Periodontal (Gum) Disease

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.