Patient Information:
- Name: John Doe, Age: 45, Gender: Male, Contact: (555) 123-4567
Chief Complaint(s):
- Gum bleeding for 2 weeks
- Swelling and pain in the gums
- Bad breath
History of Presenting Complaints:
- Gum bleeding started 2 weeks ago, initially mild but progressively worsening. Aggravated by brushing and alleviated by rinsing with salt water. Associated with swelling and pain, intensity 6/10, constant.
- Bad breath noticed for the past month, persistent despite regular brushing.
Past Dental History:
- Root canal treatment on upper right molar in 2018, successful outcome.
- Scaling and root planing in 2020, moderate improvement.
Past Medical History:
- Hypertension, diagnosed in 2015, managed with medication (Lisinopril).
- Allergic to penicillin.
Personal History:
- Brushes twice daily, flosses occasionally, uses mouthwash once daily.
- Smokes 10 cigarettes per day for the past 20 years.
Family History:
- Father had periodontal disease.
Extra Oral Examination:
- No lymph node enlargement.
- Facial symmetry normal.
- TMJ examination normal, 3-finger mouth opening test normal.
Intra Oral Examination:
- Soft tissue examination: Buccal mucosa, tongue, palate, and floor of the mouth appear normal.
- Gingival examination: Generalized gingival inflammation, redness, and swelling. Bleeding on probing, moderate exudation.
- Periodontal examination: Periodontal pocket depth 5-7 mm in multiple sites, clinical attachment loss, furcation involvement in molars, gingival recession noted.
- Hard tissue examination: 28 teeth present, missing lower left second molar, dental caries on upper left first premolar, restored teeth in good condition, mild attrition, mobility grade I in lower incisors.
- Oral hygiene status: Fair, based on OHI index.
- Occlusion analysis: Class I occlusion, mild overbite, no crossbite, slight crowding in lower anterior teeth.
Radiographic Findings:
- Panoramic radiograph shows horizontal bone loss, periodontal ligament widening, no cysts or tumors.
Laboratory Investigations:
- Blood sugar: 110 mg/dL (normal).
- Hemoglobin: 14 g/dL (normal).
Diagnoses:
- Chronic periodontitis
- Dental caries on upper left first premolar
Prognosis:
- Overall prognosis is guarded due to smoking habit.
- Individual prognosis for lower incisors is poor due to mobility.
Treatment:
- Scaling and root planing in all quadrants.
- Oral hygiene instructions: Emphasize brushing twice daily, flossing, and use of antiseptic mouthwash.
- Smoking cessation counseling.
- Review in 4 weeks for reassessment and further treatment planning.
