Free Dental Hygiene Soap Note

The patient reports sensitivity in the lower left molars while consuming cold beverages.

The patient has a history of seasonal allergies; no significant changes in medical history since the last visit. Reports taking over-the-counter antihistamines occasionally.

The patient underwent scaling and root planing six months ago and reports good compliance with oral hygiene instructions.

• Moderate plaque on lower left posterior molars.

• Slight gingival inflammation around #18 and #19.

• Probing depths 1-3 mm; 4 mm pocket on distal #19.

Bitewing radiographs show no evidence of new caries or bone loss.

No abnormalities in occlusion or temporomandibular joint (TMJ) function.

Localized mild gingivitis in the lower left quadrant with slight periodontal pocketing on #19.

• A suboptimal flossing technique was noted during the demonstration.

• Possible dietary factors contributing to sensitivity.

• Full-mouth prophylaxis, focusing on the lower left quadrant.

• Applied fluoride varnish for sensitivity relief.

• Demonstrated proper flossing technique.

• Recommended sensitivity toothpaste and limiting acidic drinks.

• Scheduled a six-month follow-up for routine care and to monitor the periodontal pocket on #19.