SOAP Note Template (Dentistry)
Published: 10/22/2025
About this template:
This dental SOAP note template provides comprehensive documentation for dental visits. It includes sections for oral examination findings, periodontal charting, radiographic findings, and treatment procedures. The template supports thorough documentation of preventive care, restorative procedures, and patient education, ensuring clear communication and continuity of care across dental visits.
Preview template
Subjective: 42-year-old female presents for routine dental cleaning and examination. Reports sensitivity in lower right posterior teeth when consuming cold beverages over the past month. No pain with chewing. Brushes twice daily with soft-bristled toothbrush, flosses 3-4 times per week. No bleeding gums. Medical history significant for well-controlled hypertension. Last dental visit 9 months ago.
Objective: Extra-oral examination unremarkable with no facial swelling or lymphadenopathy. Intra-oral examination reveals generalized mild plaque and calculus accumulation. Gingival tissues show mild inflammation with isolated areas of 4mm pockets on distal of #3 and #14. Periodontal probing depths otherwise 1-3mm throughout. Examination of tooth #30 reveals moderate gingival recession with exposed root surface and mild cervical abrasion. Caries detected on tooth #19 (distal surface). Existing restorations intact. Occlusion stable with no signs of bruxism.
Assessment and Plan:
- Generalized gingivitis with localized moderate periodontitis
- Cervical abrasion with recession on tooth #30 causing thermal sensitivity
- Dental caries, tooth #19 distal
- Prophylaxis completed today with ultrasonic and hand scaling
- Application of fluoride varnish to sensitive area on #30
- Schedule appointment for composite restoration on tooth #19
- Recare interval maintained at 6 months
Patient Education:
- Discussed proper brushing technique to avoid further abrasive damage (gentle circular motion, not horizontal scrubbing)
- Recommended desensitizing toothpaste for daily use on sensitive areas
- Reinforced importance of daily flossing to improve gingival health
- Educated on early signs of periodontal disease and importance of regular cleanings
Patient verbalizes understanding of treatment recommendations. Restorative appointment scheduled for next week.
