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L6 Developing the Treatment Plan

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Developing the Treatment Plan12

DENT 4215: Introduction to Clinical Dental Practice

Presented by: Manorika Ratnaweera

The University of Western Australia acknowledges that its campus is situated on Noongar land, and that Noongar people remain the spiritual and cultural custodians of their land, and continue to practise their values, languages, beliefs and knowledge.

Artist: Dr Richard Barry Walley OAM

Introduction to Treatment Planning

Learning Outcomes and Objectives3

Clinical Implementation4

  • Compose and implement initial treatment plans to prepare patients for further dental treatment.
  1. Develop fundamental knowledge necessary to begin creating treatment plans for patients
  2. Documenting treatment plans

Information Gathering and Diagnosis

Process of Information Gathering5

  1. Information Gathering
  • Patient history
  • Radiographic examination
  • Clinical examination
  • Diagnostic aids
  1. Evaluation of Findings
  2. Significant Findings
  3. Risk Analysis
  4. Comprehensive Diagnosis

Diagnostic Classifications6

  • Definitive diagnosis: When several findings point clearly to a specific disease entity.
  • Differential diagnosis: When the findings suggest several possible conditions; the process of distinguishing among the list of possibilities.
  • Tentative diagnosis: When the diagnosis is uncertain, but it is prudent to begin some type of treatment.

Treatment Objectives and Modifiers7

Treatment Planning Workflow8

A comprehensive diagnosis list leads to treatment objectives, which are then filtered through patient and practitioner modifiers to achieve informed consent and the final treatment plan(s).

Patient Modifiers

  • Interest in Oral Health (OH)
  • Financial capability (Can afford vs. Cannot afford)
  • Attendance patterns (Regular attender)
  • Psychological factors (Fear of dentistry, poor motivation)
  • Lack of interest in OH

Practitioner Modifiers

  • Development of an “Ideal treatment plan”
  • Focus on removing disease
  • Correct treatment for each problem
  • Proper sequencing of procedures
  • Selection of best materials
  • Time efficiency

Treatment Objectives

Definition and Rationale

Definition of a Treatment Plan9

According to Sturdevant (1995), a treatment plan is a “carefully sequenced series of services designed to eliminate or control etiological factors, repair existing damage and create a functional maintainable environment.”

Rationale and Purpose

  • Created as a response to the problem list.
  • Establishes the schedule and sequence of treatment.
  • Develops a course of action that encompasses the ramifications and sequelae of treatment to serve patients’ needs.

Objectives of Treatment Planning10

  • Address patient’s problem/s
  • Sequence and prioritize care
  • Provide estimates of costs
  • Facilitate informed consent
  • Maintain accurate record keeping
  • Fulfill medico-legal requirements
  • Enable communication with other clinicians

Phases of the Treatment Plan11

The development of a treatment plan is organized into five distinct phases:

  1. Systemic phase
  2. Acute phase
  3. Disease Control phase
  4. Definitive phase
  5. Maintenance phase

Phase 1 Systemic Phase12

Objectives of the Systemic Phase13

  1. Health Evaluation: Evaluate the severity and complexity of health issues and assess how they may affect dental treatment.
  2. Diagnosis and Referral: Recognize signs and symptoms of undiagnosed conditions and refer the patient to a physician for evaluation.
  3. Treatment Modification: Limit or modify dental treatment based on systemic findings.
  4. Prevention of Adverse Outcomes:
  • Manage potential emergencies in the dental office.
  • Prevent serious postoperative complications (e.g., antibiotic prophylaxis for high-risk dental procedures in specific medical conditions).

Clinical Outcomes and Risk Categories

Clinical Outcomes and Management

  • Postponing or Limiting Treatment: Necessary for conditions such as uncontrolled hypertension, specific INR levels, requirement for antibiotic prophylaxis, or unstable angina.
  • Physician Consultation:
    • Prescribing or altering patient medication.
    • Managing hypertension.
    • Addressing suspected systemic disease identified in the dental office.
  • Stress Management: Critical for patients with cardiac disease, diabetes, unstable angina, or adrenal disorders.
  • Patient Positioning: Adjusting the dental chair position based on systemic needs.

Risk Categories for Selected Dental Procedures

  • Little to no risk:
    • Oral examination, radiographs, study models
  • Low risk:
    • Local anesthesia, simple restoration, prophylaxis, asymptomatic endodontics, simple extraction, orthodontics
  • Medium risk:
    • Symptomatic endodontics, multiple extractions, single implant, deep scaling and root planning
  • High risk:
    • Extensive surgical procedures, multiple implants, general anesthesia (G/A)

Phase 2 Acute Phase

Overview of Acute Care14

  • The acute phase incorporates diagnostic and treatment procedures aimed at solving urgent oral problems.
  • Patient Profiles Requiring Acute Care:
    • Patients under active treatment
    • Patients on maintenance recall
    • New patients to the dental practice
    • Patients returning to the practice after a significant absence

Emergency Versus Urgent Problems

Categorizing Urgent Problems

  • Emergency Problem: Incapacitates the patient and has the potential to become a life-threatening condition.
    • Examples: Swelling, systemic infection, trauma to face or jaws.
  • Urgent Problem: Does not require immediate attention, but the dentist or patient believes it should be attended to “now” or “soon.”
    • Example: Mild to moderate pain without active infection.

Common Acute Problems and Diagnoses

  • Complaints of Pain:
    • Pulpal or periapical origin
    • Periodontal tissue associations (e.g., periodontal abscess, NUG)
    • Tooth eruption or pericoronitis
    • Previous dental treatment complications
    • Other sources: Herpetic ulcers, traumatic ulcers, stomatitis, TMJ disorders, trigeminal neuralgia, acute sinusitis
  • Other Categories:
    • Swelling
    • Aesthetic complaints
    • Traumatic injury (teeth, soft tissues, jawbone fractures, osteomyelitis)
    • Oral pathology (lesions requiring biopsy, consultation, or referral)

Planning Considerations

  • Focus on short-term therapies within the clinician’s competency.
  • Consider long-term implications of short-term therapies or options.
  • Factors Influencing Decisions:
    • Professional factors
    • Patient factors and modifiers
    • Combination factors

Informed consent for acute care requires the patient to be fully aware of:

  1. The diagnosis
  2. All reasonable treatment options
  3. Risks and benefits of each option
  4. Nature of the recommended treatment
  5. Present and future costs of treatment

Criteria for Referral or Deferral

  • The problem or offending tooth cannot be identified.
  • The patient has a compromising systemic condition precluding immediate treatment.
  • The patient has an active infection.
  • The patient is unwilling or unable to provide consent.
  • Situations where prescribing medication is more prudent than initiating immediate treatment.

Phase 3 Disease Control Phase

Objectives of Disease Control15

  • Eradicate active disease and infection.
  • Arrest occlusal, functional, and esthetic deterioration.
  • Address, control, or eliminate causes and risk factors for future disease.
  • This phase is specifically indicated for patients with high risk factors for oral disease.

Stabilization Phase Details16

  • Also known as the Stabilization Phase.
  • Not necessary when:
    • Oral disease is already controlled.
    • Oral disease will be eliminated during definitive treatment.
  • Phase Components:
    • Management of active disease or infection.
    • Stabilization of disease and tooth status prior to definitive reconstruction.
    • Modification or elimination of risk factors predisposing the patient to recurrent disease.

Structure and Sequencing

Sequencing Guidelines

  • Chief Complaint: Address as early in the plan as possible.
  • Priority Sequencing: Treat the most severe and urgent needs first (e.g., provisional/protective restorations).
  • Quadrant/Sextant Sequencing: Organize treatment by anatomical areas.
  • Periodontal Integration: Incorporate periodontal therapy into the disease control plan.
  • Flexibility: Keep definitive phase options open by using minimalist treatment during this phase.
  • General Rule: Only procedures necessary to arrest deterioration and prevent further infection should be undertaken.

Structure of the Disease Control Phase

  1. Education
  • Etiology, prevention, and home treatment.
  • Patient roles and responsibilities.
  • Oral hygiene products (type, technique, frequency).
  • Smoking cessation (Ask, Assess, Assist).
  • Chemotherapeutics.
  1. Non-Surgical Periodontal Therapy (NSPT)
  • Plaque control, debridement, and prophylaxis.
  • Risk factor management.
  • Review and referral to periodontist if required.
  1. Caries Management
  2. Remineralization Therapy
  3. Defective Restorations
  4. Extraction/Referral

Caries Management and Risk Status

Caries Management System Protocol

  • Basic caries control protocol:
    • Caries activity tests, diagnosis, and risk assessment.
    • Oral prophylaxis and self-care coaching.
    • Saliva substitutes or stimulation.
    • Remineralization (in-clinic and home care).
    • Chemotherapeutics.
    • Diet and nutrition analysis (food diary focusing on frequency and duration of acids/sucrose).
    • Restoration of carious lesions.
    • Application of sealants on susceptible pits and fissures.
    • Reassessment.

Risk Assessment Tools

  • Caries Risk: CAMBRA
  • Periodontal Risk: PRA (Periodontal Risk Assessment)
  • Oral Cancer Risk: Oral Mucosal Malignancies assessment
  • Tooth Wear Risk: BEWE (Basic Erosive Wear Examination)

Re-Evaluation and Holding Phase

Purpose of the Holding Phase17

  • Represents the time between the control and definitive phases to allow for resolution of inflammation and healing.
  • Key Activities:
    • Reinforce home care habits.
    • Assess motivation for further treatment.
    • Re-evaluate initial treatment and pulpal responses before beginning definitive care.

Phase 4 Definitive Phase

Prerequisites for Definitive Treatment18

The definitive phase is the core of the treatment plan. Before engaging in this phase, the practitioner must affirm:

  • Disease is controlled.
  • All reasonable definitive phase treatment options and costs have been evaluated and discussed.
  • Informed consent has been obtained from the patient.

Common Definitive Procedures

Definitive Phase Procedures

  1. Periodontal Therapy: Surgical or other advanced interventions.
  2. Orthodontic Treatment.
  3. Restorative Dentistry:
  • Multi-surface or indirect restorations.
  • Occlusal assessment and treatment.
  • Esthetic procedures.
  1. Endodontic Procedures: Elective treatments.
  2. Extractions and Pre-prosthetics: Including 3rd molars.
  3. Prosthodontics:
  • Replacement of missing teeth.
  • Crowns, bridges, implants, and dentures.
  1. Specialist Care.

Restoring Individual Teeth

  • Decision Making: Involve the patient or parent; the clinician determines feasible options.
  • Professional Considerations:
    • Diagnosis and Prognosis (Excellent, Good, Favorable, Unfavorable, Poor).
    • Likelihood of remineralization.
    • Caries risk status.
    • Disease control phase outcomes.
    • Cost and patient expectations.
    • Materials and long-term implications.

Specialist Referrals

Orthodontic Referrals

  • The dentist’s role is to identify if a referral for orthodontic assessment is required.
  • Indications:
    • Elective treatment for aesthetics or function.
    • Malocclusions and impacted teeth.
    • Anterior open bite.
    • Skeletal abnormalities.

Specialist Referral Categories

  • Periodontist: For specialized periodontal care.
  • Prosthodontist: For fixed/removable prosthodontics and implants.
  • Paedodontist: For specialized pediatric care.
  • Special Care Dentist: For patients with specific needs.
  • Other Specialists: As identified by the general dentist.

Phase 5 Maintenance Phase

Principles of Maintenance19

  • Long-term success or failure of the treatment plan depends on this phase.
  • Guiding Principle: Prevention of future problems is the responsibility of the entire dental team.
  • Customization: Plans are made on an individual basis at the conclusion of the disease control and definitive phases and can be modified over time.

Rationale and Post-Treatment Assessment

Rationale and Benefits

  • Purpose:
    • Ensure long-term oral health.
    • Maintain optimum function.
    • Achieve favorable aesthetics.
    • Maintain stable clinical attachment levels.
  • Benefits: Address issues that remain unresolved after the definitive phase of treatment.

Elements for Post-Treatment Assessment

  • Patient Evaluation: Concerns/expectations met and response to treatment.
  • History Update: Medical and medication history.
  • Clinical Review:
    • Examination, re-evaluation, and diagnosis (check previous notes).
    • Update radiographs based on need or protocol.
  • Condition Assessment:
    • Periodontal condition.
    • Occlusal and functional status.
    • Caries and restorative condition of teeth.
  • Risk Management:
    • Disease risk (status and severity).
    • Risk factors (predisposing and modifying).
  • Prevention: Recommendations for in-clinic/home remineralization, smoking cessation, and oral health education (OHE).
  • Future Planning:
    • Identify remaining or new treatment required.
    • Re-establish recall intervals based on risk and need.

Treatment Plan Summary and Outcomes

Defining Success20

  • Success is achieved when the patient and clinician agree that disease is controlled, and the dentition is functional, stable, and aesthetically acceptable.
  • Outcomes are specific tangible results closely linked to risk assessment and prognosis determination.

I. Systemic Treatment Summary21

  • Consultation with patient’s healthcare provider.
  • Premedication requirements.
  • Stress and fear management.
  • Special positioning of the patient.
  • Treatment considerations for systemic disease.

II. Acute Treatment Summary22

  • Emergency treatment for pain or infection.
  • Treatment of the urgent chief complaint when possible.

III. Disease Control Summary23

  • Restorability: Caries removal to determine the status of questionable teeth.
  • Extractions: Removal of hopeless or problematic teeth (including provisional replacement).
  • Periodontal Control:
    • Oral hygiene instruction.
    • Initial therapy (scaling, root planning, prophylaxis).
    • Controlling contributing factors (replacing defective restorations, eliminating habits/smoking).
  • Caries Control:
    • Risk assessment.
    • Provisional and definitive restorations (amalgam, composite, glass ionomers).
  • Maintenance: Repair defective restorations and perform endodontic therapy for pathologic conditions.
  • Stabilization: Use of foundation restorations and post-treatment assessment.

IV. Definitive Treatment Summary24

  • Advanced periodontal therapy.
  • Occlusal stabilization (vertical dimension, anterior guidance, plane of occlusion).
  • Orthodontic or orthognathic surgical treatment.
  • Occlusal adjustment and esthetic dentistry (whitening, restorations).
  • Definitive restoration of individual teeth (direct/indirect) for endodontically treated, key, or other teeth.
  • Elective extraction of asymptomatic teeth.
  • Replacement of missing teeth (fixed partial dentures, implants, removable partial dentures, complete dentures).
  • Post-treatment assessment.

V. Maintenance Therapy Summary2526

  • Periodic visits and ongoing monitoring.

No dental care and treatment even when provided by a clinically competent dentist, however excellent in a technical sense, has any real value unless it serves the best interest of the patient.

References27

  • Stefanac, S. & Nesbit, S. (2024). Diagnosis and Treatment Planning in Dentistry (4th Ed.). Mosby Elsevier

Footnotes

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  27. Original PDF page 44: L6 Developing the treatment plan-4215, p.44 ↩

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