This document presents the case of a 54-year-old female patient, Naseen Naaz, who presented with chronic periodontitis. Her medical history included high blood pressure. Clinically, she had poor oral hygiene, plaque, calculus, bleeding gums, and periodontal pockets and attachment loss. Radiographs showed bone loss. She was diagnosed with generalized chronic severe periodontitis. Her proposed treatment included scaling and root planing, dental health education, oral hygiene instruction, possible open flap debridement and soft tissue regeneration, and periodic maintenance therapy.
2. Documented Case History
Date of examination: 7th February 2022
Candidate’s initials: SZ
Case Number: 01
Patient’s Initials: NN
Case Summary:
Chronic Periodontitis
Periodontal Management:
1. Non-Surgical periodontal treatment
2. Maintenance therapy
5. Patient Details
o Name: Naseem Naaz
o Sex: Female
o Age at start of treatment: 54 years
o Marital status: Married
o Attitude: Co-operative
o Address: Shireen Jinnah Colony
6. Chief Complain
Patients wants cleaning of her teeth and gums bleeding
on brushing also complains of tartar and sensitivity
from 10 days.
7. Medical History:
High blood pressure
No known drug allergy
Dental History:
Bleeding of gums on brushing
No TMJ problems
Social History:
None
Family History:
No relevant family history
Drug History : Patient takes medication for High blood
pressure but does not remember the name and she has been
taking it from past 5 years.
8. Oral Hygiene Practices
Brushes once a daily
No use of interdental cleaning aids
No use of mouthwash
9. Clinical Examination
Extra-Oral Examination
Lymph nodes: Non-palpable
Facial symmetry: Normal
Lips: Competent
Mouth opening: Normal
TMJ: Normal
Facial Profile: Class II
10. Clinical Examination
Intra-Oral Examination
Oral hygiene status:
Poor
Plaque retentive factors: sub gingival and interdental
calculus
Soft tissue:
upper Pale red, rolled marginal gingiva and round interdental papilla,
lower flat interdental papilla and edematous marginal, soggy and
puffy, smooth and shiny, stippling absent, cyanotic or bluish gingiva
Probing depth, bleeding on probing and attachment loss as charted
16. Diagnosis
Perio:
Generalized chronic severe periodontitis
Possible Etiological Factors:
Poor oral hygiene
Local factors: supra and sub-gingival plaque and
calculus
17. Treatment Consideration
Treatment aims and objectives:
Dental education and motivation
Control of periodontal disease
Restoration of missing and hopeless prognosis teeth
Maintenance of function and health of existing dentition
Patient’s concern, oral image and attitude towards
treatment:
She is aware of her periodontal condition including the extent
and severity of the periodontal destruction
She is co-operative about her dental treatment
She wishes that her teeth look esthetically pleasing and her
gums don’t bleed
18. Treatment Consideration
Initial Phase:
Dental health education
Oral hygiene instruction: reinforce charter’s
technique with soft bristle brush, use of floss and
mouthwash
Initial periodontal therapy: scaling and root planning
Re-assess patient’s oral hygiene, compliance and
prognosis of remaining teeth, redebridement of
residual periodontal pockets
19. Treatment Consideration
Definitive Phase:
Open flap debridement
Soft tissue regeneration
Maintenance Phase:
3 to 4 monthly reviews for periodontal maintenance
Reinforce oral hygiene
21. Treatment Sequence
Examination and Diagnosis
charting and records
Scaling and root planning
Dental health education – Etiology of periodontal disease
Oral hygiene instruction: advised patient to brush twice a
day
Initial Periodontal Therapy
Scaling and root planning of all four quadrants
Extraction of 17
