ODRP 726 Patient Diagnosis and Treatment Planning

 Gingivitis  #8 MF discolored composite  #30 F recurrent decay FGC  The patient has all teeth present except third molars.  Patient’s chief complaint: Check-up

 What is the treatment to accomplish?  Patient’s treatment objectives can be quite different from those of the dentist

 Short-term ◦ Chief complaint  Relieve pain  Restore broken tooth  Long-term ◦ Stay free from pain ◦ Replace teeth to restore function ◦ Have a nice smile ◦ Extract all teeth and get dentures ◦ Don’t want teeth to keep breaking

 Determination of goals starts with the interview and can continue through the examination process  Use open-ended questions ◦ How well are you able to eat? ◦ How do you feel about the appearance of your teeth?  You may need to educate the patient about the feasibility of their options ◦ Patient wants to keep all their teeth – severe perio ◦ Patient wants to replace existing bridge – decay is too deep

 Positive modifiers ◦ An interest in oral health ◦ The ability to afford dental treatment ◦ A history of regular dental care  Negative modifiers ◦ Time and/or financial constraints ◦ Fear of dental treatment ◦ Lack of motivation ◦ Poor oral health ◦ Destructive oral habits ◦ Poor general health ◦ Diet high in refined carbohydrates

 Remove or arrest all decay  Eliminate pain  Provide the correct treatment for each problem  Select the best material for a restoration  Ensure that the problems are addressed in the correct order  Provide the ideal treatment ◦ Replace all missing teeth ◦ Improve esthetics ◦ Restore all problematic teeth

 Knowledge and experience  Technical skills  Lack of specialists  Treatment planning philosophy ◦ All amalgams must be removed and replaced with alternative materials ◦ If any amalgam larger than an occlusal must be replaced, with a crown ◦ Restorations (amalgams, crowns) with open margins and no pathology are not replaced ◦ 3 rd molars should always be removed when the patient is young

 Takes into account patient and dentist goals and modifiers ProblemIdeal DDS Goal Patient Modifiers Dentist Modifiers Modified Tx Plan Missing #9ImplantExpenseDoes not have skill Referral not available FPD Stayplate Severe perio Extract Replace with RPD Wants to keep teeth Believes that teeth have poor prognosis Make RPD to accommodate additional teeth as they are extracted

 Possible goals of patient ◦ Extract all teeth CD/CD ◦ Only place required fillings and crowns and replace/reline RPD’s ◦ Full mouth reconstruction

 Important in complex cases  Key teeth often serve as abutments for fixed or removable partial dentures ◦ Retaining key teeth can stabilize prosthesis and prevent bone resorption  Retention of key teeth can improve the overall prognosis  Loss of key teeth can limit the number of options available to a patient

 Periodontally stable ◦ Little mobility ◦ First molars, canines  Favorably positioned in the mouth ◦ Spread throughout the arch ◦ Little supraeruption, tipping, rotation  Restorable ◦ No caries below or near the alveolar crest

 Interview of patient and evaluation of health history  Examination of patient  Determine the risks associated with the patient’s medical conditions and medications  Request medical consultations as needed  Determine which treatment plan modifications are required for this patient

 Limited Evaluation  During the initial visit, you become aware of acute conditions which should be treated immediately, before continuing with the Comp Oral Eval

 Resolve symptomatic problems ◦ Pain, swelling, infection, broken teeth, missing restorations  Typical types of treatments ◦ Extractions, endodontic treatment, perio therapy, provisional restorations, repair prostheses

 Often treatment is a palliative solution if the long-term status of the tooth is uncertain ◦ Gross caries – instead of extraction or root canal treatment, do pulpectomy ◦ Instead of replacing lost restoration, place temporary

 All parts of the patient evaluation occur in a Limited Evaluation – however, they are generally more “limited”  The findings, both negative and positive take on more importance due to the urgency of the situation.

 New Patient ◦ Abbreviated health history  Current patient: ◦ Update the existing health history

 Have you had any recent hospitalizations, surgeries, or major medical problems?  Are you currently being treated by a physician?  Do you have any heart or breathing problems?  Do you have any allergies to any medication, food or other substance such as latex?  Do you have any bleeding problems?  Have you had a joint replacement?  What medications are you taking (over-the-counter, herbs and prescribed)?  (If female) Are you pregnant or taking birth control pills?  What do you do for exercise?  Do you have any other health problem that you are aware of?

 Must be thoroughly investigated to insure that there are no systemic health limitations or contraindications to dental treatment  If this can’t be determined a phone or written consult is required before treatment can take place ◦ Temporary can be placed ◦ Antibiotics and/or analgesics can be prescribed

 Comprehensive dental history not needed  Questions related to the complaint are appropriate ◦ When was the root canal placed? ◦ Have you been treated for gum disease? ◦ How has this problem been treated in the past?

 Overall health status ◦ Signs of anxiety or stress ◦ Labored breathing ◦ Patient in wheelchair ◦ Jaundice present  Vital signs  Oral cancer screening  Area of chief concern  Contiguous tissues

 May or may not require a significant amount of time  Often easily led to the tooth or site causing the problem  Testing ◦ Visual ◦ Radiographic ◦ Endodontic ◦ Periodontal probing ◦ TMD examination ◦ Cranial nerve exam

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionWhat do we need to visualize? Isolated perio problem PPDs<5 mmEntire tooth and level of bone Isolated perio problem PPDs>5 mmEntire tooth and  level of bone Symptomatic tooth ??? restorabilityPeriapical area and level of bone Symptomatic restorable toothPeriapical area Non-restorable toothAll of root and near structures Eruption pain or pericornitisAll of tooth Possible jaw fractureEntire maxilla and mandible Blunt trauma to tooth or teethEntire tooth and periapical area

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

Presenting ConditionRecommended Images Isolated perio problem PPDs<5 mmPeriapical and bitewing Isolated perio problem PPDs>5 mmPeriapical and vertical bitewing Symptomatic tooth ??? restorabilityPeriapical and bitewing Symptomatic restorable toothPeriapical Non-restorable toothPanoramic or periapical – including sinus, mandibular canal, etc Eruption pain or pericornitisPanoramic or periapical Possible jaw fracturePanoramic or CBCT Blunt trauma to tooth or teethPeriapicals of traumatized tooth/teeth and opposing teeth

 Pulpal or periapical origin  Periodontal tissues  Pericornitis or eruption  Previous dental treatment  Soft tissue lesions  Debilitated oral health  Temporomandibular disorder  Trigeminal neuralgia  Acute sinusitis

 Almost always caused by infection ◦ Pulpal/periapical ◦ Pericoronal ◦ Periodontal ◦ Lymphadenitis  Soft tissue or bony lesions

 Fractured tooth  Lost filling  Lost crown  Fractured porcelain  Loss of tooth from denture  Underlying causes ◦ Hyperocclusion ◦ Loss of VDO ◦ Insufficient crown reduction ◦ Poorly designed preparation

 Teeth ◦ Partially or completely avulsed ◦ Crown or root fracture ◦ Pulp involvement  Soft tissue ◦ Lacerations ◦ Contusions ◦ Leads to swelling  Bone ◦ Fracture

 See handout for range of options for acute problems

 Professional  Patient’s health  Complexity of the treatment  Time available for treatment  Skills, experience and confidence of the dentist  Availability of specialist  Patient  Interest and priorities  Time and financial resources to expend on treatment  Quality of oral health care  Patient’s ability to maintain dental work

 Conversation between dentist and patient is important to delineate these factors  With the need to expedite treatment, it is common to make assumptions

 Example: ◦ Badly decayed, symptomatic tooth. Patient has multiple decayed and missing teeth.  What are some assumptions the dentist might have about the best treatment for this patient?  What are some assumptions the patient might have about the treatment he thinks that he needs?

 Patient needs to be made of aware of: ◦ Consequences of the acute phase treatment ◦ Any anticipated future treatment needs  This needs to occur before a plan of care is finalized

 Same example: Badly decayed, symptomatic tooth. Patient has multiple decayed and missing teeth. In both instances the patient seems to know what she wants, and is insistent about it.  What are some long term implications of treatment that the patient should be aware of for each treatment? ◦ Treatment: Extraction ◦ Treatment: Endodontic treatment

 Dentist’s decisions ◦ How critical is this tooth to the overall oral health? ◦ What is the prognosis? ◦ In light of the patient’s other oral needs is it realistic to invest resources to try to keep it? ◦ What other treatment (endodontic, restorative periodontal)is required to insure that the tooth is functional and esthetic?

 Patient’s decisions ◦ How much time, energy and money is the patient willing to invest in saving the tooth? ◦ What is required in the way of follow-up? Is the patient ready to commit to that?

 Resolving an acute problem can be a difficult for the dentist and patient  The patient must be provided with enough information to make a decision that will meet both short and long-term needs  The dentist must develop a pattern for the process of reaching a consensus  This can be difficult when working in an acute situation

 The BEST treatment alternative is to manage the patient’s acute problem with definitive care – extraction or extirpation of the pulp (initial part of root canal treatment)

 In some situations it is prudent to prescribe medications rather than initiate treatment ◦ The problem or offending tooth cannot be identified ◦ The patient has systemic health issues that preclude treatment at the time ◦ The patient has an active infection, and there is significant risk that profound anesthesia cannot be attained or that surgical intervention may lead to further pain or spread of infection ◦ The patient is unwilling to give consent

 Prescription of medications does not end with writing the prescription  The dentist’s obligation is to follow-up to ensure resolution of the problem  The patient should be appointed for definitive treatment with you or a specialist before he leaves  If the patient fails the next appointment – the responsibility for success or failure is now on the patient

 The problem should be documented in the Treatment History using the SOAP format  The plan should include the provision of: ◦ Postoperative instructions ◦ Discussion of possible sequelae from treatment ◦ Prescriptions ◦ Guidance on what to do if the original problem persists or worsens ◦ An appointment for the definitive treatment  The dentist should always call the evening of the appointment

 It can be difficult to provide acute treatment in an already busy schedule  Protocols for handling acute problems should be developed to minimize the effect on your schedule  You can choose to work new patients into the schedule  Patients of record must be worked into the schedule

 Providing acute treatment efficiently, compassionately and professionally is one of the best ways of building your referral practice.