CASE SHEET

NAME : Mrs. Vasantha

OP. NO :

AGE : 39 years

GENDER : Female

PLACE OF BIRTH : chennai

ADDRESS : medavakkam

CONTACT NO : 9944787173

EDUCATION : 10th pass

OCCUPATION : House wife

CHIEF COMPLAINT:

Patient complaints of bleeding gums in upper and lower teeth region .

HISTORY OF PRESENTING ILLNESS:

Patient presents with the history of bleeding gums in his teeth for past 1 year. He also
presents with the history of food impaction, & malodour for past 8 months. No history of pain,
sensitivity, swelling .

PAST MEDICAL HISTORY:

No history of diabetes, hypertension, previous hospitalization, surgical intervention,

drug allergy, asthma & epilepsy

PAST DENTAL HISTORY:

First dental visit

FAMILY HISTORY:

All are apparently healthy

PERSONAL HISTORY:

NAIL BITING – nil

CLENCHING – nil
DELETERIOUS HABITS

TYPE DURATION FREQUENCY

Smokeless tobacco - - -

Smoking tobacco - - -

alcohol - - -

ORAL HUGIENE PRACTICES

Type of cleaning Tooth brush & tooth paste

Materials used Oral B tooth brush & Colgate tooth paste

Method of cleaning Horizontal strokes

Frequency of cleaning Once in the morning

Duration of brushing 5 minutes

Frequency of brushing Once daily

Frequency of changing the tooth brush 6 months once

Any other oral hygiene aids used Nil

EXTRA ORAL EXAMINATION

FACIAL ASYMMETRY- no gross facial asymmetry detected

TMJ EXAMINATION- no pain, no clicking, no jaw deviation detected on TMJ palpation

MOUTH OPENING- 42 mm

LYMPH NODES- no palpable lymph nodes detected in head & neck region
 INTRA ORAL EXAMINATION:

GINGIVA

CHANGES AREA

pale pink Generalized

COLOUR

Exaggerated scalloped marginal gingiva Generalized

CONTOUR Interdental papilla blunt

Soft and edematous Localized in lower anterior

and posteriors
CONSISTENCY

Altered Generalized

SIZE-

Altered Generalized

SHAPE

absence of stippling Generalized

SURFACE TEXTURE

Below the level of CEJ Generalized

POSITION-

Present Localized

BLEEDING ON PROBING
 Absent

EXUDATE

Localized in 26,37,46,47

FURCATION present

adequate Generalized

WIDTH OF ATTACHED
GINGIVA

PROBING DEPTH

X 4 4 3 3 3 2 2 2 2 2 4 4 4 4 X

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

X 4 4 4 3 3 3 3 - 3 3 4 3 4 4 X

MOBILITY (Miller)

X X

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

X - X
INTRA ORAL EXAMINATION:

HARD TISSUE EXAMINATION:

NUMBER OF TEETH PRESENT : 29

MISSING TEETH :28,31,38

DENTAL CARIES :26,46

ROOT STUMP : nil

TENDER ON PERCUSSION :nil

RESTORATION : nil

OVERHANGING MARGINSS :nil

FOOD IMPACTION : Present - Generalized

ANY PROSTHESIS :nil

WASTING DISEASES :nil

MALOCCLUSION :nil

OCCLUSAL TRAUMATISM :nil

FRACTURED TEETH :nil

IMPACTED : nil

CLINICALLY MISSING :28,31,38

SUPRA ERUPTON :nil

PATHOLOGICAL MIGRATION :nil

CALCULUS : present(Ca++)

STAINS :present(St+)

ANY OTHER FINDINGS:

SOFT TISSUE EXAMINATION:

LABIAL/ BUCCAL/LINGUAL MUCOSA : no abnormalities detected

TONGUE :no abnormalities detected

PALATE :no abnormalities detected

FLOOR OF THE MOUTH :no abnormalities detected

FRENUM:

Upper- at the level of muco gingival junction

Lower-at the level of muco gingival junction

INDICES

Oral Hygiene Index –Simplified (OHI-S):

Greene and Vermillion -1964

DEBRIS INDEX

16 11 26

2 1 2

2 - 2

46 31 36
CALCULUS INDEX

16 11 26

2 1 2

2 - 2

46 31 36

OHI-S= DI+CI=3.4=fair oral hygiene

RUSSELL’S PERIODONTAL INDEX

A.L Russell, 1956

X 6 6 6 6 6 6 2 2 6 6 8 6 6 6 X

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

X 6 6 6 6 6 6 6 - 6 2 2 2 6 6 X

RI=5.3 Terminal disease

INVESTIGATIONS:

Advised OPG

FINAL DIAGNOSIS:

Generalized Chronic periodontitis

PROGNOSIS: Fair Prognosis

TREATMENT PLAN:

Emergency phase:

PHASE I: Etiotrophic phase:

Oral Hygiene Instructions

Diet Counselling

Scaling and Root planning

Maintenance phase:

Check for Probing depth, calculus and bleeding on probing

PHASE II: Surgical phase:

Curettage in all Quadrants

Maintenance phase:

Check for Probing depth, calculus and bleeding on probing

PHASE III: Restorative phase:

Nil

PHASE IV: Maintenance phase:

Recall after 1 month.

Check for Probing depth, calculus and bleeding on probing

check for occlusal clearance.

TRETMENT DONE;

Date Treatment done

25/03/19 Case history taken. Diagnosis: Generalized Chronic Periodontitis

Ultrasonic scaling done & OHI given

Curettage done in 4th quadrant & tooth-16

Review done