Sample AI-powered SOAP notes.

Patient presented for restoration of tooth #14 with chief complaint of sensitivity to cold on the upper left posterior. Reports occasional sharp discomfort when chewing. No reported history of trauma. Medical history reviewed; no contraindications.

Tooth #14 with previously diagnosed MOD caries confirmed clinically and radiographically. Vital response within normal limits. No periapical pathology noted on bitewing. Soft tissues unremarkable.

Caries on the mesial, occlusal, and distal surfaces of tooth #14, restorable via direct composite restoration. Prognosis good.

Local anesthesia administered (1 carpule 2% lidocaine with 1:100,000 epinephrine). Rubber dam isolation. Caries excavated, preparation completed. Tooth restored with composite resin, occlusion adjusted, finished and polished. Patient tolerated procedure well. Post-operative instructions reviewed. Reappoint in 6 months for routine recall.

Patient presented for crown preparation of tooth #19 secondary to large existing amalgam restoration with recurrent decay. No current symptoms of pain. Patient anxious; counseled on procedure and sedation options.

Tooth #19 with existing failing amalgam, marginal breakdown, and recurrent caries noted on the distal margin. Bitewing shows no periapical pathology. Adjacent teeth and occlusion evaluated.

Tooth #19 with structurally compromised existing restoration and recurrent caries, indication for full-coverage zirconia crown.

Local anesthesia administered. Existing restoration removed, caries excavated. Tooth prepared per zirconia preparation guidelines. Digital impression captured. Temporary crown placed and adjusted. Final crown ordered. Patient scheduled for delivery in 2 weeks.

Patient presented for routine 6-month recall. No reported dental concerns. Reports daily brushing twice and flossing 3 to 4 times per week. Medical history reviewed; no changes since last visit.

Generalized mild plaque and calculus accumulation, primarily lingual aspect of lower anteriors and buccal aspect of upper molars. Gingiva pink, firm, stippled. Probing depths within normal limits (1 to 3 mm). No bleeding on probing. Full-mouth bitewing series reviewed; no new caries detected. Occlusion stable.

Healthy adult dentition with mild plaque and calculus accumulation. Generalized gingival health.

Full-mouth scaling, polishing, and fluoride varnish application. Oral hygiene reinforced, emphasis on lingual aspect of lower anteriors. Reappoint in 6 months for routine recall and bitewings.

Patient presented for 3-month periodontal maintenance following Phase I therapy completed 6 months prior. Reports compliance with home care regimen including interproximal brushes and prescription rinse.

Generalized 4 to 5 mm probing depths in posterior sextants, isolated 6 mm pocket on the mesial of #30. Bleeding on probing 18%. Mobility within normal limits. Minimal supragingival deposits; moderate subgingival calculus.

Stable Stage II Grade B periodontitis. Localized site of concern at the mesial of #30.

Full-mouth periodontal maintenance completed. Site-specific debridement at #30 mesial. Localized antimicrobial application. Patient counseled on continued home care. Continue 3-month recall interval. Reassess #30 in 6 weeks.