10 Common Dentistry SOAP Note Examples

Updated in July 2025

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List of cases

1. Dental Caries
2. Periodontal Disease
3. Dental Abscess
4. Cracked Tooth Syndrome
5. Temporomandibular Disorders
6. Dental Trauma
7. Post-Extraction Follow-up
8. Crown Preparation
9. Root Canal Therapy
10. Dental Implant Consultation

1. Dental Caries

Description

The patient presents with tooth sensitivity and suspected dental caries in the posterior region, seeking dental evaluation and treatment.

SOAP Note

Patient Name: Michael Brown

Date of Visit: 09/01/2024

Subjective

Michael Brown, a 35-year-old male, presents with sensitivity to cold and sweet substances in the upper right posterior region for past 2 months. Reports intermittent pain rated 4/10, lasting few seconds with stimuli. No spontaneous pain. Last dental visit 2 years ago. Reports irregular flossing habits and frequent soda consumption. Medical history negative for significant conditions. No known allergies.

Objective

• Vital Signs:
  • BP: 122/78 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Clinical Examination:
  • Tooth #14 (Upper Right First Molar):
    • Visible occlusal decay
    • Positive response to cold test
    • No percussion sensitivity
    • No mobility
  • Radiographic Findings:
    • Radiolucency extending into dentin
    • No pulpal involvement
    • Normal periapical region
• Periodontal Status:
  • Healthy gingival tissue
  • Normal probing depths (2-3mm)
• Oral Hygiene:
  • Moderate plaque accumulation
  • No calculus present

Assessment

1. Dental Caries (ICD-10: K02.1)
   • Moderate occlusal caries on #14
   • No pulpal involvement
   • High caries risk factors present

Plan

1. Treatment Provided Today:

   • Comprehensive examination
   • Intraoral photos
   • Oral hygiene instruction
   • Treatment plan presentation

2. Recommended Treatment:

   • Composite restoration on #14
   • Estimated treatment time: 1 hour
   • Local anesthesia required
   • Preventive sealants on other molars

3. Home Care Instructions:

   • Improve brushing technique
   • Daily flossing
   • Reduce sugar intake
   • Fluoride toothpaste use

4. Follow-up:

   • Schedule restoration appointment
   • 6-month recall examination
   • Regular fluoride treatments

CDT Codes:

• D0120 (Periodic oral evaluation)
• D0274 (Bitewings - four radiographs)
• D2392 (Resin-based composite - two surfaces, posterior)

2. Periodontal Disease

Description

The patient presents with signs and symptoms of periodontal disease, including bleeding gums and pocket formation.

SOAP Note

Patient Name: Sarah Martinez

Date of Visit: 09/02/2024

Subjective

Sarah Martinez, a 45-year-old female, presents with bleeding gums during brushing and bad breath for past 6 months. Reports tender gums and occasional pain while chewing. Last dental cleaning 3 years ago. Current smoker (1/2 pack/day for 15 years). Medical history significant for Type 2 diabetes (controlled with medication). Reports irregular dental hygiene habits.

Objective

• Vital Signs:
  • BP: 128/82 mmHg
  • HR: 76 bpm
  • RR: 16/min
• Periodontal Examination:
  • Generalized 4-6mm pocket depths
  • Bleeding on probing: 65%
  • Gingival recession: 1-3mm
  • Class II furcation involvement #3, #14
• Radiographic Findings:
  • Generalized horizontal bone loss
  • Localized vertical defects
  • Calculus deposits visible
• Clinical Findings:
  • Moderate to heavy calculus
  • Gingival inflammation
  • Plaque score: 75%

Assessment

1. Generalized Moderate Chronic Periodontitis (ICD-10: K05.3)
   • Generalized bone loss
   • Multiple risk factors
   • Poor oral hygiene

Plan

1. Treatment Provided Today:

   • Comprehensive periodontal examination
   • Full mouth radiographs
   • Periodontal charting
   • Oral hygiene instruction

2. Recommended Treatment:

   • Scaling and root planing (4 quadrants)
   • Local anesthesia required
   • Chlorhexidine rinse prescription
   • Smoking cessation counseling

3. Home Care Instructions:

   • Electric toothbrush recommended
   • Interdental brushes use
   • Twice daily chlorhexidine rinse
   • Smoking cessation resources

4. Follow-up:

   • 4-6 week re-evaluation
   • 3-month periodontal maintenance
   • Regular diabetic monitoring

CDT Codes:

• D0150 (Comprehensive oral evaluation)
• D0210 (Full mouth radiographs)
• D4341 (Scaling and root planing - four or more teeth per quadrant)

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