Clinical Treatment Planning

Treating Clinician:

The plans where useless, but the planning was indispensable. Dwight Eisenhower, WW2

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Patient Name:Gender:Date of Birth:Age:Marital Status:Race:Date of Initial Examination:Occupation: Personality Type:

Treatment Planning Case Presentation.

Introduction and Background.

Introduction-Background

Chief Dental Complaint:

Reason for Initial Visit:

Oral Image and Expectation:

Medical History

ASA:Medications: Allergies:Smoker:Systemic Diseases:

Dental HistoryPrevious Dental Treatment History: What does the patient desire?

Diagnostic FindingsHead and NeckNodes: TMJ/Mandibular:Range of Motion: Functional:Joint sounds:Tenderness to musculature palpation:Myofacial pain:Headaches:

Extra-Oral - Face/Profile/Symmetry

Extra-Oral : Lips/Smiles

Extra-Oral - Buccal Corridors

Combination Chart

Periodontal Chart

GI – PI – Heavily restored

Intra-oral Images: (Soft tissue)

LR

Intra-oral, Anterior – (Soft Tissue)

LR

Intra-oral - Occlusal Views LR

Radiographs LR

Radiographs LR

Radiographs LR

Radiographs LR

Radiographs LR

Images - Intra oral, Including casts LR

Images - Intra oral, Including casts LR

Images - Intra oral, Including casts LR

R Intra-oral.

Description and Images LR

Occlusal Notes

Class occlusion:Class:Incisal guidance and Canine GuidanceNo non-working interferences.CO/CR/MIP - relationship: Slide

Occlusal Images LR

Occlusal Images LR

Occlusal Images LR

Problem list

Summary of ConcernsInteresting issues related to this case that warrant discussion prior to treatment? •Wear•Expectation•Are there phasing issues? • Depending on treatment plan chosen, see treatment outline below.Are there conflicts between what is best and what the patient wants or will tolerate?•Possible cost, depending on treatment plan chosen

Diagnosis and Prognosis

AAP Type: AAP Hopeless: #’sGuarded: #’s See risk factors.Good: The rest, assuming homecare improvement, and patient pursues prescribed treatment.

Comprehensive CareComprehensive Care

CariesEndodonticsPeriodonticsPeriodontics

Restorative Dentistry

PredictabilityFunction and

Esthetics.

Treatment Planning Work Sheet.Additional consultations requested:Disease control, aka. Initial Therapy, Phase 1 Therapy,

Restorative: Periodontal: Endodontic: Oral Surgical: Other:

Reconstructive DentistryPeriodontal:Orthodontic:Oral Surgical:Restorative:Prosthodontic:Esthetic enhancement:Functional:Other:

MaintenanceProfessional:Patient:

•Treatment Plan•Break out time - 30 min

•Group A Ideal, costs are not a factor•Group B Ideal, costs are a factor•Group C The best you can do,

costs and time are major factors.

•Outline Goals/Objectives of Treatment

Doctors Proposed

Treatment Plan

Phase I: Disease control. Includes:

Periodontal: HCI;

PROPOSED

Phase II

PROPOSED

Phase III

PROPOSED

Phase IVDefinitive treatment

Phase IV

PROPOSED

Phase V

PROPOSED

Phase VI:

Phase VII Maintenance q 3 months, alternating

with the Periodontist.

PROPOSED

Actual treatment provided

Actual treatment providedDisease Control: Caries/SRP/Endo/Etc

Actual treatment providedOrthodontic/Oral surgery/Orthognathics

Actual treatment providedRestorative

Actual treatment providedReconstructive

Actual treatment providedMaintenance

Actual treatment providedSupplemental over time/

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Name Tags and CE sheets

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