Clinical Assessment
Extraoral and Intraoral Examination:
Skin and lips presented dry with scaring on his lower lip. Oral mucosa consisted of hyperkeratinization on the buccal mucosa. Tongue presented as white hairy tongue on the posterior region, coated and fissured. High caries risk. Occlusion class II on the right by canine and class I on the left by molar. Color of gingiva was pigmented with magenta coloration, areas presented cyanotic with general marginal redness. Moderate BOP with exudate on tooth #15.
Radiographic Examination:
Generalized moderate to severe horizontal bone loss. Calculus was presented in interproximal spaces. Abscess located at the apex of tooth #15.
Periodontal Examination:
Clinical attachment levels (CAL) of 1-3mm were on 16 teeth covering 24 sites, CAL of 4-5mm were on 23 teeth covering 77 sites, and CAL of 6mm and greater were on 17 teeth covering 55 sites. BOP was on 26 teeth covering 125 sites. Suppuration was noted on 1 tooth. Furcation involvement was noted on 5 teeth covering thirteen sites. Mobility was noted on 24 teeth.
Risk Factors:
Use of tobacco for over 30 years, type 2 diabetic, high caries risk and poor oral hygiene.
Extraoral and Intraoral Examination:
Skin and lips presented dry with scaring on his lower lip. Oral mucosa consisted of hyperkeratinization on the buccal mucosa. Tongue presented as white hairy tongue on the posterior region, coated and fissured. High caries risk. Occlusion class II on the right by canine and class I on the left by molar. Color of gingiva was pigmented with magenta coloration, areas presented cyanotic with general marginal redness. Moderate BOP with exudate on tooth #15.
Radiographic Examination:
Generalized moderate to severe horizontal bone loss. Calculus was presented in interproximal spaces. Abscess located at the apex of tooth #15.
Periodontal Examination:
Clinical attachment levels (CAL) of 1-3mm were on 16 teeth covering 24 sites, CAL of 4-5mm were on 23 teeth covering 77 sites, and CAL of 6mm and greater were on 17 teeth covering 55 sites. BOP was on 26 teeth covering 125 sites. Suppuration was noted on 1 tooth. Furcation involvement was noted on 5 teeth covering thirteen sites. Mobility was noted on 24 teeth.
Risk Factors:
Use of tobacco for over 30 years, type 2 diabetic, high caries risk and poor oral hygiene.