Title: DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION I
1DIAGNOSIS, TREATMENT PLANNING, AND CASE
CONSULTATION I
2SCENARIO
- 330 P.M., September 16, 2000
- Commonwealth Stadium
- Roar over the stadium as the CATS have just
completed a short pass. - Score is 17-14 in favor of Indiana.
- It is now 4th down and the football is on the 4
yard line of Indiana with 1 yard to go for a
first down. - Quarterback Lorensen looks at Coach Mumme.
- What does Coach Mumme do?
3A Data-Based, Phased, Problem-Oriented,Scientifi
c System for Making Treatment Decisions
4Clinical Decision-Making,Treatment Planning,
andCase Consultation Are The...
- Essence of clinical practice.
- Sun of the solar system of clinical practice.
- Core of the planet of clinical practice.
- Heart of the organism of clinical practice.
- Soul of the life of clinical practice.
- Hub of the wheel of clinical practice.
- Nucleus of the atom of clinical practice.
- and/or any other metaphor you want to employ to
recognize their centrality in practice.
5Decisions . . .
Decisions . . .
Decisions . . .
- We all make them and most of the time it seems
like a straight-forward process. - How do we learn to make decisions? Mostly by
trial and error. - While this may be a functional way to learn, it
means many poor decisions are made while learning
proceeds. - Additionally, inappropriate decisions may be made
later because learning did not proceed far enough
or fast enough.
6 Clinical Decision Making
- Treatment planning is a basic component of the
clinical practice of dentistry. - Observations during examination focus on problems
for which therapy must be planned. - Treatment planning is the vital link between
diagnosis and treatment. - Frequently, however, treatment is devised from a
simplistic, mechanistic perspective.
7Intention...
- To present a model for thinking about clinical
decisions which can provide a conceptual
framework for understanding the multifaceted,
interactive nature of the process, as well as
provide a means of applying systematic,
analytical scientific decision- making skills. - The system is characterized as being data-based,
phased, problem-oriented, incorporating a
scientific decision style.
8- There is nothing morepractical than a good
theory.
9Science Is A Way of Knowing, Thinking,
Understanding, and Creating
- Thinking Critically (Scientifically) About
Clinical Decision-Making In Dentistry
10Living As Problem Solving
- Regularly and frequently (daily) in life we
confront circumstances in which we must make a
decision. The necessity of making such a decision
is, in its essence, the presentation of a
problem a problem which we now must solve. -
- No one thinks unless presented with a
problem.
John Dewey
11Gathering Information
- The problem that has presented itself to us is
the result of some information that has come to
our awareness. - No doubt the information we have is inadequate to
deliberate comprehensively about the matter, so
the first step in a scientific decision making
process is to gather (more) information. - We may call the facts we discover in our
gathering of information our FINDINGS.
12Identifying or Stating the Problem
- Our FINDINGS of fact should now enable us to
identify or state the problem more explicitly. - We can say that the additional information we
gathered allows us to interpret the situation or
circumstance we had encountered into an explicit
STATEMENT OF THE PROBLEM.
13State the Basic GOAL or OBJECTIVE
- A problem is really only a problem if it is a
circumstance that in some way impedes the
achievement or fulfillment of a need or desire. - Not infrequently we are not sure what the need or
desire we have that is being thwarted really is.
Therefore, we must work to make explicit in our
minds specifically what our goal is in this
circumstance. - The PROBLEM STATEMENT must be translated into a
GOAL STATEMENT.
14Identify the Basic Facts, Assumptions, and
Constraints
- Facts are statements of things that are known.
- Assumptions are applied to factors which can be
changed to simplify the problem and make it
solvable. - Constraints are factors which affect the outcome
of the situation and cannot be changed.
15Generate Possible SOLUTIONS
- This is the time for creative thinking.
- Dont prejudge ideas as they are generated.
- Identify all the different potential ideas that
may resolve the problem and achieve the desired
goal. These are your TREATMENT ALTERNATIVES.
16 Analyze ALTERNATIVES
- Analyze the various ALTERNATIVES to evaluate
which of them holds the most promise of achieving
the desired goal, and can do so with the most
advantageous cost/benefit result.
17Synthesize Elements of the SOLUTION
- Most any SOLUTION to a PROBLEM will have more
than one element. - Separate the chosen SOLUTION into meaningful
elements. - Gather additional information you may need to
further develop each element. - Combine/Synthesize the elements to create a
detailed SOLUTION.
18Critique the SOLUTION
- Does it satisfy the basic GOAL or OBJECTIVE?
- Is it feasible, practical, economical, safe?
- Is it moral/legal?
19Communicate the Result of Decision-Making
- Report to appropriate individuals the result of
what you have considered, and decided (or are
recommending). - Determine the information needs of the person to
whom you are reporting the decision. - Communicate only that information to others that
they need to know. Dont overwhelm.
20Implement the Decision
- What should be done now, what is the next step?
- What is required logistically to resolve the
PROBLEM and achieve the GOAL? - Are there any impediments to implementation, and
if so, how can they be removed?
21Evaluate the RESULTS
- Did the SOLUTION work?
- Was the PROBLEM resolved?
- Was the GOAL or OBJECTIVE achieved?
22The Butterfly
-
- A Model forClinicalDecision-Making
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24Scientific Decision-Making in Clinical Dentistry
- Gather Information
- Identify the Problem(s)
- State the Goal(s) of Therapy
- Identify the Basic Facts, Assumptions,
Constraints - Generate Alternatives
- Analyze Alternatives
- Make Decision/Recommendation
- Critique the Decision/Recommendation
- Communicate The Decision/Recommendation
- Synthesize Components of Decision Into Detailed
Solution - Implement Therapy
- Evaluate the Results of Therapy
25Office Dynamics
- Diagnosis Appointment
- Consultation Appointment
- Treatment Appointments
- Post Treatment Appointment
- Recall Appointment
- ------------------------------
- Emergency Appointment
26The Dental Record
- Registration Record
- Case History Record
- Health History
- Dental History
- Clinical Examination Record
- Radiographic Record
- Problem/Plan Record (If Utilized)
- Treatment Plan Record
- Written Consultation Record
- Parents Notes Page
- Supplemental Records, (When Necessary)
- Such as, Space Analysis Record
- Treatment Record/Progress Notes
27Diagnosis Appointment
- Defined Data Base
- Data Analysis
- Supplemental Data Base
28Defined Data Base for the Child Patient
- Case History
- Health History
- Dental History
- Clinical Examination
- Behavior Assessment
29Analysis
- Analysis refers to examining the information
learned from the defined data base to determine
if the information is adequate and complete for
identifying all problems or potential problems. - Questions such as what, when, where and how are
appropriately asked. - Analysis may result in an appreciation that all
relevant information required for a thorough
diagnosis is not available and additional
information must be gained.
30Supplemental Data Base
- Radiographs
- Diagnostic Casts
- Clinical Photographs
- Space Analysis
- Dietary Analysis
- Pulpal Vitality Tests
- Water Analysis for Fluoride Content
- Laboratory Blood Studies
- Consultation with other Health Care
Professionals
31FINDINGS
- The results of all of the information gathered
through the defined and supplemental data bases
is referred to as the FINDINGS. - FINDINGS have been called the focal point of
oral diagnosis.
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33 Four Dimensions of Oral Health Problems
- FINDINGS from the information gained patients
data bases are interpreted into problems of
oral health in one of four dimensions - Immediate Problems
- Problems of Prevention
- Problems of Rehabilitation
- Problems of Maintenance
34Immediate Problems
- Health Constraints
- Parental Concerns
- Critical/Emergency Circumstances
- Problems of Diagnostic Evaluation
- Management of Behavior
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36Problems of Prevention
- These problems relate specifically to the
etiologic factors of dental pathology - host
- microflora
- substrate
- education/motivation
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38Problems of Pathology, Development and
Reconstruction
- Dental Caries
- Pulpal Pathology
- Periodontal Disease
- Craniofacial/Occusal Disharmonies
- Oral Pathoses
- Developmental Anomalies
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40Problems of Maintenance
- Oral health must be maintained, once gained.
Key concepts at this level of problem definition
and resolution are - Review
- Education/Motivation
- Periodic Evaluation
- Monitoring Unresolved Problems
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42Explicating the Process
- PROCESS PRODUCT
- Data Collection FINDINGS
- Interpret STATEMENT OF
PROBLEM(S) - Translate STATEMENT OF
GOAL(S) - Define SPECIFIC
LISTING OF PROBLEM(S) - Generate TREATMENT
ALTERNATIVES - Analyze TREATMENT
JUSTIFICATION - Interpret SPECIFIC PLAN
- Criticize OPERATIONAL
TREATMENT PLAN - Communicate
CONSULTATION/INFORMED CONSENT - Implement TREATMENT
- Evaluate NEW FINDINGS