Dental SOAP Notes: Complete Documentation Guide with Clinical Examples

DENTAL PROGRESS NOTE
Date: January 15, 2025
Patient: Jane Smith, DOB 03/12/1985 (Age 39)
Provider: Dr. Michael Chen, DDS

SUBJECTIVE
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CC: "Routine cleaning and checkup"

Patient presents for periodic examination and prophylaxis. No current dental complaints. Reports occasional sensitivity to cold on lower right side, resolves quickly. Brushing 2x daily with electric toothbrush, flossing 3-4x weekly. No medical changes since last visit. Current medications: Levothyroxine 75mcg daily. NKDA.

OBJECTIVE
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Extraoral: Symmetrical face, no swelling or masses. TMJ: bilateral clicking on opening, no pain or limitation. Lymph nodes non-palpable.

Intraoral: Soft tissues WNL. Tongue, floor of mouth, palate unremarkable. Oral hygiene good with minimal plaque.

Periodontal: Generalized probing depths 2-3mm. Localized 4mm pockets: #18-M, #19-D, #30-M, #31-D. BOP 15% (improved from 28% last visit). No mobility. Recession 1-2mm on #6, #11 facial.

Hard Tissue Findings:
- #2: Occlusal amalgam, good margins
- #3: MO composite, slight marginal staining
- #14: Lingual composite restoration, intact
- #15: DO amalgam, good condition
- #18: MOD amalgam, worn occlusal surface
- #19: Full gold crown, margins acceptable
- #30: O composite, good condition
- #31: MO amalgam, recurrent decay noted on radiograph

Radiographs: 4 BWX taken. Bone levels stable. Recurrent caries #31-M extending to DEJ. Early interproximal radiolucency #18-D (watch). All other restorations radiographically sound.

Occlusion: Class I molar relationship. Mild attrition on anterior teeth consistent with bruxism history.

ASSESSMENT
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1. Generalized mild chronic periodontitis, currently stable (improved from previous)
2. Tooth #31: Recurrent caries, mesial surface
3. Tooth #18: Questionable interproxal caries, distal (watch area)
4. History of bruxism with evidence of dental attrition
5. Overall oral health: Good with improvement in periodontal status

PLAN
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Treatment Recommendations:
1. Replace amalgam restoration #31 due to recurrent caries (D2391 - resin-based composite, one surface)
2. Monitor tooth #18 - re-evaluate in 6 months with bitewing radiograph
3. Continue current home care regimen - excellent compliance noted
4. Consider nightguard for bruxism management (D9944)
5. Prophylaxis completed today (D1110)
6. Fluoride varnish applied (D1206)

Patient Education:
- Reviewed radiographs showing recurrent decay on #31
- Discussed importance of nightguard to prevent further tooth wear
- Encouraged continued excellent oral hygiene

Informed Consent: Discussed treatment options for #31 including composite restoration vs. crown if decay extensive. Patient understands risks/benefits and opts for conservative composite restoration initially.

Follow-up:
- Schedule tooth #31 restoration within 2-4 weeks
- Return in 6 months for periodic exam and prophylaxis
- Consider nightguard fabrication at next visit

Dr. Michael Chen, DDS                    Date: 01/15/2025

DENTAL PROCEDURE NOTE
Date: January 18, 2025
Patient: Robert Martinez, DOB 07/22/1968 (Age 56)
Provider: Dr. Sarah Williams, DDS
Assistant: Maria Garcia, RDA

SUBJECTIVE
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CC: "Ready for my crown on the upper left molar"

Patient presents for crown preparation on tooth #14 following completion of endodontic therapy 3 weeks ago. Reports tooth is asymptomatic, no pain or sensitivity. Endodontic treatment completed by Dr. Johnson (endodontist) on 12/28/2024. Patient requests tooth-colored crown. Medical history: Type 2 DM (well-controlled, A1C 6.2%), HTN. Medications: Metformin 1000mg BID, Lisinopril 10mg daily. NKDA.

OBJECTIVE
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Extraoral: No facial swelling or asymmetry. No lymphadenopathy.

Intraoral: Soft tissues within normal limits. Existing temporary restoration on #14 intact.

Tooth #14 Examination:
- Temporary restoration removed, no odor or debris
- Endodontic access properly sealed
- No caries on remaining tooth structure
- Buccal cusp fractured (reason for RCT and crown)
- Adequate tooth structure remains for crown preparation
- Percussion: negative
- Palpation: non-tender
- No sinus tract or swelling
- Adjacent teeth (#13, #15) stable

Periodontal: Probing depths 2-3mm around #14, no BOP. Adequate attached gingiva.

Pre-operative Radiograph: Endodontic fill appears adequate, extends to radiographic apex. No periapical radiolucency. Bone levels normal.

ASSESSMENT
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1. Tooth #14: Post-endodontic, requires full coverage restoration
2. Adequate remaining tooth structure for conventional crown preparation
3. Systemic health: Well-controlled DM and HTN, no modifications needed
4. Prognosis: Good with proper restoration

PLAN/PROCEDURE
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Treatment: Crown preparation tooth #14, PFM (D2750)

Consent: Reviewed procedure, risks (potential for temporary sensitivity, need for adjustment, rare crown failure), benefits, alternatives (onlay vs. full crown). Patient provided informed consent.

Anesthesia:
- Achieved with 2.0mL 2% lidocaine with 1:100,000 epinephrine
- Infiltration buccal #14
- Greater palatine nerve block
- Adequate anesthesia confirmed before procedure

Procedure:
1. Isolation with cotton rolls and Dri-Angles
2. Crown preparation completed with adequate reduction:
   - Occlusal: 2.0mm clearance
   - Axial: 1.5mm reduction
   - Margin: 0.8mm circumferential chamfer, supragingival
   - All line angles rounded
   - Finish line smooth and continuous
3. Gingival retraction with #1 retraction cord (braided, non-impregnated)
4. Final impression: Polyvinyl siloxane (PVS) dual-arch technique
   - Light body syringe material around preparation
   - Heavy body tray material
   - Excellent impression quality, all margins captured
5. Bite registration: PVS in maximum intercuspation
6. Shade selection: A2 (matched to adjacent teeth), confirmed in natural light
7. Temporary crown fabricated with bis-acryl composite
   - Proper contours and contacts established
   - Margins adapted subgingivally
   - Occlusion adjusted, no premature contacts
   - Temporary cemented with non-eugenol temporary cement

Post-operative assessment:
- Occlusion verified - even contacts
- Floss passes through contacts
- Patient reports temporary feels comfortable
- No bleeding or tissue trauma

Laboratory Prescription: PFM crown, shade A2, high noble metal, contact #13-D and #15-M

Patient Instructions:
- Avoid sticky, hard foods on temporary crown
- Brush gently around temporary
- Floss carefully - pull through from side, don't pull up
- Temporary may feel slightly different from natural tooth
- Call immediately if temporary becomes loose or dislodged
- Mild sensitivity normal for few days
- Take ibuprofen 400-600mg if needed for discomfort

Medications: None prescribed - OTC ibuprofen sufficient

Complications: None

Follow-up: Crown seat appointment scheduled in 2 weeks (02/01/2025)

Dr. Sarah Williams, DDS                    Date/Time: 01/18/2025 10:45 AM

DENTAL EMERGENCY NOTE
Date: January 20, 2025, 4:30 PM
Patient: Lisa Thompson, DOB 11/05/1992 (Age 32)
Provider: Dr. James Park, DDS

SUBJECTIVE
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CC: "Severe pain and swelling on my lower right jaw for 3 days"

HPI: Patient presents as emergency add-on with chief complaint of severe, constant throbbing pain in lower right posterior area. Pain started 3 days ago as mild ache, progressively worsening. Now rates 9/10, radiating to ear and temple. Unable to sleep last night. Noticed facial swelling this morning. Reports foul taste in mouth. Ibuprofen and acetaminophen provide minimal relief. Denies fever but feels "warm." Last dental visit >2 years ago.

PMH: Generally healthy, no chronic conditions
Medications: Oral contraceptive (Ortho Tri-Cyclen)
Allergies: Penicillin (hives)
Social: Non-smoker, social alcohol use

OBJECTIVE
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Vital Signs: BP 142/88 (elevated, likely pain-related), HR 92, Temp 99.8°F, RR 18

General: Patient appears uncomfortable, holding right side of face

Extraoral:
- Obvious facial swelling right mandible, extending from angle to body
- Skin taut, erythematous, warm to touch
- Right submandibular lymph node enlarged, firm, tender
- No trismus - opening 42mm (adequate)
- No dysphagia or dyspnea

Intraoral:
- Poor oral hygiene with heavy plaque and calculus
- Severe inflammation and edema buccal vestibule adjacent to #30
- Fluctuant swelling palpable buccal to #30
- Purulent drainage expressed upon palpation
- #30: Gross carious destruction of crown, only roots remaining
- #30: Extremely tender to percussion (patient jumped)
- #30: Grade 2 mobility
- Surrounding gingiva erythematous, edematous

Radiographic (PA):
- Tooth #30: Extensive caries involving pulp chamber
- Large periapical radiolucency 8mm x 6mm
- Bone loss extending to apex
- Widened PDL space
- Root resorption noted at apex

ASSESSMENT
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1. Tooth #30: Acute periapical abscess with facial cellulitis
2. Tooth #30: Non-restorable (advanced caries, poor prognosis)
3. Generalized poor oral health/neglect
4. Systemic involvement: Low-grade fever, lymphadenopathy, facial cellulitis
5. Patient at risk for spread of infection

Severity: Moderate to severe - requires immediate intervention and antibiotic therapy

PLAN
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Immediate Treatment:
1. Establish drainage:
   - I&D of intraoral abscess (D7510)
   - Local anesthesia: 4% articaine with 1:100,000 epi (infiltration) - achieved adequate anesthesia despite infection
   - Stab incision made at point of fluctuance
   - Copious purulent drainage expressed and suctioned
   - Area irrigated with normal saline
   - Gauze wick placed for continued drainage
   - Drainage sample not cultured (clinical diagnosis clear)

2. Tooth #30 Extraction deferred today due to:
   - Active acute infection
   - Patient anxiety and fatigue
   - Need for antibiotic pretreatment
   - Will extract after infection controlled

Medical Management:
- Antibiotic: Clindamycin 300mg QID x 7 days (given PCN allergy)
  Prescription sent electronically to patient's pharmacy
  Discussed importance of completing full course
- Analgesic: Ibuprofen 600mg q6h with food + Acetaminophen 500mg q6h (staggered)
  Written instructions provided
- Chlorhexidine 0.12% rinse BID x 7 days

Patient Education:
- Explained nature of infection and need for extraction
- Reviewed antibiotic importance - MUST complete full 7 days
- Warning signs requiring ER visit:
  * Difficulty breathing or swallowing
  * High fever >101.5°F
  * Increased facial swelling
  * Swelling involving eye or neck
  * General malaise, weakness
- Pain should improve within 24-48 hours
- Salt water rinses (warm) 4-5x daily
- Soft diet, adequate hydration
- No smoking or alcohol while on antibiotics

Informed Consent:
- Patient understands #30 is non-restorable and requires extraction
- Discussed extraction procedure, risks, alternatives (none - tooth must be removed)
- Post-extraction options for replacement (implant, bridge, partial) will discuss after healing

Follow-up Plan:
1. Emergency line provided - call if worsening symptoms
2. Recheck in 2-3 days (phone call to assess antibiotic response)
3. Extraction appointment in 7-10 days after antibiotics completed
4. Comprehensive exam needed after acute care for full treatment planning

Disposition: Discharged home with prescriptions. Patient verbalized understanding of all instructions and warning signs. Emergency contact number provided.

Dr. James Park, DDS                    Date/Time: 01/20/2025 5:15 PM