Case Study Presentation

+Case Study Presentation

Team 2Lindsay Doerschuk, Ashlee Eyman, Abby Fall, Jamie Hall & Jaelyn JohnsonSpring Quarter 2013Template adapted from “Case Study/Treatment Planning” by Ann Wetmore and Mosby’s Dental

Hygiene Concepts, Cases, and Competencies (2nd ed) Case Development Worksheet

+ 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.

+

Assessment

+ 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

+ Chief Complaint

Provide documentation of the patient’s chief complaint and how it was addressed

+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

+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)

+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

+ 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

+Occlusion - Quiz The molars in this picture display:

A. Class IB. Class IIC. Class III

+Occlusion

Class 3 = molars Class 1 = canines

+ 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

+ 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.

+ Radiographs

Include radiographs for client Discuss any key anomalies or findings on the

radiographs.

+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)

+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

+ Perio Chart

Provide summary of periodontal findings Include copy of Eaglesoft periochart

+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

+Oral Risk Assessment

Attach copy of the Oral Risk Assessment form (back of consent form)

Provide summary of risks and recommendations

+

Diagnosis

+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

+ Caries Diagnosis

Discuss dental exam findings Include dental exam form (blue form) Describe any referrals recommended

+

Planning

+ Care Plan

Include copy of care plan Summarize findings and anticipated outcomes

+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

+ Consent for Treatment

Include and summarize consent for treatment form

+ Restorative Treatment Plan

Include and summarize restorative treatment plan from Eaglesoft

+

Implementation

+ Patient Education

Provide details about your preventive education Include specific homecare aids recommended and

describe techniques demonstrated Describe follow up plans for this patient

+ Preventive Product Recommendations Include any products recommended for the client and

why (e.g. toothpastes, rinses, mints, gums, etc)

+ 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)

+

Evaluation

+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

+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

+ 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

+ Evaluation and Assessment

Utilizing self-assessment skills, list any modifications that could have enhanced treatment outcomes

+

Documentation

+Operations Performed

Provide copy of autonotes from Eaglesoft