“My gums are very painful. Can you stop the pain?”
Patient: Male, 36 years old
Chief complaints: Gums are painful, bleeing spontaneously and on brushing. Pain started last night, patient could not sleep. In addition, he felt metallic taste in the mouth and has very unpleasant breath.
MHx: Has been recently diagnosed with hypertension and taking medications, Losartan tablets to control it.
Dental history: Never had any major dental treatment or orofacial trauma, visiting dental hygienist once in 2 years.
Allergies: Allergic to penicillin.
Social history: Smoker (currently smoking 20 cigarettes/day), under significant stress at work, drinking alcohol (a glass of wine daily).
Family history: Family history of periodontal diseases and tooth loss.
Oral hygiene: Brushig teeth with an electric TB once a day; does not use dental floss or ID brushes, currently using Plax to reduce bad breath.
E.O. Examination: Enlarged and sensitive submental and submandibular lymph nodes.
I.O. Examination: Heavy biofilm and calculus deposits present.
Vitality testing: All teeth are vital
Questions to ponder
- Provide diagnosis of the patient’s acute condition and discuss etiological factors.
- What is the full periodontal diagnosis according to the latest classification from 2017?
- Identify risk factors for the patient’s acute condition.
- Identify risk factors for patient’s periodontal disease.
- Treatment plan for the patient (include treatment of the acute condition).