treatment planning 2011

8/10/2019 Treatment Planning 2011

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DENTAL HEALTH SERVICES VICTORIA

Continuing Professional Development Program

Treatment planning in generaldental practice: an overview

Dr Kevin Nicholson


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Treatment planning in general

dental practice

History & Clinical Examination

Case Assessment

Treatment Planning


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Treatment planning in generaldental practice

History

Examination

Datacollection/recording

Primary input

Medical History Dental History

Clinical examination

Additionalinvestigations

Case Assessment

Evaluation of input data

Diagnosis/aetiology

Risk assessment

Prognosis

Treatment options

Treatment riskfactors

Provisional treatmentplan(s)


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dental practiceHistory

Examination

Secondary input

Training &experience

Clinical interests

Patient expectations

Patient motivation

Case Assessment


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dental practice History

Medical History

Dental History

Examination Case Assessment

Treatment Plan


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dental practiceThe agreed course of treatment

should satisfy the patients expectations

meet the patients treatment needs

must fall within the dentists range of skills &abilities

Patient needs must be met while meetingprofessional & contemporary standards in clinicalcare


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dental practiceTreatment should improveoral health

Include prevention of disease

pain management & provision of comfort

Patient motivation is a necessary prerequisite toeffective dental care

Irregular attenders must become regularattenders


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WHY PLAN TREATMENT?

Strategy for dental care should:

meet patients realistic expectations

be based on knowledge/understanding of patients

medical & dental history

personal & social history

provide goals & treatment options

provide knowledge of ongoing needs & costs


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WHY PLAN TREATMENT?

Strategy for dental care should:

be appropriate to dentists knowledge, training &experience

enhance patient confidence & well-being

educate re ongoing care & maintenance

minimise post-operative problems & patientdissatisfaction


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WHY PLAN TREATMENT?

The treatment plan should: be based on an informed & comprehensive

approach

include all feasible treatment options

ensure an appropriate order & time-span

resolvethe patients presenting complaint

provide for optimal long-term outcomes


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WHY PLAN TREATMENT?

The treatment plan should:

estimate the prognosis, including possiblesequelae & complications

minimise the risk of misunderstandings & adverselegal consequences

encourage the patients continuing confidence

facilitate ongoing monitoring & maintenance


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INITIAL APPOINTMENT

Patient interview


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INITIAL APPOINTMENT

Recording General Information Date of examination

Consulting dentist

Patient referred by

Patient name

Date of birth

Home address

Contact details

Emergency contact


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INITIAL APPOINTMENT

Medical History

Medical History Questionnaire

Current & past medical history

Systems review

Medication review


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INITIAL APPOINTMENT

Medical History General health?

Seeing physician for any health reasons?

Taking any medicines, tablets, injections?

Previously in hospital for any illness, operations,medical procedures?

Any known allergies/smoker?

Pregnant?


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INITIAL APPOINTMENT

Medical HistoryAssessment of medical history

Antibiotic cover required for any reason?

Does medical history affect diagnosis?

Does medical history affect treatment in any way?

Does current medication require change for dentaltreatment?

Will medical consultation be required?


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INITIAL APPOINTMENT

Medical History

Medical /specialist referral requiredfor combined

management?

Any change in medical statusduring course of dentalcare?

Appropriate record-keeping


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INITIAL APPOINTMENT

Psychological status

History of:

neurosis psychosis

anxiety

depression

personality traits/disorders

current medical management; other care


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INITIAL APPOINTMENT

Habits

Smoking

Sucrose drinks

Substance abuse

Parafunction, Bruxism


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INITIAL APPOINTMENT

Personal, Family & Social history Occupation

Employment status

Economic/social status Recreation, sports activities

Patient expectations & attitude

Availability to attend for treatment & maintenance

Special requirements, eg wind instrument players,singers, film/television actors


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INITIAL APPOINTMENT

Personal, Family & Social historyPatient expectations & attitude

Value of patient knowledge & experience of

treatment

Feedback from patients post-treatment

Value of patient questionnaires relating toexpectations


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INITIAL APPOINTMENT

Dental History


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INITIAL APPOINTMENT

Dental History Presenting Complaint

History PC

Past Dental History

Reasons for tooth loss

Denture history, past

experience Attendance pattern

Past dental experience

Restorative

Endodontics

Orthodontics

Periodontics

Past extractions, surgery


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CLINICAL EXAMINATION

Recording Clinical Information

Odontogram

Clinical Notes


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Extra-oral examination (Head & Neck) General morphology

Skeletal base

Skin lesions

Lymph glands

Neck & facial muscles

Lip support/seal

TMJ


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Intra-oral examination Soft tissues/oral mucosa

Underlying bony structures

Masticatory muscles

Dental examination

Periodontal examination

Occlusal examination

Existing prostheses

Oral hygiene/Saliva


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Soft tissues/Oral mucosa Tonsils, fauces, fossae

Posterior pharyngealwall

Soft palate

Lips

Cheeks

Tongue

Floor of mouth


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Soft tissues/Oral mucosa Site

Size

Shape

Colour

Surface

Surroundings

Texture

Bleeding on gentlewiping?

Description, drawing,photograph in clinical notes


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Underlying bony structures Maxillary, mandibular

Arch size, form

Residual ridge contour

Palatal vault

Maxillary tuberosities

Tori

Bony undercuts

Muscle & frenumattachments


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Masticatory muscles Elevators

Masseter, temporalis, int. pterygoid

Depressors

Mylohyoid, geniohyoid, ext. pterygoid, digastric

Tendernesson gentle palpation?

Attachment relationship to residual ridge


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Oral hygiene Halitosis

Tongue surface

stains/debris

Dental plaque

Dental calculus


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Saliva

Quantity

Quality


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Dental Teeth present, missing

(Count, account)

Attrition

Abrasion

Abfraction

Erosion/Corrosion

Caries


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Dental

Hypomineralisation

Staining, discoloration

Gingival recession,exposed root surfaces

Dentine hypersensitivity

Enamel faceting

Dentine cupping


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Dental

Open contact areas,food impaction

Plunger cusps

Restorations

adequate

inadequate

fractured

gingival overhangs


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Dental Trauma Crown infraction

Uncomplicated crown

fracture, complicatedcrown fracture

Uncomplicated crown-

root fracture,complicatedcrown-rootfracture

Root fracture


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Dental TraumaPeriodontal tissues Concussion

Subluxation (loosening)

Intrusive luxation(intrusion)

Extrusive luxation(extrusion)

Lateral luxation

Exarticulation (avulsion)


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Dental TraumaSupporting bone Comminutionof alveolar

socket

Fracture of alveolarsocket wall

Fracture of the alveolar

process

Fracture of mandible ormaxilla


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Periodontal Oral hygiene

procedures brushing

interspace brush flossing

superfloss

other

Oral hygiene Plaque index (date/score)


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Gingival,PeriodontalGingival tissue

Colour

Swelling

Bleeding Ulceration

Exudate

Suppuration

Papillae

Marginal gingivae

Attached gingivae


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Gingival, Periodontal Psuedo-pocketing

gingival swelling?

gingival hyperplasia?

Gingival tone soft, spongy

firm friable

ulceration

desaquamation


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Gingival,Periodontal

Attached gingivaAdequate width

Diminished width

Mucogingival lesion

Frenal attachments

Gingival recession Dentine

hypersensitivity


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Periodontal

Gingival recession

6 sites per tooth

Pocket probing depths 6 sites per tooth

bleeding on probing


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Periodontal Suppuration

Furcation sites

Fremitis

Mobility Gr I GrII

GrIII


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OcclusionArrangement &

position of teeth

Drifting

Tilting/inclination

Rotation

Supra-eruption

Crowding/imbrication


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OcclusionArrangement & position of teeth

Contact areas/open contacts

Diastemas

Cuspal inclines

Wear facets


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Occlusion Angle classification

Overbite/overjet

Anterior/posterior open bite

Rest vertical dimension/occlusal vertical dimension

Freeway space


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OcclusionOcclusion & articulation

Intercuspal position (ICP, CO)

Retruded contact position (RCP, CRO) ICP coincides with RCP?

Premature contacts in RCP?

Mandibular shift from initial point ofcontact in RCP?

Mandibular deviation on opening/closing?


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OcclusionOcclusion & articulation

Fremitus

Mandibular excursions; excursive contacts Working/balancing sides; protrusion

Cuspid rise; group function; balanced

occlusion? Working side interfering contacts?

Balancing side contacts?

Posterior disclusion?


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Occlusion

Occlusion & articulation

Faceting/wear of occlusal surfaces? Parafunction; clenching, bruxism?


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Occlusion


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Existing prostheses

Removable

Fixed

Implant retained

prostheses Provisional prostheses

Occlusal splints

General comments;finish, form, contour

Fit

Retention Extensions

Stability

Aesthetics

Comfort,function,speech

Occlusion/occlusalanalysis


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Further investigations

Pulpal response tests

Plaque/gingival indices

Saliva testing

Radiographicexamination

Study casts

Clinical photographs


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Further investigations

Dietary analysis

Medical investigations

Biopsy procedures

Referral tophysician/medical

specialist Referral to

dentist/dental specialist


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Further Investigations:

Extra oral Radiographs


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Intra oral Radiographs


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Intra oral Radiographs


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EXAMINATION & TREATMENT PLANNINGIN GENERAL DENTAL PRACTICE

HISTORY TAKING

CLINICAL EXAMINATION/RECORDING

CLINICAL DATA

CASE ASSESSMENT

TREATMENT PLANNING PATIENT CONSULTATION


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CASE ASSESSMENT

Evaluation of all information obtained

Existing problems? (Diagnosis)

Aetiological/ risk factors evident?

Long term outcome both with & withouttreatment? (Prognosis)

Treatment goals?

Treatment risk factors?

Strategy for management? (Treatmentoptions)

Formulation of a treatment plan


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CASE ASSESSMENT

Evaluation of all information obtained

Considering treatment goals

Overall treatment goals

Goals of individual treatment procedures

Considering treatment options

Considering treatment risk factors

Concept of the phased treatment plan

Concept of the provisional treatment plan


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TREATMENT PLANNING

Phased treatment plan

Provides for: appropriate sequential order of treatment

procedures

effective & efficient treatment needs

customised & optimal treatment needs


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TREATMENT PLANNING

Phased treatment planAllows the patient to participate in: their own treatment needs & dental health

maintenance

flexibility within and between phases ofmanagement

not all patients require treatment within allphases of management


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TREATMENT PLANNING

Phased treatment plan Phase 1 (Preliminary phase)

Phase 2 (Interim phase)

Phase 3 (Restorative/prosthetic phase)

Phase 4 (recall/review/maintenance)


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TREATMENT PLANNING

Phase 1 (Preliminary phase)

Treatment goals

Resolution of acute problems Stabilisation/elimination of active disease


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TREATMENT PLANNING

Phase 1

Treatment procedures Relieving pain & discomfort

Managing risk factors; local, systemic

Elimination active carious lesions

Extraction of teeth with hopeless prognosis


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TREATMENT PLANNING

Phase 1 Treatment procedures

Instituting effective plaque control

Initial periodontal therapy Scaling & root planing

Direct restorations

Temporary or provisional prostheses


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TREATMENT PLANNING

Phase 1 Reassessment of Phase 1

Addressed patient's presenting complaint?

Comfortable, stable dentition?

Control of risk factors; systemic, local?


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TREATMENT PLANNING

Phase 1

Tissue response to periodontal treatment?

Patient motivation to continue treatment?

Review phase 2 & 3 treatment goals


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TREATMENT PLANNING

Phase 2 (Interim phase)

Phase 2 treatment goals Elimination of active disease sites

Maintenance of gingival/periodontal health

Periodontal pocket elimination


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TREATMENT PLANNING

Phase 2 (Interim phasePhase 2 treatment goals

Regeneration of periodontal attachment

loss Infrabony defects Furcation sites

Stabilisation of gingival position, contours Management of localised gingival recession


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TREATMENT PLANNING

Phase 2 (Interim phase) Phase 2 treatment procedures

Periodontal surgery

Pocket elimination; periodontal plastic surgery

Regeneration of periodontal attachment loss

Infrabony defects

Furcation sites


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TREATMENT PLANNING

Phase 2 (Interim phase) Phase 2 treatment procedures

Direct (non-complex) restorations

Repairs/relines to existing prostheses

Oral surgery, complex extractions eg 8's

Endodontics

Orthodontics


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TREATMENT PLANNING

Phase 2

Phase 2 treatment procedures Periodontal, osseous & mucogingival surgery

Flap procedures, open debridement

Crown-lengthening procedures Gingivectomy, gingivoplasty

GTR, bone grafting/ridge augmentation

Crown-lengthening procedures

Soft tissue grafting, gingival, ridge

Implant placement procedures


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TREATMENT PLANNING

Phase 2 Phase 2 treatment procedures

Provisional prostheses


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TREATMENT PLANNING

Phase 2 Reassessment of Phase 2

Active disease sites?

Plaque score acceptable to proceed toPhase 3?

Acceptable gingival contours/aesthetics?

Patient interest/motivation?

Review Phase 3 treatment goals


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TREATMENT PLANNINGPhase 3 (Restorative/prosthetic phase)

Phase 3 treatment goals Maintenance of gingival/periodontal health

Restoration of function & aesthetics Occlusal stability

Establishing a determined occlusal scheme

Establishing a new occlusal verticaldimension


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TREATMENT PLANNING

Phase 3

Phase 3 treatment procedures Occlusal analysis/diagnostic wax up

Direct & indirect restorative procedures Fixed prosthodontics

Removable prosthodontics

Implants/prostheses

Provision of protective night guards


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TREATMENT PLANNING

Phase 3

Reassessment on completion of Phase 3

Phase 3 treatment goals met? Review treatment outcomes Phase 1, 2, 3


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TREATMENT PLANNINGPhase 4 (Recall, review, maintenance)

Phase 4 management goals Disease free long-term maintenance

Maintenance of gingival/periodontal health Long term comfort, function, aesthetics

Occlusal stability

Maintaining patient motivation &participation, responsibility

Overall patient well-being


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TREATMENT PLANNING

Phase 4

Phase 4 management procedures Check appointments, 48 hrs, 7 days, 10 days

Address concerns

Short term, 612 weeks Short term recall, review/reassessment

Longer term, 3 mths12 mths Longer term recall, review/reassessment

Maintenance program


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PATIENT CONSULTATION

Presentation & discussion of treatment plan

Patient consent

Appointments; fees & financial arrangements

Confirmation of treatment plan


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Presentation/discussion of treatmentplan

Dentist provides adequate information Questions & answers

Patient makes informed decision

Patient expectations may differ from that

of dentist Provisional/definitive treatment plan


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Patient consent Dentist must assist patient to make well-informed

decisionsabout treatment procedures

For complex procedures, expressed consent,verbal or written is required

For valid consent, information about the risks &consequencesof the proposed procedures mustbe provided

Patient must understand what is consented to!


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Appointments No. of appointments

Duration of appointments

Time frame to complete treatment plan/phases

Fees & financial arrangements


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Follow up letter confirming: Diagnosis/es, prognosis, treatment plan

Any referrals as discussed

Time lines, fees, financial arrangements

T t t l i i l


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dental practice: an overview

History & Clinical Examination

Case Assessment

Treatment Planning

T t t Pl i i G l


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Treatment Planning in General

Dental PracticeClinicians must:

Continue todevelop & enhance diagnostic skills,including aetiology, risk factors & prognosis

Provide acomprehensive treatment planforappropriate, effective & efficient treatment, referringto specialists where necessaryfor advice or

management

Evaluate all treatment outcomesand provideappropriate long term management


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EXAMINATION & TREATMENT PLANNINGReferences

Dental Practice Board of Victoria (2007). Dental Records Code

of Practice No. C003.

See also DPBV 1001 Information on Dental Records & 1002

Consent: Assisting patients to make well-informed decisions

Ibbetson, R (1999). Treatment planning. BDJ 186:11, 552-558.

McLeod, DE (2000).A practical approach to the diagnosis &treatment of periodontal disease, JADA 131:4, 483-491.

Palmer, R & Howe, L (1999).Assessment of the dentition &

treatment options for the replacement of missing teeth.BDJ 187:5, 245-255.

Renvert, S & Persson, GR (2000). Supportive periodontaltherapy,Periodontology Vol 36, 179-195.

T t t Pl i i G l


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Treatment Planning in General

Dental Practice: case study

T eatment planning in gene al


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dental practice: case study



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dental practice: case study



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dental practice: case studyGeneral Information: 65 yr old male

MH:

Generally healthy History of high bp, sees medico 1/12

Coversyl 4 mg /day last two years

Smoker 10+ per day

No family history diabetes No allergies

No CVD, no rh fever, no kidney disease, no Hep/HIV

PC:

Broken filling upper right back tooth



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dental practice: case studyHPC: Many restorations placed & broken over last few years

No pain, sensitivity, no tenderness/swelling

PDH:

Last dental treatment (Xn 16) 9 mths ago - nocomplications

Previous Xns (35, 36, 37, 46) 3-4 yrs ago

Previous fillings over last few years

RCTs (25, 45) > 5 yrs ago

Tooth coloured veneers (11, 21) 5 yrs ago

Previous scalings over last appointments



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dental practice: case studyOE: Extra-oral:

No skin lesions, no lymph node swelling/tenderness, No TMJ

tenderness/clicking; mandibular movements OK Intra-oral

Mucosa/Bony structures

Dental

Gingival/periodontal Occlusion

Existing prostheses

Oral hygiene

Saliva



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dental practice: case study Dental Missing 18, 16, 28, 35, 36, 37, 46, (48)

Recurrent caries 12MD, 13D, 26M, 44D, 45D

Heavily restored 14, 15, 11, 21, 24, 25, 45 RCT 25, 45 (adequate?)

Gingival/periodontal

Gingivae pink, firm; papillae blunted 15 - 27, 35 - 45

PPD 2-4mm all sites, except 24 - 27 proximal PPD 4 -6mm

26 DP furcation GrII, 6+ mm 26 D, 27 M

Bleeding on probing all proximal sites

No mobility



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dental practice: case study Occlusion Angle Cl I; loss of posterior occlusion R & L

Existing prostheses none

Oral hygiene

Subgingival calculus all segments ++

Plaque Index 70%

Additional investigations:


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Additional investigations:Radiographic Report

Radiographic report Panoramic radiograph of partially dentate maxilla/mandible

Intraoral periapical radiograph 24, 25, 26, 27; male patient 65yrs old

Dental structures Teeth missing: 18, 16, 28, 35, 36, 37, 46,

48 u/e (mes. angular impaction)

Restorations: Amalgam 17,13, 24, 26, 27, 38, 44, 45,47; Resin/GIC 15, 14, 12, 11, 21, 25

RCT: 25, 45 (short of apex), 25 parallel post

Dental caries: 12MD, 13D, 26M, 44D, 45D

Calculus: 27M



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Supporting structures Early horizontal bone loss all segments

Vertical bone loss:15D, 25D, 26M, 27M, 38M, 25D, 47M

Furcation bone loss: 26DP

Residual ridge bone loss: 16, 35, 36, 37

Adjacent structures:TMJ disc space regular, well-defined

Diagnoses Missing teeth: 18, 16, 28, 35, 36, 37, 46

U/E impacted: 48 mes-angular impaction

Recurrent caries?: 12MD, 13D, 26M, 44D, 45D

Inadequate RCT?: 25, 45



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Diagnoses ? Generalised chronic periodontitis with early horizontal bone

loss; irregular vertical bone loss 25, 26, 27

Furcation bone loss 26DP

Heavily restored teeth 15, 14, 11, 21, 25, 45

Additional information? FM periapical radiographs, long cone technique

Review dental history; aesthetics?, function?, comfort? Review examination data re caries, restorations/residual tooth

structure 15, 14, 11, 21, 25, 45

Full periodontal charting /assessment if not completed



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Additional investigations:Pulp sensibility

CO2 test:

15, 14, -ve

Study casts

Clinical photographs

anterior, R & L lateral views of gingivae/dentition


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Case Assessment

Diagnosis

Missing teeth as charted

Recurrent caries

Heavily restored GIC 15, 14, 25

14, 15, non-vital pulp response

Poor aesthetics 11, 21, RC veneers

Generalised chronic periodontitis (early to moderate)all sites, except

Chronic periodontitis 25 - 27 ( mod to severe), withGr II furcation bone loss 26D


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Case Assessment

Aetiology/Risk factors

Local factors; dental plaque, recurrent caries,irregular bone loss/furcation Gr II

Other factors; smoking Prognosisfor overall dentition

Fair to good

Prognosis for 26

without treatment long term prognosis poor

with management, guarded (furcation II)


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Case Assessment

Prognosis 15, 14, 25

Poor (non-vital, lack of tooth structure)

Patient motivation

Good

Treatment goals

Restore comfort, function, aesthetics Eliminate caries activity

Control, eliminate active periodontitis

Long term dental & periodontal health

Long term patient motivation, attendance


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Treatment Plan

Phase I

Scale & root plane all teeth, F application

Oral hygiene instructions; toothbrushing,

interspace brush, superfloss, home disclosingsolution

Management of dentine hypersensitivity?

Restoration 12MD, 13D, 26M, 44D, 45D

Extraction 14, 15, 25

Provisional P/- acrylic denture (aesthetics)

Refer 48 Xn


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Treatment Plan

Phase 2

Review all Phase 1, 6/52

Review OH

Gingival/periodontal status, PPD

Rescale perio sites as required, eg 26D

Reassess prognosis of 26

Refer periodontist advice 26?

PPD not reduced, bleeding, cleanability?


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Treatment Plan

Phase 3

Review specialist management 26 as required

26 for Xn if required

Review OH

Patient motivation

Restore 11, 21

Ceramic labial veneers

P/P Co-Cr removable dentures


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Treatment Plan

Phase 4

Review all treatment carried out 12/52

Review OH

Review gingival/perio status, PPD

Scale & polish all teeth, F application

Assess re ongoing maintenance

Recall examination 3 -6 months

Regular SRP (3 - 6 months?)

Reline P/P 6/12


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Treatment Planning in General Dental practice

treatment planning 2011

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