Treatment Planning in Operative Dentistry

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Treatment Planning in Operative Dentistry

• Dr. Ignatius Lee

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Status of Treatment Planning in Private Practice

• An article published in Readers Digest (Feb.,
  1997) summarized the current status of treatment
  planning in dentistry
• The article described how a patient who went to
  50 different dental offices in 28 states came
  back with treatment plans ranging from no
  treatment needed to a quote of 30,000

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Reasons for the variation in treatment planning

• Advance in dental research (e.g.)
• Changes in diagnostic techniques (e.g. pits and
  fissures caries)
• Changes in treatment philosophy (e.g. criteria
  for replacement of existing restorations)
• Treatment planning will depend on the training
  background of the dentist

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Reasons for the variation in treatment planning

• Changes in disease pattern
• Years ago dental caries was pandemic
• Today, dental caries only affect a small
  percentage of the population (17 of the
  population account for 67 of the total caries
  experience)
• Dentists are not busy enough - looking for
  optional treatments

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Reasons for the variation in treatment planning

• Explosion in treatment options/techniques in
  Operative Dentistry
• Treatment planning will depend on dentists
  treatment philosophy, clinical judgment/experience
  , clinical expertise or other reasons..

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Example in treatment options

• A 35 year-old female patient presents to your
  dental office for a routine dental exam
• CC none
• PDH regular patient (6-12 mo recall) to another
  dental office, reason for switching office is
  because of changes in dental insurance by her
  employer
• Clinical exam conservative occlusal amalgam on
  her permanent first molars that were placed when
  she was 18. All the amalgam showed a sign of
  slight marginal breakdrown. No evidence of any
  dental diseases.

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Example in treatment options

• Treatment Options
• Replace the old Class I amalgam restorations
  with
• Direct composite (135)
• Amalgam (85)
• Gold inlay (760)
• Gold foil (150)
• Indirect ceramic inlay (760)
• Indirect composite inlay (550)
• CAD/CAM inlay (760)
• OR
• No treatment - priceless

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Reasons for the variation in treatment planning

• Consumer driven demand
• Magazine
• Internet
• TV

Dentist philosophy in treatment may be influenced
by the demand of the patients (specific to the
location of the practice)
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Reasons for the variation in treatment planning

• Type and location of the dental office
• Edina/Minnetonka
• Metro//Park
• Union Gospel Mission
• Offices that advertise heavily in the area of
  esthetic dentistry

Dentist philosophy in treatment may be influenced
by the demand of the patients (specific to the
location of the practice)
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Treatment Planning in Operative Dentistry

• Evidence-based Dentistry
• American Dental Association definition of
  Evidence-based Dentistry
• Approach to oral health care that requires the
  judicious integration of systematic assessments
  of clinically relevant scientific evidence,
  relating to the patients oral and medical
  condition and history, with the dentists
  clinical expertise and the patients treatment
  needs and preferences

Ismail and Bader, JADA, Vol.135, January 2004
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Evidence Based Treatment Planning
SUMMARY

• Three elements of treatment planning
• Best available scientific evidence (diagnosis and
  treatment options)
• Dentists clinical expertise
• Patients treatment needs and preferences

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Identification of best evidence

• Information obtained from
• Randomized controlled clinical trials
• Nonrandomized controlled clinical trials
• Cohort studies
• Case-controlled studies
• Crossover studies
• Case studies
• Systemic reviews (PubMed, Journals, Cochrane)

Ismail and Bader, JADA, Vol.135, January 2004
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Dentists Clinical Expertise

• Relating to what the dentist is comfortable of
  doing - e.g. offering composite veneers vs
  porcelain veneers
• Understand your strengths and weaknesses, be
  truthful to your patients
• Understand when you need to refer to specialists

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Patients Needs/Preferences

• Probably the most neglected aspect in treatment
  planning by a student
• Try to incorporate patients preferences in
  formulating your final treatment plan
• Try to understand and address what are the TRUE
  wants and needs of the patient
• Try to to address the realistic/unrealistic
  needs and wants of the patients
• Challenge need to understand your patient in a
  relatively short period of time

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Challenges in understanding your patient

• Time
• Patient may not be telling you the whole truth
• Remember it is a two-way street try to LISTEN to
  your patient - e.g. patients true esthetic
  concern
• May have to help your patient understand the
  needs and the wants of their dental
  treatments

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Defining Oral Rehabilitation - Gordon Christensen
Example of treatment planning based on patients
preferences

• The article was written in response to concern
  within the profession that some commercial
  institutes and continuing education groups are
  advertising to the lay public that only
  graduates of their programs are capable of
  accomplishing the type of oral rehabilitations
  observed in the television cosmetic makeovers
• Levels of Oral Rehabilitation
• Treatment of Defective Teeth Only
• Treatment of Defective Teeth with an Esthetic
  Upgrade
• Treatment of All Teeth for Therapeutic or
  Esthetic Reasons
• The levels are established based on the esthetic
  preference of the patient

JADA Vol. 135 (2004) 215-217
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Treatment of Defective Teeth Only

• Patient in general are pleased with their oral
  appearance, although it may not be perfect by
  ideal standards.
• They want long lasting, comfortable dental
  restoration and a reasonable smile.
• They are not seeking the glamorous, but often
  short-lived, esthetic restorative therapy
  popularized on TV.
• They may accept bleaching, some will accept
  tooth-colored restorations

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Treatment of Defective Teeth with an Esthetic
upgrade

• Majority of patients - they want to look
  acceptable, have a pleasant smile and be able to
  eat normally.
• Most are not interested in having absolutely
  perfect-appearing teeth that are snow-white.
  However, usually they will accept a moderate
  level of esthetic upgrade while receiving therapy
  for their dental caries or defect restorations.
• These patients usually involved a phased
  treatment plans spanning several years.
• The patients should be well INFORMED of which
  part of their therapy is mandatory and which part
  is purely elective
• Usually involve bleaching, a few veneers or
  crowns and restoring any obviously displayed
  metal restorations or darkened teeth with crowns.

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Treatment of All Teeth For Therapeutic or
Esthetic Reasons

• This level of oral rehabilitation is being
  promoted in many continuing education courses and
  routinely is suggested to patients.
• Usually, crowns, veneers, elective cosmetic
  periodontal surgery, some occlusal therapy,
  perhaps elective endodontic therapy or
  orthodontics and even orthognatic surgery are
  suggested.
• Much of the treatment is for esthetic reasons
  only and is not required for any therapeutic
  reason.
• If a patient is INFORMED that the therapy is not
  required because of disease, and that it is
  elective and primarily esthetic, the matter of
  ethics becomes somewhat clearer.
• However, if the patient is led to believe that
  the mostly esthetic therapy is needed for
  therapeutic reasons, including questionable
  occlusal pathosis, or if the more conservative
  therapies are not explained to the patient, the
  practitioner is treading on unethical ground

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Understand what type of patient you are dealing
with

• May give you some clue on their preferences
• Will influence what type of treatment/procedure/ma
  terial used
• People do not change - try to make small
  incremental improvement
• Try to institute phased treatment

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Types of Patients

• Patient never been to dentist in US
• Recent immigrants
• May have a lot of unconventional dentistry done
  in his/her country
• Educate, take care of acute needs first before
  trying to fix those unconventional dentistry

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Types of Patients

• Last trip to dentist - over 5 years
• Phobic, not health conscience, only go when I
  have pain
• Try to understand where they are coming from, and
  why they are here
• Usually they have an acute need
• Take care of their acute needs, then present a
  phase approach - acute needs (disease that cause
  pain), take care of larger lesion, debridement,
  smaller lesion, missing teeth, cosmetic

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Types of Patients

• Last trip to dentist - 2 to 5 years
• No insurance, feel very uncomfortable going to a
  dentist
• Usually have an acute need
• More aggressive in prescribing treatment - less
  confidence in monitoring small lesion

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Types of Patients

• Patients that come in at least once every 2 years
• Regular patient
• More comfortable in monitoring small lesions
• Still need to understand what they preferences
  are
• Cost conscience
• I want the best
• Missing teeth not a concern
• Value your judgment and recommendation
• Just take care of my basic needs
• Esthetically sensitive

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Treatment Planning Models

• Treatment oriented model
• Problem oriented model

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Treatment Oriented Model

• Dentist examine the patient
• Dentist mentally equate the findings to the need
  for certain form of treatment
• Examination findings are summarized in the form
  of a list of treatments - TREATMENT PLAN
• Useful in simple cases

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Problem Oriented Model

• Examination lead to formulation of a list of
  problem
• Each problem on the list is then considered in
  terms of treatment options
• Informed patients of all the options
• Formulate the TREATMENT PLAN

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Problem Oriented Model
Problem Lists (Objective findings from oral and
radiograph exam)
Patients Preferences/factors (Subjective
Findings)
Caries Risk Assessment
Formulate Treatment Options
Patients Preferences Informed Consent
Treatment Plan
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Patients Preferences

• Address patients chief complain
• Ask questions - assess patients true preferences
• Understand what is the treatment objectives for
  the patient (better function, better esthetic?)
• Understand what type of patient you are dealing
  with
• Preference for the types of restorations/procedure
  s (e.g. fixed vs removable, direct vs indirect
  restorations)
• Can the patient afford the procedures he/she
  desires?
• Patients dental IQ - long term maintenance
• Esthetic - understand their true concern

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Caries Risk Assessment

• Why is it a vital part of Treatment Planning?
• Dental caries is an infectious disease.
• It is the most overlook aspect in the treatment
  planning process.
• Patients caries risk status will affect the
  treatment (materials and procedures, treatment vs
  no treatment) you are going to prescribe.
• Patients caries risk will determine recall
  intervals
  and radiograph exposure
  intervals.
• For the high risk patients (caries active or
  caries prone), a strategy to control the disease
  should be formulated and documented in the
  treatment plan.
• Review- Dr. Hildebrandts Fall semester manual -
  Current Concepts in Caries Control

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Dental Caries - an Infectious Disease

• Etiologic agent - specific pathogens (Specific
  Plaque Hypothesis)
• Signs and symptoms of the disease - localized
  dissolution and destruction of calcified tissue.
• It is very easy to focus narrowly on treating the
  signs and symptoms ONLY (restorative needs) thus
  failed to identify the underlying cause of the
  disease.
• Failure to address the underlying cause of the
  disease will allow the disease to continue.
• Restoration alone do not and will not treat the
  disease

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High Caries Risk Patients

• Must identify the underlying reason(s) for the
  high risk.
• Not been to a dentist for years or poor oral
  hygiene are seldom the ONLY factor
• Salivary flow? Diet?
• MUST educate and formulate a control measures plan

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Clinical Example

• 24 year old male presenting to your office for
  routine oral exam
• PMH - non-contributory
• PDH - not been to a dentist since high school, no
  existing restoration.
• Clinical exam - rampant caries on multiple teeth.
  Normal salivary flow. Heavy plaque on all teeth.

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Problem Oriented Model
Problem Lists (Objective findings from oral and
radiograph exam)
Patient Preferences/factors (Subjective Findings)
Caries Risk Assessment
Formulate Treatment Options
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Problem List

• Dental caries - rampant caries
• Poor oral hygiene

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Caries Risk Assessment

• Caries active
• identify the underlying reason(s)
• Poor oral hygiene and not been to dentist since
  high school should not be taken as the
  convenient reason.

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Caries Risk Assessment

• Goals
• Identify the underlying reason(s) - EDUCATE the
  patient.
• FORMULATE control measures.
• ASSESSING patients ability to change (habits).
• These goals are as important if not more
  important than the restorative part of your
  treatment plan.
• Success/failure of the restorative phase will
  depend on whether you can achieve the goals
  stated above.

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Patients Preference/Factor

• Goals
• Formulate a preliminary plan based on patients
  preferences and the overall treatment goal.
• Narrow down options

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Overall Treatment Scheme
Initial treatment phase - treating the symptoms
of the disease (massive tooth morbidity).
Therapeutic Phase - control measures
Therapeutic Phase Evaluation -evaluate the
success/failure of therapeutic phase
Final Restorative Phase
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Initial Restorative Phase

• Options available for dealing with massive tooth
  morbidity
• Direct Restoration RCT Extraction
• Treatment options
• Extract all teeth
• Extract teeth that are unrestorable only
• Extract teeth that will need RCT
• Extract teeth that are unsuitable/unnecessary to
  support a removable partial denture. E.g. do you
  want to save all the Mx anterior teeth (assuming
  they all have extensive lesions) if your
  treatment plan will involve a Mx partial denture?
• Immediate removable appliances

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Therapeutic Phase Evaluation

• Was the control measures prescribed successfully
  change the patient from high caries risk to low
  caries risk, or at least have the disease under
  control.
• No final treatment phase should be initiated
  until the risk is under control

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Final Restorative Phase

• Indirect restorations
• Crowns and bridges
• Removable appliances