Subjective:
- The patient, a 45-year-old male, presents for a pre-implant appointment with complaints of missing teeth in the lower jaw, seeking dental implants for improved function and aesthetics.
- The patient reports the missing teeth have been present for over a year, causing difficulty in chewing and affecting speech.
- The patient has tried using a removable denture, which was uncomfortable and did not alleviate the issues.
- The condition has progressively worsened, with increased difficulty in eating solid foods.
- Previous episodes include a history of periodontal disease leading to tooth loss, managed with scaling and root planing.
- The missing teeth have significantly impacted the patient's daily activities, including work and social interactions.
- Associated symptoms include mild jaw discomfort and occasional gum irritation.
Past Medical History:
- The patient has a history of periodontal disease and hypertension, managed with medication.
- Social history reveals the patient is a non-smoker and consumes alcohol occasionally.
- Family history is significant for periodontal disease in the patient's father.
- Immunization history is up to date.
Objective:
- Vital signs: Blood pressure 130/85 mmHg, heart rate 72 bpm.
- Oral examination reveals edentulous areas in the lower jaw with adequate bone structure for implant placement.
- Recent panoramic X-ray shows sufficient bone density for implant support.
Assessment:
- Likely diagnosis: Edentulism in the lower jaw due to periodontal disease.
- Differential diagnosis: None indicated.
Plan:
- Investigations planned: CBCT scan to assess bone volume and density.
- Treatment planned: Placement of two dental implants in the lower jaw.
- Relevant other actions: Referral to a dental hygienist for pre-implant cleaning and oral hygiene instructions.
Implant plan:
- Implant manufacture: Nobel Biocare.
- Implant size: 4.3mm x 10mm.
- Healing abutment size: 5mm.