Case Study Presentation
description
Transcript of Case Study Presentation
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+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
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+ 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.
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Assessment
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+ 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
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+ Chief Complaint
Provide documentation of the patient’s chief complaint and how it was addressed
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+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
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+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)
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+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
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+ 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
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+Occlusion - Quiz The molars in this picture display:
A. Class IB. Class IIC. Class III
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+Occlusion
Class 3 = molars Class 1 = canines
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+ 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
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+ 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.
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+ Radiographs
Include radiographs for client Discuss any key anomalies or findings on the
radiographs.
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+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)
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+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
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+ Perio Chart
Provide summary of periodontal findings Include copy of Eaglesoft periochart
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+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
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+Oral Risk Assessment
Attach copy of the Oral Risk Assessment form (back of consent form)
Provide summary of risks and recommendations
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Diagnosis
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+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
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+ Caries Diagnosis
Discuss dental exam findings Include dental exam form (blue form) Describe any referrals recommended
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Planning
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+ Care Plan
Include copy of care plan Summarize findings and anticipated outcomes
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+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
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+ Consent for Treatment
Include and summarize consent for treatment form
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+ Restorative Treatment Plan
Include and summarize restorative treatment plan from Eaglesoft
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Implementation
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+ Patient Education
Provide details about your preventive education Include specific homecare aids recommended and
describe techniques demonstrated Describe follow up plans for this patient
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+ Preventive Product Recommendations Include any products recommended for the client and
why (e.g. toothpastes, rinses, mints, gums, etc)
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+ 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)
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Evaluation
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+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
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+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
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+ 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
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+ Evaluation and Assessment
Utilizing self-assessment skills, list any modifications that could have enhanced treatment outcomes
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Documentation
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+Operations Performed
Provide copy of autonotes from Eaglesoft