treatment planning in operative dentistry
TRANSCRIPT
Treatment Planning in
Esthetic Operative Dentistry
Status of Treatment Planning
in Private Practice
Reasons for the variation in
treatment planning
Advance in dental research (e.g.)Changes in diagnostic techniques (e.g. pits and fissures caries)Changes in treatment philosophy (e.g. criteria for replacement of existing restorations)
Treatment planning will depend on the training background of the dentist
Reasons for the variation in
treatment planning
Changes in disease patternYears ago dental caries was pandemic
Today, dental caries affect a large percentage of
the population.
Dentists are not busy enough - looking for
optional treatments
Reasons for the variation in
treatment planning
Explosion in treatment options/techniques in operative dentistry
Treatment planning will depend on dentist’streatment philosophy, clinical judgment/experience, clinical expertise or other reasons…..
Example in treatment optionsA 35 year-old female patient presents to your dental clinic for a routine dental examCC: nonePDH: regular patient (6-12 mo recall) to another dental clinic, reason for switching clinic is because of changes in dental insurance by her employerClinical exam: conservative occlusal amalgam on her permanent first molars that were placed when she was 18. All the amalgam showed a sign of slight marginal breakdrown. No evidence of any dental diseases.
Example in treatment options
Treatment OptionsReplace the “old” Class I amalgam restorations with:
Direct composite ($50)Amalgam ($30)Gold inlay ($760)Gold foil ($150)Indirect ceramic inlay ($350)Indirect composite inlay ($60)CAD/CAM inlay ($760)
ORNo treatment - priceless
Reasons for the variation in
treatment planning
Consumer driven demandMagazine
Internet
TV
Dentist philosophy in treatment may be influenced by the
demand of the patients (specific to the location of the
practice)
Reasons for the variation in
treatment planning
Type and location of the dental clinic Mall//Park
Clinics 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)
Treatment Planning in Operative Dentistry
Evidence-based Dentistry
American Dental Association definition of “Evidence-
based Dentistry”
Approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences
Evidence Based Treatment
Planning
Three elements of treatment planning
o Best available scientific evidence (diagnosis and
treatment options).
o Dentist’s clinical expertise.
o Patient’s treatment needs and preferences.
SUMMARY
Identification of best evidence
Information obtained from:Randomized controlled clinical trials
Nonrandomized controlled clinical trials
Cohort studies
Case-controlled studies
Crossover studies
Case studies
Systemic reviews (PubMed, Journals, Cochrane)
Ismail and Bader, JADA, Vol.135, January 2004
Dentist’s Clinical Expertise
Relating to what the dentist is comfortable of doing - e.g.
offering composite veneers vs porcelain veneers
Understand your strengths and weaknesses, be truthful
to your patients
Understand when you need to refer to specialists
Patient’s Needs/Preferences
Probably the most neglected aspect in treatment planning by a studentTry to incorporate patient’s preferences in formulating your final treatment planTry to understand and address what are the TRUE “wants” and “needs” of the patientTry to to address the realistic/unrealistic “needs” and “wants” of the patientsChallenge: need to understand your patient in a relatively short period of time
Challenges in understanding
your patientTimePatient may not be telling you the whole truthRemember it is a two-way street; try to LISTEN to your patient - e.g. patient’s true esthetic concernMay have to help your patient understand the “needs” and the “wants” of their dental treatments
Defining Oral Rehabilitation
Levels of Oral RehabilitationTreatment of Defective Teeth OnlyTreatment of Defective Teeth with an Esthetic UpgradeTreatment of All Teeth for Therapeutic or Esthetic Reasons
The levels are established based on the esthetic preference of the patient
JADA Vol. 135 (2004): 215-217
Treatment of Defective Teeth Only
Patient in general are pleased with their oral appearance, although it may not be perfect by ideal standards.They want long lasting, comfortable dental restoration and a reasonable smile.They are not seeking the glamorous, but often short-lived, esthetic restorative therapy popularized on TV.They may accept bleaching, some will accept tooth-colored restorations
Treatment of Defective Teeth with an
Esthetic upgrade
Majority of patients - they want to look acceptable, have a pleasant smile and be able to eat normally. Most are not interested in having absolutely perfect-appearing teeth that are snow-white. However, usually they will accept a moderate level of esthetic upgrade while receiving therapy for their dental caries or defect restorations.These patients usually involved a phased treatment plans spanning several years.The patients should be well INFORMED of which part of their therapy is mandatory and which part is purely electiveUsually involve bleaching, a few veneers or crowns and restoring any obviously displayed metal restorations or darkened teeth with crowns.
Treatment of All Teeth For Therapeutic or
Esthetic Reasons
This level of oral rehabilitation is being promoted in many continuing
education courses and routinely is suggested to patients.
Usually, crowns, veneers, elective cosmetic periodontal surgery, some
occlusal therapy, perhaps elective endodontic therapy or orthodontics
and even orthognatic surgery are suggested.
Much of the treatment is for esthetic reasons only and is not required for
any therapeutic reason.
If a patient is INFORMED that the therapy is not required because of
disease, and that it is elective and primarily esthetic, the matter of ethics
becomes somewhat clearer.
However, if the patient is led to believe that the mostly esthetic therapy
is needed for therapeutic reasons, including questionable occlusal
pathosis, or if the more conservative therapies are not explained to the
patient, the practitioner is treading on unethical ground
Understand what type of
patient you are dealing withMay give you some clue on their preferences
Will influence what type of
treatment/procedure/material used
People do not change - try to make small
incremental improvement
Try to institute phased treatment
Types of Patients
Patient never been to dentist in Iraq
Recent immigrants from village.
May have a lot of “unconventional” dentistry done in
his/her village.
Educate, take care of acute needs first before trying to
fix those “unconventional” dentistry.
Types of Patients
Last trip to dentist - over 5 yearsPhobic, not health conscience, only go when I have painTry to understand where they are coming from, and why they are hereUsually they have an acute needTake care of their acute needs, then present a phase approach - acute needs (disease that cause pain), take care of larger lesion, debridement, smaller lesion, missing teeth, cosmetic…
Types of Patients
Last trip to dentist - 2 to 5 years
No insurance, feel very uncomfortable going to a dentistUsually have an acute needMore aggressive in prescribing treatment - less confidence in monitoring small lesion
Types of Patients
Patients that come in at least once every 2 years
Regular patientMore comfortable in monitoring small lesionsStill need to understand what they preferences are:
Cost conscienceI want the bestMissing teeth not a concernValue your judgment and recommendationJust take care of my basic needsEsthetically sensitive
Treatment Planning Models
Treatment oriented model
Problem oriented model
Treatment Oriented Model
Dentist examine the patient
Dentist mentally equate the findings to the need for
certain form of treatment
Examination findings are summarized in the form of a
list of treatments -TREATMENT PLAN
Useful in simple cases
Problem Oriented Model
Examination lead to formulation of a list
of problem
Each problem on the list is then
considered in terms of treatment options
Informed patients of all the options
Formulate the TREATMENT PLAN
Problem Oriented Model
Problem Lists
(Objective findings from
oral and radiograph exam)
Formulate Treatment Options
Patient’s
Preferences/factors
(Subjective Findings)
Caries Risk
Assessment
Treatment Plan
Patient’s Preferences
Informed Consent
Patient’s Preferences
Address patient’s chief complainAsk questions - assess patient’s true preferencesUnderstand what is the treatment objectives for the patient (better function, better esthetic?)Understand what type of patient you are dealing withPreference for the types of restorations/procedures (e.g. fixed vs removable, direct vs indirect restorations)Can the patient afford the procedures he/she desires?Patient’s dental IQ - long term maintenanceEsthetic - understand their true concern
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.Patient’s caries risk status will affect the treatment (materials and procedures, treatment vs no treatment) you are going to prescribe.Patient’s caries risk will determine recall intervals and radiograph exposure intervals.For the high risk patients (caries active or caries prone),
a strategy to control the disease should be formulated and documented in the treatment plan.
Review- Dr. Hildebrandt’s Fall semester manual - Current Concepts in Caries Control
Dental Caries - an Infectious Disease
Etiologic agent - specific pathogens (Specific Plaque Hypothesis)Signs and symptoms of the disease - localized dissolution and destruction of calcified tissue.It is very easy to focus narrowly on treating the signs and symptoms ONLY (restorative needs); thus failed to identify the underlying cause of the disease.Failure to address the underlying cause of the disease will allow the disease to continue.Restoration alone do not and will not treat the disease
High Caries Risk Patients
Must identify the underlying reason(s) for the high risk.Not been to a dentist for years or poor oral hygiene are seldom the ONLY factorSalivary flow? Diet?MUST educate and formulate a control measures plan
Problem Oriented Model
Problem Lists
(Objective findings
from oral and
radiograph exam)
Formulate Treatment Options
Patient
Preferences/factors
(Subjective Findings)
Caries Risk
Assessment
Problem List
Dental caries - rampant caries
Poor oral hygiene
Caries Risk Assessment
Caries active identify the underlying reason(s)
Poor oral hygiene and not been to dentist
since high school should not be taken as
the “convenient” reason.
Caries Risk Assessment
GoalsIdentify the underlying reason(s) - EDUCATE the patient.FORMULATE control measures.ASSESSING patient’s ability to change (habits).These goals are as important if not more important than the restorative part of your treatment plan. Success/failure of the restorative phase will depend on whether you can achieve the goals stated above.
Patient’s Preference/Factor
GoalsFormulate a preliminary plan based on
patient’s preferences and the overall
treatment goal.
Narrow down options
Overall Treatment SchemeInitial treatment phase -treating the symptoms of the disease (massive tooth
morbidity).
Therapeutic Phase Evaluation -evaluate the success/failure of therapeutic phase
Final Restorative Phase
Therapeutic Phase
- control measures
Initial Restorative Phase
Options available for dealing with massive tooth morbidityDirect Restoration RCT Extraction
Treatment optionsExtract all teethExtract teeth that are unrestorable onlyExtract teeth that will need RCTExtract teeth that are unsuitable/unnecessary to support a
removable partial 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
Therapeutic Phase Evaluation
Was the control measures prescribed
successfully change the patient from high
caries risk to low caries risk, or at least have
the disease under control.
No final treatment phase should be initiated
until the risk is under control
Final Restorative Phase
Indirect restorations
Crowns and bridges
Removable appliances
