Treatment Planning in Operative Dentistry

Dr. Ignatius Lee

Status of Treatment Planning in Private Practice

An article published in Readers Digest (Feb., 1997) summarized the current status of treatment planning in dentistry
The article described how a patient who went to 50 different dental offices in 28 states; came back with treatment plans ranging from no treatment needed to a quote of $30,000

Reasons for the variation in treatment planning

Advance in dental research (e.g.)
Changes in diagnostic techniques (e.g. pits and fissures caries) Changes in treatment philosophy (e.g. criteria for replacement of existing restorations) Treatment planning will depend on the training background of the dentist

Reasons for the variation in treatment planning

Changes in disease pattern
Years ago dental caries was pandemic Today, dental caries only affect a small percentage of the population (17% of the population account for 67% of the total caries experience) Dentists are not busy enough - looking for optional treatments

Reasons for the variation in treatment planning

Explosion in treatment options/techniques in Operative Dentistry Treatment planning will depend on dentists treatment philosophy, clinical judgment/experience, clinical expertise or other reasons..

Example in treatment options

A 35 year-old female patient presents to your dental office for a routine dental exam CC: none PDH: regular patient (6-12 mo recall) to another dental office, reason for switching office is because of changes in dental insurance by her employer Clinical exam: conservative occlusal amalgam on her permanent first molars that were placed when she was 18. All the amalgam showed a sign of slight marginal breakdrown. No evidence of any dental diseases.

Example in treatment options

Treatment Options Replace the old Class I amalgam restorations with:
Direct composite ($135) Amalgam ($85) Gold inlay ($760) Gold foil ($150) Indirect ceramic inlay ($760) Indirect composite inlay ($550) CAD/CAM inlay ($760) OR No treatment - priceless

Reasons for the variation in treatment planning

Consumer driven demand
Magazine Internet TV
Dentist philosophy in treatment may be influenced by the demand of the patients (specific to the location of the practice)

Reasons for the variation in treatment planning

Type and location of the dental office
Edina/Minnetonka Metro//Park Union Gospel Mission Offices that advertise heavily in the area of esthetic dentistry
Dentist philosophy in treatment may be influenced by the demand of the patients (specific to the location of the practice)

Treatment Planning in Operative Dentistry

Evidence-based Dentistry
American Dental Association definition of Evidencebased Dentistry Approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, with the dentists clinical expertise and the patients treatment needs and preferences
Ismail and Bader, JADA, Vol.135, January 2004

Evidence Based Treatment Planning

SUMMARY
Three elements of treatment planning
Best available scientific evidence (diagnosis and treatment options) Dentists clinical expertise Patients treatment needs and preferences

Identification of best evidence

Information obtained from:
Randomized controlled clinical trials Nonrandomized controlled clinical trials Cohort studies Case-controlled studies Crossover studies Case studies Systemic reviews (PubMed, Journals, Cochrane)
Ismail and Bader, JADA, Vol.135, January 2004

Dentists Clinical Expertise

Relating to what the dentist is comfortable of doing - e.g. offering composite veneers vs porcelain veneers Understand your strengths and weaknesses, be truthful to your patients Understand when you need to refer to specialists

Patients Needs/Preferences
Probably the most neglected aspect in treatment planning by a student Try to incorporate patients preferences in formulating your final treatment plan Try to understand and address what are the TRUE wants and needs of the patient Try to address the realistic/unrealistic needs and wants of the patients Challenge: need to understand your patient in a relatively short period of time

Challenges in understanding your patient

Time Patient may not be telling you the whole truth Remember it is a two-way street; try to LISTEN to your patient - e.g. patients true esthetic concern May have to help your patient understand the needs and the wants of their dental treatments

Example of treatment planning based on patients preferences

Defining Oral Rehabilitation - Gordon Christensen

The article was written in response to concern within the profession that some commercial institutes and continuing education groups are advertising to the lay public that only graduates of their programs are capable of accomplishing the type of oral rehabilitations observed in the television cosmetic makeovers

Levels of Oral Rehabilitation

Treatment of Defective Teeth Only Treatment of Defective Teeth with an Esthetic Upgrade Treatment of All Teeth for Therapeutic or Esthetic Reasons

The levels are established based on the esthetic preference of the patient
JADA Vol. 135 (2004): 215-217

Treatment of Defective Teeth Only

Patient in general are pleased with their oral appearance, although it may not be perfect by ideal standards. They want long lasting, comfortable dental restoration and a reasonable smile. They are not seeking the glamorous, but often short-lived, esthetic restorative therapy popularized on TV. They may accept bleaching, some will accept tooth-colored restorations

Treatment of Defective Teeth with an Esthetic upgrade

Majority of patients - they want to look acceptable, have a pleasant smile and be able to eat normally. Most are not interested in having absolutely perfect-appearing teeth that are snow-white. However, usually they will accept a moderate level of esthetic upgrade while receiving therapy for their dental caries or defect restorations. These patients usually involved a phased treatment plans spanning several years. The patients should be well INFORMED of which part of their therapy is mandatory and which part is purely elective Usually involve bleaching, a few veneers or crowns and restoring any obviously displayed metal restorations or darkened teeth with crowns.

Treatment of All Teeth For Therapeutic or Esthetic Reasons

This level of oral rehabilitation is being promoted in many continuing education courses and routinely is suggested to patients. Usually, crowns, veneers, elective cosmetic periodontal surgery, some occlusal therapy, perhaps elective endodontic therapy or orthodontics and even orthognatic surgery are suggested. Much of the treatment is for esthetic reasons only and is not required for any therapeutic reason. If a patient is INFORMED that the therapy is not required because of disease, and that it is elective and primarily esthetic, the matter of ethics becomes somewhat clearer. However, if the patient is led to believe that the mostly esthetic therapy is needed for therapeutic reasons, including questionable occlusal pathosis, or if the more conservative therapies are not explained to the patient, the practitioner is treading on unethical ground

Understand what type of patient you are dealing with

May give you some clue on their preferences Will influence what type of treatment/procedure/material used People do not change - try to make small incremental improvement Try to institute phased treatment

Types of Patients
Patient never been to dentist in US
Recent immigrants May have a lot of unconventional dentistry done in his/her country Educate, take care of acute needs first before trying to fix those unconventional dentistry

Types of Patients
Last trip to dentist - over 5 years
Phobic, not health conscience, only go when I have pain Try to understand where they are coming from, and why they are here Usually they have an acute need Take care of their acute needs, then present a phase approach - acute needs (disease that cause pain), take care of larger lesion, debridement, smaller lesion, missing teeth, cosmetic

Types of Patients
Last trip to dentist - 2 to 5 years
No insurance, feel very uncomfortable going to a dentist Usually have an acute need More aggressive in prescribing treatment - less confidence in monitoring small lesion

Types of Patients
Patients that come in at least once every 2 years
Regular patient More comfortable in monitoring small lesions Still need to understand what they preferences are:
Cost conscience I want the best Missing teeth not a concern Value your judgment and recommendation Just take care of my basic needs

Treatment Planning Models

Treatment oriented model Problem oriented model

Treatment Oriented Model

Dentist examine the patient Dentist mentally equate the findings to the need for certain form of treatment Examination findings are summarized in the form of a list of treatments TREATMENT PLAN Useful in simple cases

Problem Oriented Model

Examination lead to formulation of a list of problem Each problem on the list is then considered in terms of treatment options Informed patients of all the options Formulate the TREATMENT PLAN

Problem Oriented Model

Problem Lists
(Objective findings from oral and radiograph exam)

Patients Preferences/factors
(Subjective Findings)

Caries Risk Assessment

Formulate Treatment Options Patients Preferences Informed Consent

Treatment Plan

Patients Preferences
Address patients chief complain Ask questions - assess patients true preferences Understand what is the treatment objectives for the patient (better function, better esthetic?) Understand what type of patient you are dealing with Preference for the types of restorations/procedures (e.g. fixed vs removable, direct vs indirect restorations) Can the patient afford the procedures he/she desires? Patients dental IQ - long term maintenance Esthetic - understand their true concern

Caries Risk Assessment

Why is it a vital part of Treatment Planning?
Dental caries is an infectious disease. It is the most overlook aspect in the treatment planning process. Patients caries risk status will affect the treatment (materials and procedures, treatment vs no treatment) you are going to prescribe. Patients caries risk will determine recall intervals and radiograph exposure intervals. For the high risk patients (caries active or caries prone), a strategy to control the disease should be formulated and documented in the treatment plan. Review- Dr. Hildebrandts Fall semester manual - Current Concepts in Caries Control

Dental Caries - an Infectious Disease

Etiologic agent - specific pathogens (Specific Plaque Hypothesis) Signs and symptoms of the disease - localized dissolution and destruction of calcified tissue. It is very easy to focus narrowly on treating the signs and symptoms ONLY (restorative needs); thus failed to identify the underlying cause of the disease. Failure to address the underlying cause of the disease will allow the disease to continue. Restoration alone do not and will not treat the disease

High Caries Risk Patients

Must identify the underlying reason(s) for the high risk. Not been to a dentist for years or poor oral hygiene are seldom the ONLY factor Salivary flow? Diet? MUST educate and formulate a control measures plan

Clinical Example
24 year old male presenting to your office for routine oral exam PMH - non-contributory PDH - not been to a dentist since high school, no existing restoration. Clinical exam - rampant caries on multiple teeth. Normal salivary flow. Heavy plaque on all teeth.

Problem Oriented Model

Problem Lists (Objective
findings from oral and radiograph exam)

Patient Preferences/factors
(Subjective Findings)

Caries Risk Assessment

Formulate Treatment Options

Problem List
Dental caries - rampant caries Poor oral hygiene

Caries Risk Assessment

Caries active
identify the underlying reason(s) Poor oral hygiene and not been to dentist since high school should not be taken as the convenient reason.

Caries Risk Assessment

Goals
Identify the underlying reason(s) - EDUCATE the patient. FORMULATE control measures. ASSESSING patients ability to change (habits). These goals are as important if not more important than the restorative part of your treatment plan. Success/failure of the restorative phase will depend on whether you can achieve the goals stated above.

Patients Preference/Factor
Goals
Formulate a preliminary plan based on patients preferences and the overall treatment goal. Narrow down options

Overall Treatment Scheme

Therapeutic Phase - control measures Initial treatment phase treating the symptoms of the disease (massive tooth morbidity).

Therapeutic Phase Evaluation -evaluate the success/failure of therapeutic phase

Final Restorative Phase

Initial Restorative Phase

Options available for dealing with massive tooth morbidity Direct Restoration RCT Extraction Treatment options Extract all teeth Extract teeth that are unrestorable only Extract teeth that will need RCT Extract teeth that are unsuitable/unnecessary to support a removable partial denture. E.g. do you want to save all the Mx anterior teeth (assuming they all have extensive lesions) if your treatment plan will involve a Mx partial denture? Immediate removable appliances

Therapeutic Phase Evaluation

Was the control measures prescribed successfully change the patient from high caries risk to low caries risk, or at least have the disease under control. No final treatment phase should be initiated until the risk is under control

Final Restorative Phase

Indirect restorations Crowns and bridges Removable appliances