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Case Presentations DMD3 Tips

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Case Presentations1

DMD3 - 20262

Dr. Mina Dizdarevic

Case Presentations1

Aim of the Assessment3

The Case Presentation is designed to assess a dental student’s integrated knowledge from a combination of didactic and pre-clinical teaching, as well as patient treatment, clinical experiences, and activities throughout their time at the Dental School.

Case Presentations1

Aim of the Student4

Students need to show examiners that they are maintaining their duty of care to patients by offering an appropriate and justified treatment plan, which has resulted in effective management and an improvement to the patients’ dental status.

Case Presentations1

Clinical Workflow Analysis5

graph TD
    A("<b>CHIEF<br>COMPLAIN &<br>EXPECTATIONS</b>") --> PL
    B("<b>FAMILY<br>and<br>SOCIAL<br>HISTORY</b>") --> PL
    C("<b>MEDICAL<br>and<br>DENTAL<br>HISTORY</b>") --> PL
    D("<b>EXTRA and<br>INTRA<br>ORAL<br>EXAM</b>") --> PL
    E("<b>ORAL<br>HYGIENE<br><br>DIET<br>ANALYSIS</b>") --> PL
    F("<b>SPECIAL<br>TESTS,<br>OCCLUSAL<br>ANALYSIS</b>") --> PL
    G("<b>TOOTH<br>INVESTIGATION</b>") --> PL
    H("<b>SPECIALIST<br>OPINIONS</b>") --> PL

    PL["<b>Problem List</b>"] <--> I("<i>(Analysis)</i>")
    I <--> DI("<b>DIAGNOSIS</b>")

    style PL stroke:#000,stroke-width:2px,color:#ff0000
    style DI stroke:#000,stroke-width:2px,color:#ff0000
    style A stroke:#000,color:#0070c0
    style B stroke:#000,color:#0070c0
    style C stroke:#000,color:#0070c0
    style D stroke:#000,color:#0070c0
    style E stroke:#000,color:#0070c0
    style F stroke:#000,color:#0070c0
    style G stroke:#000,color:#0070c0
    style H stroke:#000,color:#0070c0

Case Presentations1

Generic Approach6

  1. Chief complaint – History
  2. Medical history
  3. Dental History
  4. Social History
  5. Family History
  6. Oral Hygiene
  7. Diet
  8. Investigation / Special tests
  9. Problem list
  10. Diagnosis
  11. Treatment (options, complications, pros and cons)
  12. Referral/s (if needed)
  13. Short term and long term treatment/goals etc
  14. Review appointments

Case Presentations1

Chief / Presenting Complaint7

Straight from NOTES

Examples:

  • “I’m in so much pain with swelling and bleeding and is causing bad breath. It also hurts to eat on the back LHS and so I eat with my anterior teeth”
  • “I would like my chipped front tooth fixed”
  • “My upper and lower dentures are uncomfortable and I can’t eat”
  • “I went to a government dental clinic in Morley and told they couldn’t replace my crown, so I came here to get it replaced.”

Case Presentations1

Chief / Presenting Complaint – Pain Assessment8

  • Site – Point where you feel the pain
  • Onset – when did you first noticed the pain?
  • Character – Describe the type of pain: sharp, dull, constant, off and on, throbbing, etc.
  • Radiation – Does the pain spread out from the original source?
  • Associations – What other symptoms accompany the pain? Bad breath? Looseness of the tooth? Jaw clicking or popping?
  • Time course – What did the pain start? Does it occur at specific times of day?
  • Exacerbating or relieving factors – What makes the pain worse or better? What medications or remedies have you already tried?
  • Severity – How would you rate the pain on a scale of 1 to 10, where 1 is barely noticing some discomfort and 10 is an emergency room visit?

Case Presentations1

Chief / Presenting Complaint – History Example9

“My upper and lower dentures are uncomfortable, and I can’t eat”

  • Patient presented to OHCWA for the first time in 2022
  • All teeth were periodontally compromised with hopeless prognosis
  • Immediate complete dentures were made in January last year after all teeth were extracted in the DMD exo clinic using a staged approach.

Case Presentations1

Medical History10

Know MOA’S Example:

  • You’ll get grilled ex. If plt has hypertension → what drugs? → how effects dental?
Medical ConditionMedicationDental Implications
HypertensionTwynsta: Telmisartan with amlodipine, 50mg, oral, once daily Dithiazide: hydrochlorothiazide, 12.5mg, oral, once dailyARBs:
- Dry mouth Calcium channel blockers:
- Gingival hyperplasia
- Dry mouth
Diuretics:
- Dry mouth
- Lichenoid reactions (Southerland, 2016)
Chronic Obstructive Pulmonary Disorder (COPD)Trelegy: Fluticasone with umeclidinium and vilanterol, one puff/day- Breathing difficulties in supine position may require patient to be positioned more upright in the dental chair (Devlin, 2014) - Increased risk of oral thrush (TRELEGY, 2023)
Gastro-Oesophegeal Reflux Disease (GORD)Nexium: Esomeprazole, 20mg, oral, once dailyErosion of enamel (Wilder-Smith, 2004)

Case Presentations1

Dental, Social, and Family History11

Dental History

  • Previous dental treatment - not associated with presenting complaint

Social History

  • Patient’s occupation and family members: how this may influence stress levels, motivation and attendance.
  • Current smoker (smoke or chew tobacco), former smoker.
    • Note the number of cigarettes smoked/day, years of smoking
  • Recreational drugs
  • Alcohol intake (units per week)

Family History12

  • Medical conditions affecting other family members (e.g. diabetes or heart disease).
  • History of periodontal disease in the family (tooth loss at a young age)

Oral Hygiene

  • Frequency
  • Method

Diet

  • High and extreme caries risk: full diet analysis

Case Presentations1

Modifying/Risk Factors Example13

Social History

  • Patient Smokes 10-15 cigarettes/day since she was 35 years old

Family history

  • Mother lost all her teeth in her 30s

Oral hygiene

  • Brush 1x day with manual toothbrush, no flossing

Case Presentations1

Patient Background Example14

Social History

  • Migrated to Australia from South Africa to care for elderly mother
  • Currently lives alone, but has brother and son also living close by in WA
  • Runs a jewelry making class

Dental History

  • 22 implant was placed in the 1980s, but “fell out” in 2021.
  • Multiple posterior PFM crowns made in the 1990s.
  • Direct and indirect restorations and endodontic treatment done at OHCWA over the last 3 years.

Oral Hygiene

  • Brushes twice a day (Morning and night)
  • Electric toothbrush
  • Fluoridated toothpaste
  • Uses Pixters daily for interdental cleaning
  • Rinses with salt water in the mornings and Colgate Neutrafluor mouthwash at night

Diet

  • Generally avoids soft drinks but will occasionally have diet Pepsi
  • 3 cups of black coffee every morning, no sugar
  • Does not usually eat fruits, other than tomato and avocado

Case Presentations1

Risk Factor Pathophysiology15

graph TD
    A["Social History, Family History, Dental History, Diet, Oral Hygiene"] -->|Smokes 10-15 cigarettes/day Poor oral hygiene Family history of perio disease| B["Modifying/Risk factors"]
    B -->|Periodontitis| C["Pathophysiology of disease"]

Case Presentations1

Extra-Oral Exam16

  • Profile photos: frontal, lateral, high smile, rest position (De-identify patient) ↳ Black Bars over eyes
  • Facial symmetry
  • TMJ
  • MoM
  • Lymph nodes
  • Smile aesthetics
  • etc

NAD: State even if there are no abnormalities detected

Case Presentations1

Intra-Oral Exam17

  • Soft & hard tissues: Labial mucosa, Frenal attachments, Gingiva, Palate, FoM, Tongue, etc
  • Tooth charting
  • CPITN,
  • Plaque Score,
  • Perio Chart
11: Abutment - sat
12: Crown prep but no temporary or crown
13: Absent
14: Palatal caries
15: Absent
16: Absent
17: Heavy O wear
18: Absent		21: Pontic
22: Abutment - sat
23: FCC - sat
24: Bu GIC catch on margin; heavy O wear
25: Absent
26: Absent
27: Absent
28: Absent
41: Absent
42: Gingival recession; D surface brown stain; comp build up, 42L caries
43: Rotated distally, translated anteriorly; Bu, M recession; heavy O wear; exposed dentine; 43M cavitation and 43L caries
44: FCC - sat
45: Absent
46: Absent
47: FCC - sat
48: Absent		31: Gingival recession, composite buildup
32: Absent
33: O wear; Bu recession; Bu cavitation, arrested caries
34: Ceramic onlay - sat; Bu recession, heavy O wear; class V Bu GIC, catch
35: Missing
36: FCC - sat
37: Absent
38: Absent
  • Missing: 18, 22, 24, 25, 28, 38, 48
  • Non-carious tooth surface loss: 23B abrasion lesion
  • Endodontically treated teeth: 44 and 46 — temporarily restored with Ketac silver and SS band

Case Presentations1

Denture Examination18

  • Age
  • Retention
  • Stability
  • Occlusion
  • Aesthetics
  • Overall patient satisfaction

Example

MaxillaryMandibular
Age4.5 years4.5 years
AppearanceGoodFair (missing tooth)
RetentionPoorGood
StabilityPoorGood
Patient satisfactionPoorGood

Intraoral photos with dentures - RPD

Case Presentations1

Investigation / Special Tests19

Radiographs

  • Date and Xray interpretation

Example: Bitewings (17/03/2023)

  • RHS: Radiolucencies observed under 15 crown and 14 crown
  • LHS: radiolucency under 37B amalgam

Clinical Tests

  • Results for Cold, EPT, Percussion, Palpation tests

Case Presentations1

Caries Risk Assessment (CAMBRA)20

  • Protective factors: Access to fluoride products, F water
  • Saliva test: Resting pH, Stimulated saliva volume, Stimulated saliva buffering capacity
  • Diet assessment: Exposure to sugars
  • Clinical/radiographic exam: Plaque score, Caries, White spot lesions, Non-cavitated lesions (xray), Existing restorations
TABLE 3 (Part 1) | Updated CAMBRA caries risk assessment form* for ages 6 year through adult (January 2021)**.
Patient Name:Reference Number:
Provider Name:Date:
Caries risk assessment component* (Check yes only in the appropriate shaded column)Column 1 Score: -1Column 2 Score: +2Column 3 Score: +3
Protective factors – Question itemsCheck if Yes*
1. Fluoridated water✓
2. F toothpaste at least once a day
3. F toothpaste 2X daily or more✓
4. 5,000 ppm F toothpaste✓
5. F varnish last 6 months
6. 0.05% sodium fluoride mouthrinse daily
7. 0.12% chlorhexidine gluconate mouthrinse daily 7 days monthly
8. Normal salivary function✓
Biological or environmental risk factors Question itemsCheck if Yes*
1. Frequent snacking (> 3 times daily)
2. Hyposalivatory medications✓
3. Recreational drug use
Biological risk factors – Clinical Exam
1. Heavy plaque on the teeth✓
2. Reduced salivary function (measured low flow rate)***
3. Deep pits and fissures
4. Exposed tooth roots✓
5. Orthodontic appliances
Disease indicators – Clinical examCheck if Yes*
1. New cavities or lesion(s) into dentin (radiographically)
2. New white spot lesions on smooth surfaces
3. New non-cavitated lesion(s) in enamel (radiographically)
4. Existing restorations in last 3 years (new patient) or the last year (patient of record)✓
Column total score (Columns 2 + 3 — 1):Column 1 Total:Column 2 Total:Column 3 Total:
Yes in column 3 likely indicates high or extreme risk.-4+6+6
Yes's in columns 1 and 2: use the caries balance-below
***Hyposalivation plus high risk factors = extreme risk
Final Overall Caries Risk Assessment Category (check) determined as per guidelines below
LOW [ ] MODERATE [ ] HIGH [X] EXTREME [ ]

*Check only the yes answers in the appropriate shaded column. Enter a score of -1, +2 or +3 for each yes checked. Unshaded columns are left blank. Assess the caries risk as per instructions in Table 3 (part 2) below. **Modified from Featherstone et al. [11] with permission of California Dental Association Journal. ***This material may be used free of charge for the purposes of patient care, education, academic works, research, health promotion, health policy and related activities. However, permission must be obtained before this material is used for commercial purposes. Refer to the second page (part 2) for instructions for use as guidelines for caries risk assessment.

Case Presentations1

Periodontal Risk Assessment21

Do this EVEN IF P/T DOESN’T HAVE PERIO

Periodontal risk assessment (Lang & Tonetti, 2003)

Age51
Number of teeth and implants17 (1 - 32)
Number of sites per tooth / implant🔘 6
Number of BOP-pos. sites82 of 102
Number of sites with PPD≥5mm21
Number of missing teeth11
% Alveolar bone loss (estimated in % or 10% per 1mm)70 %
Syst./Gen.🔘 No
Envir.🔘 Occasional smoker (OS)
  • Polygon surface: 130.769
  • Periodontal Risk: high
  • Suggested Recall interval: 3 Months
  • HIGH RISK

Case Presentations1

Prognosis22

Add reference Periodontal, Restorative, Endodontic, Occlusion - Overall. “Your own opinion” → Just justify it.

Prognoses
PerioGGGGGGGGGGG
RestoFFQFFGGGFFC
EndoGGQGGGGGGGG
OccGGGGGGGGGGG
OverallFFQFFGGGFFC
18171615141312112122232425262728
48474645444342413132333435363738
PerioGGGGGGGGGGGGGGG
RestoFNFCGGGGGGGFFF
EndoGCGGGGGGGGGGGG
OccGFGGGGGGGGGGGG
OverallFNFCGGGGGGGFFF

Prognosis Key (Samet & Jotkowitz, 2009):

  • G: Good
  • F: Fair
  • Q: Questionable
  • C: Compromised
  • N: Non-salvageable

Case Presentations1

Problem List23

  • Aesthetics: related to natural or artificial teeth
  • Host-related: factors that affect oral and dental health (habits, medication, medical condition)
  • Pathology: related to hard and soft tissues (include the complete perio and endo diagnosis)
  • Morphology: occlusal problems, hypomineralisation, bony exostosis, hypocementosis

Example: 1.17 Problem list

  • Poor smile aesthetics and unsatisfactory CrCo P/- (presenting complaint)
    • Multiple root stumps, discolouration due to caries
    • Unsatisfactory CrCo P/- design and loss of retention due to fracture of abutment tooth 24
  • Host-related
    • Bipolar disorder & hypothyroidism managed by medication
    • Dry mouth
    • Smoker
    • Frequent and high intake of sugary & acidic foods and drinks
    • Questionable OH compliance / dental attendance record
  • Pathology
    • Carious root stumps 24, 33, 43
    • Frank cavitation due to caries 11, 13, 21, 22, 23, 31, 32, 34, 35, 41, 44, 45
    • Moderate to severe generalized chronic periodontitis modified by smoking (AAPD, 1999) / Periodontitis Stage 4 Grade C modified by smoking (Papapanou et al, 2017)
    • Pulpless and infected RCS and chronic apical periodontitis due to caries 24, 32, 33 (Abbott & Yu, 2004; Abbott, 2004)
    • Recurrent aphthous ulcerative disease
    • Denture stomatitis of the anterior hard palate
  • Morphology
    • Cl II tendency
    • Vertically impacted 38, 48
    • Hypercementosis 13, 23, 24, 34, 35, 44, 45
    • Missing teeth - Mx Kennedy Cl I, Md Kennedy Cl II Mod 1
    • Large, bulbous Mx anterior alveolar ridge
    • Loss of posterior support

Case Presentations1

Diagnosis and Treatment Options24

Diagnosis

  • Summary of problem list

Treatment Options

  • Options for control and reconstructive phase
  • All options even if the patient cannot afford
  • Pros and Cons
  • No treatment is also an option

Case Presentations1

Case Progress and Final Slides25

Case Progress

  • Photos of the Case

Last Slides

  • Reflections
    • Limitations
    • What could be done better
  • Reference list

Case Presentations1

Preparation and Requirements26

Prepare 2-3 cases

  • Photos
  • Study Models
  • Radiographs

Why three cases?

  • 1 for Case Pres in DMD3
  • 2 for spare, resits or supplementary Don’t go for anything to complex - i.e. if you do vd you’ll be absolutely grilled

Timeline27

  • Semester 1 (DENT5310)
    • CP slides/PDF (formative)
    • Submit for feedback
  • Semester 2 (DENT5311)
    • Case presentation (summative) + Portfolio
    • 45 minutes: 15-20 mins presentation, 20-25 mins questions

Examiners:

  • Two examiners – tutors, academic staff (examiners not disclosed).
  • In some sessions there will be an observer.

Case Presentations1

Case Selection Guidelines28

  • Select your case presentation patient early.
  • Enough time to formulate and develop a treatment plan that you can perhaps complete before the exam*
  • Select reliable patients
  • Give preference to Multi-disciplinary cases (endo, perio, pros) or Complex medical history (polypharmacy) with completed control phase
  • Avoid very Complex cases in DMD3
  • Ask help from Clinic coordinators or Module coordinator for case selection

*The selected case does not need to be finished in DMD3

  • Do not forget to obtain all the basic initial information and records (study models, photographs and radiographs) for all potential case presentation patient
  • Maintain caseload
  • Do not ignore your other patients

Case Presentations1

Oral Presentation and Portfolio29

Oral Presentation: If you are not accustomed or do not feel comfortable speaking in public:

  • Practice your presentation with a friend
  • Timing

Case Portfolio Patient Types30

  • 1x periodontitis management case
  • 1x restorative treatment case using removable dentures (complete or partial)
  • 1x restorative treatment case using fixed restorations
  • 1x treatment involving the management of dental aesthetics
  • 1x multi-disciplinary case

Mandatory Requirements:

  • At least one case in your portfolio must include Endodontics for the management of pulp/root canal diseases, and Extractions for the management of teeth with overall hopeless prognosis (these procedures should not be limited to the multi-disciplinary case).
  • Paedodontics and Orthodontic cases can also be used in your case portfolio to illustrate the multi-disciplinary case and aesthetic case.
  • The dental aesthetics case can involve for example direct and indirect restorations, internal tooth bleaching, orthodontic procedures.

Case Presentations1

Additional Resources31

  • Example Case Pres
  • Rubric’s
  • Logbook

Dr. Mina Dizdarevic

Footnotes

  1. Original PDF page 28: Case Presentation DMD3 Tips- annotated, p.28 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10 ↩11 ↩12 ↩13 ↩14 ↩15 ↩16 ↩17 ↩18 ↩19 ↩20 ↩21 ↩22 ↩23 ↩24 ↩25 ↩26 ↩27

  2. Original PDF page 1: Case Presentation DMD3 Tips- annotated, p.1 ↩

  3. Original PDF page 2: Case Presentation DMD3 Tips- annotated, p.2 ↩

  4. Original PDF page 3: Case Presentation DMD3 Tips- annotated, p.3 ↩

  5. Original PDF page 4: Case Presentation DMD3 Tips- annotated, p.4 ↩

  6. Original PDF page 5: Case Presentation DMD3 Tips- annotated, p.5 ↩

  7. Original PDF page 6: Case Presentation DMD3 Tips- annotated, p.6 ↩

  8. Original PDF page 7: Case Presentation DMD3 Tips- annotated, p.7 ↩

  9. Original PDF page 8: Case Presentation DMD3 Tips- annotated, p.8 ↩

  10. Original PDF page 9: Case Presentation DMD3 Tips- annotated, p.9 ↩

  11. Original PDF page 10: Case Presentation DMD3 Tips- annotated, p.10 ↩

  12. Original PDF page 11: Case Presentation DMD3 Tips- annotated, p.11 ↩

  13. Original PDF page 12: Case Presentation DMD3 Tips- annotated, p.12 ↩

  14. Original PDF page 13: Case Presentation DMD3 Tips- annotated, p.13 ↩

  15. Original PDF page 14: Case Presentation DMD3 Tips- annotated, p.14 ↩

  16. Original PDF page 15: Case Presentation DMD3 Tips- annotated, p.15 ↩

  17. Original PDF page 16: Case Presentation DMD3 Tips- annotated, p.16 ↩

  18. Original PDF page 17: Case Presentation DMD3 Tips- annotated, p.17 ↩

  19. Original PDF page 18: Case Presentation DMD3 Tips- annotated, p.18 ↩

  20. Original PDF page 19: Case Presentation DMD3 Tips- annotated, p.19 ↩

  21. Original PDF page 20: Case Presentation DMD3 Tips- annotated, p.20 ↩

  22. Original PDF page 21: Case Presentation DMD3 Tips- annotated, p.21 ↩

  23. Original PDF page 22: Case Presentation DMD3 Tips- annotated, p.22 ↩

  24. Original PDF page 23: Case Presentation DMD3 Tips- annotated, p.23 ↩

  25. Original PDF page 24: Case Presentation DMD3 Tips- annotated, p.24 ↩

  26. Original PDF page 25: Case Presentation DMD3 Tips- annotated, p.25 ↩

  27. Original PDF page 26: Case Presentation DMD3 Tips- annotated, p.26 ↩

  28. Original PDF page 27: Case Presentation DMD3 Tips- annotated, p.27 ↩

  29. Original PDF page 29: Case Presentation DMD3 Tips- annotated, p.29 ↩

  30. Original PDF page 30: Case Presentation DMD3 Tips- annotated, p.30 ↩

  31. Original PDF page 31: Case Presentation DMD3 Tips- annotated, p.31 ↩

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