Stunning AI‑Powered SOAP Notes
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SOAP NOTE
Subjective
Chief Complaint
• Presents for comprehensive examination and full-mouth radiographic assessment.
Dental History
• History of root canal therapy due to pulpal involvement; crown placed ~1.5–2 years ago.
• Completed Invisalign ~1 year ago; currently wears a retainer.
• Prior fractured amalgam restoration on #31.
• Regular use of oral irrigator; interested in oral hygiene tools.Social History
• Patient is expecting a baby and currently exploring baby names.
Objective
Radiographic Findings
• Minor periapical radiolucency on a previously treated tooth; needs evaluation.
• Radiolucency adjacent to crown margin on #19; needs evaluation.
• #31: Restoration wear noted.Hard Tissue Exam
• #12, #13: Distal incipient lesions.
• #14: Mesial incipient lesion.
• #18: Mesial incipient lesion; occlusal caries.
• Crown #19: Distal open margin.
• #31: Missing distal-lingual cusp; structurally compromised.Periodontal Exam
• Probing depths 6–7 mm at second and third molars.
• Recession noted on #5, #6, #12, #13.
• Inflammation around third molars (pericoronitis).Orthodontic Exam
• Invisalign completed ~1 year ago; stable alignment; retainer in use.
Endodontic Testing
• Previously treated tooth shows signs suggesting need for endodontic re-evaluation.
Assessment
• Previously endodontically treated tooth requires evaluation for potential retreatment.
• Incipient caries present; recommend remineralization protocol.
• Generalized gingival recession and localized periodontitis; periodontal referral indicated.
• #31: Loss of cusp and compromised structure; crown recommended.Plan
Treatment
• Crown indicated on #31 due to cusp loss and compromised integrity.
Referrals
• Endodontic evaluation for potential retreatment.
• Periodontal referral for grafting and nonsurgical therapy.Patient Education
• Reinforced daily flossing and post-meal rinsing to support remineralization.
• Recommended use of oral irrigator with floss for interdental cleaning.
• Advised gentle brushing technique with low-abrasion electric toothbrush.
• Suggested proximal brushes for third molar hygiene.
• Emphasized importance of periodontal maintenance.SOAP NOTE
Subjective
Chief Complaint
• Presents for consultation regarding dental implant placement to replace a previously extracted tooth.
Dental History
• Childhood carious lesion restored with amalgam; restoration failed, leading to extraction.
• History of multiple restorations and ceramic crowns.
• Interest in orthodontic intervention to address spacing and preserve midline diastema.
• Reports tongue thrust habit and mouth breathing.Social History
• Works in behavioral health with adults.
• From a large family with six siblings and one nephew.
• Owns a 119-pound, one-year-old Cane Corso.Objective
Radiographic Exam
• Amalgam restorations exhibit marginal discrepancies, leakage, discoloration, and fractures; evaluation for replacement recommended.
• Tooth #20: Minor gap between crown and tooth; needs evaluation.Hard tissue Findings
• Ceramic crowns on #3, #4, #5, #20, #31.
• Composite restorations: #6, #11 (distolingual); #12 (DO); #14 (MOL); #15, #21, #28 (occlusal); #18 (MOV); #19, #30 (MODB); #29 (DO).Orthodontic Exam
• Diastema and flaring noted; tongue thrust contributing to spacing.
• Right: Class III molar and canine relationship.
• Left: Class I molar and canine relationship.
• Myofunctional therapy and tongue posture correction recommended.
• Invisalign discussed to maintain diastema and manage spacing.Assessment
• Fractured amalgam restorations with compromised margins; replacement indicated.
• Crown-to-tooth interface on #20 needs evaluation for marginal integrity.
• Spacing and flaring linked to tongue thrust habit; intervention advised.
• Suspected mouth breathing; consider myofunctional and/or speech therapy.
• Missing tooth #21; dental implant indicated.
• Risk-benefit-alternatives discussed: implant vs. bridge vs. no treatment.
• Patient interested in Invisalign to preserve diastema and correct spacing.
• Plan includes restoration assessment and possible full-coverage crown for #19.Plan
Treatment
• Implant placement discussed for missing tooth at site #20 (previously extracted #21).
• Recommended replacing defective amalgam restorations with composite restorations for structural and esthetic improvement.
• Evaluate #19 for potential full-coverage crown due to fracture risk.Patient Education
• Reviewed Invisalign benefits: hygiene-friendly, preserves diastema; estimated duration 18–24 months.
• Advised on proper care of aligners; report attachment loss promptly.
• Reviewed esthetic benefits of composite restorations over amalgam.
• Advised limiting abrasive agents like baking soda; discussed whitening alternatives (e.g., Opalescence, whitening strips).
• Emphasized closing interproximal spaces to prevent food impaction and gingival inflammation.
• Encouraged myofunctional therapy and tongue posture training.
• Suggested nasal dilators to promote nasal breathing.Follow-up
• Return scheduled on 3/31/2025 for prophylaxis.
• Address three structurally compromised teeth.
• Evaluate #19 for crown conversion at next visit with Dr. Curtis.
• Confirm dental insurance benefits for the current coverage year.SOAP NOTE
Subjective
Chief Complaint
• New patient presents for a comprehensive dental examination and full-mouth radiographs in preparation for prophylaxis.
Medical History
• Reports hormonally linked migraines with associated oral swelling.
• History of clenching contributing to orofacial muscle tension.Social History
• Employed as a software engineer.
• Planning upcoming travel to San Diego.Objective
Intraoral/Extraoral Findings
• Bilateral tori present.
• Mallampati Class 4 airway classification.
• Mild ankyloglossia.
• Bilateral cheek hyperkeratosis consistent with chronic cheek biting.Occlusion
• Class III canine and Class I molar relationship on the right.
• Class I canine and molar relationship on the left.
• Overbite: 4mm; Overjet: 1mm.
• Midline discrepancy and posterior angulation present.TMJ Evaluation
• Jaw pain and clicking on mastication consistent with TMJ dysfunction.
• Clenching likely contributing to joint stress and myofascial discomfort.
• Recommend evaluating occlusal scheme and envelope of motion; occlusal guard may be indicated.Hard Tissue
• #15: Occlusal chip on existing restoration; polishing indicated.
• #18, #31: Noted occlusal wear.
• #19, #30: Existing OB composite restorations with clinically acceptable margins.Periodontal Findings
• 2–3mm lingual recession on #22–27.
• Localized pocketing and calculus near retainer bar.
• Recommend retainer bar removal to facilitate debridement and reduce gingival irritation.Orthodontic Findings
• Posterior crossbite, spacing, and mild midline deviation.
• Retainer bar potentially affecting alignment.
• Recommend aligner therapy following bar removal; consider soft tissue recontouring as adjunct.Assessment
• Parafunctional activity (clenching) contributing to TMJ symptoms, tori development, and muscle tightness.
• Occlusal chip on #15.
• Abnormal occlusal scheme with Class III canine on right, mild midline deviation, 4mm overbite, 1mm overjet.
• Chronic cheek biting consistent with bilateral hyperkeratosis.
• Mallampati Class 4 suggests potential airway restriction.
• Periodontal recession and inflammation localized to retainer bar area.
• OB composite restorations on #19 and #30 with acceptable margins; no intervention required at this time.Plan
• Polish #15 to smooth chipped restoration.
• Fabricate occlusal guard or consider myosplint for TMJ relief.
• Recommend removal of retainer bar to improve gingival health and allow for re-scanning.
• Refer for orthodontic consultation: aligner therapy and potential soft tissue recontouring.Patient Education
• Instructed to use water flosser as adjunct to flossing.
• Advised to avoid chewing on symptomatic side.
• Encouraged use of stress-reduction techniques (e.g., breathing exercises, app-based tools).
• Reinforced proper tongue posture: maintain contact with the palate to reduce parafunctional activity and prevent cheek biting.