Assessment: A 75 year old caucasian female patient visited for a routine dental cleaning. Blood pressure was 136/82 pulse: 76 corresponds to hypertension stage 1 (patient was informed of findings). I reviewed the patients medical, social, and dental history through the patient interview and gathered all relevant information. The patients last physical annual medical checkup was on 3/3/25. She stated that she suffers from S’jogrens syndrome, she is on infusions, and is taking prescribed and OTC medications. Patient reported to taking Gammagard to treat S’jogrens for the last 10 years as an injection solution, Cevimeline HC1 30mg capsule 3x a day for the last 30 years to treat S’jogrens, Duloxetine HCL 30mg capsule 2x a day for 30 years to treat S’jogrens. Rosuvastatin for calcium/cholesterol 10mg tablet for 1 year. buPROprion Hcl ER for anxiety/pain 300mg capsule 2x a day for the last 30 years. Etrace for vaginal dryness 0.1mg/gm for 30 years. She said she does not experience any side effects from these medications. Pt. says they are allergic to Codeine (nausea occurs when in contact) and she is also allergic to Latex (rash and itching occurs when in contact). She is also taking vitamin D3 liquid vitamins and Advil OTC. She has been taking Valtrex for the herpetic lesion on the vermillion border. The patient is an ASA: 3 Due to having S’jogrens syndrome and having a high blood pressure, as well as being on infusions. She does not smoke or consume alcohol. She is not taking illicit drugs. The patients last dental checkup was for a cleaning on 1/2/2025 and a total of 4-5 radiographs were taken. She has extreme xerostomia due to having S’jogrens syndrome. She said that she has sensitivity to hot and cold on anterior teeth and that she experiences halitosis. Patient reported to using a manual TB 2x a day and flosses everyday. She does not use Listerine mouthwash because she says it burns her tongue from the alcohol content, nor does she use a tongue scraper.
An objective finding was proceeded. During the intra and extra oral examination, the patient had a red herpetic lesion that was in the process of healing on the right side of the vermilion border. The patient had severe xerostomia with zero saliva present due to S’jogrens syndrome. The dental charting of this patient was that she had a bilateral class 1 occlusion with an overjet of 3mm and an overbite of less than 15%. Wisdom tooth #16 was missing. Occlusal composites on #1, #2, #3, and #4. Incisal composites on anterior maxillary teeth. PFM crowns on #13, #14, #15, #19, #23, #24, #15, #30, #31, and #32. Buccal composites on #4, #5, #6, #10, #11, #12, #20, #22, #27, #28 and #29. The gingival statement was that the gingiva was pink with stippling. Rolled margins and slight BOP. CEJ is coronal to the GM. The perio charting consisted of generalized 2-3mm probing depths. No mobility or recession was detected and there was slight BOP. There was biofilm along the gingival margin. No subgingival or supragingival calculus present. The case type that was established was a light gingivitis without radiographic evidence.
Diagnosis: Since it was decided that the patient was a light gingivitis without radiographic evidence, I came to the conclusion based off of the patients perio chart that she did not have periodontal disease, despite having S’jogrens syndrome which causes severe xerostomia and the absence of saliva, and has been on infusions and taking different medications for treatment. According to CAMBRA – the patients caries risk was high due to xerostomia. Instructed the patient to use more fluoride products, preferably ACT fluoride as well as prevident 5000 and to begin using the modified bass brushing technique.
Plan: After completing all assessments and gathering relevant information, the treatment plan was developed and discussed with the patient who signed it off and gave consent. The treatment plan consisted of only 1 visit which included OHI, CAMBRA, hand scaling and using the ultrasonic on the entire dentition to completion, modifying treatment every few minutes to spritz water from the air water syringe since the patient has severe xerostomia, engine polishing with fine paste, and applying Sodium Fluoride varnish 5% with post-op instructions. Patient denied PI and therefore that was not included in the treatment plan.
Implementation: After the patient signed the treatment plan and gave consent, since the patient denied PI, we went over OHI and I introduced the ACT fluoride as well as Prevident 5000 which would be especially beneficial for her specific case. I demonstrated how to use the modified bass brushing technique and why it is useful. CAMBRA was also completed so that the correct caries risk was established and proper home care measures were being obtained. I began hand scaling and using the ultrasonic on each quadrant to completion. Every few minutes I had to spritz water from the air water syringe so that my patient was comfortable throughout the whole procedure and was not in discomfort since she suffers from severe xerostomia. I engine polished with fine paste and applied Sodium Fluoride varnish 5% with post-op instructions. No referrals have been given.
Evaluation: I observed my patients understanding of all the information given to her by asking her to demonstrate the modified bass brushing technique to me. I also asked follow up questions to assess my patients understanding of what gingivitis is and that it can be reversed unlike periodontitis. Since my patient did not have supragingival nor subgingival calculus there was not much more to evaluate in terms of the health of my patients teeth and gums after the treatment was conducted other than dental and perio charting.
Documentation: All intake data/assessments documented. Patient signed all documents and consent forms.