Transcript Treatment Planning in Operative Dentistry

Treatment Planning in
Operative Dentistry
Dr. Ignatius Lee
Status of Treatment Planning
in Private Practice
An article published in Reader’s 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
dentist’s 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 patient’s
oral and medical condition and history, with the
dentist’s clinical expertise and the patient’s 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)
Dentist’s clinical expertise
Patient’s 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
Dentist’s 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
Patient’s Needs/Preferences
Probably the most neglected aspect in
treatment planning by a student
Try to incorporate patient’s preferences in
formulating your final treatment plan
Try to understand and address what are the
TRUE “wants” and “needs” of the patient
Try to 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. patient’s 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 patient’s 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)
Patient’s
Preferences/factors
(Subjective Findings)
Caries Risk
Assessment
Formulate Treatment Options
Patient’s Preferences
Informed Consent
Treatment Plan
Patient’s Preferences
Address patient’s chief complain
Ask questions - assess patient’s 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?
Patient’s 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.
Patient’s caries risk status will affect the treatment (materials and
procedures, treatment vs no treatment) you are going to prescribe.
Patient’s 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. Hildebrandt’s 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
Caries Risk
Assessment
(Subjective Findings)
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 patient’s 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.
Patient’s Preference/Factor
Goals
Formulate a preliminary plan based on
patient’s 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