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Medical History

73yr old male, here for prophylaxis before necessary dental treatment.
Had recent aortic and mitral valve replacement in Nov. 2020. Initially came in with no medical clearance or antibiotic prophylaxis, so we rescheduled in order to obtain a medical clearance and make sure the patient had antibiotic prophylaxis prior to treatment.
Patient reported mild allergy to penicillin in the past but their cardiologist wrote them a prescription for amoxicillin - patient reported using this after their surgery and had no side effects. So, we asked this patient to come in an hour early and take 4 tablets of Amoxicillin 500 mg.
Patient had prior sublingual gland resection in 2010 due to past sarcoma, has a graft on anterior portion of his tongue as a result.
COVID screening negative, temp 97.4. BP 117/81 p 79. ASA III.

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EO/IO

EO WNL, IO revealed forearm skin graft on anterior portion of the tongue due to sarcoma, surgery completed in 2010, presents with hair.

Initially was discovered in our City Tech Dental Hygiene clinic!

Overjet 1mm, overbite 0%
Bilateral class I occlusion, anterior crossbite and crowding.

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Dental Charting

This patient has several amalgam restorations, recurrent decay, and implants.
He also has severe decay reaching the root, almost in an abfraction like manner on #26, #25 severely decayed down to the root, the crown is no longer visible on this tooth.

Patient given referral for multiple carious lesions - severe caries risk.

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Periodontal Condition

This patient had generalized deep pocketing, generalized severe recession and BOP.
Several mobile teeth and some removed and scheduled to be removed in patient’s future dental appointment in Columbia Dental College.

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Periodontal Condition

Patient recently had FMS exposed at NYU Dental a week prior to this appointment, did not have them present.

�Based on previous x-rays on file and perio charting this patient is a perio stage III grade C. This patient was of course given a referral to see a periodontist as well.

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Personal Homecare

This patient had a PI score of 1.8, along the gingival margin but also on the facial surfaces of the teeth. Because of this, demonstrating the modified bass method with a soft toothbrush was the best recommendation for this patient.

The gingiva was pale pink, generalized moderate recession, moderate BOP, flaccid, and inflamed.

Heavy deposits and moderate staining are present as well.

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Limited Treatment

Although this patient has many mobile teeth and deep pocketing, we decided to handscale while avoiding mobile teeth #7,8,10 (grade I mobility) and teeth #23, 25, 26 (grade II mobility). The patient did not feel comfortable being put completely supine so he was kept semi supine.
Gently polished with medium grit paste to help remove staining, patient did not want NaF 5% varnish.
Referrals were given for periodontal disease, multiple caries and restorations.
This patient is currently under the care of Columbia Presbytarian and is receiving dental treatment there for possible extractions and bridges needed.
Recare schedule every three months.