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1 Saudi Commission for Health Specialties (SCHS) SAUDI BOARD IN PEDIATRIC DENTISTRY PROGRAM (SB-PD)
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Saudi Commission for Health Specialties (SCHS)

SAUDI BOARD IN PEDIATRIC DENTISTRY PROGRAM

(SB-PD)

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TABLE OF CONTENTS Message from the Chairman, Saudi Board in Pediatric Dentistry ……….3 Contributors…………………………………………………………………………………… 4 I. Purpose ……………………………………………………………………………………….5 II. Resident’s Instructions….……………………………………………………………..6 III. Submission Process………………………………………………………..………….11 IV. Categories of Cases …………………………………………………….…………..…13 Category 1……………………………………………………….……………………………...13 Category 2…………………………………………………………….………………………...14 Category 3………………………………………………………….…………………………...16 Category 4…………………………………………………………………………….………...21 Category 5…………………………………….......…………………………….24 Category 6…………………………………………………………………..…..26 V. Summary of Evaluation for the Case Documentation’s Minimum Requirements per Category…………………………...…………………..…28 VI. Case Review Worksheet/Evaluation per Category………………………32 VII. Patient Record Content Requirements …………………………….....54 VIII. Final Evaluation for the Case Review Section………………….…...63 IX. Questions…………………………………………….………………….….63 Appendix A Certificate of Originality………………………………………..…….64 Appendix B Sample of Case Review Presentation Documentation……65 Category 6 (Restorative Therapy without Use of Sedation or General Anesthesia)

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MESSAGE FROM THE CHAIRMAN, SAUDI BOARD IN PEDIATRIC DENTISTRY (SB-PD)

Dear Residents: I would like to welcome you for the Saudi Board in Pediatric Dentistry (SB-

PD) of the Saudi Commission for Health Specialties (SCHS). Thank you for

choosing to have the training for specializing in pediatric dentistry. Pediatric dentistry aims to improve oral health in children and encourage

the highest standards of clinical care. The protection and oral health of

pediatrics are the responsibility of the entire dental pediatric profession.

Thus, we advocate to work towards developing and continue educating

competent pediatric dentists through an extensive review and clinical

examination of their cases. Thus, the objective in developing this manual is to provide guidance to

residents on the bit-by-bit process of preparing the Comprehensive Case

Presentations – its documentations and format to pass the Evaluation

Criteria. In closing, I would like to express my sincerest thanks to the people who

helped me and supported in coming up this manual – from the Scientific

Committee to the Local Supervisory Committee, and to the administrative

assistants. To the residents, my best wishes for all of you and good luck for

a successful training years. Keep up the hard work for an excellent quality

profession ahead.

Salem Alkahtani, BDS, MSc, DABP, FAAPD, FICD Co Chairman, Saudi Board in Pediatric Dentistry

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Contributors to the Clinical Case Review Section Handbook Dr. Ali Al-Ehaideb

Dr. Salem Alkahtani

Prof. Najlaa Alamoudi

Dr. Manal Al-Malik

Dr. Emad Al-Badawi

Dr. Ghadah Malki

Prof. Abdullah Al-Mushayt

Prof. Omar El Meligy

Dr. Sulaiman Al-Tamimi

Dr. Aziza Aljohar

Dr. Fares Al-Sehaibany

Dr. Amal Al Shedoukhi

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I. PURPOSE Case review provides each resident the opportunity to demonstrate and

document proficiency in the diagnosis and treatment documentation of a

broad range of clinical problems common to the contemporary practice of

pediatric dentistry. The clinical judgment and skills demonstrated in the

cases selected by the resident must be of a standard expected from a

pediatric dentist who aspires to be in a consultant status. Thus, Case Review enables the resident to document sustained successful

treatment results that are of high quality, and demonstrate an ability to

assess the physical and psychological health of the pediatric patient. In addition, this enables the resident to demonstrate an excellent records

system.

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II. RESIDENT’S INSTRUCTIONS Specific instructions to be used in preparing for the Case Review Section

are enumerated below:

1.The Saudi Board in Pediatric Dentistry (SB-PD) endorses the American

Academy of Pediatric Dentistry‘s (AAPD) Guidelines and Quality Assurance

Criteria. The resident should be familiar with these guidelines and criteria

and follow them in the treatment of each child represented in each case. 2.The Case Review Section requires submission of five (5) having 2

categories for R1 and R2 and 10 cases with 3 categories for R3 and R4 fully

documented cases for each academic year in different sub-categories of

pediatric dental patient care documented with specific criteria for

presentation (for a total of thirty (30) cases for the whole program). 3. Each case should have a registration number (Code No.) composed of:

3.1 Resident’s SCHS Number e.g. 123456

3.2 Resident’s Level when the case was started e.g. R1 3.3 Month & Year when the case was completed e.g. December 2008 3.4 Case Category/Sub-Category e.g. Trauma in Primary Teeth is 1A 3.5 Case Number out of the 10 cases submitted as part of his/her clinical

requirement at the end of each level e.g. 4th case Therefore the Code No.is written as: 123456-R1-1208-1A-04

4. Each case should have a verification form (see Appendix A as an

example) signed by the resident stating that he/she is the treating dentist and he/she will be held responsible of any misleading information.

5. Each case must represent not only the resident’s best effort but also a

successful outcome. Case selection is critical to success, as the fulfillment of

every requirement is mandatory. Omission of any one of the required items

for a particular case will result in a failure for that case.

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6. Each of the 40 cases must demonstrate comprehensive care and treatment of all patient needs. Providing limited care is not acceptable and is grounds for failure. Since the complete patient treatment record must be submitted, each case will be evaluated for comprehensive patient care, using the AAPD’s Guidelines and Quality Assurance Criteria. All comprehensive care must have been completed by the resident. For example, the case of a child treated for a periodontal problem must also include treatment by the resident for other needs of the patient, such as trauma treatment, restorative care and/or orthodontic treatment. Likewise, if a trauma case is selected, the preventive program, restorative care and orthodontic evaluation provided by the resident will also be assessed. Each patient record must include the content requirements as outlined in this booklet for each area of care rendered to the patient.

7. Delivery of comprehensive care required of the resident includes management of the orthodontic needs of the child. In the case of a complex malocclusion, the orthodontic management may involve the timely and appropriate referral to a consulting orthodontist. The case presentation and patient record should document the resident’s recognition of the malocclusion problem and provide a summary plan for orthodontic management. The exception to the orthodontic referral option is the submission of a Category 3 Case – Active Treatment of a Malocclusion. This category of case must be managed solely by the resident to meet the submission content requirement.

8. The case reviews must be developed only from patients treated by the resident.

9. Residents are required to submit a complete case documentation requirements (see Appendix B as an example of complete documentation for case presentation) of each case, which include:

9.1 Case Review Summary (MS Word format) 9.2 Photocopy of the original patient record 9.3 Typed copy of the patient record (MS Word format) 9.4 Required radiographic/photographic/study model documentation

The case documentation requirements are designed to allow assessment of the case criteria and comprehensive care aspects of diagnosis and treatment related to:

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9.5 A complete medical, dental, and social history with implications to dental treatment. 9.6 Complete examination findings to include facial patterns, intra-oral assessment of hard and soft tissues, functional occlusion, habits, oral hygiene patterns, behavior, and consultations. 9.7 Radiographs as appropriate for comprehensive care to include periodic bitewings. Full mouth assessment with panoramic radiographic or full mouth periapical survey required in mixed dentition patients. 9.8 Complete treatment plan, appropriate informed consent, progress notes per guidelines and complete records demonstrating comprehensive care. 9.9 Documentation of future treatment needs if not addressed currently. 9.10 Comprehensive carefully provided by the resident including prevention, growth and development assessment, restorative and other current identified needs.

10. The case review summary must follow a specific presentation format for each of the individual submitted case categories. The basic presentation outline would be:

10.1 Medical and Dental History 10.2 Clinical Assessment Findings 10.3 Radiographic Assessment Findings 10.4 Case Diagnosis Summary and Treatment Rationale 10.5 Treatment Objectives/Treatment Plan 10.6 Treatment Rendered 10.7 Preventive Program/Recalls 10.8 Results of Treatment: Resident Assessment 11. Each case submission must include a copy of the original complete treatment record. Each case must have a copy of the patient record in MS Word format. This patient record must be the same as that used by the resident in daily practice, including medical and dental history forms, initial and periodic clinical examination findings, sequenced treatment plans, patient progress note entries of treatment rendered, consultation with parents and other professionals, signed consent forms, and any other details of care provided to the patient by the resident. The resident must include a legend for the interpretation of each patient record when unique or unusual abbreviations and symbols are used in the recording of notes.

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12. Diagnostic radiographs are required for the case submission related to specific case criteria and for assessment of comprehensive care. If original radiographs are submitted, the resident should retain copies of the original radiographs. If duplicates are submitted, they must be adequately imaged for assessment as to diagnostic findings. All radiographs must be mounted in chronological order, dated, and labeled as to treatment stage (e.g. pretreatment, progress, recall, post-treatment). The radiographs must be mounted on clear acetate sheets or in a punch-out mount, which is in turn placed in clear sheet protectors. Digital obtained radiographs are acceptable. 13. The required photographs must be diagnostic, high resolution, and colored. The photographs must be presented in chronological order, dated, and labeled as to the stage of treatment (e.g. pretreatment, progress, recall, post-treatment). 14. All case documentation should be clearly and neatly labeled including the date when obtained. Case documentations should be completely filled out including name of patients, and most importantly, the residents should sign the documents as well as the supervisor of the institution. Any documents which lack the signature of the supervisor will be rejected.

15. Resident should be familiar and cautious with critical errors which could cause significant harm to the health and well-being of the patient and which demonstrate a lack of understanding of the most important aspects of patient health care. Committing of any critical error may result in failure of clinical section. The following represent examples of critical errors, but are not limited those listed below:

15.1 Failure by the candidate to provide and document comprehensive oral health care for the patient, i.e. providing limited care only is not acceptable. 15.2 Failure to have a medical history or to note any abnormalities. 15.3 Failure to note previous dental experience of child and any unusual treatment that had been rendered. 15.4 Failure to consult with other health care providers such as physicians, pediatricians, cardiologists, psychologists, etc. when the medical history indicates such a treatment conference should be obtained prior to planning and rendering surgical, periodontal or restorative care. 15.5 Failure to record abnormalities that appear on the radiographs. 15.6 Radiographs that are elongated, foreshortened or cone cut

compromising diagnostic value. Periapical radiographs that do not show

root ends and surrounding bone clearly. Bitewing radiographs that have

overlapping contacts of the teeth and radiographs with blurred images.

Recall Bitewing or Periapical radiograph with space maintainer.

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15.7 Radiographs that are too light, too dark or have no contrast. Radiographs that are chemically stained. 15.8 Taking too many radiographs in an attempt to be thorough. Example: complete mouth periapical radiographs and a panoramic radiograph for comprehensive restorative case. Submitting a cephalogram in a case involving a simple posterior cross bite in the primary dentition. 15.9 Failure to submit proper radiographs according to AAPD guidelines. Example: no cephalogram for orthodontic case in which serial extraction was performed. 15.10 Failure to have a plan of treatment for each case. 15.11 Failure to document the preventive program that was used. Failure to note the results of preventive program. No attempt to provide nutrition or diet counseling to parents and child. No attempt to maintain plaque control procedures. No toothbrush or flossing instructions. Failure to provide patient with optimal fluoride therapy. 15.12 Failure to evaluate and record the condition of the periodontal tissues (Periodontal screening and recording/PSR). 15.13 Eliminating the gingival floor or failing to break contact with adjacent teeth in a Class II preparation. Excessive flare of proximal outline. Creating a pulp exposure or excessive destruction of tooth structure during cavity preparation of an incipient lesion. Amalgam or composite flash overlying cavo-surface margin. Absence of proximal contact when applicable. Amalgam or compose overhang at gingival wall. Improper proximal contour of restoration. 15.14 Unsuccessful pulp therapy evidenced by periapical pathology which increased or remained the same on the last available post-treatment film; internal or external resorption present on the post treatment film; or a soft tissue abscess, associated with the tooth, present at the 6-24 months post treatment evaluation. 15.15 Performing a pulpotomy when another procedure such as indirect pulp therapy should be considered. Improper indication for pulpotomy such as periapical pathology. 15.16 Over-extending the cervical margins of the crown. Improper adaptation of crown at the cervical margin. Opening the bite with cemented crown. Failure to remove the cement from the gingival sulcus. Inadequate contact with proximal teeth when applicable. Marring the surface of an adjacent tooth during preparation. Failure to use a stainless steel crown on a posterior tooth that has had a pulpotomy or pulpectomy.

15.17 Failure to submit proper casts of high quality and good detail. Casts must be trimmed, finished and labeled correctly. Failure to submit proper records for the type of interceptive orthodontic cases that has been treated. Example: no arch length analysis or cephalogram for a serial extraction case. Performing treatment without justification. Lack of clearly defined treatment plan. Absence of progress notes in write-up.

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15.19 Failure to submit proper document as per case category e.g consents/ records of General Anesthesia /Sedation, etc. 16. All cases to be submitted must be in a Soft copy (CD of the case presentation in MS Power Point and the full detailed text in MS Word). CDs should be labeled with resident’s name, level, SCHS #, and the date of submission.

III. SUBMISSION PROCESS Timing and other instructions for the submissions of cases for review are

written below as guide for residents:

1. R1 and R2 residents should submit five (5) cases with 2 categories,

while R3 and R4 should submit (10) cases with 3 categories. All Residents

should submit comprehensive cases following the guidelines for complete

case documentation requirements, for review of the Local Supervisory

Committee (LSC) of the region every academic year.

2. A total of thirty (30) registered, documented comprehensive cases are to

be submitted and reviewed for the four-year program.

3. The LSC will review the cases every academic year and inform the

residents in case of lack of documentation or rejection of cases.

4. The resident will have the chance to complete the documentations or

submit another case in lieu of the rejected case on the deadline set by the

LSC.

5. The R1 & R2 resident will choose one (1) case from the 5 submitted

cases and R3 and R4 will choose two (2) cases from the 10 submitted cases

every academic year to be utilized for the oral examination before the

Examination Committee of the region.

6. The resident should submit ten (10) cases on the 4th quarter of their

2nd year, for the evaluation of the Program’s Examination Committee. At

least 60% of the submitted cases should receive a satisfactory grade as part

of the promotion requirements to the 3rd level. Otherwise, the resident will

repeat the 2nd year and his/her clinical training will be considered as

incomplete, as the decision of the Program’s Examination Committee is

final.

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7. During the 4th year of the resident, it is the option of the resident to

submit to the Program’s Examination Committee all or part of the 30

registered clinical cases for an initial review and comments on or before the

end of the 1st quarter of the Academic Year. Twenty (20) out of the 30 cases

are the cases submitted during the R1, R2, and R3. If there are rejected

cases, then the resident could submit a replacement; for cases subject to be

rejected for re-submission, the resident could re-submit the case with the

required modification(s) and/or documentation(s). The resident should

take all the risk if he/she opts not to submit the 30 registered clinical cases

for review.

8. On the 4th quarter of the 4th year of the resident, he/she should submit

30 documented comprehensive care cases in different categories and sub-

categories to the Program’s Examination Committee for evaluation. All

the 30 cases, which are equivalent to 100% of the cases, should be

evaluated at least with satisfactory level in order for the resident to pass

the clinical assessment of the 4th year. Otherwise, the resident will repeat

the 4th year and his/her clinical training will be considered as incomplete,

as the decision of the Program’s Examination Committee is final.

9. The resident could appeal or resubmit the rejected or subject for

rejection case(s) during the allowable period, at his/her own risk since the

final acceptance/evaluation of the 10cases during the 2nd year and 30

cases during the completion of the Program is the decision of the Program’s

Examination Committee which is deemed to be final. The evaluation of the

LSC in the region for the cases of each academic year is considered as

guidance for the resident.

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IV. CATEGORIES OF CASES

Requirements for the categories and sub-categories of the thirty (30) cases are outlined below. Omission of any one of the required items for a particular case will result in a failure for that case. Fulfillment of the requirements for the case reviews, however, does not ensure success for a resident, as the quality of treatment and the quality of the records are also important. Attention to detail in preparing and submitting cases is absolutely necessary for the residents to pass this section. The resident must choose the 30 cases, from the six (6) case categories and

their sub-categories enumerated below for the clinical assessment part:

1. Trauma 2. Periodontal Therapy 3. Active Treatment of a Malocclusion 4. Restorative Therapy Using Sedation or General Anesthesia 5. Restorative Therapy for a Child with Special Health Care Needs 6. Restorative Therapy for a Child without Use of Sedation or General

Anesthesia CATEGORY 1: Comprehensive Care of a Pediatric Patient with Emphasis

on Dental Trauma

The resident may present a patient requiring treatment of a dental trauma condition from one of four different types or sub-categories of dental trauma:

1. Case 1A– Coronal Fracture of a Permanent Incisor Involving Enamel or Dentine with or without Pulp Involvement

2. Case 1B – Complete Avulsion of Permanent Incisor, Treated with Replantation

3. Case 1C– Root Fracture of a Permanent Incisor 4. Case 1D– Crown Fracture or Luxation Injury of Primary Incisor

Involving Pulp Therapy

Permanent Incisor: Traumatic injury of a permanent incisor must involve either singly or in combination of a coronal crown fracture involving the enamel and dentin (Case 1A), a complete traumatic avulsion (Case 1B), or a root fracture (Case 1C). The documentation of the permanent incisor trauma must include a preoperative radiograph of the affected area that clearly shows the entire tooth structure and adjacent alveolar area. If a root fracture is involved, the preoperative radiograph must clearly demonstrate the area of root fracture. Preoperative intra-oral photographs of the area of trauma are required at the initial trauma examination and following the initial trauma treatment.

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If a pulp exposure is involved in the trauma, a direct pulp cap or Cvek pulpotomy is acceptable as the definitive pulp therapy. If an apexification procedure was used, the tooth must be treated to a complete final fill with gutta percha or MTA. If a root canal is required, the final fill with gutta percha or MTA, must be performed by the resident. For avulsions, root fractures, and/or luxation injury, the splinting procedures must be documented. Treatment results of successful therapy must be documented at least 9 to 12 months after the completion of treatment with post-treatment radiographs duplicating the imaging of the area of trauma and an intra-oral photograph of the successfully treated tooth.

Primary Incisor: A crown fracture involving the pulp or a luxation injury of a primary incisor, which required a pulpectomy, may be presented as Case 1D. The primary incisor trauma must be documented with preoperative radiographs of the affected area, which clearly shows the entire tooth structure, and adjacent alveolar area. A preoperative intra-oral photograph of the area of trauma is required for Case 1D. Results of successful therapy must show retention of the traumatized primary incisor at least 9 to 12 months after the completion of treatment. Documentation must include post-treatment radiographs duplicating the imaging of the area of trauma and an intra-oral photograph of the successfully treated tooth.

CATEGORY 2: Comprehensive Care of a Pediatric Patient with Emphasis on Periodontal Therapy The resident may present a patient requiring treatment of a periodontal condition from one of five different types or sub-categories of periodontal management. Regardless of sub-category selected, the resident must provide all direct patient treatment procedures involved in the periodontal soft tissue management. Consultation with a periodontist is acceptable in diagnostic and planning stages, but the actual treatment interventions must be performed by the resident. Comprehensive pediatric dental care must also be provided by the resident in documentation of the case. The sub-categories for this category are:

1. Case 2A– Treatment of Generalized or Localized Aggressive Periodontitis 2. Case 2B– Surgical Correction of a Muco-gingival Defect 3. Case 2C– Treatment of Acute Necrotizing Ulcerative Gingivitis

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4. Case 2D– Surgical Management of a Labial or Lingual Frenum • Option 1: Surgical Management of Frena • Option 2: Surgical Management of Restrictive Lingual Frenum 5. Case 2E– Surgical Management of Fibrous Gingival Hyperplasia

Case 2A – Treatment of Aggressive Periodontitis: Treatment rendered for generalized or localized juvenile (prepubertal) periodontitis must be documented with complete mouth pre- and post-treatment periapical and bitewing radiographs supported by complete periodontal mouth probings. A complete intra-oral photographic series to include anterior, right and left lateral views in occlusion, and maxillary and mandibular full arch views of all erupted teeth must be provided for both pre- and post-treatment stages. A minimum of six (6) months follow-up documentation after the completed treatment phase is required for presentation.

Case 2B - Surgical Correction of a Muco-gingival Defect: Surgical correction of a mucogingival defect properly diagnosed and treated in the mixed dentition requires documentation with pre-treatment and post-treatment periapical radiographs of the defected area. Intra-oral photographs of the site must be provided which clearly show the pre-treatment defect and the post-surgical soft tissues. Pre- and post-treatment periodontal probings of the defected area must be documented. The post-treatment radiographs, photographs, and periodontal probings must be obtained at a minimum of 6 months after the completed surgical treatment.

Case 2C - Treatment of Acute Necrotizing Ulcerative Gingivitis: Treatment rendered for Acute Necrotizing Ulcerative Gingivitis (ANUG) must be documented with complete pre-treatment and post-treatment periapical and bitewing radiographs supported by complete periodontal mouth probings. Complete intra-oral photographic series to include anterior view in occlusion, lateral views of the right and left sides in occlusion, and maxillary and mandibular full arch views of all erupted teeth must be provided for both the pre-treatment and post-treatment stages. A complete description of all therapy instituted must be included. A minimum follow-up of 6 months after the completed treatment phase with documentation as described is required for presentation.

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Case 2D – Surgical Management of Labial or Lingual Frenum: Option 1:Surgical correction of prominent maxillary or mandibular frenum

in the pediatric patient must be documented with pretreatment radiographs and intra-oral photographs of the site. Pre-treatment documentation must clearly show the defect

and the need for surgery. Post-treatment documentation must include radiographs and intra-oral photographs of the frenectomy site clearly showing successful treatment results as to soft tissue health and proper dentitional alignment. The post-treatment documentation must be at a minimum of 6 months after the completed treatment.

Option 2:Surgical correction of a restrictive lingual frenum in the pediatric patient must be documented with intraoral photographs of the site, report from physician or allied health professional of the feeding or speech problems, and a request for surgical correction. Post-treatment documentation must include intraoral photographs of the surgical site and documentation of improved function from the referring health professional.

Case 2E - Surgical Management of Fibrous Gingival Hyperplasia: Surgical correction of either localized or generalized fibrous gingival hyperplasia must be documented with pre-treatment and post-treatment periapical radiographs of the involved areas. Intra-oral photographs must be provided which clearly show the pre-treatment and the post-surgical soft tissues. Pre-treatment and post-treatment periodontal probings of the defected area must be documented. The post-treatment radiographs, photographs, and periodontal probings must be obtained at a minimum of 6 months after the completed surgical treatment. CATEGORY 3: Comprehensive Care of a Pediatric Patient with Emphasis on Orthodontic Therapy The management of a malocclusion problem requiring active tooth movement is represented by 2 options or sub-categories involving orthodontic therapy – an interceptive case in the primary or mixed dentition or a comprehensive case treated into the full adolescent permanent dentition. The quality of orthodontic records in any orthodontic case, regardless of complexity level, is critical in

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establishing a sound diagnostic basis for treatments rendered and to assess the outcomes of those treatments. The presentation for either type of orthodontic case submission must include the history and etiology of the problem, the hard and soft tissue findings associated with the orthodontic problem addressed, the analysis of clinical, radiographic, photographic, and diagnostic study model patient records, the treatment plan with rationale and objectives to include appliances used, a description of the actual course of treatment, the plan for retention, and a critique of results achieved in terms of facial, skeletal, dental, and functional relationships. The 2 sub-categories for orthodontic therapy are:

Case 3A – Interceptive Orthodontics Case: Correction of an anterior crossbite, posterior crossbite, or space regaining in the primary or early mixed dentition. Interceptive treatment must restore occlusion development to a normal pattern for the primary or mixed dentition. The interceptive treatment must address a developing malocclusion problem and restore the child’s occlusion to a normal pattern for the primary or mixed dentition. The interceptive procedures may involve the correction of: The interceptive treatment must address a developing malocclusion problem and restore the child’s occlusion to a normal pattern for the primary or mixed dentition. The interceptive procedures may involve the correction of: • A dental anterior crossbite in the primary or mixed dentition; • A posterior crossbite in the primary or mixed dentition; • Ectopic permanent molars in at least one quadrant of the mixed dentition; or,

• Space regaining in at least one quadrant of the mixed dentition. After correction of the developmental problem involving active tooth movements, the assessment of interceptive treatment outcomes must indicate all of the patient’s developmental orthodontic needs have been met and the child’s occlusion reflects normal functional and esthetic patterns for the primary or mixed dentition. In addition, future orthodontic management needs such as the eruption of the remaining teeth and dento-facial growth patterns must have been identified if applicable and plans presented to treat the needs and are addressed for future consideration. The orthodontic records required for presentation of an interceptive type case beyond normal documentation of comprehensive care include: 1. Radiographs- A complete mouth intra-oral radiographic survey or an extra-oral panoramic radiograph with bilateral bitewing radiographs is required for all orthodontic case submissions. Appropriate follow-up radiographs to assess treatment as well as comprehensive pediatric dental care must be provided. A lateral cephalometric radiograph with diagnostic analysis may be required for some interceptive cases to rule out skeletal

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discrepancies. 2. Study Casts- Appropriately trimmed pre- and post-treatment centric occlusion diagnostic study casts. Pretreatment casts must be obtained within 6 months prior to the start of appliance therapy.

Post-treatment study casts must be obtained at the time of removal of active appliance or within 12 months of that date.

3. Intra-oral Color Photographs - Three intra-oral color photographs of the dentition demonstrating a frontal view, right lateral buccal view, and left lateral buccal view in full occlusion obtained before and after the interceptive therapy. Two optional views are occlusal images of the full maxillary and mandibular arches. Pre-treatment photographs must be obtained within six months prior to start of appliance therapy. Post-treatment photos must be obtained at the time of removal of active appliance or within 12 months of that date.

Case 3B – Comprehensive Orthodontic Case: Correction of a complex malocclusion with comprehensive management required into the adolescent permanent dentition with utilization of fixed appliances. Overall treatment may involve multiple phases to include growth modification, but must show final completion into the permanent dentition. Comprehensive orthodontic management involves correction of a complex malocclusion utilizing fixed band-bond appliances into the full adolescent permanent dentition. The overall orthodontic treatment may involve multiple phases to include growth modification and/or a first phase of segmental appliances, but the more complex nature of the presenting malocclusion must be corrected into the full adolescent permanent dentition to include erupted second permanent molars and harmony of the dento-facial structures. Evaluation of the comprehensive results will be based on treatment that:

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• Produces balance and harmony in soft tissue and dentoskeletal proportions; • Maximizes esthetics of the teeth and face; • Achieves bilateral Class I buccal occlusion free of interferences; • Achieves normal overjet and overbite relationships; • Establishes proper dentitional alignment with favorable correction of all rotations, axial inclinations, angulations, and complete space closure. • Coordinates upper and lower arch-forms with optimal function and all teeth aligned within their supporting structures to include the second molars. • Maintains good oral health of teeth, supporting tissues and adjacent structures. • Supports a stable outcome in terms of oral health. • Provides a sound retention plan for maintaining stability of the achieved results. The orthodontic records required for presentation of a comprehensive orthodontic management case beyond the normal documentation of comprehensive care include: 1. Full-mouth Radiographs - A complete mouth intra-oral radiographic survey or an extra-oral panoramic radiograph with bilateral bitewing radiographs is required for all comprehensive orthodontic case submissions at both the pre- and post-treatment stages of therapy. The pretreatment radiographs must be obtained within six months prior to the start of appliance therapy. The post-treatment radiographs must be obtained at the time of active appliance removal or within 12 months of that date. Appropriate progress radiographs to assess multiple phases of treatment as well as comprehensive pediatric dental care must be provided.

2. Lateral Cephalometric Radiographs With Diagnostic Analysis - Lateral cephalometric radiographs with diagnostic tracings are required for all comprehensive orthodontic case submissions at both the pre- and post-treatment stages of therapy. The pretreatment cephalometric radiograph must be obtained within six months prior to start of appliance therapy. The post-treatment cephalometric radiograph must be obtained at the time of active appliance removal or within 12 months of that date. Appropriate progress cephalometric radiographs to assess multiple phases of treatment must be provided if first phase treatments addressed growth modification issues, if significant breaks in treatment occurred or if complications arose which required major treatment planning changes.

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Residents may use any cephalometric analysis they wish provided measurements are based on valid standards and properly assess the relationships of the maxilla to the cranial base, mandible to the cranial base, maxillo-mandibular skeletal relationships, vertical facial growth patterns, maxillary and mandibular dental positions, and soft tissue profile. All cephalometric radiographs must be accurately traced as to anatomical structures, soft tissue profile, landmarks and reference lines.

Tracings may be done by hand using indelible marking pens or can be computer generated. Pretreatment tracings must be accomplished using black marking elements, final tracings using red marking elements. Any progress tracings should be accomplished with blue marking elements. A composite superimposition of the pretreatment and post-treatment tracings using the same colors as the individual tracings and registered on the cranial base is required. All tracings should be enclosed in transparent plastic protectors without backings for superimposition by the examiners.

3. Study Casts- Appropriately trimmed pre- and post-treatment centric

occlusion diagnostic study casts. The pretreatment casts must be obtained

within six months prior to the start of appliance therapy. Post-treatment

study casts must be obtained at the time of removal of active appliance or

within 12 months of that date. Appropriate progress models to assess

multiple phases of orthodontic treatment must be provided if significant

breaks in the phases of treatment or complications occurred which will

require major treatment planning changes.

4. Intra-oral Color Photographs- Three intra-oral color photographs of the

dentition demonstrating a frontal view, right lateral buccal view, and left

lateral buccal view in full occlusion obtained before and after the

interceptive therapy. Two optional views are occlusal images of the full

maxillary and mandibular arches. The pretreatment photographs must be

obtained within six months prior to the start of appliance therapy. The

post-treatment photos must be obtained at the time of removal of active

appliance or within 12 months of that date. Appropriate progress photos to

assess multiple phases of orthodontic treatment must be provided if there

are significant breaks in the phases of treatment or complications arises

which required major treatment planning changes. Refer to the reference

instructions for photographic requirements.

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5. Extra-oral Facial Photographs - Two extra-oral facial photographs in color are required at both the pre- and post-treatment stages of comprehensive orthodontic therapy. The photographs must show a frontal facial view and a lateral profile view oriented to Frankfort Horizontal. The pretreatment extra-oral photographs must be obtained within six months prior to the start of appliance therapy. The post-treatment photos must be obtained at the time of removal of active appliance or within 12 months of that date. Appropriate progress photos to assess multiple phases of orthodontic treatment must be provided if there are significant breaks in the phases of treatment or complications arises which required major treatment planning changes. Refer to the reference instructions for photographic requirements.

CATEGORY 4: Comprehensive Care of a Pediatric Patient with Emphasis on Restorative Therapy Using Sedation or General Anesthesia for Patient Management

The resident may select a patient requiring comprehensive restorative dental treatment in the primary or mixed dentition in which patient behavior was managed using either conscious sedation (Case 4A) or general anesthesia (Case 4B). The case categories are defined by the technique utilized for patient management. The baseline restorative requirements are identical for either type of management case.

Case 4A– Restorative therapy using sedation for patient management and treatment of (3) quadrants or more with interproximal caries and one tooth at least with pulp therapy and stainless steel crown.

Case 4B– Restorative therapy using general anesthesia for patient management and treatment of (3) quadrants or more with interproximal caries and one tooth at least with pulp therapy and stainless steel crown.

Restorative/Radiographic Requirements

In both types of patient management cases, definitive restorative treatment must be performed on extensive carious lesions that involve either:

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1. The proximal surfaces in each of 3 posterior quadrants or; 2. The proximal surfaces in each of 2 posterior quadrants and one or more proximal surfaces in the anterior incisor segment. Regardless of which of the above criteria are met as a baseline for presentation, at least one primary molar must require a pulpotomy or pulpectomy and be restored with a stainless steel crown to qualify for case presentation. The choices of restorative materials for other restorations are at the discretion of the resident, but must restore proximal surface lesions in each of the posterior quadrants or anterior segment presented for evaluation. All restorations must be documented in the patient chart as to material chosen and surfaces restored. Preoperative radiographs must include bitewing films, which clearly show the inter-proximal surfaces of all erupted posterior teeth. If the bitewing films do not clearly show the periapical areas of cariously involved primary teeth with potential for pulp pathology, then periapical films of these teeth must be provided to meet diagnostic needs. If the child is in the primary dentition and the primary incisors and/or primary canines are involved with caries or a history of trauma, occlusal radiographs of the involved area are required. If any permanent teeth have erupted, periapical/occlusal films of the anterior segments and/or a panoramic radiograph must be included to assess the development of the dentition in addition to the required bitewing films. The pre-treatment radiographs must be obtained within six months prior to the initiation of restorative care. Post-operative radiographs documenting the restorative procedures performed must be obtained at a minimum of 6 months and no more than 24 months after completion of all treatment. The post-operative films must include bitewing films, which clearly show the inter-proximal surfaces of all erupted posterior teeth. If the bitewing films do not clearly show the periapical areas of pulpally treated teeth, then separate periapical films of these – teeth must be provided to meet diagnostic needs. If anterior teeth were restored in the initial phase of treatment, the final restorations must be similarly documented with appropriate radiographs. If the child was initially treated while in the primary dentition and permanent teeth have subsequently erupted, periapical/occlusal films of the anterior segments and/or a panoramic radiograph must be included to assess the development of the dentition in addition to the required bitewing films. The resident is reminded that comprehensive care to include prevention, monitoring of the developing occlusion, and other identified pediatric oral health needs are the responsibility of the presenting clinician.

Patient Management Requirements

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The case categories are defined by the patient management technique as follows: Case 4A:The conscious sedation must involve enteral or parenteral administration to manage the child. Inhalation sedation alone will not be admissible. The administration of the chosen sedation regimen must adhere to procedures with full monitoring per the current AAPD guidelines, Guidelines for the Elective Use of Minimal, Moderate, and Deep Sedation, and General Anesthesia for Pediatric Dental Patients. A copy of a time-based sedation record must be included in the patient chart. The patient and sedation record must include documentation of: Case Review Section Guidelines

• Rationale for using conscious sedation in behavior management. Informed parental consent.

• Pre- and post-sedation instructions to parents. • Dietary precautions, NPO status. • Preoperative health and airway assessment. • Patient age and weight. • Sedative agents, route of administration, dosage administered. • Local anesthetics administered - type, concentration, amount and

location of anesthetic deposition. • Time-based sedation record with monitoring of vital signs through

length of procedure. • Response to medications, effectiveness of sedation. • Use of supplemental behavior management techniques. • Patient status upon dismissal / instructions to parents. • Any complications.

Case 4B:The general anesthesia protocols must adhere to procedures per the current AAPD Guidelines, Guidelines for the Elective Use of Minimal, Moderate, and Deep Sedation, and General Anesthesia for Pediatric Dental Patients. A copy of the surgical/operative report must be included in the patient chart. The record of a case treated under general anesthesia must include documentation of:

Rationale for using general anesthesia in behavior management. Informed parental consent. Pre- and post-operative instructions to parents. Dietary precautions, NPO status. Documentation of preoperative physical examination. Patient age and weight.

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Copy of the preoperative dental treatment plan. Copy of hospital/ambulatory center consent for general anesthesia. Copy of anesthesia record. Copy of the operative report. Preoperative and/or intra-operative radiographs. Patient status upon dismissal/instructions to parents. Any intra-operative and/or postoperative complications. Documentation of dental procedures accomplished e.g. teeth restored, surfaces, and restorative materials. Documentation of preventive oral health counseling. CATEGORY 5: Comprehensive Care of a Pediatric Patient with Emphasis on Restorative Therapy for a Child with Special Health Care Needs This is a comprehensive restorative care for a child presenting medical, physical and/or mental disabilities, which require special management to accomplish comprehensive dental care. A letter from the primary physician or photocopy of the medical record describing the disability must be provided. Management may involve use of conscious sedation, general anesthesia or non-pharmacological behavior techniques to accomplish the dental treatment. Inter-proximal caries must be restored in two sextants or more with at least one primary tooth requiring pulpotomy or pulpectomy.

Examples of medical, physical or developmental disabilities, which would qualify as to special needs, would include a child with: • A cleft lip and cleft palate • Advanced syndromic craniofacial anomalies (e.g. Treacher-Collins,

Crouzon’s) • Moderate to severe mental retardation • Moderate to severe cerebral palsy • Autism • A legally defined sight or hearing deficit • Down syndrome • Cyanotic cardiac anomalies • Hemophilia • A pediatric malignancy requiring chemotherapy and/or radiation

therapy • A history of organ transplantation • Sickle Cell Disease • Severe juvenile arthritis • Amelogenesis or dentinogenesis imperfecta

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These serve as examples of case types, which would typically require patient management or treatment planning modifications in delivery of comprehensive pediatric dental care. There are other conditions, which would qualify by meeting the special needs criteria. The special needs patient must present inter-proximal caries requiring definitive restoration of at least two teeth. The inter-proximal restored teeth must be from at least two separate posterior quadrants or from one posterior quadrant and one anterior incisor segment. At least one primary tooth must be treated with a pulpotomy or pulpectomy. The choices of restorative materials are at the discretion of the resident, but must restore proximal surface lesions in each of the restorative segment presented for evaluation. All restorations must be documented in the patient chart as to material chosen and surfaces restored. The patient’s management may involve use of non-pharmacological behavior techniques, conscious sedation, or general anesthesia to accomplish the dental treatment. If conscious sedation or general anesthesia is used, the resident should review the sedation/general anesthesia documentation requirements for Case 4 (Restorative care for a patient using sedation/general anesthesia). The documentation for Case 5 (if sedation/general anesthesia is used) must include the documentation relating to this adjunctive therapy. Preoperative radiographs must include bitewing films, which clearly show the inter-proximal surfaces of all erupted posterior teeth. If the bitewing films do not clearly show the periapical areas of cariously involved primary teeth with potential for pulp pathology, then periapical films of these teeth must be provided to meet diagnostic needs. If the child is in the primary dentition and the primary incisors and/or primary canines are involved with caries or a history of trauma, occlusal radiographs of the involved area are required. If any permanent teeth have erupted, periapical/occlusal films of the anterior segments and/or a panoramic radiograph must be included to assess the development of the dentition in addition to the required bitewing films. The pretreatment radiographs must be obtained within six months prior to the initiation of restorative care. Post-operative radiographs documenting the restorative procedures performed must be obtained at a minimum of six months and no more than 24 months after completion of all treatment. The post-operative films must include bitewing films, which clearly show the inter-proximal surfaces of all erupted posterior teeth. If the bitewing films do not clearly show the periapical areas of any pulpally treated teeth, then separate periapical films of these teeth must be provided to meet diagnostic needs. If anterior teeth were restored in the initial phase of treatment, If the child was initially treated while in the primary dentition and permanent teeth have subsequently erupted, periapical/occlusal films of the anterior segments and/or a panoramic radiograph must be included to assess the development of the dentition in addition to the required bitewing

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films. The resident is reminded that comprehensive care to include prevention, monitoring of the developing occlusion, and other identified pediatric oral health needs are the responsibility of the presenting clinician. CATEGORY 6: Comprehensive Care of a Pediatric Patient with Emphasis on Restorative Therapy for a Child without Use of Sedation or General Anesthesia

The resident may present a patient requiring comprehensive restorative care in the primary or mixed dentition who was managed without the use of either conscious sedation or general anesthesia. The use of nitrous oxide/oxygen inhalation is acceptable. The child’s behavior must be assessed and documented throughout treatment.

To meet baseline restorative criteria, the patient must require definitive restorative treatment of extensive carious lesions involving:

1. The proximal surfaces in each of 3 posterior quadrants or; 2. The proximal surfaces in each of 2 posterior quadrants and one or more proximal surfaces in the anterior incisor segment. Regardless of which of the above restorative needs criteria are met as a baseline for presentation, at least one primary molar must require a pulpotomy or pulpectomy and be restored with a stainless steel crown to qualify for case presentation. The choices of restorative materials for other restorations are at the discretion of the resident, but proximal surface lesions must be restored in each of the posterior quadrants or anterior segment presented for evaluation. All restorations must be documented in the patient chart as to material chosen and surfaces restored. Oral hygiene instructions to the child and parent with the proposed prevention program must be documented to include assessment of fluoride needs.

Preoperative radiographs must include bitewing films, which clearly show the inter-proximal surfaces of all erupted posterior teeth. If the bitewing films do not clearly show the periapical areas of cariously involved primary teeth with potential for pulp pathology, then periapical films of these teeth must be provided to meet diagnostic needs. If the child is in the primary dentition and the primary incisors and/or primary canines are involved with caries or a history of trauma, occlusal radiographs of the involved area are required. If any permanent teeth have erupted, periapical/occlusal films of the anterior segments and/or a panoramic radiograph must be included to assess the development of the dentition in addition to the required bitewing films. The pretreatment radiographs must be obtained within six months prior to the initiation of restorative care. Post-operative

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radiographs documenting the restorative procedures performed must be obtained at a minimum of six months and no more than 24 months after completion of all treatment. The post-operative films must include bitewing films, which clearly show the inter-proximal surfaces of all erupted posterior teeth. If the bitewing films do not clearly show the periapical areas of pulpally treated teeth, then separate periapical films of these teeth must be provided to meet diagnostic needs. If anterior teeth were restored in the initial phase of treatment, the final restorations must be similarly documented with appropriate radiographs. If the child was initially treated while in the primary dentition and permanent teeth have subsequently erupted, periapical/occlusal films of the anterior segments and/or a panoramic radiograph must be included to assess the development of the dentition in addition to the required bitewing films. The resident is reminded that comprehensive care to include prevention, monitoring of the developing occlusion, and other identified pediatric oral health needs are the responsibility of the presenting clinician.

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V. SUMMARY OF EVALUATION FOR THE CASE DOCUMENTATION’S MINIMUM REQUIREMENTS

PER CATEGORY:

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Category 6-Evaluation of Restorative Therapy For a Child Without Use of Sedation or General

Anesthesia

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VI. CASE REVIEW WORKSHEET/EVALUATION

PER CATEGORY This section will serve as a guide of information or checklist for the residents on the requirements per category that they have to meet before the case can be evaluated, followed by the case review evaluation, so that residents will be guided accordingly.

CASE REVIEW EVALUATION WORKSHEET 1

Case 1. Comprehensive Care of a Pediatric Patient with Emphasis on Dental Trauma ___________ 1. A completed medical and dental history ___________2. Radiographs must be diagnostic and clearly show the periapical

area of the involved tooth. ___________ 3. Radiographs as appropriate for comprehensive care. ___________ 4. Description of pulp therapy and trauma record. ___________ 5. Minimum of 9 – 12 months post-treatment radiograph showing

clearly the periapical area plus bitewings. ___________6.Minimum of 9 – 12 months post-treatment intra-oral

photograph of area of trauma. ___________ 7. Treatment plan and progress notes include a description of the

trauma and complete records demonstrating comprehensive care.

___________8. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative and other identified needs.

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Case 1. Comprehensive Care of a Pediatric Patient with Emphasis on Dental Trauma

Resident’s SCHS No. ______________________ Examiner: ____________________________

If Primary Tooth (*). If Cvek Pulpot/Pulp Cap (¢) If 2˚ Open Apex (@) If 2˚ Closed Apex (#) 1= Unsatisfactory 2= Below Average

3= Average 4 = Above Average

If 2˚ Necrotic (%) If 2˚ Root Fracture (+) If 2˚ Root Necrotic (?) If 2˚ Closed Apex Avulsed ($) 5 = Outstanding Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

No. Required For

Care

Points

1 2 3 4 5 N/A

1 Medical and Dental history, no contraindication All

2 Medical and dental history content All

3 Clinical condition of patient All

4 Radiographs diagnostic and including apex All

5 Radiographs for comprehensive care All

6 Pulp therapy described All

7 Pulp therapy followed biologic principles including use of antibiotics (if indicated)

All

8 Final fill * @ # $ &% ?

9 Cvek pulpotomy or pulp cap with Ca(OH)2 ¢

10 2˚ open apex, necrotic, Ca(OH)2+ gutta percha (GP) @ %

11 2˚ close apex, avulsed replanted ASAP # $

12 Splinted 7 – 10 days # $

13 Ca(OH)2 fill within 2 wks of avulsion # $

14 GP 1 – 12 months after Ca(OH)2 # $

15 2˚ open apex, avulsed, replanted ASAP &

16 Splinted 7 – 10 days &

17 Monitored and tx’d if necessary &

18 If 2˚ root fracture, segments approx. ASAP + ?

19 Rigid splint 3 – 4 mos. + ?

20 Monitored 3w, 6w, 6 – 12 m + ?

21 If necrotic was tx w/RCT or surgery ?

22 Behavior assessed All

23 Post-op care noted, timing explained All

24 Prognosis described All

25 9 –12 mos. Post-op radiograph include Apex. All

26 9 – 12 mos. Post-op intra-oral photograph All

27 Patient info. complete, including health update All

28 Hard tissue exam All

29 Soft tissue and periodontal exam All

30 Treatment plan All

31 Progress notes All

32 Care comprehensive per guidelines All

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CASE REVIEW EVALUATION WORKSHEET 2-A Case 2A. Treatment of Generalized or Localized Aggressive Periodontitis

___________ 1. A completed medical and dental history

___________ 2. Radiographs as appropriate for comprehensive care.

___________ 3. Complete mouth intra-oral photos per guidelines.

___________ 4. Complete mouth probing.

___________ 5. Minimum of 6 – 12 months post-treatment full mouth photos

and probing, complete mouth periapical and 2 bitewings. ___________6. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

___________7. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 2A. Treatment of Generalized or Localized Aggressive Periodontitis

Resident’s SCHS No. ______________________ Examiner: ____________________________

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CASE REVIEW EVALUATION WORKSHEET 2-B

Case 2B. Surgical Correction of a Muco-gingival Defect

__________ 1. A completed medical and dental history.

__________ 2. Pre-treatment periapical radiographs of the area involved.

__________ 3. Radiographs as appropriate for comprehensive care.

__________ 4. Pre- and post-treatment probing measurements of the defect.

__________ 5. 6 – 12 months post-treatment radiographs.

__________ 6. 6 – 12 months post-treatment intra-oral photo of the surgical

site. __________7. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________8. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 2B. Surgical Correction of a Muco-gingival Defect Resident’s SCHS No. ______________________ Examiner: ___________________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications

2 Medical and dental history content 3 Periapical XR of the area involved 4 Radiographs per guidelines for

compressive care

5 Comprehensive care per guidelines 6 Probing of the defect 7 Photos and XR demonstrate need 8 Objectives and goals defined

9 6 – 12 mos. post-tx XR show evidence of health in affected site

10 6 – 12 mos. post–tx photo shows healthy band of attached gingiva

11 Post-tx excellent OH

12 OI, plaque scores, fluoride

13 Pt. info complete, including health update

14 Hard tissue exam

15 Soft tissue and periodontal exam

16 Treatment Plan

17 Progress Notes

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 2-C Case 2C. Treatment of Acute Necrotizing Ulcerative Gingivitis __________ 1. A completed medical and dental history. __________ 2. Pre-treatment periapical radiographs of involved sites. __________ 3. Radiographs as appropriate for comprehensive care. __________ 4. Complete mouth intra-oral photos per guidelines. __________ 5. Post-treatment probing measurements of the involved sites. __________6. 6 – 12 months post-treatment full mouth photos and

radiographs of involved sites. __________ 7. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care. __________ 8. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative and other identified needs.

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Case 2C. Treatment of Acute Necrotizing Ulcerative Gingivitis

Resident’s SCHS No. _______________________ Examiner: _______________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications

2 Medical and dental history content 3 Periapical XR of the area involved 4 Radiographs per guidelines for

compressive care

5 Comprehensive care per guidelines 6 Complete mouth intra-oral photos 7 Photos and XR demonstrate need 8 Objectives and goals defined Photos show necrotic papillae,

gingivitis

Documentation of bld., pain, fetor oris 9 6 – 12 mos. post-tx FM photos and XR

of involved sites show table bone, post-tx probings show few bleeding pts., pockets stable

11 Post-tx excellent OH 12 OHI, plaque scores, fluoride 13 Pt. info complete, including health

update

14 Hard tissue exam

15 Soft tissue and periodontal exam

16 Treatment Plan

17 Progress Notes

Consultant Name: _________________ Signature: _____________ Date: __________

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

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CASE REVIEW EVALUATION WORKSHEET 2-D

Case 2D. Surgical Management of a Labial or Lingual Frenum

__________ 1. A completed medical and dental history.

__________ 2. Pre-treatment periapical radiographs of involved area.

__________ 3. Radiographs as appropriate for comprehensive care.

__________ 4. Pre-treatment photo of involved area.

__________ 5. 6 – 12 months post-treatment photo.

__________ 6. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________ 7. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 2D. Surgical Management of a Labial or Lingual Frenum Resident’s SCHS No. _____________________ Examiner: ____________________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications

2 Medical and dental history content 3 Periapical XR of involved area 4 Radiographs per guidelines for all care 5 Comprehensive care per guidelines 6 Objectives and goals 7 Photos and XR show frenum causing a

problem

8 6 – 12 mos. post-tx photo shows good tissue mobility and health

9 Post-tx excellent OH 10 OHI, plaque scores, fluoride 11 Pt. info complete, including health

update

12 Hard tissue exam

13 Soft tissue and periodontal exam

14 Treatment Plan

15 Progress Notes

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 2-E Case 2E. Surgical Management of Fibrous Gingival Hyperplasia

__________ 1. A completed medical and dental history.

__________ 2. Pre-operative periapical radiographs of surgical site.

__________ 3. Radiographs as appropriate for comprehensive care.

__________ 4. Complete full-mouth, pre-op intra-oral photos per guidelines.

__________5. 6 – 12 months post-treatment complete mouth intra-oral photos.

__________6. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________7. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 2E. Surgical Management of Fibrous Gingival Hyperplasia Resident’s SCHS No. ____________________ Examiner: ____________________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications

2 Medical and dental history content 3 Pre-op periapical radiographs of surgical

sites

4 Radiographs for comprehensive care

5 Comprehensive care per guidelines

6 Complete mouth intra-oral photo

7 Photos and XR demonstrate need

8 Probing measurements – pre and post treatment

9 Objectives and goals

10 Photos show fibrotic gingival w/o acute gingivitis

11 Gingival interferes with eruption, covers teeth or causes OH problem

12 6 – 12 mos. Post-tx photos show normal gingiva, exposed crown, no inflammation, pockets < 3mm

13 Post-tx excellent OH

14 OHI, plaque scores, fluoride 15 Pt. info complete, including health update 16 Hard tissue exam

17 Soft tissue and periodontal exam

18 Treatment Plan

19 Progress Notes

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 3-A

Case 3A. Comprehensive Care of a Pediatric Patient with Emphasis on

Orthodontic Therapy – Interceptive Orthodontic Case

Type of Category Case submitted: __________ 1. Cross-bite in the primary or early mixed dentition.

__________ 2. Single tooth cross-bite in the mixed dentition.

Requirement: __________ 3. A completed medical and dental history.

__________ 4. Radiographs as appropriate for comprehensive care.

__________ 5. Pre-treatment casts polished in centric occlusion.

__________ 6. Pre-treatment photos (full face, profile, and 3 intra-oral).

__________ 7. Minimum of 9 – 12 months post-treatment casts and photos

(full face, profile, and 3 intra-oral).

__________ 8. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________ 9. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 3A. Comprehensive Care of a Pediatric Patient with Emphasis on

Orthodontic Therapy – Interceptive Orthodontic Case Resident’s SCHS No. ____________ Examiner: ___________Date: _________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications

2 Medical and dental history content 3 Radiographs for comprehensive care

4 Comprehensive care per guidelines

5 Cast polished in CO, bases min. 1”, anatomy

shown clearly

6 Complete mouth intra-oral photo

7 Oral habits have been addressed

8 Medical history, allergies, airway

9 Oral Hygiene addressed

10 Objectives defined

11 Objectives met

12 Progress within expected time frame

13 9 – 12 mos. results stable per photos and

casts, photos must be facial, profile and 3

intraoral

14 Functional and in good occlusion, free of interferences

15 Retention adequate to hold occlusion during growth

16 Follow-up care planned

17 Oral habits eliminated

18 All ortho needs met or identified and planned 19 Pt. info complete, including health update 20 Hard tissue exam

21 Soft tissue and periodontal exam

22 Treatment Plan

23 Progress Notes

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 3-B Case 3B. Comprehensive Care of a Pediatric Patient with Emphasis on

Orthodontic Therapy – Comprehensive Orthodontic Case

__________ 1. A completed medical and dental history.

__________ 2. Radiographs as appropriate for comprehensive care.

__________ 3. Panoramic and cephalometric radiographs for Class II, III, and

banded cases.

__________ 4. Cephalometric analysis.

__________ 5. Pre- and post-treatment casts polished in centric occlusion.

__________ 6. Pre-treatment photos (full face, profile, and 3 intra-oral).

__________ 7. Minimum of 9 – 12 months post-treatment photos (full face and

profile), radiographs (panoramic and cephalometric) and casts.

__________ 8. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________ 9. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 3B. Comprehensive Care of a Pediatric Patient with Emphasis on Orthodontic Therapy – Comprehensive Orthodontic Case

Resident’s SCHS No. _____________ Examiner: _____________Date: _________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications 2 Medical and dental history content 3 Comprehensive care per guidelines 4 Periapical XR of tooth-bearing areas 5 Pano and cephalometric for Class II, III or banded case 6 Ceph shows skull, landmarks clear, profile 7 Pre and post tx tracings accurate 8 Casts polished in CO, bases min. 1” show anatomy clearly 9 Photos show face and profile, and 3 intra-oral 10 Case classified per Angle 11 Ceph analysis accurate 12 Face, age, lips, soft tissue, habits 13 Medical History, Allergies, Airway 14 Perio assessed OH addressed 15 Risks identified 16 Objectives defined and consistent with dx. 17 Objectives obtainable 18 Time table established 19 Objectives met, justification if not 20 Progress within expected time frame 21 3-6 mos. Results stable per photos, XR, casts 22 Functional, good occlusion, free of interferences 23 Esthetics 24 Good facial harmony 25 Good axial inclination 26 Good dental and perio health 27 Retention adeq. to hold occl. during growth 28 Consistent with maintaining perio health 29 Future planned (tooth eruption, growth) 30 Oral habits eliminated 31 All ortho needs met or identified and planned 32 Pt. info complete, including health update 33 Hard tissue exam 34 Soft tissue and periodontal exam 35 Treatment Plan 36 Progress Notes

1 = Unsatisfactory 3 = Average 5 = Outstanding

2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 4

Case 4. Comprehensive Care of a Pediatric Patient with Emphasis on

Restorative Therapy Using Sedation or General Anesthesia for Patient

Management

__________ 1. A completed medical and dental history.

__________ 2. Radiographs as appropriate for comprehensive care.

__________ 3. Pre-treatment periapical radiograph of pulpally involved teeth.

__________ 4. Behavior and sedation/GA record.

__________ 5. Proximal caries have been treated with restorations in 3

sextants.

__________6. 6 – 24 months post-treatment bitewing and periapical

radiographs of teeth receiving pulp therapy.

__________7. All caries have been removed and treated (or justification

provided if not treated with definitive restorations).

__________ 8. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________9. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

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Case 4. Comprehensive Care of a Pediatric Patient with Emphasis on Restorative Therapy Using Sedation or General Anesthesia for Patient Management

Resident’s SCHS No. ___________ Examiner: ________________Date: _______________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications 2 Medical and dental history content 3 Hard tissue exam 4 Soft tissue and periodontal exam 5 Radiographs for comprehensive care 6 Pre and post-tx periapical XR of pulp therapy 7 BW / PA demonstrate interproximal caries in 3 sextants 8 All pathologies noted 9 OHI to child/parent, fluoride assessed and Rx. 10 Plaque quantified, amount present is described 11 Referrals and consults sought, if indicated 12 Treatment plan complete and accurate 13 Future needs identified, if not addressed currently 14 Behavior and sed / GA record 15 Behavior assessed 16 Proximal restorations in 3 post sextants, or 2 posterior +

anterior

17 Pulp therapy successful pre periapical XR 6-9 months. 000Post-tx.

18 No caries identified and tx’d successful per BW’s 6-9 months. Post-tx.

19 Restoration contoured and anatomic 20 Contacts present 21 All caries removed (or justified) 22 Future needs, including ortho, addressed 23 Unusual tx explained 24 Progress Notes Complete

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 5

Case 5. Comprehensive Care of a Pediatric Patient with Emphasis on

Restorative Therapy for a Child with Special Health Care Needs

__________ 1. A completed medical and dental history.

__________ 2. Radiographs as appropriate for comprehensive care.

__________ 3. Pre-treatment periapical radiograph of pulpally involved teeth.

__________ 4. Pre-treatment photos per guidelines.

__________ 5. Behavior assessment.

__________ 6. Proximal caries in 2 sextants have been restored.

__________7. 6 – 24 months post-treatment bitewings and periapical

radiographs of all teeth with pulp therapy.

__________8. All caries have been removed and treated (or justification

provided if not treated with definitive restorations).

__________ 9. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________10. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

__________11. Copy of physician consultation and clearance, prior to dental

treatment.

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Case 5. Comprehensive Care of a Pediatric Patient with Emphasis on Restorative Therapy for a Child with Special Health Care Needs Resident’s SCHS No. ___________ Examiner: _____________Date: _________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications 2 Medical and dental history content 3 Hard tissue examination 4 Soft tissue and periodontal examination 5 Documentation of disability 6 Radiographs for comprehensive care 7 Comprehensive per guidelines 8 Pre and post-tx periapical XR of pulp therapy 9 BW / PA demonstrate interproximal caries in 2 sextants 10 XR good quality 11 All pathologies noted 12 OHI to child/parent, fluoride assessed and Rx. 13 Plaque quantified, amount present is described 14 Referrals and consults sought, if indicated 15 Treatment plan complete and accurate 16 Future needs identified, if not addressed currently 17 Behavior and sed / GA record, if sedation/GA used 18 Behavior assessed 19 2 Proximal restorations in 2 sextants 20 Pulp therapy successful per periapical XR 6-24 months. Post-

tx.

21 No caries identified and tx’d successful per BW’s 6-24 months. Post-tx.

22 Restoration contoured and anatomic 23 Contacts present 24 All caries removed (or justified) 25 Future needs, including ortho, addressed 26 Unusual tx explained 27 Progress Notes Complete

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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CASE REVIEW EVALUATION WORKSHEET 6

Case 6. Comprehensive Care of a Pediatric Patient with Emphasis on

Restorative Therapy for a Child without Use of Sedation or General

Anesthesia

__________ 1. A completed medical and dental history.

__________ 2. Radiographs as appropriate for comprehensive care.

__________ 3. Pre-treatment periapical radiograph of pulpally involved teeth.

__________ 4. Behavior and assessed.

__________5. Proximal caries have been treated with restorations in 3

sextants.

__________ 6. Minimum of 6 – 24 months post-treatment bitewing and

periapical radiographs of teeth receiving pulp therapy.

__________ 7. All caries have been removed and treated (or justification

provided if not treated with definitive restorations).

__________ 8. Treatment plan and progress notes per guidelines and complete

records demonstrating comprehensive care.

__________9. Comprehensive care provided by the resident including

prevention, growth and development assessment, restorative

and other identified needs.

__________ 10. Copy of physician consultation and clearance prior to dental

treatment.

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Case 6. Comprehensive Care of a Pediatric Patient with Emphasis on Restorative Therapy for a Child without Use of Sedation or General Anesthesia Resident’s SCHS No. __________ Examiner: _______________Date: _________________

No.

Points 1 2 3 4 5 N/A

1 Medical and dental history, no contraindications 2 Medical and dental history content 3 Hard tissue exam 4 Soft tissue and periodontal exam 5 Radiographs for comprehensive care 6 Pre and post-tx periapical XR of pulp therapy 7 BW / PA demonstrate interproximal caries in 3 sextants 8 All pathologies noted 9 OHI to child/parent, fluoride assessed and Rx. 10 Plaque quantified, amount present is described 11 Referrals and consultation sought, if indicated 12 Treatment plan complete and accurate 13 Future needs identified, if not addressed currently 14 Behavior assessed at each appointment 15 Proximal restorations in 3 post sextants, or 2 posterior +

anterior

16 Pulp therapy successful per periapical XR 6–24 mos. Post-tx 17 No caries identified and tx’d successful per BW’s 6–24 post-

tx.

18 Restoration contoured and anatomic 19 Contacts present 20 All caries removed (or justified) 21 Future needs, including ortho, addressed 22 Unusual tx explained 23 Progress Notes Complete

1 = Unsatisfactory 3 = Average 5 = Outstanding 2 = Below Average 4 = Above Average Na = Not Applicable

Consultant Name: _________________ Signature: _____________ Date: __________

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VII. PATIENT RECORD CONTENT MINIMUM

REQUIREMENTS

Below is a summary of the required patient record contents that must be

followed for each case submitted:

1. Patient Information

The patient information form must include:

1.1 Name

1.2 Birthdate

1.3 Sex

1.4 Age

1.5 Weight

1.6 Height

1.7 Race

2. Medical History

The information on the medical history must include:

2.1 Current treatment being provided by the physician

2.2 Current medications

2.3 Check list of possible medical programs

2.4 History of hospitalizations

2.5 History of allergies

2.6 History of drug reactions

2.7 History of developmental and behavioral problems

An interpretation should be included in the report of the medical history.

3. Dental History

The dental history must include:

3.1 Previous dental care

3.2 Behavioral response to past dental and medical care

3.3 Chief complaint

3.4 Oral hygiene practices

3.5 Fluoride use and fluoride level in the water

3.6 Oral habits

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3.7 History of headaches, bruxism, TMJ/TMD problems

3.8 Dental trauma

3.9 Parental assessment of child’s anticipated dental behavior

An interpretation has to be included also in the report of the dental history.

4. Health History Update

The current medical and dental health must be reviewed at every periodic

examination of 6 months or longer. It must contain:

4.1 Medical treatment since the last history

4.2 Change in the child’s health status or medications

4.3 Change in fluoride use

4.4 Trauma sustained

4.5 Concern of the parent may have about the child’s dental health

5. Consent Form

This form should have the signature of the patient or the guardian of the

patient.

6. Treatment Plan

Treatment recommended must be planned per sequential visit. It must also

include:

6.1 Treatment alternatives, if applicable

6.2 Timing for referral to other professionals

6.3 Tooth number and surfaces to be treated, pulp therapy anticipated,

restorative procedure and restorative materials to be used

6.4 Behavior management

6.5 Surgical procedures

6.6 Preventive and periodontal therapy

6.7 Orthodontic therapy or considerations

7. Hard Tissue Examination

The systematic clinical and radiographic examination performed during the

initial and periodic evaluation must contain:

7.1 TMJ/TMD evaluation

7.2 Occlusal and orofacial development

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7.3 Pathosis/Anomalies

7.4 Missing and supernumerary teeth, teeth clinically present

7.5 Caries, including incipient lesions

7.6 Existing restorations

7.7 Oral habits

7.8 Dentofacial growth supervision

8. Soft Tissue Examination

The systematic examination performed during the initial and periodic

evaluation must contain:

8.1 Extra and intra-oral pathosis (abnormalities of the attached gingival,

tongue, buccal mucosa, etc.)

8.2 Oral hygiene status and plaque quantification

8.3 Periodontal health and documentation of periodontal disease (PSR)

9. Progress Notes

This section of the record must be typed as it was written in the original

record, in sequence, as the treatment was performed. It must include,

when applicable:

9.1 Date of treatment

9.2 Teeth treated, procedures performed, restorative materials used

including bases, pulp medicaments

9.3 Doctor providing care

9.4 Treatment complications and prognosis

9.5 Radiographs taken

9.6 Local anesthetic – type and concentration, dose (mg) or volume (ml)

9.7 Other pharmacologic agents administered

9.8 Patient behavior

9.9 Behavior management technique used (restraints, etc.)

9.10 Preventive and periodontal therapy and instructions

9.11 Dietary recommendations

9.12 Prescriptions written

9.13 Parent consent

9.14 Referrals

9.15 Consultations with other professionals

9.16 Phone conversations

9.17 Emergency treatment

9.18 Cancellations and failures

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10. Supplementation Information:

10.1 Sedation Records

When enteral or parenteral sedation has been used manage a child, the

candidate must follow “The Guidelines for the Elective Use of Conscious

Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients”

(Latest AAPD Guidelines). The record must include:

10.1.1 Instructions to parents

10.1.2 Dietary precautions

10.1.3 Pre-operative health and airway evaluation

10.1.4 Reason for sedation, NPO verification

10.1.5 Age, weight

10.1.6 Sedative agents, route, dose

10.1.7 Consent for sedation

10.1.8 Length of procedure

10.1.9 Local anesthetic – type, dose

10.1.10 Vital signs – pre, intra, and post-operative monitoring

10.1.11 Effectiveness of sedation

10.1.12 Use of supplemental behavior management techniques

10.1.13 Patient status upon dismissal/instructions to parents

10.1.14 Complications

10.2 General Anesthesia

The record of a case treated under general anesthesia must contain the

following information:

10.2.1 Pre-operative instructions to parents

10.2.2 Dietary precautions

10.2.3 Documentation of pre-operative physical examination

10.2.4 Reason/justification for use of general anesthesia

10.2.5 Age/weight

10.2.6 Copy of consent

10.2.7 Copy of anesthesia record

10.2.8 Copy of the operation report

10.2.9 Copy of the pre-operative dental plan of care

10.2.10 Pre- and/or intra-operative radiographs

10.2.11 Documentation of post-operative evaluation within four

weeks following provision of care

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10.2.12 Documentation of preventive oral health counseling 10.2.13 Teeth, surfaces, and applicable restorative materials are documented 10.2.14 Pulp therapy medicaments are documented 10.2.15 Any intra/post-operative complications are documented 10.2.16 Post-operative instructions are documented

10.3 Trauma Record

The record of a dental trauma sustained and treated must contain the following information:

10.3.1 Description of how, when, where the trauma occurred 10.3.2 Radiographic findings 10.3.3 Treatment rendered 10.3.4 Prognosis/instructions for care 10.3.5 Follow-up required 10.3.6 Future treatment needs anticipated as a result of the accident

10.4 Orthodontic Treatment/Records

The orthodontic care rendered to a child must be thoroughly documented

and should be contained in a separate area of the comprehensive care

record. It must contain the information as delineated on pages 4 and 5

under Category 3 requirements.

Model Lt. Occlusion Model Frontal Occlusion Model Rt. Occlusion

Figure 1. Example of before and after trimmed and polished orthodontic

study casts

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11. Radiographic Requirements

Digital radiographs are required. These radiographs must be mounted, dated and presented for examination electronically Radiographs must be of high diagnostic quality and with good contrast. Bitewings must clearly show the proximal surfaces of all posterior teeth, including the distal surface of the canine. They must have no chemical stains or cone-cuts. The periapical radiographs must clearly show the entire periapical area of pulpally involved tooth. All periapical radiographs must show the teeth proportionately without being foreshortened or elongated. The resident should study the radiographs in this brochure for examples of diagnostic radiographs, which would be acceptable (Figure 2).

Figure 2 Examples of Diagnostic

Radiographs

12. Photographic Requirements All Digital photographs must show the affected area clearly without extraneous tissues and must be in focus (taken in the ratio of 1:1 and 1:1.5). In addition to the other photograph requirements as stated in Section V,

cases from Category 1 require one photograph of the traumatized tooth

taken 12 months after the treatment. The photograph must show the tooth

in question and the tooth on either side in that arch. Extra-oral tissues

should not be visible. Figure 3 illustrated this requirement.

In addition to the other photograph requirements as stated in Section V,

cases from Category 1 require one photograph of the traumatized tooth

taken 12 months after the treatment. The photograph must show the tooth

in question and the tooth on either side in that arch. Extra-oral tissues

should not be visible. Figure 3 illustrated this requirement.

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Tooth # 21: 12 months Post treatment

Figure 3. Example of photograph required for the trauma case

Complete mouth intra-oral photographs consisting of a lateral occlusal view of the right side and the left side in occlusion, an anterior view in occlusion, and occlusal views of the maxillary and mandibular arches showing the occlusal surfaces of all erupted teeth. The photographs must be oriented horizontally and include the teeth and surrounding intra-oral tissues, with the lips visible only at the periphery of the photograph. Figure 4 illustrates this requirement.

Figure 4. Example of complete mouth intra-oral photographs

In addition to the photograph requirements as stated in Section V, cases

from Categories 2B and 2D require an intra-oral photograph or

photographs of the affected tissues. Figure 5 illustrates a muco-gingival

defect before and 6 months after, surgical correction.

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Before treatment After treatment

Figure 5. Example of photographs required for the periodontal case, 2B

Cases from Category 3 require one facial view and one profile view of the patient before and after treatment, and three intra-oral photographs that include right lateral, left lateral, and anterior views in full occlusion before and after therapy (Figure 6).

Extra-oral photos before treatment

Intra-oral photos before treatment

Figure 6. Example of photographs required for a full banded orthodontic case

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Extra-oral photos after

Intra-oral photos after

Figure 6. Example of photographs required for a full banded orthodontic case

(continued)

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VIII. FINAL EVALUATION FOR THE CASE REVIEW SECTION

1. The residents must attain at least 60% acceptance of the 10 cases submitted

at the end of the 2nd year (R2). Otherwise, the resident will repeat the 2nd

year.

2. The resident must attain 100% acceptance of all the 30 cases submitted

during R1 &R2 (5 each level), R3& R4 (10 each level). Otherwise, the

resident will repeat the 4th year and his/her clinical training will be

considered as incomplete.

IX. QUESTIONS Residents who have questions about the Case Review Section are

encouraged to write directly to:

Salem Alkahtani, BDS, MSc, DABP, FAAPD, FICD Chairman, Saudi Board in Pediatric Dentistry

E-mail: [email protected]

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APPENDIX A CERTIFICATE OF ORIGINALITY

CERTIFICATE OF ORIGINALITY

Each of the cases submitted by me represents my own treatment exclusively. Each aspect of the treatment was performed by me during my enrollment in Saudi Board in Pediatric Dentistry (SB-PD) Program. I have satisfied any requirements regarding confidentiality and access to health records for submitting the cases for its use in the examination process. I give the Board permission to copy part or all of the case history materials for its documentation. I understand that the Board may perform an investigation relating to my performance of the work in the case histories. I agree to make the name of the patient known to the Board upon request and cooperate with the Board in any effort to contact the patient or the patient’s parent/guardian. I agree to indemnify and hold the Board harmless from and against any claim, loss, expense or liability, including reasonable attorneys’ fees, arising out of or related to the submission of the case reviews to the Board and any investigation that the Board may deem necessary.

__________________________________

SIGNATURE OF CANDIDATE OVER PRINTED NAME

_________________ Date

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Comprehensive Care of a Pediatric

Patient with Emphasis on

Restorative Therapy without the Use of

Sedation or General

Anesthesia

Case code No 2011023220718-

R3-0114-06-01

(CATEGORY 6)

Date started 18/12/2013

Date finished 28/01/2014

King Fahad Armed Forces Hospital

(KFAFH)

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PATIENT IDENTIFICATION

Pt’s Name: Nouf

Gender: Female

D.O.B: 2-12-2008

Age: 5 years

Nationality: Saudi

Living Area: Jeddah

Education: KG 1

FAMILY & SOCIAL HISTORY

Parents’ Education:

Father: High school

Mother: High school

Parents’ Occupation:

Father: Employee

Mother: Housewife

Parents’ Socioeconomic Status:

Middle class

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CHIEF COMPLAINT

Her father said, “I want to restore her

decayed teeth ”

HISTORY OF PRESENT

COMPLAINT

On 18th

of December 2013, Nouf the 5 years old female was

referred from a general dentist in the screening clinic. After an

examination in the paediatric dental clinic, treatment is decided for

Nouf.

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MEDICAL HISTORY

Medical History: Healthy ASA I.

The child’s father reported that Nouf is a healthy girl and she is

seeing her physician for regular check-up.

Her medical history was negative for rheumatic fever, bleeding

disorders, liver disease, cardiovascular disorders, lung disorders,

allergies or other serious illness or medical conditions, and no

contraindications to treatment were disclosed.

Birth Condition: Normal.

Family Disease: None (In her family, no infectious diseases were

discovered).

Medication: None.

History of Hospitalization: None.

Allergies: No known allergy.

Vaccinations: She got all her vaccination regularly and up to date.

Interpretation & Justification:

Nouf had no medical problems and no contraindications to

restorative dental treatment and comprehensive care, therefore it

was concluded that treatment could proceed.

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DENTAL HISTORY

History of Dental Visit:

Drinking Water: Her family is using fluoridated bottled water for

drinking.

Infancy Feeding: Breast + bottle feeding (2 year).

Diet: 3 meals/day, Her father confirmed this assessment and

indicated that Nouf had many snacks everyday (four to five

times/day that are highly retentive carbohydrate such as caramel).

Oral physiotherapy: She is brushing her teeth irregularly and not

on daily bases. She never use the floss.

Oral habits: No history of trauma for the primary dentition or

abnormal oral habit was reported.

Interpretation & Justification:

This is the first dental visit for Nouf. She is referred from a general

dentist in a screening clinic. After clinical examination, treatment

is decided for Nouf. She needs multiple restorative treatment.

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BEHAVIOR Nouf was cooperative during dental examination. It was reported

also, from the general dentist at previous screening visit. Her

personality is friendly, outgoing, and talkative.

Interpretation & Justification:

The patent’s previous dental behavior indicated that she would be

cooperative dental patient. Tell, Show, and Do approach was

planned to manage the child's behaviour.

Frankl Classification:

Definitely positive (+, +).

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Examination, Diagnosis

and Treatment Plan

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EXAMINATION AND

FINDINGS

The head and neck evaluation revealed natural asymmetric face

with straight facial profile.

There was no discernible facial pathology.

The examination of the TMJ revealed no tenderness or joint

noise and jaw opening occurred smoothly without any deviations

through a full range of movements.

No enlarged lymph nodes were palpated in the neck or

submandibular area. The cheeks and lips were of normal color

and no abnormalities were detected visually or by palpation.

Child appeared to have a good muscle balance during

swallowing.

Hair, nails, and hands appeared normal.

The intra oral soft tissue examination revealed no apparent

pathology of the tongue, floor of the mouth, palate, oropharynx,

tonsils, or buccal mucosa.

The labial and lingual frena appeared normal.

The gingiva is diagnosed with Generalized mild marginal

plaque induced gingivitis.

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CLINICAL

EXAMINATION

I-EXTRA-ORAL

Hair: WNL

Face: Natural asymmetric

Tempromandibular Joint: WNL

Lymph Nodes: Non-Palpable L.N

CLINICAL EXAMINATION

I-EXTRA-ORAL

Facial Profile: Straight

Lips: Competent

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CLINICAL EXAMINATION

PHYSICAL GROWTH

PERCENTILE CHART

(NCHS)

Age: 5 years

Weight:

17 Kg below 50% of her age

Height:

104 cm below 50% of her age

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CLINICAL EXAMINATION

I-INTRA-ORAL

Soft tissue:

Tongue

Floor of the mouth

Soft & hard palate

Buccal mucosa

Hard tissue:

Primary dentition.

Multiple occlusal and proximal carious posterior and anterior

teeth.

}WN

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CLINICAL EXAMINATION

I-INTRA-ORAL

Soft Tissue: (oral health evaluation):

Gingiva (marginal & IDP): Generalized mild marginal

plaque induced gingivitis

Debris Index (DI): 3

Oral Hygiene: Poor

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CLINICAL

EXAMINATION

I-INTRA-ORAL HARD

TISSUE

Arch Shape

U-shape

U-shape

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CLINICAL

EXAMINATION

I-INTRA-ORAL

OCCLUSION

Primary Molar

(terminal plane)

Relationship:

Right: Mesial Step Left: Mesial Step

Primary Canine

Relationship:

Right: Class I Left: Class I

Primary Incisors

Relationship:

Overjet: 1 mm Overbite: 10 % Coincident midlines

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CLINICAL EXAMINATION

DIAGNOSTIC AID

DIET ANALYSIS

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Diet Recommendation:

Improve diet quality and quantity by increase vegetable, milk, and

grains intake.

Decrease sugar intake especially between meals.

Use sugar free chewing gums, or rinse after school breakfast.

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DIAGNOSTIC AID

CARIES RISK ASSESSMENT

(CAT)

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DIAGNOSTIC AID

DIGITAL RADIOGRAPHS

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Interpretation & Justification: Based upon the clinical and radiographic examination. The child

has multiple carious primary teeth need to be restored in order to

prevent early loss of space and deterioration of occlusion.

DIAGNOSIS

Five years old Saudi female child (ASA I) with no known drug

allergies (NKDA) has poor oral hygiene and severe early

childhood caries (S-ECC).

Her behavior is positive toward dental treatment. She is at high

caries risk category according to Caries-risk Assessment (CAT).

The gingiva is diagnosed with generalized mild marginal plaque

induced gingivitis.

TREATMENT OBJECTIVES The progression of dental caries can be stopped by

treatment in order to: • Preserve the tooth structure.

• Prevent further destruction of the tooth.

• Minimize future pain and discomfort.

• Return the tooth to the functional condition.

• Return the tooth to an esthetic condition.

• Improve the oral health.

• Monitor the development of the patient’s occlusion and dentition.

TREATMENT RATIONALE Treatment of Multiple carious teeth should be done as soon as

possible to minimize further damage to the dental and

supporting structures. The possible complication in the

absence of treatment would be the following:

• Discomfort or pain which leads to neglect oral hygiene.

• Impaired function, lead to decrease child general health.

• Tooth Fracture, sensitivity, abscess, infection and tooth loss.

• In severe cases, cellulites.

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DENTAL CHARTING Pre treatment 18-12-2013

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BEHAVIOR MANAGEMENT

TREATMENT PLAN

PREVENTIVE PHASE

Oral prophylaxis

& oral hygiene

instructions

Scrub brushing technique with youth multitufted soft nylon

toothbrush and fluoridated tooth paste, flossing by the

parents.

Repeat disclosure of plaque; tooth brushing evaluation and

oral hygiene instructions to parents and child at each recall

visit.

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Topical fluoride

application

A fluoride program for caries prevention by reducing

demineralization and encouraging remineralization.

Prophylaxis and topical fluoride treatment in office at 3-6

months intervals until caries rate declines substantially.

Use an ADA approved fluoride toothpaste at least twice a

day by the parents or caregiver.

Diet counseling

A plan to reduce snack frequency

and fermentable carbohydrates

ingestion included:

Repeat discussion with parents and child concerning the

etiology of dental caries and the role played by fermentable

carbohydrates.

Repeated discussion with parents and child concerning the

need to reduce the frequency of snack ingestion. Scrub

brushing technique with youth multitufted soft nylon

toothbrush and fluoridated tooth paste, flossing by the

parents.

Repeat disclosure of plaque; tooth brushing evaluation and

oral hygiene instructions to parents and child at each recall

visit.

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TREATMENT PLAN

RESTORATIVE PHASE

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TREATMENT PLAN

RECALL AND

MAINTENANCE PHASE Recall visits every 3 months in order to:

Evaluate the restorations

Assessment of the eruption of the permanent teeth

OHI reinforcement

Topical fluoride gel application

Diet instructions

Oral prophylaxis

POST OPERATIVE RECORDS

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PROGRESS NOTES

1st

visit 18-12-2013

As previously stated the patient was referred from a general

dentist. Her medical, dental and behavioral histories were taken.

Head and neck, intraoral examination, and charting were

completed. Two bitewing, four posterior, and two anterior

periapical radiographs were taken. Disclosing solution was applied

and Debris Index (DI) was recorded (DI = 3). Child and her father

were shown the clinical results and oral hygiene instructions were

provided including brushing technique (scrub technique), type of

toothbrush recommended (youth multitufted soft nylon toothbrush)

and flossing technique. Fluoridated toothpaste was recommended.

Pamphlet on tooth brushing (scrub technique), flossing and

fluoride were given to child and her father. I discussed my

preliminary findings and recommendations with child's father and

he was interested in restorative treatment. The restorative treatment

plan was discussed. The patient father was encouraged to reduce

the frequency of carbohydrate ingestion by Nouf. Less cariogenic

substitutes were discussed. Extra and Intraoral photographs were

taken. Dental prophylaxis and 1-minute APF (1.23%) topical

fluoride tray treatment were completed. Post fluoride treatment

instructions were given i.e. nothing by mouth for 30 minutes.

• Behaviour: +, +

• Next visit: #55 and #54

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2nd

visit 25-12-2013

The father accompanied Nouf for this visit. There was no pain or

complaint from the restored teeth. Plaque was disclosed, scored

and recorded (DI = 0). Nouf was rewarded for the improvement of

her oral hygiene. The patient’s father together with his daughter

indicated that they are doing well in reducing the daily cariogenic

food intake.

•Topical anesthesia “Benzocaine” for 3-5 minutes, local anesthesia

infiltration 1 carpule 1.8 ml “ 2% lidocaine with 1:100,000

epinephrine”, complete isolation with rubber dam using clamp

W2A.

•Tooth # 55: caries excavation (OM), acid etching with phosphoric

acid 37%, bonding agent application, composite A1 restoration,

and sealant.

•Tooth # 54: (OD) caries excavation,), acid etching with

phosphoric acid 37%, bonding agent application, composite A1

restoration, and sealant.

2

5-12-2013

• Behaviour: +, +

• Next visit: #65 and #64

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3rd

visit 31-12-2013

The father accompanied Nouf for this visit. There was no pain or

complaint from the restored teeth. Plaque was disclosed, scored

and recorded (DI = 3). Reinforcement of oral hygiene instructions.

•Topical anesthesia “Benzocaine” for 3-5 minutes, local anesthesia

infiltration 1 carpule 1.8 ml “ 2% lidocaine with 1:100,000

epinephrine ”, complete isolation with rubber dam using clamp

W2A.

•Tooth # 64: caries excavation (MOD), SSC preparation,

formocresol pulpotomy for 5 minutes, IRM, SSC D4 cementation.

•Tooth # 65: (OM) caries excavation, acid etching with phosphoric

acid 37%, bonding agent application, composite A1 restoration,

and sealant.

31-1

2-2013

• Behaviour: +, +

• Next visit: Q7

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4th

visit 14-01-2014

The father accompanied Nouf for this visit. There was no pain or

complaint from the restored teeth. Her oral hygiene is progressed.

The father said that the patient’s father is brushing her daughter

teeth twice a day with fluoridated toothpaste.

•Topical anesthesia, IANB and long buccal infiltration of with 1.8

mm of 2% lidocaine with 1:100,000 epinephrine, complete

isolation with rubber dam using clamp W2A.

•Tooth # 75: (OM) caries excavation, acid etching with phosphoric

acid 37%, bonding agent, composite A1 and sealant.

•Tooth # 74: caries excavation (OD), acid etching with phosphoric

acid 37%, bonding agent, composite A1 and sealant.

14

-01-2014

• Behaviour: +, +

• Next visit: Q8

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5th

visit 9-01-2014

The father accompanied Nouf for this visit. There was no pain or

complaint from the restored teeth. Plaque was disclosed, scored

and recorded (DI = 0).

•Topical anesthesia, IANB and long buccal infiltration of with 1.8

mm of 2% lidocaine with 1:100,000 epinephrine complete

isolation with rubber dam using clamp W2A.

Tooth # 85: (O) caries excavation, acid etching with phosphoric

acid 37%, bonding agent, composite A1 and sealant.

•Tooth # 84: acid etching with phosphoric acid 37%, bonding

agent, and fissure sealant.

• Behaviour: +, +

• Next visit: Anterior teeth

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6th

visit 28-01-2014

The father accompanied Nouf for this visit. There was no pain or

complaint from the restored teeth. Plaque was disclosed, scored

and recorded (DI = 0).

•Topical anesthesia “Benzocaine” for 3-5 minutes, Local

anesthesia infiltration 1 carpule 1.8 ml “ 2% lidocaine with

1:100,000 epinephrine ”. Partial isolation with cotton rolls.

•Tooth # 51, #61, #52, and #62:

Caries excavation, tooth preparation for prefabricated veneered

steel crown, crowns selection (Nu smile).

Tooth #51: A2

Tooth #52: B3

Tooth #61: A2

Tooth #62: B3

• Behaviour: +, +

• Next visit: 3 months recall

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TIME TABLE FOR

TREATMENT

ESTABLISHED

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TREATMENT RESULTS

The patient’s treatment is completed and the patient’s chief

complaint is the resolved (caries).

Healthy soft tissues are maintained.

Accepted oral hygiene level is achieved as measured by

Debris Index from 3 at the first visit to 0 at the six months

recall.

Maintaining the patient’s positive behavior throughout the

treatment phases (Frankl rating scale from definitely

positive +, + to definitely positive +, +).

Patient's occlusion is being monitored.

FOLLOW UP PLAN

3 MONTHS RECALL

3 months recall visit 25-04-2014

• The mother accompanied Nouf for this visit. No change in

medical history since last visit. Extra and intra-oral

examinations were performed. Hard tissue exam revealed no

evidence of clinical carious lesions, restorations were intact and

asymptomatic. Soft tissue examination was within normal

limits.

• OHI reinforcement (scrub technique, flossing)

• Oral prophylaxis

• Fluoride gel application (APF topical fluoride tray treatments

were completed)

• Dietary advice

• Behavior: +, +

• OH: good (DI= 0)

• Next visit: recall after 3 months

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FOLLOW UP PLAN 6

MONTHS RECALL

6 months recall visit 20-07-2014

• The mother accompanied Nouf for this visit. No change in

medical history since last visit.

Nouf was sent to do radiographic examination. Extra and

intra-oral examinations were performed. Hard tissue exam

revealed no evidence of clinical carious lesions, restorations

were intact and asymptomatic. Soft tissue examination was

within normal limits.

• OHI reinforcement (scrub technique, flossing)

• Oral prophylaxis

• Fluoride gel application (APF topical fluoride tray treatments

were completed)

• Dietary advice

• Behavior: +, +

• OH: good (DI = 0)

• Next visit: recall after 6 months

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6 MONTHS RECALL PHOTOGRAPHS

AND RADIOGRAPHS

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DIETARY EVALUATION FORM

DIETARY EVALUATION Yes No

BASIC FOODS Does your child have 2 pieces (5 ounces) daily of

meat, chicken, fish, eggs, or beans?

(One piece = 2-3 ounces like the size of a bar of soap

or the inside of your palm).

Does your child have 2 1/2 cups daily of vegetables?

(Like broccoli, sweet peas, carrots, bean sprouts,

spinach, celery, etc.) (One cup equivalent = 1 cup

cooked or fresh veg. like the size of a computer

mouse or 2 cups of leafy veg.)

Does your child eat 1 1/ 2 cups daily of fruit? (Like

mango, banana, apple, grapes, orange, kiwi, etc.)

(One cup = 1 medium size fruit like the size of a

tennis ball, 1/2 cup dried fruits, 1 cup fresh 100%

juice)

Does your child eat 6 pieces daily of grains? (like

bread, pasta/noodles, rice. Tortillas, cereal, crackers)

(One piece = 1 slice of bread or ½ cup cooked

Cereal/rice/pasta) (like the size of the small fist, 4

crackers, 2 heaping tablespoons cooked rice)

Does your child have 3 cups daily of milk or milk

products? (like low fat milk, 1%, skim/fat-free,

cheese, yogurt, soy milk) (One cup = 1 cup (250 ml)

of milk or yogurt, 2 slice processed cheese)

DIET SCORE: 5=Excellent, 4=Fair, <4=Needs

Improvement

Does your child eat spread cheese on regular bases?

DRINKS Does your child drink any of these drinks MORE than 1 time per

day BETWEEN MEALS? Regular soda-pop (Coke/Pepsi, Sprite, Mountain

Dew, lemon or orange soda, etc.)

Juice or drinks (Juice = fresh, frozen, canned, or

natural or artificial fruit juice.) (Sun top, Tang,

Vimto …..etc)

Sports or energy drinks, or flavored waters?

(Powerade, Gatorade, Redbull, Rockstar, Propel,

etc.)

Any drink WITH added sweeteners (sugar, honey,

molasses) (like hot chocolate, tea or coffee

(including iced), etc.)

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Does your child SIP slowly on any of the above

rather than just drinking it?

If your child usually have MORE than 1 time

between meals of any of the above drinks each day,

how many per day usually

2 3 4 or

more

Dietary Evaluation Yes No SNACKS AND DESSERTS

Does your child eat any of these foods MORE than 1 time per day BETWEEN

MEALS ONLY AS SNACKS

Cake/pastry (cake, cupcakes, donuts, cookies, pies,

sugared cereal, muffins, moon cakes, Konafa,

Maamoul, Massoub…… etc.)

Candy (like: chocolate, caramel, or other candies)

Lollipops or hard candies (i.e.: Skittles, Starbursts,

Jolly Ranchers)

Packaged Cereals or crackers

Does your child usually have MORE than 1 snack

between meals each day?

If yes, how many per day usually 2 3 4

Does your child eat any of these foods BETWEEN MEALS ONLY AS

SNACKS

A. Fruit like: Apple slices, banana or orange

B. Cheese and crackers or Peanut butter toast

C. Potato chips/graham crackers/cookie/cake

D. Lollipop or Candy bar like Snickers

E. Fruit roll-up or Dried fruits like dates

F. Other

If other, Please Explain:

CARIOGENIC SCORE: 15 No =Excellent, 13 No =Good, <13 No =Needs

Improvement/Increased Risk

Note that details of the patients are not supplied for confidentiality purposes. Actual submission of this sheet should have all the information needed i.e. name of patient, signature of dentist/resident, etc.

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Note children below 3 years old will use the Diet analysis according to AAPD

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Simplified Oral Hygiene Index (OHI-S) (Greene and Vermillion) (Debris Index)

1

st visit 2

nd visit

- Six teeth are examined - Six teeth are examined DI = 3 DI = 0 3

rd visit 4

th visit

- Six teeth are examined - Six teeth are examined DI = 3 DI = 0

0 = No debris or stain. 1 = Soft debris < 1/3 of the tooth surface or present of stains. 2 = Soft debris > 1/3. 3 = Soft debris > 2/3.

0=good, 1=Fair, 2=Poor, 3=Poor Note: if primary dentition, use teeth #55, 51, 65, 85, 71, 75

46 (L)

16 (B) 11 (La) 26 (B)

31 (La) 36 (L) 46 (L)

16 (B) 11 (La) 26 (B)

31 (La) 36 (L)

46 (L)

16 (B) 11 (La) 26 (B)

31 (La) 36 (L) 46 (L)

16 (B) 11 (La) 26 (B)

31 (La) 36 (L)

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1. Facial Profile: straight

2. Lip Posture: competent

3. Facial Symmetry: natural symetrical

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3 months recall

- Six teeth are examined DI = 0

46 (L)

16 (B) 11 (La) 26 (B)

31 (La) 36 (L)

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6 months recall

- Six teeth are examined DI = 0

46 (L)

16 (B) 11 (La) 26 (B)

31 (La) 36 (L)


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