Treatment Planning

Objectives Relation between diagnosis and treatment plan Types of treatment plan Considerations for treatment planning Treatment plan matrix Sequential Treatment Plan

Introduction Excellence in dental care is achieved through the dentist’s ability to: Assess the patient Determine his or her needs Design an appropriate plan of treatment Execute the plan with proficiency

Definition Treatment plan The sequence of procedures planned for the treatment of a patient after diagnosis Glossary of Prosthodontic Terms Establishing diagnosis is the key to effective treatment planning Illogical to pursue any course of treatment without knowing what is being treated

Diagnosis must include All problems that have been highlighted by the clinician and radiological examination, including features that, although abnormal require no active treatment Treatment plan can thus be considered A carefully sequenced series of services designed to eliminate or control etiological factors, repair existing damage and create a functional and maintainable environment

A sound treatment plan depends on Thorough patient evaluation Dental expertise Understanding of indications and contra- indications of different procedures Prediction of patient’s response to treatment

Modifying Factors Patient related Dentist/operator related

Patient related factors Systemic health Demands Motivation Plaque control Emotional status Anxiety Priorities, time available Financial capabilities

Dentist related factors Dentist’s skill, knowledge and experience Access to technical and laboratory support Access to specialist services

Treatment Planning Considerations Treatment Planning Models Treatment Matrix Sequential Treatment Plan

Considerations

Three things must be considered: What does the patient want? What can the patient tolerate? What can be achieved?

What does the patient want? Patients may present with unrealistic views of what is possible Patients may be unaware of modern techniques Dentist’s duty to inform, encourage and occasionally dissuade

What can the patient tolerate? Attention span and tolerance to treatment Ability to obtain a good standard of oral hygiene Problems associated with postural hypotension, raised blood pressure and reduced cough reflex etc. Physiological and pathological changes associated with age and medication

Notes Don’t comment definitively on treatment until examination, diagnostic tests and diagnosis are complete Formulation of treatment plan requires consultation with patient to select the most appropriate and acceptable plan

In any complex treatment schedule, build in contingency plans Prepare for failures and allow for ‘what if?’ Good oral hygiene and adherence to preventive advice is of prime importance Work on one segment of the mouth at a time In anxious patients, carry out the simplest procedures first

Treatment Planning Models

Planning Models TREATMENT-BASEDPROBLEM-BASED MODELS

Treatment-based Model

Examination findings are summarized in the form of a list of needed treatment which becomes the treatment plan Focus is on what has happened and how to treat it Little or no consideration on why it happened

Problem-based Model

Each diagnosis (problem) is then considered in terms of treatment options Focus on what is happening and why Different advantages and disadvantages No treatment is also an option Optimal solution for each diagnosis is chosen, and assigned to the treatment plan matrix

Diagnosis Formulation Chief complaint Patient’s goals of treatment Medical history Dental history Examination Extra-oral Intra-oral

Diagnosis or Problem List Listed under categorical headings or domains (e.g. periodontal problems, endodontic problems etc.) List is dynamic and can be modified as new problems arise

Problem-based Planning Dentists formulates a mental image of the optimal condition to which patient can be rehabilitated

Requires decision on: Teeth which are not periodontically and restoratively salvageable Teeth that need to be replaced Most appropriate form of prosthodontic replacement

Treatment Plan Matrix

Treatment plan can be divided into phases to ensure inclusion of all elements The treatment plan matrix is to be reflected in the “Treatment Plan” section of the dental chart Not sequenced

Treatment Plan Matrix Systemic Phase If necessary Emergency Phase If necessary Control Phase Treatment Phase Maintenance Phase

Systemic Phase Addresses the general health status of the patient and its relationship to the oral cavity and dental treatment

Emergency Phase This phase addresses those dental problems that constitute the patient’s chief complaint, are producing symptoms, or are potential source of acute symptoms

Involves the management of pain and/or infection and includes Relief of dental pain due to pulpal involvement through Caries excavation/sedative temporary restoration Emergency endodontics Pulpotomy, pulpectomy Extraction Incision and drainage

Relief of dental pain due to periodontal involvement through Irrigation Curettage Incision and drainage Extraction

Definitive or palliative treatment of soft- tissue lesion through Excision Cautery Topical medication Prescription of appropriate analgesic/antibiotic agents for problems

Control Phase The objectives of this phase are to Eliminate active disease Eliminate potential causes of disease Remove conditions preventing maintenance

Includes Caries control Sugar restriction Fluoride application Oral hygiene instructions Diet survey Caries risk assessment

Periodontal treatment Plaque control Scaling and root planning Establishing the prognosis of periodontically involved teeth

Restorative treatment Excavation of caries and restoration Temporary or final, depending on whether a definitive prognosis for the tooth has been arrived at and on the location of the caries Establishing the restorative prognosis of grossly carious teeth

Treatment Phase Operative dentistry Oral surgery Periodontal surgery Endodontic therapy Orthodontic treatment Others

Review and confirmation of Restorative treatment Occlusal preparation Crowns and fixed partial dentures Removable partial dentures Complete dentures

Maintenance Phase Periodic recalls, checking Plaque and calculus Gingival condition Caries Restoration failure Occlusion, tooth mobility Other pathological changes

Notes Replacement of existing restoration Defective restoration Marginal voids, poor proximal contour or overhang, recurrent caries, carious ditching, unacceptable esthetics Tooth requires cuspal coverage Existing restoration is contributing to disease or preventing maintenance New restoration can improve present situation

Sequential Treatment Plan

Process of sequencing the needed treatment in a time frame Treatment sequencing follows the logic of the medical model Disease is treated in the priority of importance to the patient’s overall health Ignores the common technique of treating by specialty

Sequencing of the treatment is completed by arranging the solutions to various problems in a set order

TREATMENT SEQUENCING Chief complaint Medical/systemic care Emergency care Treatment plan (matrix) presentation Disease control Additional diagnostic procedures Reevaluation Definitive care Maintenance care

Chief Complaints

Medical/systemic Care

Emergency Care

Treatment Plan Matrix

Disease Control

Additional Diagnostic Procedures

Reevaluation

Definitive Care

Maintenance Care

References AWG Walls, IE Barnes. Treatment planning for the Ageing patient. Dental Update Dec 1989: Bartlett DW & others. Factor influencing treatment planning of restorative dentistry in general practice: Part 1. Dental Update Sept 1995: Bartlett DW & others. Factor influencing treatment planning of restorative dentistry in general practice: Part 2. Dental Update Oct 1995: Davis RD. Patient evaluation and problem-oriented treatment planning. In: Fundamentals of Operative Dentistry. Eds Schwartz, Summitt & Robbins. Quintessence Publishing Co. 1996, Illinios, USA. Pages