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Treatment Planning
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Objectives Relation between diagnosis and treatment plan Types of treatment plan Considerations for treatment planning Treatment plan matrix Sequential Treatment Plan
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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
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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
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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
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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
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Modifying Factors Patient related Dentist/operator related
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Patient related factors Systemic health Demands Motivation Plaque control Emotional status Anxiety Priorities, time available Financial capabilities
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Dentist related factors Dentist’s skill, knowledge and experience Access to technical and laboratory support Access to specialist services
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Treatment Planning Considerations Treatment Planning Models Treatment Matrix Sequential Treatment Plan
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Considerations
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Three things must be considered: What does the patient want? What can the patient tolerate? What can be achieved?
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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
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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
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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
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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
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Treatment Planning Models
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Planning Models TREATMENT-BASEDPROBLEM-BASED MODELS
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Treatment-based Model
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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
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Problem-based Model
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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
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Diagnosis Formulation Chief complaint Patient’s goals of treatment Medical history Dental history Examination Extra-oral Intra-oral
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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
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Problem-based Planning Dentists formulates a mental image of the optimal condition to which patient can be rehabilitated
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Requires decision on: Teeth which are not periodontically and restoratively salvageable Teeth that need to be replaced Most appropriate form of prosthodontic replacement
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Treatment Plan Matrix
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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
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Treatment Plan Matrix Systemic Phase If necessary Emergency Phase If necessary Control Phase Treatment Phase Maintenance Phase
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Systemic Phase Addresses the general health status of the patient and its relationship to the oral cavity and dental treatment
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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
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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
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Relief of dental pain due to periodontal involvement through Irrigation Curettage Incision and drainage Extraction
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Definitive or palliative treatment of soft- tissue lesion through Excision Cautery Topical medication Prescription of appropriate analgesic/antibiotic agents for problems
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Control Phase The objectives of this phase are to Eliminate active disease Eliminate potential causes of disease Remove conditions preventing maintenance
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Includes Caries control Sugar restriction Fluoride application Oral hygiene instructions Diet survey Caries risk assessment
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Periodontal treatment Plaque control Scaling and root planning Establishing the prognosis of periodontically involved teeth
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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
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Treatment Phase Operative dentistry Oral surgery Periodontal surgery Endodontic therapy Orthodontic treatment Others
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Review and confirmation of Restorative treatment Occlusal preparation Crowns and fixed partial dentures Removable partial dentures Complete dentures
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Maintenance Phase Periodic recalls, checking Plaque and calculus Gingival condition Caries Restoration failure Occlusion, tooth mobility Other pathological changes
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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
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Sequential Treatment Plan
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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
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Sequencing of the treatment is completed by arranging the solutions to various problems in a set order
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TREATMENT SEQUENCING Chief complaint Medical/systemic care Emergency care Treatment plan (matrix) presentation Disease control Additional diagnostic procedures Reevaluation Definitive care Maintenance care
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Chief Complaints
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Medical/systemic Care
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Emergency Care
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Treatment Plan Matrix
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Disease Control
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Additional Diagnostic Procedures
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Reevaluation
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Definitive Care
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Maintenance Care
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References AWG Walls, IE Barnes. Treatment planning for the Ageing patient. Dental Update Dec 1989: 438-443. Bartlett DW & others. Factor influencing treatment planning of restorative dentistry in general practice: Part 1. Dental Update Sept 1995: 292-296. Bartlett DW & others. Factor influencing treatment planning of restorative dentistry in general practice: Part 2. Dental Update Oct 1995: 334-337. 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 27-50.
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