1. Dental treatment planning
Prof. Elsanousi M Taher
BDS, M.Sc., FFDRCSI
Faculty of Dentistry
LIMU

2. The goal of dental treatment plan is the formulation of a strategy to solve the patients dental complaints and problems depending on diagnostic data base or problem list of the patient
Effective dental treatment planning is one of the most challenging aspects of dentistry

3. Aims and objectives of treatment plan:
Manage the emergency or urgent complaint. e.g. Relief of pain
Prioritize the treatment needs in the interest of the patient
Restore function and esthetic
Achieve the highest standard of care
Prevent any further deterioration of patient oral health

4. Steps to reach treatment plan:
Collection of data
Proper diagnosis of chief complaint
Listing the dental problems of the patient
Determine the medical status of the patient
Determination of management options

5. Decision making process:
It is mutual decision
Explain the options: advantages, disadvantages, limitations
Listing possible solutions for patient problems:
Some of the patient’s problems can only be solved by specific procedures
Others have alternative solutions
The ideal treatment plan might not be feasible
The agreed treatment plan is documented in patient’s file

6. The patient problems may include:
Chief complaint problem
Problems related to medical conditions:
Previously diagnosed
Discovered through systemic review and clinical examination
Problems related to other oral conditions (dental or non dental) that patient may not be aware of them e.g. white patch or nasty appearing ulcer

7. Urgent Less urgent: Non urgent: The chief complains may be: Pain
Acute infection
Bleeding
Traumatic injury
Less urgent:
Lost restoration
Mild symptoms of pulpitis and carious lesions
May be treated by temporary restorations
Non urgent:
Routine checkup
Oral prophylaxis
Replacement of missing teeth
Can be delayed until a definitive TP is formulated

8. The C.C and reason for attendance must be clearly taken and recorded
If communication problem exist due to age or language barriers ask for help (parents or interpreter)
The TP will depend on whether the patient is attending for an emergency relief of pain or for routine checkup

9. THE CHIEF COMPLAINT PROBLEM:
Should be managed first whenever possible to show the patient that you care and makes him/her accept the comprehensive treatment plan unless:
There is more serious or urgent conditions
There is a need for some treatment to be done before dealing with chief complaint (oral prophylaxis before implant and fixed prosthodontics)

10. The management of urgent C.C may include:
Palliative treatment to control symptoms of the diagnosed problems
Analgesics & antibiotic
incision and draining (I & D)
Pulp extirpation
Temporary restoration
Curative treatment:
Directed towards elimination of the problem e.g. extraction or RCT.
It is an optimal goal whenever possible

11. The emergency treatment need to be followed by definitive treatment if patient agreed
If the patient is not interested in definitive or comprehensive treatment record that in his/her file in clear terms

12. PROBLEMS RELATED TO POTENTIAL MEDICAL CONDITIONS
Recognition of medical problems and prevention of their potential complications by modifications of dental procedures is of high importance
This may include:
Previously diagnosed medical conditions (PMH)
Discovered medical conditions (systemic review and clinical examination)

13. Previously diagnosed medical conditions:
The effectiveness of current medications used in their treatment need to be assessed
The need for medical consultations in such cases is often indicated in:
Poor patient understanding of the nature of the problem
Poor records
Failure to comply with medical treatment
Long duration since the condition was evaluated
Features suggestive of ineffective treatment (systemic review finding)
The effect of the expected physiological or emotional stress of the procedure on the patient

14. Current medical condition & medications that may necessitate certain modifications include:
Prophylactic antibiotic as in patients with rheumatic heart disease
Early morning appointment for diabetic patients
Dental consideration for dialysis patient
Dental considerations for patients with H/O heart attack
Dental considerations for patients on anticoagulants: prove to be threat in surgical procedures

15. Current medical condition & medications
Dental considerations for patients with epilepsy
Dental considerations for patients with hemophilia
Dental considerations for pregnant patient
Dental considerations for terminally ill patients
Hypersensitivity: allergic or idiosyncratic
A reaction to a medication that is unusual and unpredictable, specific to a particular person. Unlike allergy, it can occur on first exposure to the medication, unlike a side effect, it affects only very few individuals.

16. Discovered medical conditions:
Any undiagnosed disease revealed by the history, review of systems or clinical examinations put a moral and ethical responsibility on practicing dentist for proper referral or consultations of his or her patient
Must be listed in patient problems
Don’t put patient on stress
You may ask for basic investigation e.g. DM, anemia
Always remember that you are not a medical doctor !!

17. ORAL DISEASE AND CONDITIONS:
Gingivitis and Periodontitis
Caries, Pulpitis and its sequel
Complications of eruption
Missing teeth
Non dental oral lesion
Others

18. Gingivitis and Peridontitis:
OHI and plaque control
Scaling & root planning
Surgical elimination of tissue defects
Extraction of poorly prognosed teeth

19. Pulp related problems:
Reversible pulpitis:
Excavation of deep caries
Placement of calcium hydroxide and temporary restoration
Wait and see for 7-10 days:
Symptom free: restore as usual
Symptom persisted or increased: deal as irreversible pulpitis
Irreversible pulpitis: RCT or Extraction

20. If in doubt to distinguish between reversible and irreversible pulpitis, deal with the case as reversible pulpitis until proven otherwise (periodic checkup)

21. Management of carious teeth:
Carious teeth treatment should be prioritized on the basis of greatest axial extension of the lesion
Heavily restored teeth with suspected recurrent caries may necessitate complete removal of the old filling

22. Incipient caries: It is reversible No need for cavity preparation
Managed by:
Improvement of OH
Less cariogenic food
Fluoride application
The exception to this role is when other surface of the tooth require conventional restoration e.g. occlusal cavity with incipient proximal or smooth surface caries

23. Carious cavity lesions:
Prepare and restore
Select proper filling material:
Composite
Amalgam
Glass ionomer restoration
Compomers
Heavy filled and RCT teeth will be weakened on long-term and may need to be
Ceramic crowned
Porcelain-fused to metal crowned
Cast gold crowned

24. Eruption problems:
Buccally or palatally placed canine
Crowding
Impacted third molars
Others
Optimal solutions are dependent on clinical situation and guidelines:
Extraction
Orthodontic
Extraction and orthodontic
Leave as it is

25. Buccally placed canines and crowding

26. Impacted canines

27. Consultations with the followings are essentials:
Orthodontist
Pedodontist
Oral surgeon
Oral medicine

28. Treatment options for replacement of missing teeth:
Fixed prosthesis:
Short span: three unit bridge
Long span:
a double a abutment design
Cantilever bridge
Acid etch or “Maryland “ bridges
Dental Implant
Removable prosthesis:
Immediate partial
Transitional denture
Complete denture

29. Always take into account the implications and consequences of specific treatment options:
Most treatment options create additional treatment needs or definite consequences in the treatment planning procedures (Treatment complications)
e.g. treatment of badly carious lower first molar → extraction→ space→ drift→ 3 unit bridge

30. Ideal treatment plan is not always achievable and a compromised plan may be the best option
The final step in treatment plan is to rearrange all the treatment procedures necessary to solve the patient problems and needs in the most logical treatment sequence (prioritizing the treatment)

31. Factors that affect or determine the treatment goals and treatment plan
The patient perspective
Dentists perspective

32. The patient perspective:
The patient dental expectation
Financial limitations
Patient dental attitude
Self image
Age of the patient
Patient occupation
Prognosis of the proposed dental treatment
Existing dental conditions

33. The patient perspective:
The patient chief complaint should become the dentist’s treatment priority but more urgent problems should not be ignored while treating chief complaint

34. The patient perspective
The patient dental expectations: Which can be ranged from:
Care limited to treatment of painful tooth
Patient who wants to retain teeth regardless of treatment complexity
Past dental history may be regarded as reliable indicator of the patient real attitude
The dentist must be suspicious of the high patient expectations

35. The patient perspective
Financial limitations:
It is a challenge for the dentist to convince the patient to pay for painless dental problem with long term adverse effects
It is an ethical dentist responsibility to provide the best treatment possible although the high cost may be an obstacle
Financial limitation may reflect:
Inadequate income
Adequate income with preference to spend for other things
Policies dictated by third party

36. The patient perspective
The financial problem can be overcome by payment planes, delaying most expensive restorative treatment, omitting elective procedures and giving priority to disease control procedures
Unfortunately, there are times, when even minimal care is beyond the patient ability

37. The patient perspective
Patient dental attitude:
May reflect a complex mixture of inaccurate knowledge, misinformation and impression of past bad experiences
Asymptomatic patient may not be interested in comprehensive plan
Negative attitude towards dentistry can be changed by gaining confidence of the patient and establishment of good dentist-patient relationship

38. The patient perspective
Existing dental conditions and status:
Caries risk and susceptibility
Location and number of missing teeth
Condition of alveolar bone
Others

39. The patient perspective
Self image:
Some expectations are unrealistic or unattainable
Age of the patient:
Patient occupation:
Prognosis of the proposed dental treatment:
The prognosis for any dental reconstruction should be at least 5 years

40. Dentists perspective: is affected by:
The patient’s dental condition
Prognosis
Operator’s knowledge and updating
Experience and technical skills
Treatment plan philosophy
Potential complications of dental treatment
Referral for specialty treatment
Public or private services

41. The patient’s dental condition:
This is the most important factor that influence the treatment plan
The dentist obligation is to give high priority to chief complaint and active disease/s
Any diagnostic uncertainty must be solved before treatment plan is formulated

42. Prognosis:
Dentist will always be blamed for unsuccessful or failed treatment (implant now)
The procedure with high expectation for success should be offered for the patient and to let him or her decide
The selected treatment plan may be affected by expected life span of the patient

43. Operator’s knowledge:
New graduated GDP may adopt an ideal treatment plan giving no account to patients desires and modifying factors
GDP in practice for many years with substantial clinical experience may not improve his knowledge and not in line with new techniques or treatments options
The good dentist is a lifelong learner, keeping up with current development in the profession (continuing education courses, critical reading of literature)

44. Experience and technical skills:
The GDP may have no experience with RCT of multi-rooted teeth. This treatment may not be offered to the patient unless the dentist is interested in referring the patient to a colleague
Referral option should always be available for second opinion or for full or partial management of the case

45. Treatment plan philosophy:
Treatment plan adopted by experienced dentist always reflect his or her philosophy:
Removal of wisdom teeth
Unwarranted removal of sound amalgam restoration and replacement with gold or composite restoration
Giving the choices between two or more treatment alternatives, the dentist is most likely to chose the option that is consistent with his/her philosophy of dental care or experience

46. Potential complications of dental treatment:
Treatment planning options are occasionally selected specifically to avoid the possibility of certain treatment complications as in treatment plan for a patient at risk of infective endocaraditis or patient with hereditary bleeding disorders

47. Referral for specialty treatment: depends on
Availability of the specialist
Acceptance of the patient to be referred
Public or private services

48. Types of treatment plans
Emergency dental treatment
Limited treatment plan
Tentative or provisional dental plan
Comprehensive dental treatment plan

49. Limited dental treatment:
Treatment solutions for specific problem that is not urgent e.g. Patient may request treatment of anterior teeth before marriage
Planning on the basis of limited treatment goals should represent exceptional situations rather than a routine method of dental practice
The temptation to adopt tooth by tooth problem solving approach should be avoided

50. Tentative or provisional dental plan:
Some dental diagnoses and prognoses are so complex that no definitive or complete treatment can be planned until the results of intermediate therapy is determined (the outcome of the initial treatment can not be confidentially predicted)
The specification of additional treatment decisions is deferred or listed in general terms until the effectiveness of initial treatment can be assessed

51. Tentative or provisional dental plan:
An example of such a tentative plan may be adopted for a patient with advanced Peridontitis, with questionable prognoses on several potential abutment teeth. If all teeth are retained, a fixed prosthesis would be indicated, the loss of one tooth may indicate a removable partial denture, and loss of more teeth may indicate a complete denture or implant.

52. Comprehensive dental treatment (holistic):
Plan decided by the patient and dentist to solve all the patient oral and dental problems
It is the preferred approach as all aspects of care are targeted
Referral for specialty is part of comprehensive treatment and delaying of certain elective procedures are consistent with comprehensive procedure as long as the plan will eliminate all patient problems

53. Comprehensive TP:
Definitive treatment phases: this would be adopted for those who seek routine dental treatment or who have had successful emergency treatment and wants to have total oral care

54. Phases of comprehensive treatment plan Pretreatment phase:
Pretreatment phase: may need to be done before commencement of active treatment
Specialized radiographs CT, MRI
Study models
Medical or dental consultations
Treatment phases:
Phase I: Treatment of acute problems
Phase II: Disease control and stabilization phase
Phase III: Restoration of esthetic and function
Phase IV: Re-evaluation of treatment
Phase V: Maintenance care phase (Recall phase)

55. Phase I: Treatment of acute problems:
to control pain or acute infections
Extraction of painful tooth
I&D of an abscess
Management of traumatic injuries
Pulpectomy
Excavation of deep caries lesions
Sedative temporary restoration
Pulp capping
Biopsy of a lesion

56. Phase II: Disease control and stabilization phase:
Only well motivated patients will go to this stage
The purpose of this phase is to:
Control active oral disease and infection
Stop occlusal and esthetic deterioration
Management any risk factors that cause oral problems ( e.g. preventive measures).

57. Conservative treatment:
Common procedures during Disease control and stabilization phase include:
Periodontal treatment:
OHI
Curettage
Scaling and root planning
Surgical periodontal therapy
Conservative treatment:
Composite and amalgam restorations of carious lesions
Caries risk assessment and prevention
Management of non carious tooth loss (erosion, attrition and abrasion)
Endodontic therapy
Oral and maxillofacial surgery:
Extraction of hopeless teeth
Treatment of any soft tissue pathology

58. Phase III (Restoration of esthetic and function (Oral rehabilitation)
Aims to rehabilitate the patient’s oral conditions and include procedures that improve appearance and function like:
Additional periodontal therapy including periodontal surgery
Orthodontic treatment and occlusal therapy
OS: preprosthetic & orthognathic surgery
Replacement of missing teeth with fixed or removable appliances (including implants)

59. Phase IV: Re-evaluation of treatment): the goal is to confirm that:
All treatment has been adequately completed with no omission
No new lesion have developed
Patient adapted to any appliance provided
Patient has adhered to home care advise

60. Phase V: Maintenance care phase (Recall phase):
It depends on patient motivation
To maintain optimum treatment results achieved
Prevent relapses and disease recurrences
Support the patient
Monitor the level of disease control
Assess and maintain treatment previously carried out
Reinforce patient motivation and responsibility for his/her oral health
Early identification of new dental or oral lesions
The success depends on regular recall system

61. Setting priorities (the optimal treatment sequences)
The final step in formulating the dental treatment plan is to rearrange all the treatment procedures necessary to solve the patient’s problems in the most logical treatment sequence.
The order in which dental procedures are completed is determined by consideration of the priorities from the perspective of both the patient and the practitioner.
Unfortunately, esthetic problems are of high priority to the patient may seen rather secondary to the dentist compared with extensive decay affecting several molars.
Despite this divergence of opinion, planning the sequence of the procedures, should allow high priority problems to be solved early in treatment and prevent complication resulting from delaying treatment or poor sequencing e.g. Fabrication of a ceramic metal crown before completing periodontal therapy

62. Please note that:
Treatment plan for the patient is an opinion of what the dentist thinks is best for the patient “treatment plans are to large extent are opinions”
The dentist should not be offended if the patients seek a second opinion (in fact reluctant patient should be encouraged to do so)

63. More than one way may exist to plan treatment for a patient and several plans may be acceptable
Most treatment plans are compromises, few are ideal.
Several “best” treatment plans may exist and they are the ones that are closest to ideal yet practical for a particular patient.

64. Best treatment plan is defined “as the plan that represent the most effective practical treatment approach for a given patient, taking into account all factors affecting formulation of treatment plan including availability of delivery” and accepted by the patient.

65. Every patient deserves to know the best treatment plan possible for him or her and it is the responsibility of the dentist to offer such treatment. If a certain part of the care is not within the dentist’s usual practice or experience , the patient should be referred for that therapy. If the patient refuses such referral , an appropriate treatment plan modification or a compromise may be made

66. In summery, patient treatment priorities generally include attentions to chief complaint, solving the patient perceived problems within the financial resources and obtaining reasonable prognosis which minimizing inconvenience, pain and complications

67. Case presentation
Case presentation is the process of explaining the diagnostic findings, the necessary dental treatment and the possible complications of dental treatment to the patient and obtaining the patient’s consent to begin treatment
This process started once the dentist has build up relationship of trust
The dentist has to use his communication skills to reach consensus on treatment plan

68. Case presentation
If handled poorly, the patient may perceive the dentist as uncertain, lacking confidence, self serving, arrogant or even incompetent
Use simple language and avoid technical terms to convey your massage

69. Case presentation
Use radiographs, photographs, study models and pamphlets to educate patient and visualize their problems
Encourage patient to ask questions and clarify any doubts
Educate the patient about the nature of his chief complaint and other existing problems
Inform the patient about the short and long term prognoses

70. Case presentation
Explain treatment options with advantages and disadvantages of each
Explain the possible complications, why they might occur and how can be solved
Record the patient-dentist agreement on the best approach to solve the patient problem
The barriers that may prevent the patient from accepting treatment (pain, cost, time, phobia …etc.) must be clearly addressed