THE ODTP PROCESS A Case-Based Overview

THE ODTP PROCESS A Case-Based Overview
Orientation to the Clinical Practice of General Dentistry, Fall Quarter Alan W. Budenz, MS, DDS, MBA

Heather – a new patient Screened by faculty September 26, 2005
Designated as a 2nd Year teaching case

I would like a bridge for my lower front teeth
Chief Concern (CC): I would like a bridge for my lower front teeth

The ODTP Process: Step 1 Preparation
Pre-appointment preparation Review chart Read screening and/or treatment notes Review health history Review radiographs Make notes Plan out the first appointment

The Pacific Health History Questionnaire Form - Comprehensive - Standardized - Translations

The Pacific Health History Questionnaire Form
Section 1: General Questions Designed to elicit general information about the patient’s health, and whether they have seen a physician recently, are currently in pain, or have had any problems with prior dental treatment.

Section 2: Signs and Symptoms Focuses on various signs and symptoms that are indicative of medical problems. Signs = indications of disease that can be observed by the practitioner. Symptoms = problems associated with a disease that are experienced by the patient, but cannot be seen by the practitioner.

Section 2: Signs and Symptoms Note: No time frame is specified for any of these signs or symptoms. Determining the relevance of the time frame is the responsibility of the practitioner.

Section 3: Specific Diseases Concentrates on specific diseases which have been previously diagnosed by a physician. All of these diseases have a systemic effect. Therefore, all of these diseases have potential ramifications on dental care delivery.

Section 3: Specific Diseases The patient’s physiology is compromised by their medical problems, and many dental procedures have a significant physiologic impact. Therefore, the dental procedure may need to be modified to insure patient safety.

Section 4: Treatments Discusses medical treatments and prosthetic devices which may have a bearing on dental management of the patient. Decisions regarding dental management depend on the patient’s specific situation and the extent of the treatment and/or resultant outcome.

Section 5: Medications and Drugs Elicits important information on prescription drugs, over-the-counter medications, natural remedies, and any other drugs the patient might be taking. Documents the extent of any problems noted on other parts of the health history, or possibly problems not identified by the patient.

Section 6: Women Only Elicits specific information relative to women uniquely. Pregnancy and the use of birth control pills are especially pertinent to dental care delivery.

Section 7: All Patients Consists of a catch-all question designed to elicit information the patient feels is appropriate to provide, but which has not been otherwise directly queried.

Patients should sign and date the health history after initially completing it. The patient should review, update, and re-sign the form at each recall visit. At start of each appointment, ask “Have there been any changes in your health?” Note response in the treatment record.

The Health History Form
In our clinic, the patient fills out a medical questionnaire when they first register. This must be followed up with a verbal interview by the student doctor To insure that the patient properly understood the questions To ask about and obtain a history about any positive responses To insure that a negative response was what the patient intended for certain questions.

The Pacific Health History Interview Sheet

The Health History Interview Form
The separate interview sheet provides a location for notation of any significant findings and a description of any dental management considerations. It is best not to alter or make notations on the patient’s Health Questionnaire form. The interview sheet is used to ensure that any positive questionnaire responses are followed up and appropriately documented.

The Pacific Health History Interview Form
Includes 6 questions that need to be verbally asked of every patient: Do you have any… Cardiovascular problems? Infectious diseases? Allergies to medicines (or latex)? Bleeding problems? Take any medications? Other medical problems not asked about?

The six areas covered by these questions are extremely important to the dentist and it is appropriate to ask them again to insure that the patient properly understands and correctly answers the questions. Cardiovascular problems? Infectious diseases? Allergies to medicines (or latex)? Bleeding problems? Take any medications? Other medical problems not asked about?

Cardiovascular problems? Comprise the bulk of medical problems that require dental management considerations. 51% of patients with medical complexities have CV problems with the incidence rapidly increasing with age. (Smeets et al, Preventative Medicine 1998) Heart disease is the leading cause of adult deaths in the U.S. Stroke is the third leading cause of death in adults in the U.S.

Most specifically, patients should be asked if they have any history of “heart problems or heart murmurs”. If “yes”, questions to ask: When was the problem first diagnosed? Did your doctor ever say you should take antibiotics before dental treatment? Did your doctor ever say you don’t need to take antibiotics before dental treatment? For heart murmurs specifically: Was it termed functional or organic? Is there regurgitation?

Infectious diseases? Hepatitis is the most common infectious disease with implications for dental complications. HIV+ and AIDS often produce significant oral and systemic changes. Note: All patients should be treated as though they are infectious, i.e. universal precautions are the standard infection control protocol for all patients, with one exception...

Infectious diseases? The one exception... Active tuberculosis requires additional precautions, and these patients should generally be treated only in a hospital isolation facility.

Allergies to medicines (or latex)? Patients should be asked about allergies to any medications in general, and specifically about possible allergies to: Antibiotics Pain medications, including aspirin Narcotics Local anesthetics Latex

Hematologic, bleeding problems? Has the patient ever had any bleeding problems or do they bruise easily? Positive responses may be indicative of undiagnosed hematologic disease. Referral to or consultation with the patient’s physician may be indicated.

Take any medications? Indicates that the patient’s medical problems are severe enough to require medical treatment. Knowing any medications that the patient may be taking allows the dentist to be alert to possible side effects, toxicity, or drug interactions that may occur during dental care.

Take any medications? The increasing use of over-the-counter, natural, and herbal medications and supplements may have a significant impact on the delivery of dental care. Patients often fail to disclose these medications unless specifically asked about them.

Other medical problems not asked about? This catch-all question asked in a one-on-one confidential setting may elicit significant information that a patient may be reluctant to write down on a form. May also induce the patient to discuss anxieties and concerns they may have regarding dental treatment. Allows dentists to establish a thoughtful and caring rapport with their patients.

The ODTP Process: Step 1 Medical History Review
“Yes” answer to #3: Hospitalized or serious illness (3yrs) Listed: Lung problem What questions do you want to ask?

“Yes” answers to #4: Being treated by physician Listed: Anemia, GERD What questions do you want to ask?

“Yes” answers to #37: Stomach problems, ulcer What questions do you want to ask?

“Yes” answers to #62: Taking medications Listed: Warfarin, Prevacid What questions do you want to ask?

“Yes” answers to #63: Tobacco What questions do you want to ask?

Health History Review From your analysis of the medical history:
Is the patient’s medical condition controlled and stabilized under the supervision of a physician? Do you need to make any care delivery accommodations because of the patient’s health status?

Dental Management of Medically Complex Patients
Good sources for information on this subject: From the UOP web site: Protocols for the Dental Management of Medically Complex Patients Protocols for the Dental Management of Patients with HIV Disease Little, Falace, Miller & Rhodus, Dental Management of the Medically Compromised Patient, 6th Edition, Mosby-Year Book, Inc., 2002 (will get in 2nd Year Student kit)

The ODTP Process: Step 1 Radiographic Interpretation
Patient has brought in an FMX dated 4/20/99. Do we need a new FMX?

Complete a Radiographic Diagnosis Worksheet (available in Radiology)

Radiographic Findings: #2: possible mesial caries #3: gross distal caries w/ apical radiolucencies #13, 24, 25: severe vertical bone loss #14: gross mesial caries w/ apical radiolucencies #4, 17, 30, 32: missing

All of this should be done BEFORE your first appointment with Heather.
The ODTP Process: Step 1 All of this should be done BEFORE your first appointment with Heather. The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will make upon the patient.

The First Appointment: D0150 Initial Oral Examination
Greet Heather in the waiting room and introduce yourself. Ask her how she is today. Does she have any tooth pain? Give her a brief overview of what you are going to do during this appointment.

The First Appointment: D0150 Initial Oral Examination
Give her a brief overview of what you are going to do this appointment: “Today I’m going to do a very thorough examination of all of your teeth and gums, and then I’ll be able to discuss with you what dental care you need and what treatment options you have. I particularly want to evaluate your lower front teeth.”

The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs
Review the health history with the patient (MH) Take vital signs (VS) Perform intra- and extraoral exams (EOE & IOE) Take diagnostic casts if needed

Health History: Ask your questions from your Step 1 review of the completed form and record Heather’s responses to your questions on the Health History Interview Sheet.

Where do you record this information?
The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs What is significant in Heather’s health history for safe delivery of dental treatment? Where do you record this information?

Do you still have questions about Heather’s health? If so, how do you get them answered?

Physical exam (PE) findings:
The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Physical exam (PE) findings: VS: BP 105/70 – R, pulse 77 reg. EOE & IOE: all WNL

What questions do you want to ask?
The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs This is a good time to start gathering a dental and social history of Heather. What questions do you want to ask?

Dental History: HCC: currently asymptomatic.
DH: Last dental appt. for delivery of a maxillary partial denture, June 2000. Has had sporadic dental care most of her life. Perio: “deep cleanings” occasionally Ortho and Endo : none OS: #1,3,13,14,16 ext. at UOP in 1999; #4,19,30,32 ext. prior, different times Restorative: moderate restorations: amalgams, crowns, bridge #29 – 31, maxillary removable partial denture (RPD).

Social History: Grew up in Ireland, lived in Berlin, moved to Arizona in 1985, moved to LA in 1989, moved to SF in 1998. Parents deceased; 2 sisters, 1 brother living in Ireland. Separated from husband who lives in Arizona with their 19 y.o. son. Lives with 3 roommates in SF. Enjoys reading and furniture restoration.

After completing Step 2, “present” your patient to the ODTP instructor before proceeding to any invasive examination, i.e. perio probing. Faculty will sign your paperwork and “grade” the steps in the computer.

The ODTP Process Use any waiting time during the ODTP appointment to take clinical photographs of Heather. Basic patient intake photographs for chart record (7) Full frontal face Profile face Full frontal teeth occluded Right lateral teeth occluded Left lateral teeth occluded Full upper arch Full lower arch Additional images as needed for unique conditions or needs

The ODTP Process: Step 3 Periodontal Examination
Review x-rays, complete full mouth probing and comprehensive periodontal examination Diagnose periodontal disease status Plan periodontal treatment therapy Plan follow-up/maintenance care

Chart all findings in the computer and on the buff-colored Baseline Clinical Examination form

Periodontal Findings: Recession: generalized 2 – 4 mm w/ 8 mm #25 facial Pockets: generalized 3 – 4 mm w/ localized 5 – 7 mm Plaque index: 1 – 2 Mobilities: #23 – 25 Class 2, severe vertical bone loss Furcations: Class I & II on all remaining molars, Class I on #5 & 12

What is your periodontal diagnosis? Does Heather have active or stabilized disease? Since we have x-rays from 1999 and now from 2005, we can compare bone levels, furcas, and defects.

What is your periodontal diagnosis? Generalized moderate chronic periodontitis with localized severe chronic periodontitis What is the etiology? Moderate generalized bacterial plaque and calculus; heavy smoker and moderate alcohol intake.

What is Heather’s prognosis? Generally fair as is, good if she quits smoking and improves her oral hygiene; prognosis poor for 23 – 25. Treatment plan: 4 quads root planing, ITE, recall interval to be determined.

The ODTP Process: Step 4 Oral Hygiene Instruction
Full instruction customized to your patient’s individual needs. After completing Steps 3 and 4, “present” your patient to the Perio instructor. Faculty will sign your paperwork and “grade” the steps in the computer.

The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing
Charting of restorations, caries, pathology Ortho/occlusion screening Caries risk assessment List all findings and tentative solutions

Charting of restorations, caries, pathology: in the computer Ortho/occlusion screening: in the computer and on Orthodontic Screening form

Caries risk assessment: on Caries Risk Assessment form. What is the patient’s risk level and how will we, the patient and you together, manage their caries risk level?

List all hard tissue findings and tentative solutions: on ODTP Dental Examination Worksheet in detail. List all restorations: if no problem, write WNL; if problem, describe exactly what it is and where.

The ODTP Process: Step 5 Dental & Occlusal Exam
View of Heather’s maxillary arch:

View of Heather’s mandibular arch:

Anterior view of Heather’s dentition:

View of Heather’s right lateral side:

View of Heather’s left lateral side:

Clinical Findings: #1,3,4,13,14,16,17,19,30,32: missing #2: MO amalgam with mesial recurrent caries at ginigival margin #5: MOD amalgam – WNL #12: PFM crown – WNL #15: FVC crown – WNL #18: PFM crown – WNL #21: DO amalgam – WNL #23, 24, & 25: guarded/poor perio prognosis #28: DO amalgam – WNL #29 – 31: FVC 3-unit bridge – WNL

The ODTP Process: Step 6 Tentative Treatment Plan
Determine the ideal treatment options for the various dental problems found. Determine appropriate alternative treatment choices for the dental problems found. Discuss treatment goals with the patient.

In Heather’s case, her dental problems are: Moderate generalized periodontitis disease with localized severe disease Caries on the Mesial of #2 Severe bone loss & mobility #23, 24, & 25 What treatment options does she have?

Moderate to severe periodontitis What treatment options does she have? 4 quadrants of root planing No treatment What are the risks, benefits, and alternatives (RBAs) of each option?

Caries on the Mesial of #2 What treatment options does she have? M or MOL amalgam Full veneer crown (FVC) No treatment What are the risks, benefits, and alternatives (RBAs) of each option?

Severe bone loss & mobility #23 – 25 What treatment options does she have? Re-evaluate following perio therapy Extract and replace teeth with…? No treatment What are the risks, benefits, and alternatives (RBAs) of each option?

After completing your hard tissue examination and formulating a tentative treatment plan, “present” your patient to the ODTP instructor. Discuss findings and treatment options with the instructor and the patient.

After “presenting”, reviewing, and discussing your findings and treatment options with the ODTP instructor and your patient, The ODTP instructor will decide if specialist consultations are needed.

After completing your hard tissue examination and formulating a tentative treatment plan with your patient and the ODTP instructor, The faculty will sign your paperwork and “grade” the steps in the computer.

The ODTP Process: Step 7 Treatment Prioritizing/Contract
Prioritize and finalize the treatment plan with the patient and review it with the ODTP instructor. Enter the treatment into the computer in prioritized sequence, print it out and have the patient sign the printout. Have the ODTP instructor clinically approve your treatment plan in the computer.

The ODTP Process: Step 7 Treatment Prioritizing/Contract
For Heather’s case, the priorities are: 4 quadrants of root planing M amalgam on #2 Re-evaluate perio health for status of #24 & 25. Are these teeth salvageable? If not, what replacement options does she have?

The ODTP Process: The Final Step
At the completion of your appointment, or during “down” times during the appointment, Write up your treatment record.

Treatment Records The quantity of information gathered from the comprehensive patient examination process can be overwhelming. It is therefore essential to have a systematic method for recording and organizing all of the data.

Treatment Records Paperwork can be viewed as a burden, but it is also a necessary fact of life in every practice. Just do it, and get used to it! (It’s only going to get worse!) Learn how to make the paperwork serve your needs. “The palest ink is stronger than the best memory.”

Treatment Records The treatment record is perhaps the single most important document in the patient chart. It is essential that every aspect of patient care be fully documented. “If it isn’t written down, it didn’t happen.”

Treatment Records “The complete record contains a description of the patient’s original condition, your diagnosis and treatment plan, progress notes on the treatment performed and the results of that treatment. It should also contain the patient’s personal data, health history information, and informed consent documentation. The record should be organized logically and in language that is comprehensible to all who use it.” (Dentist’s Guide to Keeping Patient Records: Strategies & Solutions, California Dental Association, 1996)

Treatment Records The patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care. This ongoing record is the practicing dentist’s first reference at every subsequent patient visit.

Treatment Records “The patient record not only serves as the history of the therapeutic and business relationship between dentist and patient, but also it is the most reliable – and most relied upon – defense against a malpractice allegation. Malpractice allegations remain subjective until they can be substantiated, and sound records are an objective and factual measure of the actual treatment provided.” (Liability Lifeline, TDIC, California Dental Association, 1994)

Treatment Records The patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care. From a legal standpoint the patient treatment record has the greatest credibility, and when properly filled out, offers the best defense against litigation.

Treatment Records Document all treatment visits by chronological order, what services were performed, details of the procedures including what materials were used, and note any complications. Document all instructions, referrals, and recommendations given to the patient with notation of all RBAs discussed.

Treatment Records Document the informed consent process and any significant questions and comments made by the patient. Document all patient contacts: appointments, telephone calls, letters, etc. Document all failed and cancelled appointments, late arrivals, etc.

Treatment Records Ten rules for complete patient records:
Use a consistent style and standard abbreviations for all entries to foster your professionalism, and thereby your credibility. Use blue or black ink only – colors do not copy well, and pencil smears and fades over time and can be too easily altered, reducing the credibility of your records.

Use a single line to cross out errors. Do not use whiteout – not only is it messy, but it may be construed as an effort to conceal information. Date and explain any corrections, making corrections as they happen with the true date of the correction entry.

Write legibly – an illegible record can lead to inappropriate guesswork and suggests a careless, disorganized attitude. Note discussions of treatment options including the risks, benefits, and alternatives (RBAs) – list all options discussed. A handy abbreviation: DWP = discussed with patient

Express your honest concerns about patient needs – this reflects an understanding of the patient’s needs and documents that the dentist listened to, noted, and possibly addressed the patient’s expressed needs. Record missed appointments and failure to follow instructions, and record your attempts to educate and change patient behavior. This information can be vital for documenting your due diligence in caring for the patient.

Never write derogatory remarks in the record – this does not mean you should not record negative information, such as a patient’s failure to follow treatment advice, but record all remarks in a dispassionate and objective manner. Adapted from the June/July 1995 New York State Dental Journal

Treatment Records The SOAP note entry format
A clear, concise, and standardized form for recording all patient information and treatment Forms the basis for analyzing all patient data including treatment outcomes Is a universal format for discussing your patient with physicians or specialty practitioners, and for case reports in the dental/medical literature

Treatment Records The SOAP note entry format S = Subjective
O = Objective A = Assessment P = Plan/Procedure

Treatment Records The SOAP note entry format S = Subjective
What does the patient tell you? Includes CC = Chief Concern HCC = History of Chief Concern MH = Medical History DH = Dental History SH = Social History

Treatment Records The SOAP note entry format O = Objective
What are your observations? Includes PE/VS = Physical Exam & Vital Signs EOE & IOE = Extra- & Intraoral Exams Summary of appearance of both soft and hard tissues RE = Radiographic Exam

Treatment Records The SOAP note entry format A = Assessment
What is your diagnosis? Includes Periodontal diagnosis Caries risk assessment Restorative diagnosis Addresses patient’s chief concern

Treatment Records The SOAP note entry format P = Plan/Procedure
What treatment did you or will you provide? Includes complete notes on Treatment plan discussion Procedures done or planned Instructions, recommendations, referrals Prescriptions DWP: RBAs

The Treatment Record: S.O.A.P. Notes
For ALL procedures: First line: the date and procedure code and description

For ODTP we use an extended SOAP note: 10/3/05 D0150 Initial oral exam (S: Subjective) ID: Patient age, sex, etc. CC: Chief Concern HCC: History of Chief Concern MH: Medical History DH: Dental History SH: Social History

For ODTP we use an extended SOAP note: (O: Objective) PE: Physical Exam (VS, EOE, IOE, TMJ) Perio Dx: Periodontal Exam findings RE: Radiographic Exam findings Hard Tissue Exam findings

For ODTP we use an extended SOAP note: (A: Assessment) Periodontal Diagnosis Hard Tissue “Diagnosis” Caries Risk Assessment Make sure the patient’s CC is addressed!

For ODTP we use an extended SOAP note: (P: Plan/Procedure) Includes complete notes on DWP: Treatment plan discussion: RBAs – options and decisions Treatment plan or procedures done Instructions, recommendations, referrals, prescriptions NA or NV: Next Appointment or Visit

For restorative appts., etc., use abbreviated SOAP note: (P: Plan/Procedure) Treatment progress notes include: Tooth/region and procedure Type, dose, location of anesthetics Isolation technique All materials and medications used Shade, occlusion, lab prescription Post-operative instructions given Treatment outcomes

Treatment Records Patient privacy (HIPPA)
Patient privacy must be respected at all times Charts must be regarded as confidential, privileged information Patient’s have entrusted their personal information to us We, as doctors, are privileged to have access to this confidential patient information Therefore, we must make every effort to preserve chart, and thereby patient, confidentiality at all times

Patient Presentation A derivative of the SOAP note format
The presentation should be a brief summation of significant findings and history. The SOAP note format helps practitioners to organize their thoughts Analyze patient data Frame in an standard sequence

Patient Presentation S O A P Example:
Mary is a 42 y.o. African-American female with a chief concern to have her teeth cleaned and bleached. She has a medical history significant for hypertension controlled with the beta-adrenergic blocker Propanolol and for use of the antidepressant medication Zoloft. Her initial oral exam was completed Sept. 1, 2005 and her perio treatment of 4 quadrants of root planing was completed on Sept. 15th. Her hypertension is controlled today with blood pressure measured at 134/88 on her right arm, and a strong, regular pulse of 72. Tooth #12 has a distal carious lesion with a good restorative prognosis. Today I’m treating #12 with a DO amalgam. I will minimize the use of vasoconstrictor containing local anesthetic in this patient due to the use of non-specific beta-blocker and CNS depressant medications. S O A P

The ODTP Process: Points to remember:
Yes, the ODTP process is time consuming. A well done examination and treatment plan are the key to successful patient care.

The ODTP Process: Points to remember:
The ODTP appointment is an excellent time to build patient rapport. The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will have upon the patient.

That's All, Folks! Unless…

THE ODTP PROCESS A Case-Based Overview

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