Treatment Planning in Operative Dentistry

Dr. Ignatius Lee

Status of Treatment Planning in Private

PracticeAn 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

planningAdvance 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 patternYears ago dental caries was pandemicToday, 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

planningExplosion 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 examCC: nonePDH: regular patient (6-12 mo recall) to another dental office, reason for switching office is because of changes in dental insurance by her employerClinical 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 OptionsReplace 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)

ORNo treatment - priceless

Reasons for the variation in treatment

planningConsumer driven demandMagazine InternetTV

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

planningType and location of the dental office Edina/MinnetonkaMetro//ParkUnion Gospel MissionOffices 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 “Evidence-based 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

Three elements of treatment planningBest available scientific evidence (diagnosis and treatment options)Dentist’s clinical expertisePatient’s treatment needs and preferences

SUMMARY

Identification of best evidence

Information obtained from:Randomized controlled clinical trialsNonrandomized controlled clinical trialsCohort studiesCase-controlled studiesCrossover studiesCase studiesSystemic 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 veneersUnderstand your strengths and weaknesses, be truthful to your patientsUnderstand when you need to refer to specialists

Patient’s Needs/Preferences

Probably the most neglected aspect in treatment planning by a studentTry to incorporate patient’s preferences in formulating your final treatment planTry to understand and address what are the TRUE “wants” and “needs” of the patientTry to to address the realistic/unrealistic “needs” and “wants” of the patientsChallenge: need to understand your patient in a relatively short period of time

Challenges in understanding your

patientTimePatient may not be telling you the whole truthRemember it is a two-way street; try to LISTEN to your patient - e.g. patient’s true esthetic concernMay have to help your patient understand the “needs” and the “wants” of their dental treatments

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 RehabilitationTreatment of Defective Teeth OnlyTreatment of Defective Teeth with an Esthetic UpgradeTreatment of All Teeth for Therapeutic or Esthetic Reasons

The levels are established based on the esthetic preference of the patient

Example of treatment planning based on patient’s preferences

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

upgradeMajority 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 electiveUsually 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 ReasonsThis 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 withMay give you some clue on their preferencesWill influence what type of treatment/procedure/material usedPeople do not change - try to make small incremental improvementTry to institute phased treatment

Types of Patients

Patient never been to dentist in US

Recent immigrantsMay have a lot of “unconventional” dentistry done in his/her countryEducate, take care of acute needs first before trying to fix those “unconventional” dentistry

Types of Patients

Last trip to dentist - over 5 yearsPhobic, not health conscience, only go when I have painTry to understand where they are coming from, and why they are hereUsually they have an acute needTake 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 dentistUsually have an acute needMore aggressive in prescribing treatment - less confidence in monitoring small lesion

Types of Patients

Patients that come in at least once every 2 years

Regular patientMore comfortable in monitoring small lesionsStill need to understand what they preferences are:

Cost conscienceI want the bestMissing teeth not a concernValue your judgment and recommendationJust take care of my basic needsEsthetically sensitive

Treatment Planning Models

Treatment oriented model

Problem oriented model

Treatment Oriented Model

Dentist examine the patientDentist mentally equate the findings to the need for certain form of treatmentExamination findings are summarized in the form of a list of treatments - TREATMENT PLANUseful in simple cases

Problem Oriented Model

Examination lead to formulation of a list of problemEach problem on the list is then considered in terms of treatment optionsInformed patients of all the optionsFormulate the TREATMENT PLAN

Problem Oriented Model Problem Lists (Objective findings

from oral and radiograph exam)

Formulate Treatment Options

Patient’s Preferences/fact

ors(Subjective Findings)

Caries Risk

Assessment

Treatment Plan

Patient’s PreferencesInformed Consent

Patient’s PreferencesAddress patient’s chief complainAsk questions - assess patient’s true preferencesUnderstand what is the treatment objectives for the patient (better function, better esthetic?)Understand what type of patient you are dealing withPreference 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 maintenanceEsthetic - understand their true concern

Caries Risk AssessmentWhy 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 factorSalivary flow? Diet?MUST educate and formulate a control measures plan

Clinical Example

24 year old male presenting to your office for routine oral examPMH - non-contributoryPDH - 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)

Formulate Treatment Options

Patient Preferences/fact

ors(Subjective Findings)

Caries Risk Assessment

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 AssessmentGoals

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

GoalsFormulate a preliminary plan based on patient’s preferences and the overall treatment goal.Narrow down options

Overall Treatment SchemeInitial treatment

phase - treating the symptoms of the disease (massive tooth morbidity).

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

Final Restorative Phase

Therapeutic Phase - control measures

Initial Restorative Phase

Options available for dealing with massive tooth morbidityDirect Restoration RCT Extraction

Treatment optionsExtract all teethExtract teeth that are unrestorable onlyExtract teeth that will need RCTExtract 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 restorationsCrowns and bridgesRemovable appliances