Case Study Presentation

1. Case Study Presentation Team 2 Lindsay Doerschuk, Ashlee Eyman, Abby Fall, Jamie Hall & Jaelyn Johnson Spring Quarter 2013 • Template adapted from “Case Study/Treatment Planning” by Ann Wetmore and Mosby’s Dental Hygiene Concepts, Cases, and Competencies (2nd ed) Case Development Worksheet

2. Case Selection Criteria • Client has several skin grafts. • Selection Criteria: State the criteria by which you selected the case for presentation. • Interesting gingival grafts in several locations • Something we haven’t talked about yet and first time we’ve seen grafts • Seeing a class 3 occlusion for the first time.

3. Assessment

4. Patient Information • Profile: Summary of the basic information about the patient (e.g. age, psychosocial history, cultural influences, social factors, barriers to care, etc.) • 29 year old white male • Client puts a lot of emphasis on homecare • Client is aware of appearance of teeth • Had braces from age 13-16 and 25-27 • DHT every 6 months

5. Chief Complaint • Provide documentation of the patient’s chief complaint and how it was addressed

6. Medical History • Based on client’s medical history, provide summary of patient’s systemic health and ASA Classification • Describe the client’s vital signs • Include a copy of the client’s health history

7. Medication History • Include a summary of the client’s medications and their effect on dental treatment • Provide evidence of client’s medications (bright pink form)

8. Dental History • Last DHT 5/8/2013 • Describe history of previous dental surgeries, procedures, ortho, etc (from green EO/IO form) • Wisdom teeth removed 2001 (Age 17) • Gingival grafts - #11 22-24 27 • 2011 Mandibular 1st premolars removed 2011 prior ortho

9. EO/IO Exam Findings • Provide overview and documentation of EO/IO findings • Use proper lesion description for all deviations from normal • Grafts and enlarged submandibular glands • Include intra-oral photos for significant findings • Include EO/IO form

10. Occlusion - Quiz • The molars in this picture display: • Class I • Class II • Class III

11. Occlusion • Class 3 = molars • Class 1 = canines

12. Plaque Control Record • Provide documentation of the client’s initial plaque score using Eaglesoft • 34% • Was there light, moderate, or heavy plaque? Where was it primarily located (gingival margin, interproximal, posteriors, etc)? • Light plaque primarily along gingival margin. More on lingual than buccal. More on posterior. • What were client’s current homecare practices at the first visit? • Brushes twice a day with sonicare • Flosses three times a week • Uses fluoridated toothpaste

13. Calculus Detection • Include a copy of the client’s calculus detection. • Does the client have light, moderate, or heavy calculus? • light • Is there subgingival or supragingival calculus? • Subgingival posterior • Supragingival on lingual of mand. anteriors • If possible, include pictures of supragingival calculus.

14. Radiographs • Include radiographs for client • Discuss any key anomalies or findings on the radiographs.

15. Dental Chart • Provide copy of dental chart from Eaglesoft • Summarize dental findings and conditions • May include intraoral photos • #11 • #22-24 • #27 • Occlusion (Molars = class 3)

16. Dental Hygiene Caries Exam • Summarize dental hygiene caries exam findings (suspicious areas) • #30 sealant fell out and dark staining • Include a summary of diagnodent findings

17. Perio Chart • Provide summary of periodontal findings • Include copy of Eaglesoftperiochart

18. Dietary Assessment • Gather the dietary assessment (complete 24-Hour Food Record/Nutrition Assessment Form) for your client • Specify any current or potential nutritional deficiencies • Evaluate the potential impact the various issues may have on oral health

19. Oral Risk Assessment • Attach copy of the Oral Risk Assessment form (back of consent form) • Provide summary of risks and recommendations

20. Diagnosis

21. Gingival Description and Periodontal Diagnosis • Provide summary of gingival description ie. pink, firm, puffy, edematous, etc. • Pink, firm, localized areas of puffiness • Include the periodontal diagnosis

22. Caries Diagnosis • Discuss dental exam findings • Include dental exam form (blue form) • Describe any referrals recommended

23. Planning

24. Care Plan • Include copy of care plan • Summarize findings and anticipated outcomes

25. Hygiene Treatment Plan: Appointment Sequence • Formulate a dental hygiene treatment plan • Sequence appointments according to priorities based on patient needs • Include the back of the care plan

26. Consent for Treatment • Include and summarize consent for treatment form

27. Restorative Treatment Plan • Include and summarize restorative treatment plan from Eaglesoft

28. Implementation

29. Patient Education • Provide details about your preventive education • Include specific homecare aids recommended and describe techniques demonstrated • Describe follow up plans for this patient

30. Preventive Product Recommendations • Include any products recommended for the client and why (e.g. toothpastes, rinses, mints, gums, etc)

31. Services Completed • Describe treatment provided for the client during each phase of treatment including: • Debridement details (amount of plaque/calculus found during instrumentation, difficult areas) • Polish (selective or coronal, type of prophy paste used and why) • Fluoride (type and percentage and why)

32. Evaluation

33. Outcomes Evaluation • Discuss the outcomes of treatment and education provided • Review whether completed care addressed the client’s goals, risks, patient concerns • Include actual outcomes column of care plan

34. Oral Self-Care Evaluation • Provide summary of patient’s understanding and effectiveness of oral hygiene • Include final PASS score and discuss changes made in plaque score throughout appointment sequence

35. Future Care Recommendations • List any future care recommendations based on evaluation data • Provide documentation of any further referrals needed • Supportive care interval: recommended interval for recare

36. Evaluation and Assessment • Utilizing self-assessment skills, list any modifications that could have enhanced treatment outcomes

37. Documentation

38. Operations Performed • Provide copy of autonotes from Eaglesoft