CC: Patient reports intermittent cold sensitivity on lower right molars for the past 3 months. Denies swelling, trismus, or systemic symptoms.

HPI: Pain is provoked by cold and relieved on removal of stimulus, rated 3/10 at worst. No associated paresthesia or dysesthesia.

Medical Hx: No significant medical history. Medications include vitamin D only. NKDA. No history of bisphosphonate use or radiation to the head and neck.

Social Hx: Non-smoker, occasional alcohol. Dental attendance pattern irregular, emergency-driven.

EO: NAD. No facial swelling or asymmetry. TMJ WNL, no joint sounds or deviation. Lymph nodes non-palpable, non-tender. IO: Oral hygiene fair with localized plaque accumulation. Gingiva erythematous with blunted papillae in posterior sextants.

Perio: Probing depths range from 2–4 mm with isolated 5 mm pockets on 3-6 and 4-6. BOP present in >30% of sites (generalized). Mobility: 1° mobility on 3-1 and 4-1.

Hard tissue: Existing amalgam and composite restorations on multiple posterior teeth, margins intact with no recurrent caries. Radiographic exam reveals no periapical pathology.

Pulp testing: Cold test on 4-6 elicited sharp, non-lingering response. EPT readings within normal limits. Percussion mildly tender on 4-6. Palpation non-tender buccal and lingual.

Occlusion: MI with bilateral, evenly distributed contacts. Excursive movements reveal no working or non-working interferences.

Dx: Generalized stage II, grade B periodontitis with localized plaque-induced gingivitis. Secondary diagnosis: occlusal trauma on mandibular incisors due to deep overbite.

Tx plan (Phase I): OHI, full-mouth scaling and root planing by quadrant, and re-evaluation in 6 weeks. Adjuncts: localized subgingival irrigation with 0.12% chlorhexidine.

Tx plan (Phase II/III): Consider occlusal adjustment and nightguard fabrication. Long-term maintenance: 3–4 month periodontal maintenance intervals.

Informed consent: Risks, benefits, and alternatives discussed, including potential for transient sensitivity following scaling. Patient verbalized understanding and consented to proposed treatment plan.

Anesthesia: 2 carpules 2% lidocaine with 1:100,000 epinephrine via IANB and long buccal. Hemostasis achieved without complication. No complications. Post-op instructions given verbally and in written format.

Progress note (Visit 2): Patient presents for SRP UR and LR quadrants. Subjective: Patient reports mild sensitivity following last visit, improving.

Objective: Gingival inflammation reduced compared to baseline. Plaque scores improved with fewer deposits. BOP reduced to <20% of sites.

Radiographic interpretation: Periapicals and bitewings demonstrate generalized horizontal bone loss of 20–30%. Lamina dura intact around most teeth. PDL spaces within normal limits.

Restorative charting: Existing restorations include class I amalgams on 3-6, 3-7, 4-6, 4-7. Proposed restorations: replacement of defective amalgam on 3-6 O.

Prosthodontic considerations: Occlusal vertical dimension appears maintained. Missing teeth: 1-8, 2-8, 3-8, 4-8. Prosthetic options reviewed: implant-supported FDP.

Risk assessment: Caries risk low based on CAMBRA criteria. Periodontal risk moderate with family history of periodontitis. Occlusal risk elevated due to bruxism.

Patient education: Reviewed proper brushing and interdental cleaning techniques. Provided written instructions on post-SRP care. Patient verbalized understanding and willingness to improve oral hygiene.

Follow-up: Patient to return for SRP of remaining quadrants and recall exam in 6 months. Patient advised to call clinic if pain, swelling, or systemic symptoms develop.