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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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Reasons for the variation in
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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Reasons for the variation in
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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Reasons for the variation in
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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Reasons for the variation in
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