03 treatment planning

8/3/2019 03 Treatment Planning

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Treatment Planning in

Operative DentistryDr. Ignatius Lee


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Status of Treatment Planning

in Private PracticeAn article published in Readers Digest

(Feb., 1997) summarized the current status

of treatment planning in dentistry

The article described how a patient who went to 50different dental offices in 28 states; came backwith treatment plans ranging from no treatment

needed to a quote of $30,000


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Reasons for the variation in

treatment planning

Advance in dental research (e.g.)

Changes in diagnostic techniques (e.g. pitsand fissures caries)

Changes in treatment philosophy (e.g.criteria for replacement of existing

restorations)

Treatment planning will depend on thetraining background of the dentist


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treatment planning

Changes in disease pattern

Years ago dental caries was pandemicToday, dental caries only affect a smallpercentage of the population (17% of thepopulation account for 67% of the total caries

experience)

Dentists are not busy enough - looking foroptional treatments


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treatment planning

Explosion in treatment

options/techniques in OperativeDentistry

Treatment planning will depend ondentists treatment philosophy,

clinical judgment/experience, clinicalexpertise or other reasons..


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Example in treatment options

A 35 year-old female patient presents to yourdental office for a routine dental exam

CC: none

PDH: regular patient (6-12 mo recall) to

another dental office, reason for switchingoffice is because of changes in dentalinsurance by her employer

Clinical exam: conservative occlusal

amalgam on her permanent first molars thatwere placed when she was 18. All theamalgam showed a sign of slight marginalbreakdrown. No evidence of any dental

diseases.


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Example in treatment options

Treatment Options

Replace the old Class I amalgamrestorations with:

Direct composite ($135)Amalgam ($85)

Gold inlay ($760)

Gold foil ($150)

Indirect ceramic inlay ($760)Indirect composite inlay ($550)

CAD/CAM inlay ($760)

OR

No treatment - priceless


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treatment planningConsumer driven demand

MagazineInternet

TV

Dentist philosophy in treatment may be influenced by the

demand of the patients (specific to the location of the

practice)


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treatment planningType and location of the dental office

Edina/Minnetonka

Metro//Park

Union Gospel Mission

Offices that advertise heavily in the area of

esthetic dentistry

Dentist philosophy in treatment may be influenced by the

demand of the patients (specific to the location of the

practice)


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Treatment Planning in Operative Dentistry

Evidence-based Dentistry

American Dental Association definition of Evidence-

based Dentistry

Approach to oral health care that requires thejudiciousintegration of systematic assessments of clinically

relevant scientific evidence, relating to the patients

oral and medical condition and history, with thedentists clinical expertise and the patients treatment

needs and preferences

Ismail and Bader, JADA, Vol.135, January 2004


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Evidence Based TreatmentPlanning

Three elements of treatment planningBest available scientific evidence(diagnosis and treatment options)

Dentists clinical expertise

Patients treatment needs and

preferences

SUMMARY


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Identification of best evidence

Information obtained from:

Randomized controlled clinical trials

Nonrandomized controlled clinical trialsCohort studies

Case-controlled studies

Crossover studies

Case studies

Systemic reviews (PubMed, Journals, Cochrane)

Ismail and Bader, JADA, Vol.135, January 2004


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Dentists Clinical Expertise

Relating to what the dentist iscomfortable of doing - e.g. offering

composite veneers vs porcelain veneersUnderstand your strengths andweaknesses, be truthful to your patients

Understand when you need to refer tospecialists


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Patients Needs/Preferences

Probably the most neglected aspect intreatment planning by a student

Try to incorporate patients preferences informulating your final treatment plan

Try to understand and address what are theTRUE wants and needs of the patient

Try to address the realistic/unrealistic needsand wants of the patients

Challenge: need to understand your patient ina relatively short period of time


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Challenges in understanding

your patientTime

Patient may not be telling you the whole truth

Remember it is a two-way street; try toLISTEN to your patient - e.g. patients trueesthetic concern

May have to help your patient understand the

needs and the wants of their dentaltreatments

E l f t t t l i b d ti t f


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Defining Oral Rehabilitation - Gordon

ChristensenThe article was written in response to concern within the profession

that some commercial institutes and continuing education groupsare advertising to the lay public that only graduates of their

programs are capable of accomplishing the type of oralrehabilitations observed in the television cosmetic makeovers

Levels of Oral RehabilitationTreatment of Defective Teeth Only

Treatment of Defective Teeth with an Esthetic UpgradeTreatment of All Teeth for Therapeuticor Esthetic Reasons

The levels are established based on the estheticpreference of the patient

Example of treatment planning based on patients preferences

JADA Vol. 135 (2004): 215-217


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Treatment of Defective Teeth Only

Patient in general are pleased with their oralappearance, although it may not be perfectby ideal standards.

They want long lasting, comfortable dentalrestoration and a reasonable smile.

They are not seeking the glamorous, but

often short-lived, esthetic restorative therapypopularized on TV.

They may accept bleaching, some will accepttooth-colored restorations


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Treatment of Defective Teeth with anEsthetic upgrade

Majority of patients - they want to look acceptable, have apleasant smile and be able to eat normally.

Most are not interested in having absolutely perfect-appearingteeth that are snow-white. However, usually they will accept a

moderate level of esthetic upgrade while receiving therapy fortheir dental caries or defect restorations.

These patients usually involved a phased treatment plansspanning several years.

The patients should be wellINFORMED

of which part oftheir therapy is mandatory and which part is purely elective

Usually involve bleaching, a few veneers or crowns andrestoring any obviously displayed metal restorations ordarkened teeth with crowns.


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Treatment of All Teeth For Therapeutic orEsthetic Reasons

This level of oral rehabilitation is being promoted in many continuingeducation courses and routinely is suggested to patients.

Usually, crowns, veneers, elective cosmetic periodontal surgery, someocclusal therapy, perhaps elective endodontic therapy or orthodonticsand even orthognatic surgery are suggested.

Much of the treatment is for esthetic reasons only and is not required forany therapeutic reason.

If a patient is INFORMED that the therapy is not required because ofdisease, and that it is elective and primarily esthetic, the matter of ethicsbecomes somewhat clearer.

However, if the patient is led to believe that the mostly esthetic therapyis needed for therapeutic reasons, including questionable occlusalpathosis, or if the more conservative therapies are not explained to thepatient, the practitioner is treading on unethical ground


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Understand what type of

patient you are dealing withMay give you some clue on theirpreferences

Will influence what type oftreatment/procedure/material used

People do not change - try to make

small incremental improvementTry to institute phased treatment


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Types of Patients

Patient never been to dentist in US

Recent immigrants

May have a lot of unconventional

dentistry done in his/her country

Educate, take care of acute needs firstbefore trying to fix those unconventional

dentistry


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Types of Patients

Last trip to dentist - over 5 yearsPhobic, not health conscience, only go when Ihave pain

Try to understand where they are comingfrom, and why they are here

Usually they have an acute need

Take care of their acute needs, then presenta phase approach - acute needs (diseasethat cause pain), take care of larger lesion,debridement, smaller lesion, missing teeth,cosmetic


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Types of Patients

Last trip to dentist - 2 to 5 years

No insurance, feel very uncomfortablegoing to a dentist

Usually have an acute need

More aggressive in prescribingtreatment - less confidence inmonitoring small lesion


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Types of Patients

Patients that come in at least once every 2years

Regular patient

More comfortable in monitoring small lesions

Still need to understand what they preferences are:

Cost conscienceI want the best

Missing teeth not a concern

Value your judgment and recommendation

Just take care of my basic needs


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Treatment Planning Models

Treatment oriented model

Problem oriented model


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Treatment Oriented Model

Dentist examine the patient

Dentist mentally equate the findings to

the need for certain form of treatment

Examination findings are summarized inthe form of a list of treatments -

TREATMENT PLANUseful in simple cases


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Problem Oriented Model

Examination lead to formulation of a listof problem

Each problem on the list is thenconsidered in terms of treatment options

Informed patients of all the options

Formulate the TREATMENT PLAN


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Problem Oriented ModelProblem Lists

(Objective findings from oral andradiograph exam)

Formulate Treatment Options

Patients

Preferences/factors(Subjective Findings)

Caries Risk

Assessment

Treatment Plan

Patients PreferencesInformed Consent


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Patients PreferencesAddress patients chief complainAsk questions - assess patients true preferences

Understand what is the treatment objectives for the patient(better function, better esthetic?)

Understand what type of patient you are dealing with

Preference for the types of restorations/procedures (e.g. fixed vsremovable, direct vs indirect restorations)

Can the patient afford the procedures he/she desires?

Patients dental IQ - long term maintenance

Esthetic - understand their true concern


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Caries Risk AssessmentWhy is it a vital part of Treatment Planning?

Dental caries is an infectious disease.

It is the most overlook aspect in the treatment planning process.

Patients caries risk status will affect the treatment (materials andprocedures, treatment vs no treatment) you are going to prescribe.

Patients caries risk will determine recall intervalsand radiograph exposure intervals.

For the high risk patients (caries active or caries prone), a strategy tocontrol the disease should be formulated and documented in thetreatment plan.

Review- Dr. Hildebrandts Fall semester manual - Current Concepts inCaries Control


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Dental Caries - an InfectiousDisease

Etiologic agent - specific pathogens (Specific PlaqueHypothesis)

Signs and symptoms of the disease - localizeddissolution and destruction of calcified tissue.

It is very easy to focus narrowly on treating the signsand symptoms ONLY (restorative needs); thus failedto identify the underlying cause of the disease.

Failure to address the underlying cause of thedisease will allow the disease to continue.

Restoration alone do not and will not treat thedisease


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High Caries Risk Patients

Must identify the underlying reason(s)for the high risk.

Not been to a dentist for years or poororal hygiene are seldom the ONLYfactor

Salivary flow? Diet?

MUST educate and formulate a controlmeasures plan


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Clinical Example

24 year old male presenting to youroffice for routine oral exam

PMH - non-contributoryPDH - not been to a dentist since highschool, no existing restoration.

Clinical exam - rampant caries onmultiple teeth. Normal salivary flow.Heavy plaque on all teeth.


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Problem Oriented Model

Problem Lists (Objectivefindings from oral and

radiograph exam)

Formulate Treatment Options

Patient

Preferences/factors(Subjective Findings)

Caries Risk

Assessment


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Problem List

Dental caries - rampant caries

Poor oral hygiene


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Caries Risk Assessment

Caries active

identify the underlying reason(s)

Poor oral hygiene and not been to dentistsince high school should not be taken asthe convenient reason.


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Caries Risk Assessment

GoalsIdentify the underlying reason(s) - EDUCATE thepatient.

FORMULATE control measures.

ASSESSING patients ability to change (habits).These goals are as important if not more importantthan the restorative part of your treatment plan.

Success/failure of the restorative phase will dependon whether you can achieve the goals stated above.


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Patients Preference/Factor

Goals

Formulate a preliminary plan based on

patients preferences and the overalltreatment goal.

Narrow down options


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Overall Treatment Scheme

Initial treatment phase -treating the symptoms ofthe disease (massive

tooth morbidity).

Therapeutic Phase Evaluation -evaluate

the success/failure of therapeutic phase

Final Restorative Phase

Therapeutic Phase

- control measures


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Initial Restorative Phase

Options available for dealing with massive tooth morbidityDirect Restoration RCT Extraction

Treatment options

Extract all teeth

Extract teeth that are unrestorable onlyExtract teeth that will need RCT

Extract teeth that are unsuitable/unnecessary to support a removablepartial denture. E.g. do you want to save all the Mx anterior teeth(assuming they all have extensive lesions) if your treatment plan will

involve a Mx partial denture?Immediate removable appliances


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Therapeutic Phase Evaluation

Was the control measures prescribedsuccessfully change the patient from

high caries risk to low caries risk, or atleast have the disease under control.

No final treatment phase should be

initiated until the risk is under control


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Final Restorative Phase

Indirect restorations

Crowns and bridges

Removable appliances

03 treatment planning

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