Mr. S.S is a 66-year-old White male with multiple systemic conditions. He suffers from Hypertension, type II diabetes, and Acid reflux. Patient reports taking Metformin 1000mg 2x/day for 6 years, Prandin 4mg 3x/day, Farxiga 5mg 1x/day, Metropolol 200mg/night, Losartan 100mg 1x/day, Chlortalidone 25mg (2 yrs) for Hypertension, Lovastin 40mg 1x/night for prevention of high Cholesterol. Tamsulosin .8mg capsule at night for benign prostate hyperplasia. Low dose aspirin 81mg for prevention of clotting. Takes Omeprazole 40mg 1x/morning for GERD, Allopurinol 50mg 1/day to prevent gout.
Vitals: 118/82 P:76, last A1c 7.2 (3/22/2021)- ASA II due to controlled medical conditions.
The patient reports tonsils were removed as a child. Has bilateral linea alba, dry fissured tongue, with a red lesion on the right/left labial commissure.
Pt. presented with 27 teeth, multiple restorations including crowns and fillings on the occlusal surfaces and incisal edges; and a fractured tooth on #7. A complete periodontal evaluation showed generalized 3-4 periodontal pockets w/ localized 5mm pockets on some posterior teeth. Pt. had light supra/subgingival calculus generalized.
4HBWs exposed on 09/14/2021 showed <15% of horizontal RBL, no cavities, or presence of calculus. Based on radiographic and clinical findings, the pt. was classified with moderate gingivitis due to generalized BOP and no presence of recession.
The treatment plan was scheduled for one visit. The patient was taught how to effectively use the floss to remove dental biofilm and a referral for the evaluation of leukoplakia on buccal of #19 was given. Pt. was scheduled to return in 4months for the next cleaning.
