Case-Based Review Strategy: A Systematic Approach to NBDHE Case Questions

Core Review

The Systematic Case Analysis Protocol

When you open an NBDHE case, follow this sequence EVERY time. Do not skip steps, and do not jump to the questions before completing the analysis.

Step 1: Read the Chief Complaint This orients you to WHY the patient is seeking care. Is it a specific problem (pain, swelling, broken tooth) or a routine visit? The chief complaint determines the initial focus of the appointment.

Step 2: Medical History Scan for conditions that affect dental treatment:

• Cardiovascular: Hypertension, coronary artery disease, history of MI, stroke, heart valve conditions, presence of pacemaker/ICD
• Endocrine: Diabetes (type 1 vs. 2, control status), thyroid disorders
• Respiratory: Asthma, COPD
• Musculoskeletal: Arthritis (affects oral hygiene, positioning), osteoporosis
• Infectious disease: Hepatitis, HIV
• Other: Cancer, bleeding disorders, seizure disorders, allergies, pregnancy

Step 3: Medications Every medication listed should have a REASON — cross-check against the medical history. Key medication classes to watch for:

• Anticoagulants/antiplatelets (warfarin, clopidogrel, apixaban, aspirin): Bleeding risk. Check INR if on warfarin. Know whether to consult physician before invasive procedures.
• Antihypertensives: May cause orthostatic hypotension, xerostomia, gingival hyperplasia (calcium channel blockers), lichenoid reactions.
• Bisphosphonates / antiresorptives: Risk of medication-related osteonecrosis of the jaw (MRONJ).
• Antidiabetic agents: Hypoglycemia risk during appointments. Schedule morning appointments after meals.
• Immunosuppressants / corticosteroids: Infection risk, impaired healing, possible adrenal suppression requiring steroid supplementation.

Step 4: Allergies Document all allergies. Latex allergy requires a latex-free environment. Drug allergies (especially penicillin, codeine, NSAIDs) dictate prescribing decisions. Allergies must appear in the case and you must ACT on them — this is a common NBDHE trap.

Step 5: Vital Signs

Vitals MUST be internally coherent with the medical history and medications:

• A patient on lisinopril (antihypertensive) should have a medical history of hypertension and may have elevated BP (unless well-controlled)
• A patient with uncontrolled diabetes may have delayed healing and increased infection risk
• If vitals are abnormal, decide: Can treatment proceed? Does the patient need medical clearance? Document and recheck.

Step 6: ASA Classification

ASA III patients require careful consideration — you may need medical consultation, shorter appointments, and careful monitoring.

Step 7: Dental History Assess prior experiences, frequency of care, oral hygiene habits, and patient concerns. A patient who only visits for emergencies has different needs than one in regular recare.

Step 8: Periodontal Findings The perio chart must match the medical history:

• Poorly controlled diabetes → worse periodontal status
• Smoking → deeper pockets, more attachment loss, reduced bleeding (nicotine vasoconstriction can mask inflammation)
• Phenytoin, nifedipine, cyclosporine → gingival hyperplasia (drug-induced gingival enlargement)

Step 9: Radiographic Findings Radiographs must be consistent with the perio chart:

• If the perio chart shows 7 mm pockets on tooth #19, the radiograph should show corresponding bone loss
• Caries on radiographs should correlate with clinical findings

Step 10: Synthesize Risk → Determine Priorities → Answer Questions

Now — and only now — look at the questions. You will be asked to make treatment decisions, identify contraindications, prioritize procedures, and demonstrate clinical reasoning. Because you have already synthesized all data, the answers will be grounded in the complete patient picture.

Priority Hierarchy in Treatment Planning

When multiple treatment needs exist, prioritize using this framework:

1. Pain/infection control (emergency treatment)
2. Disease control (caries removal, periodontal debridement)
3. Prevention (fluoride, sealants, oral hygiene instruction)
4. Function (restoration, prosthodontics)
5. Esthetics

The CAPE Mnemonic for Perio Case Analysis

• Characteristics of disease (pocket depths, BOP, CAL, furcations, mobility)
• Associated risk factors (smoking, diabetes, genetics, plaque)
• Periodontal diagnosis (AAP classification: stage, grade, extent)
• Expected treatment (initial therapy, re-evaluation, surgical if indicated)

Common Traps

• Trap: Missing the allergy. Cases often include a medication allergy and then ask about prescribing. If the patient is allergic to penicillin and a question asks about antibiotic prophylaxis, amoxicillin is contraindicated — you must select an alternative (clindamycin, azithromycin, cephalexin depending on allergy severity).
• Trap: Accepting vitals that don't match the history. If BP is 148/92 and the history says "no medical conditions," something is wrong — hypertension may be undiagnosed.
• Trap: Treating ASA III patients like ASA I. ASA III means systemic disease is present and requires modification.
• Trap: Ignoring drug-induced oral effects. Nifedipine = gingival enlargement. Anticholinergics = xerostomia. Bisphosphonates = MRONJ risk.