Patient reports bleeding gums when brushing and a loose feeling in the lower right back teeth for about three months.
Periodontal charting completed 20-Aug-2026: full mouth, six sites per tooth. Treated quadrants below.
| Tooth | Facial probing | Lingual probing | Bleeding | Mobility |
|---|---|---|---|---|
| Tooth #2 (UR) | MB 6 mm, B 5 mm, DB 6 mm | ML 5 mm, L 4 mm, DL 6 mm | BOP: yes | Mobility: I |
| Tooth #3 (UR) | MB 6 mm, B 5 mm, DB 7 mm | ML 6 mm, L 4 mm, DL 6 mm | BOP: yes | Mobility: I |
| Tooth #4 (UR) | MB 5 mm, B 4 mm, DB 5 mm | ML 5 mm, L 3 mm, DL 5 mm | BOP: yes | Mobility: 0 |
| Tooth #5 (UR) | MB 5 mm, B 3 mm, DB 5 mm | ML 4 mm, L 3 mm, DL 5 mm | BOP: yes | Mobility: 0 |
| Tooth #28 (LR) | MB 5 mm, B 3 mm, DB 5 mm | ML 4 mm, L 3 mm, DL 5 mm | BOP: yes | Mobility: 0 |
| Tooth #29 (LR) | MB 5 mm, B 4 mm, DB 6 mm | ML 5 mm, L 4 mm, DL 6 mm | BOP: yes | Mobility: 0 |
| Tooth #30 (LR) | MB 7 mm, B 5 mm, DB 6 mm | ML 6 mm, L 5 mm, DL 7 mm | BOP: yes | Mobility: II |
| Tooth #31 (LR) | MB 6 mm, B 5 mm, DB 6 mm | ML 6 mm, L 4 mm, DL 6 mm | BOP: yes | Mobility: I |
Upper left and lower left quadrants probe 2 to 3 mm with localized bleeding; no root planing planned there.
Radiographic findings: full-mouth series (FMX) taken 20-Aug-2026 shows horizontal bone loss of 30 to 40% at teeth #2 to #5 and #28 to #31, with subgingival calculus on #3, #30 and #31.
Diagnosis: generalized periodontitis, Stage III, Grade B. ICD-10 K05.323 (chronic periodontitis, generalized, severe).
Plan: scaling and root planing recommended in the upper right and lower right quadrants, re-evaluation 6 weeks after treatment, then periodontal maintenance every 3 months.