DPHS Sample Case Presentation SAMPLE CASE PRESENTATION Presenting clinical by takemehome

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									                                                            DPHS 640 – Sample Case Presentation

                              SAMPLE CASE PRESENTATION


       Presenting clinical information (reason for seeking dental treatment). I first saw Ms.

X, a 36-year-old female, for an initial evaluation in March of 2007. Ms. X came to our clinic

because she had “a lot of problems with my teeth,” including pain on the lower left that was

worsened by hot liquids and percussion. Ms. X said that the last time she went to a dentist was

about 3 years earlier, when she went to an emergency clinic with a toothache. The tooth was

extracted, and Ms. X said, “I swore I’d never go back to another dentist – that was so horrible

and painful.”

       Means of assessing patient's fears and concerns. Ms. X made her fears of dentistry

known as soon as she sat down in the chair. By her report, she had “always hated dentists,” and

had only seen dentists as an adult when she was in pain. Because she indicated that she was

fearful right away, I decided to give her the Dental Fear Survey (DFS) and then ask her follow-

up questions about her fears based on how she answered the survey questions.

       Description of patient's fears, including the etiology/consequences of fear(s). Based

on her responses on the DFS, it appeared as though Ms. X was most fearful of dental injections.

Ms. X indicated that she was afraid of the sight of the syringe and feeling of the injection. To

follow up on this topic, I asked Ms. X what her past experiences were with dental injections.

Ms. X stated that, in her experiences, injections “are always painful,” and that she thought she

might be allergic to local anesthetic. When asked about this further, Ms. X noted that “my heart

always races and I feel shaky” after injections of local anesthetic.

       I asked Ms. X if there were other aspects of dentistry that were difficult for her, and she

said, “I worry that dentists are always thinking I’m a terrible person because I don’t take better




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                                                              DPHS 640 – Sample Case Presentation

care of my teeth.” At this point, Ms. X became tearful and said, “I just want to be able to go to

the dentist like normal people.”

       I asked Ms. X how long she had felt fearful of dental treatment. Ms. X said that when

she was 6 years old, she became very upset and scared when her dentist tried to give her an

injection. According to Ms. X, the dental assistant and another staff member “held me down

while the dentist gave me a shot.” Ever since that time, according to Ms. X, she has been

“terrified” of dentists, dental injections, and being out of control in the dental chair.

       Clinical/dental treatment plan. Ms. X had extensive dental needs. She required

endodontic therapy on #5, #19, and #30. Numbers 15 and 31 were severely broken and required

extraction. Ms. X also required a replacement of an MOD restoration on #3 and new restorations

on #13 and #18. Ms. X also required full-mouth scaling and prophylaxis.

       Description of how treatment plan is presented to patient, taking fear(s) into

account. Because Ms. X expressed worry about looking like “a terrible person” for not taking

care of her teeth, I did not want to overwhelm her with her dental treatment needs all at once for

fear of sounding like I was criticizing her. I also wanted to try to reassure her that I would do my

best not to recreate her previous negative experiences.

   I began by praising Ms. X for facing one of her greatest fears and being proactive about her

oral health. I told Ms. X that most people are at least somewhat afraid of going to the dentist,

and that she wasn’t alone in her concerns. Then, I told Ms. X that while she did have some teeth

that needed treatment, we would proceed at a pace that was comfortable for her, so that we could

get to know each other and work together to help her feel more comfortable during treatment.

Ms. X said that she thought that sounded like a good way to proceed, then asked about her

treatment needs.




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                                                            DPHS 640 – Sample Case Presentation

   I presented her treatment needs to Ms. X in writing and also went over the written treatment

plan with her in person. I reassured her that, while her treatment needs may seem overwhelming,

all her treatment was very straightforward from a dental standpoint. Ms. X said that she was not

surprised that she needed so much dental work, and seemed resigned to her dental needs. I

suggested to Ms. X that we start with the easiest treatment on the plan, and asked her what

sounded like the easiest treatment for her to tolerate. Ms. X responded, “I’ve never really had a

problem with cleanings.”

   We decided to begin with the full-mouth scaling in two treatment sessions, followed by the

restorations. We planned to treat any infections with antibiotics and limited pain medication as

possible to allow Ms. X to develop coping skills prior to completing any endodontic treatment or

extractions. Ms. X agreed to this treatment plan, and we scheduled our first session.

       Means by which treatment plan was implemented, taking fear(s) into account. When

Ms. X appeared for her first cleaning appointment, we reviewed ways in which she could help

herself feel more relaxed and comfortable during treatment. I taught her how to breathe slowly

and deeply, and how to keep her muscles relaxed. We also talked about how Ms. X can imagine

herself in a pleasant spot, instead of in the dental chair. Ms. X said she enjoyed a recent camping

trip with her husband and children, and said she would try to imagine this scene during

treatment. I also encouraged Ms. X to raise her hand if she felt uncomfortable or wanted to take

a break. At the end of this session, Ms. X said that she had never felt as relaxed during a dental

appointment, although she was still “a little nervous.” I said it was normal to be nervous, but that

I was very glad she felt comfortable.

   After completing the scaling appointments, we had one “injection rehearsal” appointment,

where we rehearsed the steps involved in receiving an injection while practicing the coping skills




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                                                             DPHS 640 – Sample Case Presentation

she already knew. Ms. X reported anxiety during the first “cap-on” rehearsal, but then reported

less anxiety during a second and third rehearsal. She asked for only one “cap-off” rehearsal, and

was then able to receive an actual injection. Ms. X noted that she felt some pressure during the

injection, but no pain, and felt much more comfortable than in the past, since she was able to

raise her hand at any point to stop the injection.

   Since she had reported being “allergic” to the anesthetic before, I injected a very small

amount at first and asked Ms. X how she felt. She said she could feel her heart racing, and I

encouraged her to take some slow, deep breaths. Ms. X said that she felt “much better” after

doing this, and we were able to proceed. I explained the role of epinephrine in the anesthetic,

and said that she was likely feeling a very normal reaction to this. Ms. X said she hadn’t known

about that before, and said that she didn’t think she was really allergic to the anesthetic after

being able to slow her heart rate down on her own through breathing and relaxation.

       Once Ms. X successfully received an injection, her confidence in her ability to tolerate

restorations, endodontic therapy, and extractions was greatly increased. We successfully

completed the necessary restorations, with Ms. X reporting less and less anxiety with each filling

done. While Ms. X was originally anxious about the endodontic therapy “because I’ve heard

horror stories about root canals,” she said she felt calmer after I explained that root canal

treatments are not very different from fillings; most patients report that root canals are “boring.”

I reminded Ms. X of how well she had used her coping skills in the past, and how far she had

come. We were able to proceed through both the endodontic treatments and extractions with

only mild anxiety on Ms. X’s part (and mine, too!).

       Patient's response to treatment. Ms. X initially expressed doubt that she could tolerate

any dental treatment without “knocked out,” but was willing to try behavioral methods because




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                                                          DPHS 640 – Sample Case Presentation

of the cost of sedation. She also wanted to be able to receive regular dental treatment. Ms. X

worked hard at practicing her coping skills at home and using them during treatment. Although

she needed reminders to breathe deeply at first, she began doing this more on her own as

treatment went on. Also, as she was able to successfully manage her anxiety during more and

more procedures, her confidence grew, and she felt better about how her oral health was

improving. Ms. X is now focused on regular maintenance appointments and maintaining her

improved oral health.

       Alternative strategies - "Plan B.” Some patients, when faced with a large treatment

plan, become overwhelmed and do not return to begin treatment. While Ms. X was initially

hesitant to begin behavioral anxiety management, she agreed to try. Had she been unwilling to

do so, an option may have been to use less expensive sedative options than conscious sedation,

such as oral sedatives and/or nitrous oxide, to complete the more invasive work before using

more behavioral techniques to complete the more minor procedures. One risk of this option,

however, is that Ms. X may have attributed her success to the medication instead of her own

coping abilities. For Ms. X, then, the behavioral techniques appeared to be the most successful

approach.




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