Periodontal Disease

Patient Information

• The patient is David Thorne, a 52-year-old male, residing at 42 Stirling Highway, Nedlands, WA 6009 (Phone: 0412 345 678, Medicare: 2948 58291 1).

Chief Complaints

• Bleeding gums on brushing for 6 months
• Loosening of lower front teeth for 2 months
• Persistent halitosis for 4 months

History of Presenting Complaints

• The patient reports insidious onset of gingival bleeding over the past 6 months, provoked by toothbrushing and biting hard foods, which resolves spontaneously within minutes.
• He noted progressive mobility of the mandibular anterior teeth over the past 2 months, accompanied by a dull, intermittent ache exacerbated by mastication.
• He experiences continuous halitosis for 4 months, which is only temporarily relieved by mouthwash.
• The patient is concerned about the unsightly black triangles developing between his lower front teeth and the appearance of elongated teeth.

Past Dental History

• Extraction of 36 due to gross caries (12/05/2018) - uncomplicated healing.
• Routine ultrasonic scaling and polishing (15/08/2021) - patient failed to attend subsequent maintenance appointments.
• Composite resin restorations on 16 and 26 (20/11/2019).

Past Medical History

• Type 2 diabetes mellitus (T2DM) diagnosed in 2019.
• Essential hypertension diagnosed in 2020.
• Appendicectomy (2005).
• Current medications: metformin (Diabex®) 1,000 mg PO BID, perindopril (Coversyl®) 5 mg PO OD.
• Allergies: Penicillin (manifests as maculopapular rash).

Personal History

• The patient brushes once daily in the morning using a medium-bristle manual toothbrush with a horizontal scrubbing technique, and he does not use dental floss or interdental brushes.
• He smokes 15 cigarettes per day (20 pack-year history), consumes 4 standard alcoholic drinks on weekends, and reports nocturnal bruxism and daytime jaw clenching during work stress.

Family History

• The patient's father had T2DM and lost all his teeth by age 60 due to severe periodontal disease.

Extra Oral Examination

• Bilateral submandibular lymph nodes are palpable, mobile, firm, and non-tender; the face is symmetrical, lips are competent, and the TMJ assessment reveals a normal 3-finger mouth opening (42 mm) with mild right-sided clicking on closing and tenderness over the bilateral masseter muscles.
• Mild perioral skin dryness is noted, with no angular cheilitis present.

Intra Oral Examination

• Soft tissue examination: The buccal mucosa shows a bilateral linea alba, while the tongue, hard and soft palate, floor of the mouth, and vestibule appear normal with no ulcerations or masses.
• Gingival examination: The gingiva is generalised erythematous to cyanotic with rolled margins, blunted interdental papillae, soft and oedematous consistency, loss of stippling, generalised bleeding on probing (BOP 68 %), purulent exudation on digital pressure at 31 and 41, inadequate width of attached gingiva (< 1 mm) in the mandibular anterior region, and a positive gingival tension test at the lower labial frenum.
• Periodontal examination: Probing pocket depths (PPD) range from 5 mm to 8 mm posteriorly and 6 mm to 7 mm in the mandibular anteriors, with generalised clinical attachment loss (CAL) of 4 mm to 6 mm, Grade II furcation involvement on 16, 26, and 46, Miller's Class III gingival recession of 3 mm on 31 and 41, mucogingival defect at the lower central incisors, and a Silness and Löe Plaque Index score of 2.4.
• Hard tissue examination: There are 27 teeth present with 36, 18, 28, 38, and 48 missing; secondary caries is noted on 26, amalgam restoration on 46 with a mesial overhang, composite restoration on 16, pathologic labioversion and diastema between 31 and 41, generalized moderate occlusal attrition, cervical abrasion on 13 and 23, Grade II mobility on 31 and 41, Grade I mobility on 16 and 26, shade A3.5, and heavy subgingival and supragingival calculus deposits with extrinsic tobacco staining.
• Oral hygiene status: Oral hygiene status is poor according to the Simplified Oral Hygiene Index (OHI-S score 4.2).
• Occlusion analysis: The patient exhibits Angle's Class I malocclusion on a Class I skeletal base, 3 mm overbite, 4 mm overjet, open contact between 31 and 41, mild mandibular anterior crowding, generalised wear facets, premature contact on 46, secondary trauma from occlusion in the lower incisors, and a Grade II positive Fremitus test on 31 and 41.

Radiographic Findings

• The orthopantomogram (OPG) and full-mouth periapical radiographs reveal generalised horizontal bone loss of 40 % to 50 %, angular vertical bone defects mesial to 16, 26, and 46, radiolucency in the furcation areas of 16, 26, and 46, widening of the periodontal ligament space around 31 and 41, mesial tipping of 37 into the edentulous 36 space, and secondary caries beneath the distal margin of the 26 restoration.

Laboratory Investigations

• Full blood count (FBC): Haemoglobin 145 g/L, WBC 8.2 x 10^9/L, Platelets 250 x 10^9/L.
• Coagulation profile: Bleeding time 3 mins, Clotting time 5 mins.
• Erythrocyte sedimentation rate (ESR): 22 mm/hr.
• Glycated haemoglobin (HbA1c): 7.6 %.
• Fasting blood glucose: 7.8 mmol/L.

Diagnoses

• Generalised Stage III Grade C Periodontitis
• Secondary occlusal trauma (31, 41)
• Secondary dental caries (26)

Prognosis

• The overall periodontal prognosis is fair, contingent upon smoking cessation, improved glycaemic control, and strict adherence to plaque control and supportive periodontal therapy.
• The individual prognosis for teeth 31 and 41 is questionable due to advanced attachment loss and mobility, while 16, 26, and 46 carry a fair-to-guarded prognosis due to Grade II furcation involvement.

Treatment

• Phase I (Nonsurgical): Quadrant-wise subgingival scaling and root planing (SRP) under local anaesthesia, removal of the overhanging margin on 46, caries excavation and composite restoration on 26, and occlusal coronoplasty on 46.
• Systemic antimicrobial therapy: azithromycin (Zithromax®) 500 mg PO OD for 3 days as an adjunct to SRP.
• Phase II (Surgical): Periodontal re-evaluation at 6 weeks post-SRP, followed by open flap debridement (OFD) in persistent deep pockets (> 5 mm) and frenectomy of the lower labial frenum.
• Phase III (Restorative): Provision of an occlusal splint (nightguard) to manage nocturnal bruxism.
• Instruct in the Modified Bass brushing technique twice daily using a soft-bristled toothbrush and fluoridated toothpaste.
• Prescribe chlorhexidine gluconate (Savacol®) 0.2 % mouthwash 10 mL topical rinse BID for 2 weeks.
• Initiate daily interdental cleaning using appropriately sized Piksters® interdental brushes.
• Provide brief intervention for smoking cessation and refer to GP for optimisation of T2DM management.
• The patient is scheduled for a periodontal re-evaluation in 6 weeks (25/05/2026) and will subsequently be placed on a 3-monthly Supportive Periodontal Therapy (SPT) recall schedule.