Comprehensive Dental Examination

Practitioner Details

Practitioner: Dr Marcus Vance, DDS (in consultation with Sarah Jenkins, OTR/L, Occupational Therapist)

Type of Examination Conducted

Examination type: Comprehensive oral evaluation and adaptive oral-hygiene assessment. Verbal and written informed consent obtained from patient.

Presenting Complaint

Presenting complaint: "My bottom right back tooth aches when I drink cold water, and my hands are getting too stiff to hold my toothbrush properly."

Dental history: Last dental review 18 months ago (14/10/2024). Hx of routine amalgam and composite restorations. Brushes 1x/day using standard manual toothbrush; unable to use conventional string floss due to bilateral hand weakness and reduced fine motor dexterity.

Medical history: Rheumatoid arthritis (RA) diagnosed 2018, managed by rheumatology. Osteoarthritis of bilateral hands. Hypertension.

Social history: Non-smoker. EtOH: 1-2 units/week. Retired schoolteacher, lives with spouse. Receives outpatient occupational therapy for ADL adaptations.

Medications:

• methotrexate (Trexall®) 15 mg PO qWk
• folic acid 5 mg PO qWk
• amlodipine (Norvasc®) 5 mg PO OD
• ibuprofen (Advil®) 400 mg PO PRN for joint pain

Allergies: Penicillin (urticaria). Latex: NAD.

Clinical Findings and Observations

E/O Examination: Symmetrical face, no submandibular or cervical lymphadenopathy. TMJ: mild crepitus R side on opening, no tenderness to palpation, 3-finger mouth opening achieved (40 mm). Lips competent and hydrated.

I/O Examination

Soft-tissue examination: Mild buccal linea alba bilaterally. Tongue, hard/soft palate, floor of mouth, and vestibule: NAD.

Oral cancer screen (FoM, palate, pharynx, soft tissues: NAD

Gingiva: Generalized marginal erythema and rolled margins, most pronounced in posterior sextants. Generalized BOP, no purulent exudate. Adequate attached gingiva throughout; tension test negative.

Hard tissue examination: 28 teeth present (18, 28, 38, 48 missing). Tooth 46: MO defective composite with secondary caries, positive to cold testing (lingering 5 seconds), TTP negative, mobility Grade 0. Intact amalgam restorations on 16, 26, 36. Generalized mild attrition on lower anterior incisal edges. Moderate supragingival and subgingival calculus on lingual of lower anteriors and buccal of upper molars. Shade A3.

Oral hygiene status: Fair to poor (OHI-S score: 3.2). Heavy plaque accumulation along posterior cervical margins, consistent with limited upper-extremity reach and grip strength.

Occlusion analysis: Angle's Class I molar and canine relationship. Overjet 3 mm, overbite 30%. No crossbite or open contacts. Mild lower anterior crowding. Wear facets on 31, 32, 41, 42. Fremitus negative.

Other I/O findings: Mild xerostomia noted; saliva slightly frothy.

Radiographic Findings

Bitewings (L and R) and periapical radiograph of 46 taken today (15/04/2026) with patient verbal consent. Findings: Radiolucency beneath mesial box of 46 restoration extending into middle third of dentine, approx 1.5 mm from pulp horn. No periapical radiolucency on 46. Generalized horizontal bone loss of 10-15% in molar regions, stable compared to radiographs from 14/10/2024.

Blood tests (10/04/2026): FBC normal, Hb 13.4 g/dL, Platelets 240,000 /µL, ESR 24 mm/hr, random blood glucose 95 mg/dL.

Biopsy: Not indicated (NAD).

Diagnosis

1. Reversible pulpitis and secondary dental caries, tooth 46.
2. Generalized plaque-induced gingivitis (aggravated by impaired manual dexterity secondary to RA).

Treatment Options Discussion

1. Tooth 46:
   • Option A: Removal of defective composite and caries, placement of new MO posterior composite restoration. Risks: deep caries may approach pulp, potential need for Future RCT, post-op sensitivity. Cost: $245.
   • Option B: Glass ionomer cement (GIC) restoration. Benefit: fluoride release. Risk: higher wear rate. Cost: $190.
   • Option C: No treatment. Risk: progression to irreversible pulpitis, necrosis, abscess, eventual extraction.
2. Gingivitis: Full-mouth ultrasonic scaling and prophylaxis, paired with OT-guided adaptive oral hygiene aids ($135).

Patient asked if the injection would affect her blood pressure medication and whether an electric toothbrush is too heavy for her wrists. Reassured regarding local anaesthetic safety; discussed lightweight sonic brush options with built-up handles. Patient elected for Option A (composite restoration on 46) and prophylaxis today.

Proposed Treatment Plan

Proposed treatment plan:

• Today (15/04/2026): Comprehensive exam, radiographs, full-mouth scaling and polish, OHI with adaptive equipment modification.
• Next visit: 46 MO composite restoration under LA.
• 6-month recall for examination and supportive periodontal therapy.

Consent

Signed informed consent obtained for today's diagnostic radiographs, scaling/prophylaxis, and planned restorative treatment on 46.

Procedures Conducted

Full-mouth ultrasonic and hand scaling completed to remove supra- and subgingival calculus. Prophylaxis paste applied with rubber cup. Desensitizing varnish (5% sodium fluoride) applied to 46 and cervical margins. In collaboration with OT, fitted a closed-cell foam grip tubing over the patient's manual toothbrush handle to increase diameter for palmar grasp.

Instrument Tracking

Autoclave Cycle #2026-0415-B2; Ultrasonic scaler pack #US-8842; Exam kit #EX-1094; Hand scaler cassette #HS-4410.

CDT Codes: D0150 (Comprehensive oral evaluation), D0272 (Bitewings - two radiographic images), D0220 (Intraoral - periapical first radiographic image), D1110 (Prophylaxis - adult).

Medications/Therapeutics

• sodium fluoride 5% varnish (Duraphat®) 0.4 mL applied topically chairside; advised no eating/drinking for 30 mins and soft diet today.
• sodium fluoride 1.1% (5,000 ppm) dental cream (Prevident 5000 Plus®) - 51 g tube - apply a pea-sized amount to brush topically QHS after routine brushing, expectorate and do not rinse.

Advice Provided

Instructed on modified Bass brushing technique utilizing the built-up foam handle and recommended a lightweight battery-operated floss holder (water flosser also discussed as an alternative for impaired finger flexion). Provided printed fee estimate ($245) for the upcoming 46 MO restoration; signed quotation placed in chart.

Follow-Up and Referrals

Scheduled 45-minute appointment on 29/04/2026 at 10:00 MST for 46 MO composite restoration. Copy of oral hygiene ergonomic recommendations sent to patient's Occupational Therapist (Sarah Jenkins, OTR/L) for ongoing ADL integration.

Unusual Events

• None. Patient tolerated chair positioning well with an extra cervical support pillow provided for neck comfort.

Additional Digital and Laboratory Information

Intra-oral photographs taken of 46 and lower anterior lingual calculus pre- and post-scaling, uploaded to digital chart (Ref #IMG-99201). No laboratory work required.

Final Notes

Patient tolerated scaling well with minimal gingival bleeding post-procedure. Demonstrated good ability to hold the modified foam-grip brush handle in clinic. Re-evaluate plaque control and dexterity adaptations at the restorative visit in 2 weeks.

Other Details

Patient has full capacity and makes own healthcare decisions; no substitute decision-maker required.

No history of FTA.

Written and verbal patient consent confirmed and documented in electronic health record.