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COMPREHENSIVE ORAL EVALUATION — ADULT NEW PATIENT (D0150)
Date: April 28, 2026   Provider: Dr. P. Singh, DDS — Lic #DDS-44210
Patient: 47-year-old female   MRN: 88421

CHIEF COMPLAINT:
"My back tooth on the lower right is sensitive to cold and I haven't been to a dentist in about four years."

MEDICAL HISTORY:
Hypertension on lisinopril 10 mg daily. Type 2 diabetes, A1c 7.1% in March 2026, on metformin 1000 mg BID.
NKDA. No bisphosphonates, no anticoagulants, ASA I.
BP today 132/80, HR 76. Patient has not had a flu vaccine this season.

DENTAL HISTORY:
Last cleaning 4 years ago. Brushes 1x/day, no flossing, no mouthrinse. No history of orthodontics. No bruxism reported but partner notes occasional grinding at night.

EXTRAORAL EXAM:
Head, neck, TMJ symmetric. Bilateral masseter and temporalis non-tender. TMJ — no clicking, no deviation, MIO 42 mm. Submandibular and cervical lymph nodes non-palpable. No facial swelling.

INTRAORAL EXAM:
Lips, buccal mucosa, vestibule, hard and soft palate, FOM, lateral and ventral tongue, oropharynx — WNL, no leukoplakia, no erythroplakia, no ulceration. Oral cancer screening: negative.
Saliva — adequate flow, no candidiasis.
Gingiva — generalized erythema and edema posteriorly, rolled margins, papillae blunted #2–3 and #14–15.

PERIODONTAL CHART (six-point probing, MB-B-DB-ML-L-DL):
#2  4-3-5  4-3-5   BOP +   #15 5-4-5  4-3-4  BOP +
#3  4-3-4  3-3-4   BOP +   #14 4-3-4  3-3-4  BOP +
#18 5-4-6  4-3-5   BOP +, Class I furcation buccal
#19 4-3-4  3-3-3
#30 5-3-4  3-3-4   BOP +
#31 5-3-5  3-3-4   BOP +
Anterior teeth generalized 2–3 mm, no BOP.
Mobility: 0 throughout. Recession: 1 mm #6, #11, #22, #27.
Bleeding on probing index: 38%. Plaque index: 62%.

HARD TISSUE — CARIES & EXISTING RESTORATIONS:
#3  O composite (intact)         #14 MO amalgam (intact)
#15 DO amalgam — recurrent decay distal margin
#19 O amalgam (intact)
#30 D caries clinically and radiographically — patient's chief complaint, +cold, no lingering pain
#31 MO caries clinically, into dentin on bitewing
#32 partial bony impaction, asymptomatic
Anterior teeth caries-free.

OCCLUSION:
Class I molar bilaterally. Overjet 2 mm, overbite 25%. No premature contacts. Mild incisal wear #8–9, #24–25.

RADIOGRAPHIC FINDINGS (4 BWX + PA #30, taken today):
#15 recurrent decay distal under amalgam, into dentin.
#30 distal interproximal caries to DEJ. PA #30 — apex intact, PDL space WNL, no periapical lesion.
#31 mesial caries to DEJ.
Generalized horizontal bone loss 2–3 mm, posterior more pronounced. No periapical pathology.

DIAGNOSIS:
1. Generalized chronic moderate periodontitis, Stage III Grade B (K05.30).
2. Dental caries — #15 D recurrent, #30 D, #31 M (K02.61).
3. Asymptomatic partial bony impaction #32 (K01.1).
4. Plaque-induced gingivitis (K05.10) overlying periodontitis.
5. Type 2 diabetes — modifying factor for periodontal disease.

TREATMENT PLAN — PHASED:
Phase I — Disease Control (next 6 weeks):
  1. Scaling and root planing, all four quadrants — D4341 x 2 (UR/UL), D4341 x 2 (LR/LL), local anesthetic.
  2. Chlorhexidine gluconate 0.12% rinse, 15 mL BID x 2 weeks.
  3. Composite restoration #30 distal — D2391.
  4. Composite restoration #31 mesial — D2391.
  5. Replace #15 DO amalgam with composite — D2392.
Phase II — Definitive (6–12 weeks):
  6. Surgical extraction #32 — D7240, refer or in-house with sedation; ibuprofen 600 mg q6h PRN, amoxicillin 500 mg TID x 5 days only if signs of infection at time of extraction.
  7. Re-evaluation and pocket re-charting at 6 weeks post-SRP. If residual pockets >5 mm, refer to periodontist for surgical consult.
Phase III — Maintenance:
  8. Periodontal maintenance every 3 months — D4910.
  9. Bitewings annually, FMX every 5 years.
 10. Custom occlusal guard at next appointment for nocturnal grinding — D9944.

PRESCRIPTIONS WRITTEN TODAY:
- Chlorhexidine gluconate 0.12% oral rinse, 16 oz, swish 15 mL BID x 2 weeks.
- Ibuprofen 600 mg, #20, 1 tab q6h PRN post-SRP soreness.

PATIENT EDUCATION & CONSENT:
Reviewed periodontal disease in plain language, the link with diabetes, and importance of A1c control. Demonstrated modified Bass technique and floss; patient returned demo. Discussed financials and insurance coverage; patient verbally accepted Phase I; will return signed treatment plan at next visit.

NEXT APPOINTMENT:
SRP UR + UL in 5 days, 75 minutes with hygienist Maria. Post-op call same evening.

Last reviewed: April 2026 — PatientNotes Clinical Team