Developing the Treatment plan. **THE UNIVERSITY OF WESTERN AUSTRALIA** DENT 4215- Introduction to Clinical Dental Practice -Manorika Ratnaweera The University of Western Australia **DENT 4215** — Introduction to Clinical Dental Practice *Presenter:* Manorika Ratnaweera # Acknowledgement of country 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  Acknowledgement of Country 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* Artwork by Dr Richard Barry Walley OAM featuring stylized black lines and concentric circles on a cream background, representing Noongar cultural values and connection to land. # **Learning outcome** 3. Compose and implement initial treatment Plans to prepare patients for further dental treatment. The University of Western Australia 3. Compose and implement initial treatment plans to prepare patients for further dental treatment. ## **Learning objectives** 1. Develop fundamental knowledge necessary to begin creating treatment plans for patients 2. Documenting treatment plans 1. Develop fundamental knowledge necessary to begin creating treatment plans for patients 2. Documenting treatment plans Information gathering Patient history • Radiographic examination • Clinical examination • Diagnostic aids Comprehensive diagnosis **Comprehensive diagnosis** Risk analysis Significant findings Evaluation of findings  #### Assessment and Data Collection - Patient history - Radiographic examination - Clinical examination - Diagnostic aids #### Diagnostic Evaluation - Comprehensive diagnosis - Risk analysis - Significant findings - Evaluation of findings This flowchart illustrates the process of reaching a comprehensive diagnosis, starting with 'Information gathering' (which includes patient history, radiographic examination, clinical examination, and diagnostic aids). The data flows downward through 'Evaluation of findings' to 'Significant findings', which is then combined with 'Risk analysis' to inform the final 'Comprehensive diagnosis'. # Diagnosis * 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 6 #### Diagnostic Categories - **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 - *Comprehensive diagnosis list* - *Treatment objectives* - *Patient modifiers* - *Practitioner modifiers* - *Treatment plan(s)* - *Interest in OH* - *Can afford* - *Regular attender* - *Lack of interest in OH* - *Cannot afford* - *Fear of dentistry* - *Poor motivation* - *Informed consent* - *"Ideal treatment plan"* - *Removing disease* - *Correct treatment for each problem* - *In a correct sequence* - *Select best material* - *Efficient in time*  #### Key Components of Planning - Comprehensive diagnosis list - Treatment objectives - Patient modifiers - Practitioner modifiers - Treatment plan(s) - Informed consent #### Patient Modifiers - Interest in OH - Can afford - Regular attender - Lack of interest in OH - Cannot afford - Fear of dentistry - Poor motivation #### Ideal Treatment Plan Goals - Removing disease - Correct treatment for each problem - In a correct sequence - Select best material - Efficient in time This figure is a vertical flowchart illustrating the progression from diagnosis to treatment planning. It shows 'Comprehensive diagnosis list' leading to 'Treatment objectives', which are then influenced by 'Patient modifiers' (such as interest in OH, ability to afford, and motivation) and 'Practitioner modifiers' (including ideal treatment plan, removing disease, and efficiency). These factors converge at 'Informed consent' before resulting in the final 'Treatment plan(s)'. # Treatment Objectives 8   #### Treatment Objectives Clinical photo of a patient's oral cavity showing severe dental pathology, including extensive caries (tooth decay) on multiple teeth and inflamed gingival tissue. The image is labeled 'A' in the bottom left corner. Clinical photo showing a frontal intraoral view of a patient with cheek retractors in place, revealing the maxillary and mandibular dentition. The upper teeth appear to be prosthetic restorations or crowns, while the lower anterior teeth show signs of wear, spacing, and potential damage. # 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.” Sturdevant 1995 - Created as a response to the problem list - The schedule and sequence of the treatment - Developing a course of action that encompasses the ramifications and sequalae of treatment to serve patients’ needs 9 > “...is a carefully sequenced series of services designed to eliminate or control etiological factors, repair existing damage and create a functional maintainable environment.” > > *Sturdevant 1995* #### Core Principles - Created as a response to the problem list - The schedule and sequence of the treatment - Developing a course of action that encompasses the ramifications and sequalae of treatment to serve patients’ needs # Treatment plan Why do we need a treatment plan? * Address patient’s problem/s * Sequence and prioritise * Estimates of costs * Informed consent * Record keeping * Medico-Legal requirement * Communication with other clinicians 10 #### Purpose of a Treatment Plan - Address patient’s problem/s - Sequence and prioritise - Estimates of costs - Informed consent - Record keeping - Medico-Legal requirement - Communication with other clinicians # Developing the treatment plan(s) 1. Systemic phase 2. Acute phase 3. Disease Control phase 4. Definite phase 5. Maintenance phase 1. Systemic phase 2. Acute phase 3. Disease Control phase 4. Definite phase 5. Maintenance phase # Systemic phase of treatment planning 1. To evaluate the severity and complexity of health issues and to assess how this may affect dental treatment 2. Recognize signs and symptoms of undiagnosed conditions and refer patient to physician for evaluation 3. To limit or modify dental treatment based on systemic findings 4. To prevent adverse outcomes * Emergencies in the dental office * To prevent serious postoperative complications in conjunction with dental treatment Ex: antibiotic prophylaxis for high-risk dental procedures for specific medical conditions 1. To evaluate the severity and complexity of health issues and to assess how this may affect dental treatment 2. Recognize signs and symptoms of undiagnosed conditions and refer patient to physician for evaluation 3. To limit or modify dental treatment based on systemic findings 4. To prevent adverse outcomes: - Emergencies in the dental office - To prevent serious postoperative complications in conjunction with dental treatment *Example:* Antibiotic prophylaxis for high-risk dental procedures in specific medical conditions. - ==The systemic phase is completed before addressing the patient’s acute complaint or other treatment needs.== Systemic phase ```html <table> <tr> <td>ASA 1</td> <td>Normal healthy person</td> </tr> <tr> <td>ASA 2</td> <td>Well controlled DM, hypertension (HTN), asthma, mild obesity, pregnancy, smoker, extreme anxiety</td> </tr> <tr> <td>ASA 3</td> <td>Stable angina, post MI, poorly controlled HTN, massive obesity, respiratory disease with symptoms</td> </tr> <tr> <td>ASA 4</td> <td>unstable angina, liver failure, CCF, End stage renal disease</td> </tr> </table> ``` American society of Anesthesiologist (ASA) physical status classification  | Classification | Description | | :--- | :--- | | **ASA 1** | Normal healthy person | | **ASA 2** | Well-controlled DM, hypertension (HTN), asthma, mild obesity, pregnancy, smoker, extreme anxiety | | **ASA 3** | Stable angina, post-MI, poorly controlled HTN, massive obesity, respiratory disease with symptoms | | **ASA 4** | Unstable angina, liver failure, CCF, end-stage renal disease | This figure is a table detailing the American Society of Anesthesiologists (ASA) physical status classification system. It lists four categories, defining ASA 1 as a normal healthy person; ASA 2 as having well controlled DM, hypertension (HTN), asthma, mild obesity, pregnancy, smoker, or extreme anxiety; ASA 3 as having stable angina, post MI, poorly controlled HTN, massive obesity, or respiratory disease with symptoms; and ASA 4 as having unstable angina, liver failure, CCF, or End stage renal disease. - Postponing or limiting treatment -ex: uncontrolled hypertension, INR levels, antibiotics prophylaxis, unstable angina. - Consultation with physician -Prescribing or altering patient medication -Managing Hypertension -When systemic disease suspected in dental office - Stress Management (cardiac disease, diabetes, unstable angina, adrenal disorders) - Positioning the patient in dental chair - Postponing or limiting treatment - *Examples:* Uncontrolled hypertension, INR levels, antibiotic prophylaxis, unstable angina - Consultation with physician: - Prescribing or altering patient medication - Managing hypertension - When systemic disease is suspected in the dental office - Stress management (cardiac disease, diabetes, unstable angina, adrenal disorders) - Positioning the patient in dental chair > [!note] Lecturer — Medication Considerations > The patient’s medical condition and medications may affect the safety and appropriateness of dental treatment. > > - If a patient is taking medication and presents with a tooth that may need to be extracted for pain relief, the implications of that medication must be considered before proceeding. Risk categories for selected dental procedures | | | | :--- | :--- | | Little to no risk | Oral examination, radiographs, study models | | Low risk | Local anesthesia, simple restoration, prophylaxis, asymptomatic endodontic, simple extraction, orthodontic | | Medium risk | Symptomatic endodontic, multiple extraction, single implant, deep scaling and root planning | | High risk | Extensive surgical, multiple implant, G/A |  | Risk Level | Procedures | | :--- | :--- | | **Little to no risk** | Oral examination, radiographs, study models | | **Low risk** | Local anesthesia, simple restoration, prophylaxis, asymptomatic endodontic, simple extraction, orthodontic | | **Medium risk** | Symptomatic endodontic, multiple extraction, single implant, deep scaling and root planing | | **High risk** | Extensive surgical, multiple implant, G/A | This figure is a table that categorizes selected dental procedures into four risk levels: 'Little to no risk' (Oral examination, radiographs, study models), 'Low risk' (Local anesthesia, simple restoration, prophylaxis, asymptomatic endodontic, simple extraction, orthodontic), 'Medium risk' (Symptomatic endodontic, multiple extraction, single implant, deep scaling and root planning), and 'High risk' (Extensive surgical, multiple implant, G/A). # **2. Acute phase of treatment planning** * Acute phase of care incorporates diagnostic and treatment procedures aimed at solving urgent oral problems. ## **Patients who may need acute care** * Those under active treatment * On maintenance recall * New to dental practice * Returning to practice after being away for some length of time The acute phase of care incorporates diagnostic and treatment procedures aimed at solving urgent oral problems. ### Patients Who May Need Acute Care - Those under active treatment - On maintenance recall - New to dental practice - Returning to practice after being away for some length of time > [!note] Lecturer — Systemic Phase > The acute complaint must be managed, but the systemic phase must still be completed first. > - The patient’s medical condition and medications may affect management of the acute problem. **Difference between emergency problem and urgent problem** - **Emergency problem**: incapacitates the patient and has the potential to become a life-threatening condition Ex: Swelling, systemic infection, trauma to face or jaws - **Urgent problem**: does not require immediate attention but the dentist or the patient thinks should be attended to “now” or “soon” Ex: Mild to moderate pain without active infection #### Categorization of 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 the patient believes it should be attended to "now" or "soon". - *Examples*: Mild to moderate pain without active infection > [!note] Lecturer — Systemic Status > Acute treatment may be required to address an immediate patient concern, such as pain. > > - The treatment must be considered within the context of the patient’s systemic status. # Common acute problems and diagnoses ## Complaint of pain - pulpal or periapical origin - associated with periodontal tissues - periodontal abscess - NUG - associated with tooth eruption or pericoronitis - associated with previous dental treatment - Other sources of pain: - Herpetic ulcers - traumatic ulcers - stomatitis - TMJ disorders - trigeminal neuralgia - acute sinusitis. ## Complaint of swelling - Aesthetic complaints - Traumatic injury ### Trauma to teeth/soft tissues ### Jawbone fractures ### Osteomyelitis ## Other forms of oral pathology lesions that require biopsy, consultation or referral #### Complaint of Pain - Pulpal or periapical origin - Associated with periodontal tissues: - Periodontal abscess - Necrotizing ulcerative gingivitis (NUG) - Associated with tooth eruption or pericoronitis - Associated with previous dental treatment - Other sources of pain: - Herpetic ulcers - Traumatic ulcers - Stomatitis - Temporomandibular joint (TMJ) disorders - Trigeminal neuralgia - Acute sinusitis #### Complaint of Swelling - Aesthetic complaints - Traumatic injury: - Trauma to teeth/soft tissues - Jawbone fractures - Osteomyelitis #### Other Forms of Oral Pathology - Lesions that require biopsy, consultation, or referral > [!note] Lecturer — Painful Tooth Management > A patient may present with a painful tooth that appears to require extraction or another immediate intervention. Before providing treatment intended to relieve the pain, the dentist must consider: > - The patient’s systemic condition. > - The medications the patient is taking. > - The possible implications of those medications for the proposed treatment. - Treatment planning for acute phase [1] - Short term therapies within your competency - Long term implications of the short-term therapies or options - Factors influencing treatment decisions: - Professional factors - Patient factors and modifiers - Combination factors [1] Page 883 #### Treatment Planning Considerations - Short-term therapies within clinician competency - Long-term implications of short-term therapies or options - Factors influencing treatment decisions: - Professional factors - Patient factors and modifiers - Combination factors # Acquiring CONSENT for acute care * Informed consent for an acute care treatment plan requires that the patient must be fully aware of 1. The diagnosis 2. All reasonable treatment options 3. Risks and the benefits of each option 4. Nature of the recommended treatment 5. Costs of that treatment – present & future. #### Acquiring Consent for Acute Care Informed consent for an acute care treatment plan requires that the patient must 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. Costs of that treatment—present and future # Referral/Deferral - The problem or the offending tooth cannot be identified. - The patient has a compromising systemic condition that precludes treatment at this time. - **The patient has an active infection** - Patient is unwilling or unable to provide consent to treatment - In some situations, it is not only prudent but also preferable to prescribe medications rather than initiate treatment #### Indications for Referral or Deferral - The problem or the offending tooth cannot be identified. - The patient has a compromising systemic condition that precludes treatment at this time. - The patient has an active infection. - The patient is unwilling or unable to provide consent to treatment. In some situations, it is not only prudent but also preferable to prescribe medications rather than initiate treatment. ### 3. Disease control phase of treatment planning Eradicate active disease and infection Arrest occlusal, functional, and esthetic deterioration Address, control or eliminate causes and risk factors for future disease. The lowercase disease control phase is indicated in a patient with high risk factors for that particular disease. #### Objectives - Eradicate active disease and infection - Arrest occlusal, functional, and esthetic deterioration - Address, control, or eliminate causes and risk factors for future disease The disease control phase is indicated in a patient with high risk factors for that particular disease. # Disease control phase * Also called Stabilisation phase * Not necessary when * oral disease is **controlled** * oral disease will be **eliminated** during definitive treatment. * Includes plans for * **-Management** of active disease or infection * **-Stabilization** of disease/teeth status prior to definitive reconstruction * **-Modify/Eliminate** risk factors that predispose the patient to the development of recurrent oral disease. - Also called the **Stabilisation phase** - Not necessary when: - Oral disease is controlled - Oral disease will be eliminated during definitive treatment - Includes plans for: - Management of active disease or infection - Stabilization of disease/teeth status prior to definitive reconstruction - Modification or elimination of risk factors that predispose the patient to the development of recurrent oral disease # Disease control phase * Address the patient’s chief complain as early in the plan as possible * **Sequence by priority**—preferably treating the most severe and urgent needs first * =provisional /protective restorations * **Sequence by quadrant/sexant** * **Integrate periodontal therapy into the disease control phase plan** * **Keep definitive phase options open with minimalist treatment in the disease control phase.** * =Generally, however, only those procedures necessary to arrest the deterioration and prevent further infection should be undertaken in the disease control phase. - Address the patient's chief complaint as early in the plan as possible - **Sequence by priority:** Preferably treat the most severe and urgent needs first (e.g., provisional or protective restorations) - **Sequence by quadrant or sextant** - **Integrate periodontal therapy** into the disease control phase plan - **Keep definitive phase options open** with minimalist treatment in the disease control phase - Generally, only those procedures necessary to arrest deterioration and prevent further infection should be undertaken in the disease control phase. - ==The patient's overall condition should be assessed before deciding which problem to address first, so the chief complaint may not always determine the first treatment.== # Disease Control Phase – Structure 1.Education - Aetiology, prevention and home treatment for dental conditions - Patients roles and responsibilities - Oral hygiene product education/advice (Type, tech, freq) - Smoking cessation (ask, assess, assist) - Chemotherapeutics **2. NSPT** - Plaque control - Debridement, prophy - Manage risk factors - Review, referral to periodontist if required 3. Caries management 4. Remineralisation therapy 5. Defective restorations 6. Extraction/referral 1. **Education** - Aetiology, prevention, and home treatment for dental conditions - Patient roles and responsibilities - Oral hygiene product education and advice (type, technique, frequency) - Smoking cessation (ask, assess, assist) - Chemotherapeutics 2. **NSPT (Non-Surgical Periodontal Therapy)** - Plaque control - Debridement and prophylaxis - Manage risk factors - Review, with referral to a periodontist if required 3. **Caries management** 4. **Remineralisation therapy** 5. **Defective restorations** 6. **Extraction/referral** > [!note] Lecturer — Periodontal Referral > Periodontal treatment may already have been completed if the patient was referred after that phase. > > - Periodontal treatment may still need to be provided as part of the current patient’s disease control plan. A cartoon illustration featuring a smiling dentist character standing next to an anthropomorphic tooth sitting in a dental chair, surrounded by generic dental office equipment like a monitor and lamp. # Disease control – Caries Management System ## • Basic caries control protocol - **Caries activity tests, diagnosis and risk assessment** - **Oral prophylaxis** - **Oral self care instructions/coaching** - **Saliva substitutes/stimulation** - **Remineralisation (in clinic and home care)** - **Chemotherapeutics** - **Diet/nutrition analysis** -Food diary – look at freq & duration (acids and sucrose) - **Restore carious lesions** - **Sealants on susceptible pits and fissures.** - **Reassessment** #### Basic Caries Control Protocol - Caries activity tests, diagnosis, and risk assessment - Oral prophylaxis - Oral self-care instructions and coaching - Saliva substitutes and stimulation - Remineralisation (in-clinic and home care) - Chemotherapeutics - Diet and nutrition analysis - Food diary: assess frequency and duration of exposure to acids and sucrose - Restore carious lesions - Sealants on susceptible pits and fissures - Reassessment > [!note] Lecturer — Carious Lesions > A large carious cavity may take priority over other conditions depending on the severity and extent of disease. > > - A provisional protective restoration may be used before periodontal treatment or other procedures when necessary. # Oral disease risk status * **Caries** risk – CAMBRA * **Periodontal** risk - http://www.perio-tools.com/PRA/en/index.asp * **Oral cancer** risk - Oral Mucosal Malignancies, Contemporary Oral Medicine. 2018:1249–1436. * **Tooth wear** risk - BEWE http://www.erosivetoothwear.co.uk/page/knowledge_base - **Caries risk:** CAMBRA - **Periodontal risk:** http://www.perio-tools.com/PRA/en/index.asp - **Oral cancer risk:** *Oral Mucosal Malignancies, Contemporary Oral Medicine. 2018:1249–1436.* - **Tooth wear risk:** BEWE (http://www.erosivetoothwear.co.uk/page/knowledge_base) • **Re-Evaluation phase** (Holding phase) • the **time** between the **control** and **definitive** phases that allows for resolution of inflammation and time for healing. • Home care habits are reinforced, motivation for further treatment is assessed, and initial treatment and pulpal responses are re-evaluated before definitive care is begun. Also referred to as the **Holding phase**. - The period between the control and definitive phases that allows for the resolution of inflammation and time for healing. - Home care habits are reinforced, motivation for further treatment is assessed, and initial treatment and pulpal responses are re-evaluated before definitive care begins. > [!note] Lecturer — Re-Evaluation Examples > Re-evaluation determines whether treatment has been effective before progressing to definitive care. > > - After endodontic treatment, an appropriate period may be allowed before obturation or subsequent treatment. > - After periodontal treatment, probing depths are reassessed to determine whether they have reduced and whether treatment has worked. * **4. Definitive phase of treatment** * Core of treatment plan. * Before engaging in definitive phase treatment, the practitioner should affirm that: * Disease controlled. * All reasonable definitive phase treatment options and costs evaluated and discussed with the patient. * Informed consent with the patient. The definitive phase serves as the core of the treatment plan. Before engaging in definitive phase treatment, the practitioner should affirm that: - Disease is controlled. - All reasonable definitive phase treatment options and costs have been evaluated and discussed with the patient. - Informed consent is obtained with the patient. > [!note] Lecturer — Treatment Options > Treatment options should not be introduced for the first time after treatment has begun. > > - For a tooth with a large restoration, the possibility of a crown should be discussed during treatment planning, even if repairing the existing restoration is also considered. > [!note] Lecturer — Maintenance Importance > Maintenance is essential for preserving the results of treatment. If maintenance is neglected, the treatment may fail to provide lasting benefit, and the patient may return in a condition similar to that at the initial visit. **Common definitive phase treatment** 1. Periodontal therapy -surgical /other 2. Orthodontic treatment 3. Restorative Dentistry - multi surface restorations / Indirect restorations - occlusal assessment and treatment - esthetical procedures 4. Endodontic procedures –elective 5. Extractions (3rd Molar) and pre-prosthetic procedures 6. Prosthodontics assessment and treatment - Replacement of missing teeth - Indication for the need of a crown, bridge, implant, dentures - Denture assessment and treatment 7. Specialist care 1. Periodontal therapy (surgical / other) 2. Orthodontic treatment 3. Restorative dentistry - Multi-surface restorations / indirect restorations - Occlusal assessment and treatment - Esthetical procedures 4. Endodontic procedures (elective) 5. Extractions (third molar) and pre-prosthetic procedures 6. Prosthodontics assessment and treatment - Replacement of missing teeth - Indication for the need of a crown, bridge, implant, or dentures - Denture assessment and treatment 7. Specialist care - Involve patient/parent in decision making - Clinicians’ role to determine reasonable and feasible treatment options - Professional considerations - Diagnosis - Prognosis (Is a prediction, estimation of the likelihood of a favorable outcome for a disease; could be: Excellent, Good, Favorable, Unfavorable, Poor) - Likelihood of remineralisation - Caries risk status - Disease control phases - Cost, patient expectations - Materials, outcomes, implications - Involve patient/parent in decision making - Clinicians' role to determine reasonable and feasible treatment options #### Professional Considerations - Diagnosis - Prognosis: Prediction or estimation of the likelihood of a favorable outcome for a disease (could be: Excellent, Good, Favorable, Unfavorable, Poor) - Likelihood of remineralisation - Caries risk status - Disease control phases - Cost and patient expectations - Materials, outcomes, and implications # Orthodontic treatment - Dentist role to identify if referral for orthodontic assessment is required. - Usually, elective treatment - Aesthetic or function - Malocclusions - Impacted teeth - Anterior open bite - Skeletal abnormalities - Referral for orthodontic assessment by an orthodontist. #### Orthodontic Treatment - Dentist role to identify if referral for orthodontic assessment is required - Usually elective treatment for aesthetics or function - Common indications for referral: - Malocclusions - Impacted teeth - Anterior open bite - Skeletal abnormalities - Referral for orthodontic assessment by an orthodontist • Periodontist: Dentists should be able to identify if referral to a periodontist is required • Prosthodontist: Fixed prosthodontics, removable prosthodontics, Implants • Paedodentist: Dentists should be able to identify if referral to a paedodontist is required • Special care dentist: Dentists should be able to identify if referral to a specialist is required • Other specialists - Periodontist: Dentists should be able to identify if referral to a periodontist is required - Prosthodontist: Fixed prosthodontics, removable prosthodontics, implants - Paedodontist: Dentists should be able to identify if referral to a paedodontist is required - Special care dentist: Dentists should be able to identify if referral to a specialist is required - Other specialists > [!note] Lecturer — Denture Planning > When planning a denture, the dentist must first determine whether it will be tooth supported, tissue supported, or mixed tooth and tissue supported. > > - This decision depends on whether the patient’s dentition is stable and whether additional tooth loss is likely. > - The appropriate denture type should be considered in light of the expected future condition and its associated costs. > - The patient should receive an estimate and a general explanation of the proposed approach; detailed design features such as rest seats can wait until the final design is established. # 5. Maintenance phase - The long-term success or failure of the plan depends on it. - Prevention of future problems is the guiding principle of the maintenance phase, and it is the responsibility of the entire dental team. - Made on an individual basis * Is made at the conclusion of the disease control phase of treatment and definitive phases * Can be modified - The long-term success or failure of the plan depends on it. - Prevention of future problems is the guiding principle of the maintenance phase, and it is the responsibility of the entire dental team. - Made on an individual basis. - Established at the conclusion of the disease control phase and definitive phases of treatment. - Can be modified as needed. # Rationale for including a maintenance phase in the treatment plan * **Purpose of maintenance phase:** * Ensure long term oral health * Optimum function * Favorable esthetics for the patient. * Maintain stable clinical attachment levels (Lang & Tonetti, 2003) * **Benefits of maintenance phase** * Address issues that remain unresolved after the definitive phase of treatment #### Purpose of Maintenance Phase - Ensure long-term oral health - Optimum function - Favorable esthetics for the patient - Maintain stable clinical attachment levels *Lang, N. P., & Tonetti, M. S. (2003).* #### Benefits of Maintenance Phase - Address issues that remain unresolved after the definitive phase of treatment | Patient concerns/expectations met | | | Patient response to treatment | | | Medical and Medication History update | | | Clinical examination, re-evaluation, diagnosis | Check notes from last exam | | Update radiographs | Based on need or protocol | | Periodontal condition | | | Occlusal /functional status | | | Caries/restorative condition of teeth | | | Disease risk | Status and severity | | Risk factors | Predisposing and modifying | | Preventive recommendations, motivation | In clinic and at home remin, smoking cessagtion, OHE | | Remaining or new treatment required | May include retreating | | Re-establish recall interval | based on risk and need |  | Assessment Component | Details / Notes | | --- | --- | | Patient concerns/expectations met | | | Patient response to treatment | | | Medical and medication history update | | | Clinical examination, re-evaluation, diagnosis | Check notes from last exam | | Update radiographs | Based on need or protocol | | Periodontal condition | | | Occlusal / functional status | | | Caries / restorative condition of teeth | | | Disease risk | Status and severity | | Risk factors | Predisposing and modifying | | Preventive recommendations, motivation | In clinic and at-home remineralization, smoking cessation, OHE | | Remaining or new treatment required | May include retreating | | Re-establish recall interval | Based on risk and need | This figure is a table listing the 'Elements for post treatment assessment' in dentistry. The left column lists specific clinical items to be assessed, such as 'Patient concerns/expectations met', 'Clinical examination, re-evaluation, diagnosis', and 'Disease risk'. The right column provides corresponding notes or actions, including 'Check notes from last exam', 'Status and severity', and 'In clinic and at home remin, smoking cessagtion, OHE'. # Treatment (Plan) outcomes * Patient + clinician = disease is controlled, dentition is functional, stable and of acceptable aesthetics * Specific tangible results of treatment * Closely linked to: -risk assessment and prognosis determination - Patient + clinician = disease is controlled, dentition is functional, stable, and of acceptable aesthetics - Specific tangible results of treatment - Closely linked to: - Risk assessment - Prognosis determination > [!note] Lecturer — Continued Maintenance > The success of treatment depends on continued maintenance after the active treatment phases have been completed. Without maintenance, the patient’s oral condition may deteriorate and the benefits of the completed treatment may be lost. Summary I. Systemic treatment A. Consultation with patient’s healthcare provider B. Premedication C. Stress and fear management D. Special positioning of the patient E. Any necessary treatment considerations for systemic disease 38 ### I. Systemic Treatment - Consultation with patient’s healthcare provider - Premedication - Stress and fear management - Special positioning of the patient - Any necessary treatment considerations for systemic disease > [!note] Lecturer — Systemic Assessment > Complete the systemic assessment before addressing the acute complaint. Identify medical conditions and medication-related considerations, and postpone or limit treatment when necessary. > > - Consult the patient’s physician regarding medication changes or prescribing. > - Use stress-management and medical-emergency prevention strategies. > - Be prepared to manage an emergency and position the patient according to the patient’s condition. Decorative cartoon illustration of a dentist and a patient in a dental chair, serving as generic subject-matter artwork rather than an instructional diagram. Summary **II.** Acute treatment A. Emergency treatment for pain or infection B. Treatment of the urgent chief complaint when possible ### II. Acute Treatment - Emergency treatment for pain or infection - Treatment of the urgent chief complaint when possible > [!note] Lecturer — Acute Treatment > Address acute problems only after considering the patient’s systemic status. Consider the implications of the patient’s medications before treatment. Cartoon clipart depicting a dentist in a white coat holding a large yellow banana with pliers in front of a surprised patient seated in a dental chair. The image features watermarks for 'eToon' and 'evlad.com' and serves as a humorous illustration likely related to the slide's theme of unexpected shocks in treatment. **Summary** III. Disease control A. Caries removal to determine restorability of questionable teeth B. Extraction of hopeless or problematic teeth 1. Possible provisional replacement of teeth C. Periodontal disease control 1. Oral hygiene instruction 2. Initial therapy a. Scaling and root planning, prophylaxis b. Controlling other contributing factors (1) Replace defective restorations, remove caries (2) Reduce or eliminate parafunctional habits, smoking D. Caries control 1. Caries risk assessment 2. Provisional (temporary) restorations 3. Definitive restorations (i.e., amalgam, composite, glass ionomers) E. Replace or repair defective restorations F. Endodontic therapy for pathologic pulpal or periapical conditions G. Stabilization of teeth with provisional or foundation restorations H. Posttreatment assessment 40 ### III. Disease Control - Caries removal to determine restorability of questionable teeth - Extraction of hopeless or problematic teeth - Possible provisional replacement of teeth - Periodontal disease control - Oral hygiene instruction - Initial therapy: - Scaling and root planning, prophylaxis - Controlling other contributing factors: - Replace defective restorations, remove caries - Reduce or eliminate parafunctional habits, smoking - Caries control - Caries risk assessment - Provisional (temporary) restorations - Definitive restorations (i.e., amalgam, composite, glass ionomers) - Replace or repair defective restorations - Endodontic therapy for pathologic pulpal or periapical conditions - Stabilization of teeth with provisional or foundation restorations - Posttreatment assessment > [!note] Lecturer — Disease Control Goals > Disease control should stabilize the patient and arrest occlusal, functional, and aesthetic deterioration. Treatment should control or eliminate causes and risk factors for future disease, with sequencing according to priority. > > - Re-evaluate the patient’s response before proceeding to definitive treatment. > [!note] Lecturer — Definitive Treatment Planning > Definitive treatment begins after disease control and stabilization. Discuss treatment options and costs, and provide informed consent before treatment. > > - Present appropriate alternatives, such as restoration repair or crown treatment. > - For dentures, determine whether support will be tooth-based, tissue-based, or mixed. > - Consider the stability of the dentition and possible future tooth loss. > - Provide the patient with a general estimate and explanation of the planned treatment. A cartoon illustration of a dentist examining a patient in a dental chair, with speech bubbles containing the dialogue 'DO YOU FLOSS?', 'GAH HUH...', 'YOUR TEETH?', and 'GAH'. The image includes a copyright notice for '©2011 mariascrivan.com' and is used as a decorative visual element rather than an instructional diagram. Summary IV. Definitive treatment A. Advanced periodontal therapy B. Stabilize occlusion (vertical dimension of occlusion, anterior guidance, and plane of occlusion) C. Orthodontic and/or orthognathic surgical treatment D. Occlusal adjustment E. Esthetic dentistry (i.e., tooth whitening, esthetic restorations) F. Definitive restoration of individual teeth (direct/indirect) 1. For endodontically treated teeth 2. For key teeth 3. Other teeth G. Elective extraction of asymptomatic teeth H. Replacement of missing teeth 1. Fixed partial dentures, implants 2. Removable partial dentures 3. Complete dentures I. Posttreatment assessment "I NEVER TRUSTED A MAN WHO WEARS A MASK." - Coleman - CS471B09 ### IV. Definitive Treatment - Advanced periodontal therapy - Stabilize occlusion (vertical dimension of occlusion, anterior guidance, and plane of occlusion) - Orthodontic and/or orthognathic surgical treatment - Occlusal adjustment - Esthetic dentistry (i.e., tooth whitening, esthetic restorations) - Definitive restoration of individual teeth (direct/indirect) - For endodontically treated teeth - For key teeth - Other teeth - Elective extraction of asymptomatic teeth - Replacement of missing teeth - Fixed partial dentures, implants - Removable partial dentures - Complete dentures - Posttreatment assessment > "I NEVER TRUSTED A MAN WHO WEARS A MASK." > — Coleman A cartoon illustration depicting a dentist in a mask and gloves examining a suspicious-looking child patient seated in a dental chair. Summary V. Maintenance therapy A. Periodic visits “First, let’s get you nice and numb for this procedure.” 42 ### V. Maintenance Therapy - Periodic visits "First, let’s get you nice and numb for this procedure." > [!note] Lecturer — Maintenance Goals > Maintenance therapy is intended to maintain long-term oral health, preserve optimum function and favourable aesthetics, and maintain stable clinical attachment levels. It should prevent the patient from returning to a condition similar to that at the initial visit. A cartoon illustration depicting a humorous scene in a dentist's office where a giant, menacing machine with multiple drill bits and sharp tools hangs from the ceiling over a patient. The image serves as a visual gag for the caption 'First, let's get you nice and numb for this procedure,' exaggerating the fear of dental work. **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.*..  > 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*... A 3D animated scene depicting a young girl with red pigtails and braces sitting in a dental chair with her mouth wide open, while a man in scrubs stands behind her holding a bag of extracted teeth. This visual serves as an illustration for the slide's text regarding the importance of patient interests over technical competence. # Reference * Stefanac, S. & Nesbit, S. (2024). *Diagnosis and Treatment Planning in Dentistry* (4th Ed.). Mosby Elsevier *Stefanac, S. & Nesbit, S. (2024). Diagnosis and Treatment Planning in Dentistry (4th Ed.). 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