1. Case Study Presentation Team Number Team Member Names Date 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 Selection Criteria: State the criteria by which you selected the case for presentation.

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.)

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 Include client’s last DHT visit Describe history of previous dental surgeries, procedures, ortho, etc (from green EO/IO form)

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

10. Occlusion Include description of occlusion classification If possible, provide pictures of occlusion

11. Plaque Control Record Provide documentation of the client’s initial plaque score using Eaglesoft Was there light, moderate, or heavy plaque? Where was it primarily located (gingival margin, interproximal, posteriors, etc)? What were client’s current homecare practices at the first visit?

12. Calculus Detection Include a copy of the client’s calculus detection. Does the client have light, moderate, or heavy calculus? Is there subgingival or supragingival calculus? If possible, include pictures of supragingival calculus.

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

14. Dental Chart Provide copy of dental chart from Eaglesoft Summarize dental findings and conditions May include intraoral photos

15. Dental Hygiene Caries Exam Summarize dental hygiene caries exam findings (suspicious areas) Include a summary of diagnodent findings

16. Perio Chart Provide summary of periodontal findings Include copy of Eaglesoft periochart

17. 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

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

19. Diagnosis

20. Gingival Description and Periodontal Diagnosis Provide summary of gingival description ie. pink, firm, puffy, edematous, etc. Include the periodontal diagnosis

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

22. Planning

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

24. 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

25. Consent for Treatment Include and summarize consent for treatment form

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

27. Implementation

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

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

30. 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)

31. Evaluation

32. 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

33. 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

34. 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

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

36. Documentation

37. Operations Performed Provide copy of autonotes from Eaglesoft