Mr. M.S. is a 67-year old- Caucasian male with the chief complaint of wanting to get his scheduled 3-months recall cleaning before having 2 implants done. This patient is not known to have any systemic conditions, is not taking any prescibed or OTC medications.
Patient has an allergen to Penicillin. His vitals were BP:119/82 P:65- corresponding to ASAII.
Dental History- He is very good with his 3-month recalls for cleanings. He had gotten a bonegraft done in August of 2021 on the upper right and lower left, in hopes to have implants placed in those areas. 
This patient’s case value was a Medium (due to generalized heavy staining from tea)/Stage III-C.
When inspection the oral cavity, the upper right area presented with a fistula. Patient was asked if he had felt any discomfort in the area and he stated that it did feel sensitive and he had believed that there were pins implanted from the bone graft that could’ve been irritated during mastication. He had previously brought it up with NYU (the facility where he is getting his implants done) about the discomfort and tenderness around the area but they had disregarded it as the bonegraft’s healing process.
The lesion was near tooth #2 on the alveolar mucossa- 3×4 round, elevated, soft, spongy leson with exudate. Ridge augmentation procedure included pins and tacks and its proximity to his maxillary sinus, which led to an infection. 
We informed the patient about the infection and adviced to have no implant done in the area until healed completely and the facility in-plan with the implants evaluates it further.
Regularly scheduled prophylaxis was done and his treatment of full mouth scaling, engine polishing and fluoride 5% varnish was done, until the next 3-months recall. Patient left more aware on why he felt so much discomfort, unfortunately, he wasn’t able to get an implant placed as excited for it as he was. He understood the circumstances and was grateful for our findings during the visit.
