curettage, sinus check
Hemostasis	Gauze pressure	Gauze + hemostatic agents, sutures
Post-op	Basic advice	Detailed POI, pain control, follow-up
Complications	None recorded	Dry socket, bleeding, nerve injury, MRONJ

The additional clinical data required for surgical extractions is highlighted by this table.

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

About the author

Dr. Rahul Joshi

Specialist Orthodontist

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

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

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Surgical Extraction SOAP Note: Ready-to-Copy Template & Guidance

Immediate Post-Op Visits (Day 1-3)

Smoker, Day 3 After Lower Molar Extraction

Smoker, Day 1 After Extraction, First Visit

Non-Smoker, Day 2 After Extraction, Dry Socket Suspected

Patient with Mild Asthma, Day 1 After Extraction, Post-Op Bleeding

Patient on Low-Dose Aspirin, Emergency Extraction, Immediate Hemostasis

Patient with Recent COVID-19, Day 3 After Extraction, Infection Signs

Patient with Chronic Kidney Disease, Day 1 After Extraction, NSAID Avoidance

Follow-Up Visits (Day 5 and beyond)

Non-Smoker, Day 5 After Extraction, Follow-Up

Patient with Osteoarthritis, Day 5 After Extraction, Suture Removal

Patient with Recent Trauma, Day 4 After Extraction, Healing Assessment

Emergency Extractions

Pregnant, First Trimester, Emergency Extraction of Carious Mandibular First Molar

Pregnancy & Anticoagulation Cases

Anticoagulated, On Warfarin, Extraction of Mandibular First Molar

Elderly, Osteoporosis on Bisphosphonate, Extraction of Maxillary Third Molar

Pregnant, Second Trimester, Extraction of Mandibular Second Molar

Patient on Clopidogrel, Extraction of Mandibular Third Molar

Systemic Disease Extractions

Diabetic, Poor Glycemic Control, Extraction of Maxillary Second Premolar

Patient with Hypertension, Extraction of Mandibular First Molar

Patient with Chronic Kidney Disease, Extraction of Maxillary Second Molar

Patient with Diabetes, Extraction of Mandibular Third Molar

Patient with Epilepsy, Extraction of Mandibular Second Molar

Patient with Hyperthyroidism, Extraction of Maxillary Second Molar

Patient with Sickle Cell Disease, Extraction of Mandibular First Molar

Patient with Allergic to Penicillin, Extraction of Maxillary Third Molar

Patient with Recent COVID-19 Infection, Extraction of Maxillary Second Molar

Patient with Recent Stroke, Extraction of Mandibular First Molar

Patient with Recent Dental Implant Failure, Extraction of Mandibular Third Molar

Patient with Asthma, Extraction of Maxillary Third Molar

MRONJ & Trauma Extractions

Patient with History of MRONJ, Extraction of Maxillary Third Molar

Patient with Recent Trauma, Extraction of Maxillary First Molar

Patient with History of MRONJ, Day 1 After Extraction, Protective Measures

Patient with Recent Dental Implant Failure, Re-Evaluation, Adjacent Tooth Extraction

Other Dental History Extractions

Patient with Allergic Rhinitis, Extraction of Mandibular Third Molar

Patient with Osteoarthritis, Extraction of Maxillary First Molar

Patient with Anemia, Extraction of Maxillary Third Molar

Patient with Smoking Cessation Program, Extraction of Mandibular First Molar

Patient with COPD, Extraction of Mandibular Third Molar

Patient with History of Dry Socket, Extraction of Mandibular Third Molar

Patient with History of Periodontitis, Extraction of Mandibular Third Molar

Patient with Recent Orthodontic Treatment, Extraction of Maxillary Second Molar

Patient with Recent Dental Trauma, Extraction of Mandibular First Molar

Post-Operative Instructions and Follow-Up Plan

Documenting Complications in a Surgical Extraction Note

Key Differences Between Surgical and Simple Extraction SOAP Notes

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