Recare visit of 55 yr old Hispanic female. ASA 2
Medical History: Patient has high cholesterol, coronary heart disease, and type 2 diabetes. She was hospitalized for 5 days due to stroke in May 2020. Patient is allergic to latex and reports to have a mint allergy although no diagnosis. She experiences irritation when using mint oral products. Last A1C test results were between 6.5-7% in 11/2019. She does not recall exact number.
Medications:
Metformin:(anti-diabetic) 500mg 1x/day for the past 5 yrs. Eliquis:(blood thinner) 5mg 2x/day. Clopidogrel:(blood thinner)- 75mg 1x/day. Entresto:(heart failure)24/26mg 1x/day. Atorvastatin:(high cholesterol) 20mg 1x/day. Carvedilol:(beta-blocker) 3.125mg 2x/day.
OTC: Multi-vitamin, B-complex, Vitamin C
Dental considerations for Eliquis: Post-procedural hemorrhage, hematoma
Patient had been in the middle of a dental implant treatment since 03/2020 and has not gone back due to COVID-19 pandemic and insurance change.
Head and neck exam findings: Patient was unable to shift lower jaw to the right, however, she reported that no discomfort was felt. Bilateral linea alba, coated tongue, and bilateral mandibular tori.
Dental charting:
Attrition: Maxillary anteriors and mandibular incisors. Abfraction was noted on #5,#10, #12, and #13.
Patient had bilateral class I occlusion with 3mm overjet and 5% overbite.
Periodontal findings:
Full Mouth Series:
Gingival statement: Quadrant 1 appeared cyanotic and inflamed, especially around implants, gingiva felt leathery and there was bleeding upon probing.
Patient had most plaque on proximals and linguals of mandibular incisors. Plaque score:1. Patient was taught “C-shaped” flossing.
Patient was categorized as Stage 1 Grade B with a medium case value.
The whole mouth was scaled using periodontal cassette and implants were scaled using implant case. Selective engine polishing was done and 5%NaFl varnish was applied. She was given post-op instructions on varnish. She was also given a referral for implant evaluation of #3 and #4. 3 month re-care was recommended to the patient.
