A Guide to Finals Patient Case Presentations

As part of most finals exams, you will be required to present a continuing care case you have worked on. This is quite a daunting time for any student, especially because it involves standing up and presenting your own dental skills! This post is aimed at helping you with patient selection and structuring of your presentation.

Case Selection

The first important step is to pick a suitable patient. There are so many variables to consider at this point.

You want to demonstrate an improvement in the patient’s oral health and a reduction in disease. There’s always a difficulty in deciding between choosing a patient you have been seeing since second year or one you have been seeing in final year. Ideally, the earlier you identify a finals patient, the longer you have to work on a structured and appropriate treatment plan. A properly staged treatment plan can take a long time for some of these patients. There is a risk with choosing a patient too late, that the treatment plan may be botched, rushed and incomplete come exam time. There will also likely be an expectation of fewer ‘mistakes’ and higher quality work for a final year patient vs a second year patient.

Having said this, when choosing a patient early on, there is a risk that your clinical knowledge is lacking and therefore you make basic mistakes or your treatment plans aren’t quite complete. It’s important to identify these before you present and reflect as well as identify ways you would rectify these in the future. Another solution to combat this relative inexperience is to plan carefully with a good tutor. Your tutor can help identify appropriate cases and ensure you are doing the correct things should you want to take them forwards as a finals patient.

Do not forget to collect the basic information and records including:

• A full clinical dental assessment
• Study models
• Photographs
• Appropriate radiographs (and at appropriate intervals as needed)

Keeping your case simple is better. You ideally want to demonstrate a multidisciplinary approach but don’t go for anything overly complicated. A case with some elements of periodontal care, simple restorations and some advanced restorations/endodontics/prostheses, with some aspect of referral for teamworking, would be sufficient. You need to demonstrate you have a suitable and evidence-based treatment plan for your patient. Often, if the case is overly complicated, you either cannot justify some treatments or you may struggle to answer questions relating to the treatment.

The Presentation/Patient Story

Patient assessment and examination is essential and key to your presentation. You should include and expand upon the following areas:

• Presenting complaint (PC):

This is the headline of why you started seeing the patient. State it simply and in the patient’s own words e.g. ‘Mr X presented to me in 2018 because he was aware of ‘holes in his teeth”. This should be related to your treatment plan.

• Medical history (MH):

Ensure your patient has an up-to-date medical history. Their medications should be recorded and further details about them, including what they are taking them for and how long for. Use the BNF to identify the relevance of medical conditions and medications to dentistry. You could easily get asked about the relevance of a patient’s conditions or medications on their dental management.

It’s important to be aware of key medical conditions and their impact on the patient’s treatment, for example:

• • Patients on bisphosphonates – there is a greater emphasis on preventing any extractions due to the risk of MRONJ.
  • Diabetic patients – periodontal care is vital due to their risks.
  • Patients on anticoagulants – consider how you would manage them in an oral surgery setting.

It is useful to consider further impacts of a patient’s conditions, such as timing of appointments for diabetics or mobility concerns for osteoporotic patients.

• Dental history (DH):

This includes any previous dental history the patient has:

• • Attendance history
  • Any anxieties
  • Oral hygiene regime – type of toothbrush, type of toothpaste, interdental cleaning, mouthwash use.
  • Dietary factors – sugar intake, frequency, any diet diary information you’ve collected.

Ensure that, again, this becomes relevant to your treatment plan.

• Social history (SH):

This is focussed on tobacco and alcohol use.

• • Tobacco history – current or historic use; frequency; type. Have you offered cessation advice and discussed risks with the patient?
  • Alcohol intake – units per week. Has the impact been discussed with the patient?
  • Recreational drug use – this may be relevant for dental treatment e.g. methadone use.

Record their occupation and living status – these may influence stress, motivation and attendance to appointments.

• Family history (FH):

Family history of general medical conditions (such as diabetes) but also any dental conditions (such as amelogensis imperfecta). This can also impact your treatment plan.

• Extra oral examination (E/O):

It is important to state, even if there are no abnormalities detected. For cases involving trauma: note scars, asymmetry or irregularities that can be observed. Note your assessment of the patient’s lymph nodes and TMJ. An assessment of the muscles of mastication may be important for patients with facial pain.

• Intra-oral examination (I/O):

This should include your dental charting and BPE record. In addition, for cases with missing dentition discuss ridge status, dimensions of the spaces, alignment of the dentition. A full periodontal assessment where relevant, but also plaque scores which would impact treatment.

• Special tests and investigations:

Any further tests that are conducted should be justified and relevant to the patient. Radiographs should be taken as per current guidelines. For example, it is suggested that for patients with a high caries risk status, bitewings are taken every 6/12.

Other tests may include vitality tests of questionable teeth.

• Diagnosis:

This will most likely include more than one diagnosis. You need to be thorough with this as, essentially, your treatment plan should link to each aspect of your diagnosis. If differential diagnoses are relevant, then include these as well. You may include diagnoses such as:

• • Caries diagnosis
  • Pulpal and periapical diagnoses
  • Periodontal diagnosis
  • Any edentulous spaces diagnoses

• Prognosis:

The success of your treatment will be impacted by both the initial dental status of the patient but also patient factors. You may want to give an overall prognosis for the patient, but you may also include individual tooth prognoses. Patient factors such as motivation and medical conditions may impact the prognoses.

• Treatment plan:

This should be an itemised list of the treatment you planned on delivering for the patient and linked to the complaint as well as the diagnoses for the patient. You may have had to change or pivot your treatment plan along the way, so make sure you explain these decisions. Ensure you document advantages and disadvantages of all the options with the patient.

• Review date and continuing care plans:

Remember that you are responsible for your patient’s aftercare and that you need to make the appropriate arrangements for them once graduating.

• Reflection:

Reflecting is crucial to show you are a developing clinician. Look back on your case and see what went well and what didn’t go well. What would you do differently? What have you learnt? If you have a patient you have been seeing from an early point in dental school, you are likely to have a little more to reflect on as chances are you made mistakes. It is important you show how you have learnt from any potential mistakes and how they have made you a better clinician.

Further Hint and Tips

Study models and photographs before and after treatment as excellent records to show how you have improved the patient’s oral health. These are also good ways to monitor the patient over time. Photographs are a must in order to demonstrate the chance. You should ideally do this for any patient you consider as a potential finals case so that they are worked up appropriately. Having such tools also means that, in the rare situation you patient doesn’t turn up, you can still present your case with some evidence.

Ensure you are aware of why you did certain treatments and the alternatives that are available. Unfortunately, saying that your tutor ‘told you’ to do the treatment is not a valid answer. You need to understand the impact of the treatment you have carried out. It is also, therefore, important to know the treatment options and the advantages and disadvantages of them for that patient. An easy example of this would be management of edentulous spaces and discussing partial denture options e.g. cobalt-chrome vs acrylic. No treatment is also a viable option in some situations – just ensure you make it relevant for your patient. You can gain some extra marks by incorporating contingency planning – what would you do in the future if your treatments fail?

You need to demonstrate teamwork so, where appropriate, refer the patient for care from other members of the team. A common example is referral to a Hygiene and Therapy colleague for oral hygiene advice, periodontal treatment and simple restorative work.

Preparation

Prepare your patient! Ensure you tell them the exam date well in advance and keep reminding them to try and avoid them not turning up. Bring your patient in relatively regularly before your exam to make sure things are ticking over appropriately. Definitely bring them in a week or so before you exams to check everything. Carry out a thorough assessment to ensure nothing has been missed and you have all the information you need. Identify any obvious ledges on restorations or any traumatic areas on dentures. Give them a scale and polish, if appropriate.

Practice your presentation with colleagues and family. Go through what you would say and allow them to ask questions. This may identify areas of further learning you need to do. They may also identify potential issues with your treatment plans or treatment you carried out. You would rather find these out early than on exam day! Writing cue cards is also useful – people often forget things whilst presenting. Be confident and be prepared.

When presenting, speak clearly, slowly and confidently – after all, this is your treatment plan so be confident about it. Introduce your patient and their age. Take your tutors through the journey the patient has been on. Whilst you are presenting, often the tutors will be looking at your patient records and the patient themselves. They might do a quick assessment of the patient’s mouth. If you make a mistake, correct yourself and continue. If you don’t know the answer to something, be honest but suggest ways you would try to find the answer. You will usually have some time presenting with the patient, but then also some time with questions away from the patient.

Ultimately, you are being assessed as to whether you are safe and sensible. You need to demonstrate that you delivered patient-centred care and delivered an overall improvement in the oral health of your patient. Choose carefully and plan thoroughly – good luck!

Other tips needed? Check out the post on finals poster presentations for other finals tips!