A guide to a successful patient case presentation

For any final year dental student, the thought of standing up and presenting a case in front of tutors eager to pick your brains and home in on even the tiniest of areas you might not know about, can be a daunting prospect. Fortunately, tutors are not all as terrible as we think and neither are the presentations...if you know what they are looking for.

A big tip to any dental student is to select your case presentation patient early and NOT in your final year. This gives you a great advantage of having enough time to formulate and develop a treatment plan that you can complete well before the exam. Think about how long you will be spending providing treatment. Some cases take longer than others. Be aware that in most students experience, lab work always takes longer than you think.

One drawback many students feel in finding a case too early is not having the experience. A solution to this is to find a good tutor who has experience in planning cases for Case Presentations and choose a plan that starts simply. Don't forget to obtain all the basic initial information and records, so that everything is covered including : BPEs, Williams chart, mobility scores, study models, photographs and radiographs.

Patient selection can prove difficult. Start by choosing a motivated, regular attender who will be reliable. The last thing you want to worry about is their non-attendance on the day! Your case doesn't have to be overly complicated. It does have to demonstrate a multidisciplinary approach involving elements of periodontal care, simple conditions and possibly more advanced restorations, endodontics or removable prostheses. Ultimately, the case presentation is designed to show tutors that you are maintaining your duty of care to patients by offering a suitable and justified treatment plan that has resulted in effective management and an improvement to the patients' dental status.

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

• Patient's presenting complaint

State it simply and in the patient's own words. Relate it to your treatment plan.

• Medical history - previous and current

Medical history forms must be completed and updated. If they are on medications, always ask what for and how long have they been on them.

Be able to relate a patient's medical history to the treatment you are offering.

For example, patients with diabetes who are undergoing periodontal treatment - start off with the basics  - SHOWING THAT YOU'RE SAFE! Explain what diabetes is and what problems could arise in a medical emergency, such a hypoglycemia. Discuss how you could reduce this risk by providing patients with appointments after meal times. Then progress on to more advanced topics such as the poor ability for wound healing and the effects that diabetes has in relation to periodontal disease.

• Dental history

This includes previous dental history and current factors such as diet and dental hygiene. Ask about toothbrushing: do they use a manual or an electric toothbrush? What toothpaste do they use (does it contain adequate fluoride)? How often do they brush? Do they use floss or use TePe brushes? Do they use mouthwash?

When discussing diet it is relevant to identify frequency of intake, type of sugar, provide a diet diary and how you helped them to improve including substitutes for snacks.

• Social history

Identify whether they currently smoke or chew tobacco, or have smoked in the past. Note the number of cigarettes smoked a day. It is a good idea to include that you have offered the patient smoking cessation advice and also informed them of the increased risk of oral cancer and periodontal disease.

Record their alcohol intake (units per week). Highlight its relevance to erosion and don't forget the relationship of liver cirrhosis to surgical complications.

Note their occupation and how this may influence stress levels, motivation and attendance.

• Family history

This can be related to medical conditions such as diabetes or heart disease. Also ask about history of periodontal disease in the family. For bonus points, include aspects relating to oral medicine such as ulcers, to show you're thinking about all aspects that could present on the initial and subsequent visits.

• Extra oral information

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.

• Intra-oral observation

This should include you're usual charting and BPE record. In addition, for cases with missing dentition discuss ridge status, dimensions of the spaces, alignment of the dentition. Look for and record recession, mobility and plaque scores.

• Special tests and Investigations

These should be discussed and justified. Emphasise the justification aspect. Radiographs need to support a provisional clinical diagnosis.

When taking radiographs, quality assure them and, using current guidelines, select an appropriate review date. For example, it is suggested that for patients with a high caries risk status, Bitewings are taken every six or twelve months.

• Diagnosis

This will most likely include more than one diagnosis. And yes missing teeth is a diagnosis. Ensure that the diagnosis is related to the initial assessment. If appropriate show that you have used a differential diagnosis and how you went through a process of elimination to come to your definitive diagnosis.

• Prognosis

State how motivated the patient is and the likelihood that the treatment you provide will be successful. Individual tooth prognoses are good to include and will support your treatment decisions. These will also help you identify contingency requirements.

• Treatment plan

This is an itemised list of treatment that you plan to provide with the patient's prior consent. Tick the items off as you go along. Document that you have discussed all treatment options available, including the advantages and disadvantages of each.

• Review date and continuing care plans for when you have graduated.

Remember that you are responsible for your patient's aftercare and that you need to make the appropriate arrangements for them after you have *fingers crossed* graduated.

Study models and photographs before and after are good records for you to reflect upon and demonstrate to the tutors that you have used methods available to you to monitor your patient's dental health. It's also good backup in case your patient leaves you high and dry on the day. Don't panic if you haven't got them or you come to find they are not the best of quality, because complete and up-to-date records should be fine.

Alternative treatments are a hot topic in case presentations. The tutors are very keen to identify that students are aware of options available and be able to support their decisions for opting to choose one treatment over another. This could include discussing why you chose to replace missing teeth with an acrylic denture, instead of a fixed prosthesis or a cobalt/chrome denture. Carefully go through the advantages and disadvantages of each option and be prepared to highlight the disadvantages in order to justify your treatment choice. Always include that no treatment is a viable option and most importantly, relate it to your patient's initial presenting complaint.

As a dental care professional, you must be able to demonstrate a good ability to work as part of a team and delegate tasks. Where appropriate, use members of your team such as the Hygiene and Therapy department to reinforce the importance of good oral hygiene and provide smoking cessation advice, periodontal treatment and simple conditions.

In the weeks running up to your case presentation make sure you have reviewed your patient and they have put the date of your exam in their diary. Give your patient a clinic appointment the week before the presentation and don't just do what everybody does: a scale and polish. Look beyond shining your restorations and removing last week's dinner. Do a thorough assessment, as if you were seeing the patient for the first time so you can't be caught out on any areas that you might have missed. One unfortunate final year had the bad luck to have a visible draining sinus "appear" on the day of the presentation. Don't let that be you!

It is highly recommended to prepare cue cards. Many people don't realise that you CAN bring cue cards into the presentations. Write them out and practice with them in front of friends, family and anyone else who's willing to listen. The more feedback you can obtain the better. Be confident. Be prepared. Think of questions that you might be asked and devise answers for these. One area that I strongly recommend spending time on is devising contingency plans should your treatment fail in the future. This will show the examiners that you are aware of and can manage all possible outcomes.

In the presentation, make sure you speak clearly and slowly. Introduce your patient and state their age. Don't rush through things. The tutors will be spending a lot of time looking at your patient and checking basic areas, such as periodontal health, restoration margins and any lesions that you may have missed. Whilst you are presenting your case, don't be put off if they interrupt you and don't be afraid to pause for a moment to develop an answer in the best way possible. If you say something that is wrong, don't try to wing it. Stop. Point out that you've said something incorrect and if possible offer the correct answer.

All in all, tutors are looking for safe and sensible students who have demonstrated a logical (and defendable) approach, providing good quality care to patients from the first visit to the final presentation and for continuing care in the capable hands of another dental student.

Emilie Abraham
Emilie Abraham qualified with BDS Honours from The University of Sheffield in 2012. She is currently employed as a Core Trainee in Oral & Maxillofacial Surgery at York Teaching Hospital.