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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 ... – PowerPoint PPT presentation

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Title: Treatment Planning in Operative Dentistry

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
  • 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
  • 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
  • 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
    Evidence-based 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
  • 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 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
  • May have to help your patient understand the
    needs and the wants of their dental

Defining Oral Rehabilitation - Gordon Christensen
Example of treatment planning based on patients
  • 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
  • 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
  • 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
  • Much of the treatment is for esthetic reasons
    only and is not required for any therapeutic
  • 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
  • May give you some clue on their preferences
  • Will influence what type of treatment/procedure/ma
    terial 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
  • 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
  • Cost conscience
  • I want the best
  • Missing teeth not a concern
  • Value your judgment and recommendation
  • Just take care of my basic needs
  • Esthetically sensitive

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
  • 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
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
  • Preference for the types of restorations/procedure
    s (e.g. fixed vs removable, direct vs indirect
  • Can the patient afford the procedures he/she
  • 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
    and radiograph exposure
  • 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
  • Failure to address the underlying cause of the
    disease will allow the disease to continue.
  • Restoration alone do not and will not treat the

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
  • 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
Initial treatment phase - treating the symptoms
of the disease (massive tooth morbidity).
Therapeutic Phase - control measures
Therapeutic Phase Evaluation -evaluate the
success/failure of therapeutic phase
Final Restorative Phase
Initial Restorative Phase
  • Options available for dealing with massive tooth
  • 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
  • No final treatment phase should be initiated
    until the risk is under control

Final Restorative Phase
  • Indirect restorations
  • Crowns and bridges
  • Removable appliances