Comprehensive periodontal evaluation

[patient's age] 45 [patient's sex] Male presented for evaluation of [reason for today's appointment] Generalized gingivitis and bleeding gums. The patient was referred by [source of the referral and reason for the referral] Dr. Emily Carter, for evaluation and treatment of periodontal disease. [Auxiliary personnel involved in today's appointment] Dental hygienist, Sarah Miller. Chief Complaint: - [chief complaint along with duration] Bleeding gums and sensitivity to cold for the past 3 months. History of Presenting Complaints: - [detailed description of all complaints including onset, progression, aggravating or alleviating factors, associated symptoms, duration, intensity, nature, frequency of symptoms, etc.] The patient reports bleeding gums when brushing and flossing. He also experiences sensitivity to cold foods and drinks. The symptoms started gradually about 3 months ago and have been progressively worsening. The bleeding occurs almost daily and is moderate in intensity. He denies any pain or discomfort, but is concerned about the bleeding. - [description of any cosmetic concerns] The patient is concerned about the appearance of his gums, noting some recession and the appearance of longer teeth. Past Dental History: - [previous dental treatments, surgeries, significant dental diseases or injuries, etc. Include dates and outcomes of treatments] Routine dental check-ups and cleanings every 6 months. No history of significant dental diseases or injuries. Last cleaning was 6 months ago. Past Medical History: - [Medical history] Hypertension, controlled with medication. - [Medications, including current prescribed medications, over-the-counter drugs, and supplements; grouped per medical condition] Lisinopril 20mg daily for hypertension. - [Surgical history] Appendectomy at age 10. - [Family history relevant to the reasons for visit or medical conditions] Father has a history of periodontal disease. - [Social history: relevant social factors, including smoking, alcohol, drug use, or occupational exposures] Smokes 10 cigarettes per day. Drinks alcohol occasionally. No drug use. - [Allergies, including details on reactions] No known drug allergies. - [Immunization history & status] Up-to-date on all vaccinations. - [Other relevant history or contributing factors] None. Personal History: - [patient's past oral hygiene practices] Brushes twice daily and flosses once daily. - [habits such as clenching, grinding, biting, tobacco chewing, smoking, alcohol intake, etc.] Smokes 10 cigarettes per day. Extra Oral Physical Examination: - [vital signs recorded during the appointment] Blood pressure: 130/80 mmHg, Pulse: 78 bpm, Respiration: 16 breaths/min. - [Physical or mental state examination findings, including system specific examination(s)] Alert and oriented. Cooperative. - [extra-oral examination findings such as lymph node examination, facial symmetry, lip] No facial asymmetries. Inferior border of mandible palpable. No pain on palpation. No CLAD. - [results of TMJ examination such as range of motion, 3-finger mouth opening test, deviation upon opening, pain upon opening or palpation, soreness of muscles of mastication] TMJ examination within normal limits. - [other extra oral examination findings] None. Intra Oral Examination: - [soft tissue examination findings including findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc.] No sores or lesions noted on gingiva, buccal mucosa, FOM, hard/soft palate, lateral borders of tongue. Floor of mouth soft, uvula midline. No swellings, no purulence, moist mucous membranes. Copious saliva. - [other intra oral examination findings] None. Periodontal and Peri-implant Findings: - [findings on oral hygiene status, e.g., good/fair/poor based on OHI index, etc.] Fair. - [gingival examination findings including color, contour, size, consistency, surface texture, position, periodontal and peri-implant phenotype, plaque index, locations of calculus, bleeding along with bleeding position, exudation, amount of keratinized gingiva, probing depths with probing position, gingival recession with recession position, positions and grade of dental mobility, positions and grade of furcation involvement, etc.] Generalized gingivitis with moderate inflammation. Generalized bleeding on probing. Probing depths range from 3-5mm. Recession noted on several teeth, particularly on the mandibular incisors. Plaque index: 2. Calculus present, moderate supragingival and subgingival calculus. No mobility. No furcation involvement. Dental Findings: - [hard tissue examination findings like number of teeth present, missing teeth, dental caries, restored teeth, periapical problems, pathologic migration, overhanging restorations, impacted teeth, supernumerary teeth, wasting disease such as attrition/abrasion/erosion/abfraction, mobility grading, shade analysis, stains / deposits, etc.] All teeth present. No caries. Several existing restorations. No periapical problems. Mild attrition on posterior teeth. No mobility. Moderate staining due to smoking. Occlusal findings: - [occlusion analysis findings such as type of occlusion (Angles classification, etc), overbite, overjet, crossbite, open contacts, crowding, facets, supra contacts, trauma from occlusion, Fremitus test, etc.] Class I occlusion. Mild crowding in the mandibular anterior region. No signs of trauma from occlusion. Radiographic Findings: - [findings from dental radiographs, noting any pathologies like caries/cysts/tumours, tooth positions, bone levels, etc. and comparisons with previous radiographs] Bitewing radiographs show moderate bone loss, consistent with generalized periodontitis. No caries or periapical pathology noted. Laboratory Investigations: - [investigations, along with results, such as blood counts, hemoglobin, platelet count, bleeding time, clotting time, ESR, blood sugar, etc.] None. - [biopsy findings] None. Diagnoses: - [diagnoses] Generalized moderate periodontitis. Prognosis: - [overall prognosis] Guarded. - [individual prognosis for teeth or implants at risk] The prognosis for individual teeth is dependent on patient compliance with treatment and maintenance. Treatment: - [treatment plans/recommendations] Scaling and root planing (SRP) in all quadrants. Oral hygiene instructions and reinforcement. Smoking cessation counseling. - [preventative plans such as oral hygiene recommendations] Patient to brush twice daily with fluoride toothpaste and floss once daily. Use of interdental brushes recommended. Regular professional cleanings every 3 months. - [review date or follow-up plans] Re-evaluation in 6 weeks. Next visit: [date and purpose of the next visit] 1 December 2024 for scaling and root planing (SRP) in the first quadrant.