Periodontal Exam Note (IH)

REFERRING DENTIST: Dr. Emily Johnson MEDICAL HISTORY: Medical Conditions: Hypertension, Type 2 Diabetes Medications: Metformin, Lisinopril Allergies: Penicillin Family History: Father had periodontal disease Social History: Smokes 10 cigarettes per day Blood Pressure: 140/90 mmHg, Pulse: 78 bpm. Patient advised on lifestyle changes to manage blood pressure. CHIEF COMPLAINT: - Bleeding gums for the past 3 months - Gums bleed during brushing and have become swollen. No cosmetic concerns reported. DENTAL HISTORY: Past periodontal treatment: Scaling and root planing in 2022 by Dr. Sarah Lee Past orthodontic treatment: None Previous hygiene interval: Every 6 months Last dental hygiene visit: 15 July 2024 Oral Hygiene: Brushes twice daily, flosses occasionally Parafunctional Habits: Clenching at night, does not use a nightguard EXTRAORAL EXAMINATION: Head/Neck/Lymph Nodes: NSF TMJ: NSF Range of motion: Normal Lips: NSF Thyroid: NSF INTRAORAL EXAMINATION: Oral Mucosa: WNL Tongue: NSF Floor of the mouth: NSF Salivary Glands: NSF Oropharynx/Palate: NSF CLINICAL FINDINGS: Missing teeth: None Implants: None Occlusion: Class I occlusion Overjet: 2 mm. Overbite: 20%. Dental midlines: Coincident Caries or defective restorations: None Wear: None Compensatory eruption: None NCCLs: None Gingival phenotype: Thin Limited Keratinized Tissue (2mm or less): Present in lower anterior region Oral hygiene: Fair, advised to improve flossing Supragingival biofilm/calculus: Moderate, especially in lower anterior region Subgingival plaque/calculus: Moderate, noted in posterior molars RADIOGRAPHIC FINDINGS: - Bitewings and selected periapicals obtained on 1 November 2024 - Radiographs show moderate bone loss around molars DIAGNOSES: - Chronic periodontitis PROGNOSIS: - Overall prognosis is fair with treatment - Specific prognosis for lower molars is guarded TREATMENT RECOMMENDATIONS: - Discussed the need for deep cleaning and potential surgical intervention if condition does not improve - Recommended scaling and root planing - Advised on smoking cessation and improved oral hygiene practices - Follow-up in 3 months for reassessment