Oral Exam Clinical Case #3

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Question 1 of 3

1. Question
You are the primary care physician caring for Grace, a 79-year-old woman, who is a resident in a long-term care facility. You are a board certified internist with a Certificate of Added Qualification in Geriatric Medicine. Grace has a history of moderate dementia and right-sided hemiplegia from a stroke at age 68. You are new to the practice and are seeing Grace for the first time. The nursing team leader of Grace’s floor has listed “oral care” as one of three primary concerns of her family, along with choking on solid foods and poor sleep.

Which behavior best exemplifies the mutual respect and trust that are foundational to interprofessional collaborative practice?
- Acknowledge that it is not always possible in a long-term care facility to examine the patient in a non-private setting. To maintain a climate of mutual respect and shared values, it is important to respect patients’ dignity and privacy while maintaining confidentiality in the delivery of patient-centered team-based care.
- Acknowledge the importance of the patients' interests.
- Recognize that individual and cultural differences that are characteristic of patients do not influence the care of those patients in an institutional setting. To maintain a climate of mutual respect and shared values, it is important to embrace the cultural diversity and individual differences that characterize patients, populations, and the health care team.
- Understand that elderly patients, particularly those with comorbidities such as dementia, have a shorter life expectancy and therefore do not require routine attention to oral care. To maintain a climate of mutual respect and shared values, it is important to manage ethical dilemmas specific to interprofessional patient- and population-centered care situations. With elderly patients, though it may be appropriate to discontinue or limit certain medical interventions based on comorbidities and life expectancy, routine oral care is required to maintain quality of life and reduce complications such as aspiration pneumonia, especially in the nursing home setting.
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Question 2 of 3

2. Question
You perform an oral examination and encounter severe gingival recession and several loose teeth. You note that Grace has significant xerostomia. You determine that Grace requires the urgent intervention of her dentist, who, after your call, agrees to see her in a few days. You also feel there would be benefit from the involvement of a social worker as a member of her health care team. You notify the nursing home social worker using the flag system in your EMR and ask the nursing team leader to communicate this plan with the patient’s family.

Antonio Moretti, DDS, MS

Which behavior best exemplifies effective communication among participating members of the healthcare team?
- Encourage use of paper-based forms of communication between team members. To appropriately deliver patient-centered care, it is important to choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function.
- Use proper dental terminology when referring to any of the patient’s oral health concerns, regardless of their medical background. To appropriately deliver patient-centered care, it is important to organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible. The nurse, when speaking with Grace and her family about the dental referral, will likely use terms such as “dry mouth” or “loose teeth” rather than “xerostomia” or “periodontal ligament detachment.”
- Explain that you will arrange for a dentist to take care of the patient’s mouth and that you will take care of all the other health concerns. To appropriately deliver patient-centered care, it is important to communicate consistently the importance of teamwork in patient-centered and community-focused care. In fact, the more the primary care provider integrates oral health into the overall health of patients, the more likely patients will see the importance of caring for their mouths as well.
- Encourage the social worker on the team to share ideas and opinions regarding the patients' care.
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Question 3 of 3

3. Question
During the initial visit with Grace, you perform a thorough medical history including an oral health history. You determine that even though Grace has hemiplegia and dementia that prevents her from adequately caring for her own teeth, she has had excellent oral care, provided by a trained clinical assistant. She was seen by a dentist 8 months ago (6 months after being admitted to this facility). At that time the dentist recommended that she increase her brushing frequency, use fluoride gel on the exposed roots that had been developing, and return in 3 months for a recheck to document changes in her oral health.

Which behavior best exemplifies effective teamwork among participating members of the healthcare team?
- Inform the team you will be making all the dental related decisions for Grace in the future. To appropriately deliver patient-centered care, it is important to apply leadership practices that support collaborative practice and team effectiveness. Strong leaders value contributions from all members of the team.
- Acknowledging that there is a shortage of dental professionals in this setting, so unfortunately, future evaluations by the dentist will be eliminated. To deliver patient-centered care, it is important to engage other health professionals – appropriate to the specific care situation – in shared patient-centered problem-solving. The plan for the patient’s care should be a product of the team.
- Encourage dental health professionals to oversee all aspects of care relating directly to the oral health of the patient. To deliver patient-centered care, it is important to integrate the knowledge and experience of other professions – appropriate to the specific care situation – to inform care decisions, while respecting patient and community values and priorities/preferences for care. This involves relinquishing some autonomy in the interests of effective team functioning.
- Develop consensus among team members around ethical principles involved in the care of patients with dementia and physical disability.
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The Oral Examination

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