Dental education - Introduction to comprehensive treatment planning for dental patients

1. 1
M d l d G id liModels and Guidelines
Follow a sequence of guidelines
Treatment planning is naturally based
on a complete and thorough history and
examinationexamination
Medical
Dental
Social
Information gathering
Dental examination should include
Full charting: dentition, soft tissue, periodontal
OPG, BW’s, PA’s as required, , q
Photographs if indicated
Study models for any complex restorative,
prosthetic, TMJ, orthodontic treatments
Mounted on semi‐adjustable articulator
Systemic considerations
Address the general medical health status of
the patient
Dentist maybe the first to detect a medical Dentist maybe the first to detect a medical
condition‐refer to patient’s doctor – e.g.
Suspected diabetic condition based on
periodontal signs
Suspected hypertensive condition
Coordination: treatment of oral
disease with medical treatment
Examples
Being cognisant of drug interactions
Dentist performing biopsy – suspected
malignancy referred to Maxillo‐facial
surgeon or to physician
Phobic patients referred to specialist
consultants for assistance in accepting
necessary dental treatment

2. 2
The Role of Dental Screening in Prevention
of Systemic Disease
Examples
Antibiotic prophylaxis
Heart valve replacement
Artificial joints (recently placed)
Pre‐surgical antibiotic and anti‐bacterial regimes
Diabetics
Immune compromised
History of poor resistance to infection
Early detection of head, neck & oral neoplasias before
metastasis can occur
Phases
Emergency/investigative
PreparatoryPreparatory
Corrective
Maintenance
Emergency / Investigative Phase
Patient’s chief complaint????????
Relief of pain
Antibiotic/analgesia
Palliative treatments – Sed. Dressing
(Exo/Endo?)
Definitive immediate treatments
Extraction of hopeless painful tooth
Restoration of a fractured tooth
Adjust a denture sore‐spot
More involved treatments
These should await proper examination,
investigation, diagnosis
Treatment then follows a designated Treatment then follows a designated
sequence that has been developed
Working towards final goal
Established by dentist in
consultation with the patient
Preparatory Treatment
Hygiene phase
OHI
Perio. therapyPerio. therapy
Cleaning
Surgery‐pocket elimination, guided tissue
regeneration
Fluoride
Dietary counselling
Oral surgery

3. 3
Continued:
Caries control
General restorative
More advance fixed pros will await completion of the
preparatory phase p p y p
Endodontic therapy‐strategic teeth
Occlusal modification
Ortho. – single teeth, comprehensive treatment
Occlusal adjustment
Trial restoration of lost vertical dimension
Alleviate symptoms
Facilitate later reconstruction
Corrective Treatment
Restoration of form, function, aesthetics
Form & Function
Restorative treatment
Fixed prosthodontics
Removable partial prosthodontics
Removable full prosthodontics
Combinations of any or all of the above
Aesthetics
Aesthetic considerations are made
during all of the corrective phase
treatments abovetreatments above
Aesthetic treatments may stand alone
using any of the treatment modalities
above
Maintenance Treatment
Treatment aimed at ensuring a continuing
healthy environment
Begins as soon as healthy environment is
established
May begin during the corrective phase
Tailored to suit the patient’s needs
Maintenance may include:
Review and modification (tailoring) of patient’s home
care routine
Periodic review and reinforcement of this
Periodic examination radiographsPeriodic examination, radiographs
Monitor status of restorations, prostheses
Detect incipient disease
Periodic scaling/cleaning
Fluoride treatment
Modification, adjustment, repair, replacement of
restorative and prosthetic hardware
Many ways to skin a cat

4. 4
Optimal Plan
Established with patient’s agreement
May be instituted and carried to completion
immediatelyimmediately
May be phased over time
Treatment considerations
Wait for successful outcomes of corrective treatment
before proceeding further
Financial considerations
Acceptable Alternative Plan
If the optimal plan is not able to be instituted for
whatever reason – cost, time factor, bias
One or more possible alternatives to offer the patient
Example:
Lost single anterior tooth
Partial denture
Bridge
Implant
Each will have indications and contra‐indications
depending on the situation and the patients
requirements
Tilly: a Lancashire Mill Worker
2
An example of preparatory & corrective
treatment required
Full denture patient
with oral candidiasis
l f f ll d d b
2
poorly fitting full upper denture opposed by
only lower anterior teeth ‐ TBA’s, periodontally
compromised, sharp
ulcer on tip of tongue
flabby upper residual ridge
History
Lives alone estranged from family
Socially awkward
2
Anxious
Embarrassed
Taking “nerve pills”
Diabetic – Poorly controlled Type Two

5. 5
Papillary Hyperplasia
Flabby Ridge
Angular chelitis & oral candidiasis –
sometimes called denture stomatitis
Preparatory treatment
Determine the nature of the tongue
ulcer – refer to oral medicine specialist?
S i l d d h fl bb
2
Surgical procedure to reduce the flabby
tissue – upper ridge – refer to oral
surgeon
Healing period – soft lining
Anti‐fungal treatment for candidiasis
Continued: Other considerations
Patient does not wish to wear a lower full
denture
Tending towards dementia (arrives once a
year seeking new dentures with a bag full
2
year seeking new dentures, with a bag full
of previous dentures to illustrate her
requirements)
Eventually confined to nursing home
Experiences pain of unclear origin,
clutching face, unable to communicate her
need
Remaining lower anteriors 2
Erosion
Attrition-porcelain
teeth on upper
denture
Tooth brush abrasion
Corrective Treatment
Consult with patient regarding an
overdenture rather than exo. of all
remaining lower teeth
2
g
Extraction of all lowers with exception of
33 & 43
Root canal treatment, decoronate 33 & 43 in
preparation for full lower overdenture
Overdenture
2
Reasonable
residual ridge
height and shape
A more
retentive,
wearable form
of full lower
denture
Bone preserved
Decoronated Canines

6. 6
Construct Full / Full Overdenture
Establish the aesthetic requirements of
patient
Dentist: suggests teeth appropriate
t ti t h i l i d h d C to patients physical size and shade C2
(skin tone)
Patient: wants small, white teeth
After reasonable consultation with
patient, dentist will need to try to
meet the patients aesthetic
requirements
The Maintenance Phase for Tilly
OHI with regard to caring for her dentures
and her mouth
Removal of dentures at night – aimed at Removal of dentures at night aimed at
prevention of candidiasis
OHI with partic. reference to retained 33, 43
Regular recall for examination and OH
coaching
Follow‐up treatment for Tilly
Pt’s dementia has progressed
Confined to nursing home
Dentist is called out to visit the nursing Dentist is called out to visit the nursing
home
Tilly keeps losing her dentures
What can the dentist offer to the nursing
home carers
The Treatment Planning Process
The general practitioner’s role is to
coordinate
Director of care
Sequencing integration continuity of careSequencing, integration, continuity of care
Involvement of specialist treatments in the
overall plan
An effective treatment plan
1. Involves the patient early in the process
2. Is comprehensive
3. Is directed towards goals derived by
interaction between practitioner & patient
The patient is the
Involve the patient as early as possible
What is the patient’s perception of their
need or want
What is their perception of your ability to
provide the service
Early involvement engenders confidence
and trust
Acceptance of treatments offered
Communication ‐
Involve the patient
Educate the patient
Present the diagnosis or planPresent the diagnosis or plan
Set a mutually recognized goal for treatment
Obtain informed consent to proceed

7. 7
to proceed
The most sophisticated, comprehensive, complicated
plan is useless if this is not what the patient requires.
Be prepared for the patient who only attends when
something is wrong (broken hurts) complains about something is wrong (broken, hurts), complains about
expense and treats you as some kind of ogre
Welcome and foster the kind of patient that sees the
value in comprehensive, excellent, contemporary
treatment
Simple
More steps in the plan, with each
subsequent step dependent on the
di t l d t preceding step, can lead to
complications
Example:
E.g. Young patient, anterior tooth
fractured below gingiva, open
t l th t d apex, root canal therapy, post and
core (no ferrule effect & poor
biological width), porcelain
crown
Potential for problems/failure
Attempt to close apex with CaOH2 may not
succeed
Need for MTA therapy to seal open apex –Need for MTA therapy to seal open apex
may not succeed
Need to orthodontically extrude tooth or
perform crown lengthening procedure
Length of remaining root for retention of
post/core (crown root ratio)
Key Tooth Concept
Create a Problem List (4) based on the information
gathered
Local, general
C t T th I t Create a Tooth Inventory (1)
Grading each tooth
+ Stable and favourable
(+) Potential – needs some mod. of position or stability
0 Sound retainable – will stand on its own
(0) Same as 0 – needs treatment or mod.
_ Tooth to be eliminated from treatment plan
Key tooth concept
Establish which are key teeth in overall dental
plan
Stability, favourable arch position, distribution ‐
lexamples
1. Single tooth missing in otherwise intact arch
2. Single remaining molar in a partial denture
case
3. Upper canines and molars – partial denture
case
4. Lower canines – full lower overdenture case

8. 8
1. Single tooth damaged in otherwise
intact arch
1
Continued:
Temporary crown
Orthodontic extrusion
Final Crown
1
2.Single remaining molar in a partial denture
case
Stability & Favourable
Arch Position
Distribution
Tooth supported more desirable than free-end saddle
3
Favourable distribution?
Better situation
with canine here
3
Stability & Retention
Milled Cro ns
Retentive Fittings
Milled Crowns
Ball Retainers
Upper canines and molars – partial
denture case
Another example of strategic p g
teeth for stability and retention
Favourable distribution

9. 9
Maintain Molars and Canines – Stability,
Retention, Favourable Distribution
Attaining stability
1. Perio therapy
Fill of osseous defects combined with guided
i itissue regeneration
Enhance stability of teeth
2. Clinical crown reduction
Improves the crown‐root ratio (decoronation
for overdenture abutment)
3. Splinting
Crown units together
1. Bone fill and Guided Tissue
Regeneration
Dental
Bone Loss
- Bone
Grafting.flv
3. Splinting – increasing stability
Cast post core unit which will be splinted
together with natural tooth
Form an abutment unit for lower partial
denture with extra‐coronal attachment to
retain the denture
The post core unit ‐ paralleled to the tooth preparation
‐ both shaped to provide maximum resistance to the
forces placed on the bridge unit by partial denture
Continued:
Splinting of two pre‐molars creates multi‐rooted unit
that will withstand forces applied by partial denture or
fixed cantilever bridge
1
Creating favourable arch position
Orthodontics
Augmenting natural tooth
distribution with implants

10. 10
Bibliography
1. Strategies in Dental Diagnosis and Treatment Planning ‐ Robert
Morris
2. Integrated Dental Treatment Planning – Kay, Shearer,
Bridgeman, Humphris
3. Atlas of Removable Partial Denture Design – Stratton/Frank,
Wiebelt
4. Treatment Planning in General Dental Practice ‐ Bain
Written and compiled by
Lea Foster