Restorative Dentistry Student Advising/Patient Treatment


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Restorative Dentistry Student Advising/Patient Treatment

  1. 1. 1 Version 2009-0527 Page____ Restorative Dentistry Student Advising/Patient Treatment Management Process-Guidelines For Affiliate Faculty We have designed a department-wide student advising system to help students plan and manage treatment for more complex patients. Affiliate faculty play a key role in this plan! This document highlights the principle features of the advising system relevant to Affiliates. For more information you may download the entire document from the UW Restorative website. The role of Affiliates during the ‘Treatment Planning’ appointment: Step 1: Determine if patient is appropriate for the predoctoral program (Appendix A). To be treated at the School of Dentistry by predoctoral students, a patient’s clinical needs must meet certain global guidelines (see Appendix A). These guidelines protect both the patient and the student. The student and affiliate should be aware that patients who do not meet the guidelines in Appendix B will be rejected by Advising teams for treatment in the predoctoral program. If the patient has appropriate needs, proceed to Step 2. Step 2: Determine if patient’s needs are complex or routine (Appendix B). During the first restorative appointment, some patients will be identified that have relatively routine needs. For these patients, the affiliate faculty should help the student develop a treatment plan. However, more complex patients (as defined in Appendix B) require a comprehensive, strategic approach for appropriate management. For these patients, the student is required to plan and coordinate treatment through their faculty advising group. Affiliates will NOT be responsible for formulating or making any major adjustments to complex treatment plans. Step 3: What to do with patients with complex treatment needs. If the patient has complex needs that are appropriate for the predoctoral level (based on Steps 1 and 2 above), the initial restorative appointment will be used for data collection and consultations only, not formulation of the treatment plan. In this case, the Affliliate should help the student collect sufficient information so that a comprehensive treatment plan can be formulated by the student’s advising team later. Appropriate activities might include: charting, helping the student diagnose caries, assuring the quality of bite records or alginate impression, assuring appropriate xrays or photographs, helping the student decide if/which consultations are needed. In the fourth year, students will take a treatment planning compentency exam for one patient, in which case, Affiliates should give the student NO aid in decisions about data collection or examination. Step 4: Maintain the integrity of the treatment plans. Affiliates should not be made responsible for the formulation or management of complex treatment plans. Therefore, please do not significantly change the treatment plan once it is formulated. If something happens that requires a major change in treatment plan (dental, health, or financial), Affiliates should refer the student back to their advising team, and should not allow the student to proceed. More routine changes e.g., adding a surface to a direct restoration with no affect on other treatment aspects) are OK. THANK YOU FOR YOUR ONGOING HELP AND COMMITMENT TO THE EDUCATION OF OUR STUDENTS. WE are indebted to YOU! 1959 NE Pacific Street, D770 Seattle, Washington 98195 206.543.5948 FAX 206.543.7783
  2. 2. Page 2 Appendix-A-Guidelines for Oral Conditions Appropriate for Care by Predoctoral Students (2009-0123) Operative and Fixed Prosthodontics These “Guidelines” suggest limitations on the abilities of undergraduate dental students to maintain a standard of care which should include the ability to complete quality comprehensive treatment in a reasonable period of time. Extremely complex treatment plans, those with a guarded or poor prognosis, or those that typically should be treated by dental specialists, should not be assigned to the undergraduate Restorative Clinic. Good or Acceptable Cases: 1. Obvious caries or defective restorations expected to be restorable with direct restorations. 2. Failing amalgam or composite restorations where crowns might be indicated. 3. Patients whose potential treatment plan could normally progress fast enough for a student to control the disease process without continued deterioration of the remaining dentition. 4. Patients requesting esthetic procedures, i.e., veneers or anterior C&B. Requests for bleaching will only be acceptable if other restorative services are clearly indicated. 5. One or two edentulous spaces in any quadrant that might be indicated for bridges or implants. 6. Implant cases involving single tooth or two adjacent tooth restorations. Potential implant cases involving more than 3 implants are normally not suitable for under-grad teaching, but may be considered as a part of a more comprehensive plan. Patients should never be told that implants will be provided until after treatment planning by both restorative and surgical departments. 7. Combination cases involving multiple disciplines, are encouraged, but only to the extent that the previous indications are met. Patients must understand that we are here to provide comprehensive dental care, and not treatments for selected procedures only. Patients should demonstrate adequate financial means or dental insurance which would allow for reasonable treatment planning options, and an ability to make schedule appointments. Patients must understand that work will progress much more slowly than in a private office. Poor or Unacceptable cases: 1. Multiple “bombed out” teeth with rampant caries, unless expected to be extracted and treated with Removable Prosthodontics. 2. Extreme occlusal wear demonstrating short, flat occlusal and incisal surfaces, and expected to require restoration at an increased vertical dimension of occlusion or “full-mouth” reconstruction. Undergraduate cases will NEVER be allowed to restore dentition at an increased vertical dimension of occlusion. 3. Multiple missing teeth in both arches where condition of occlusal plane is not easily correctable. 4. Not more than 2-3 obviously failing crowns (recurrent caries or other defect). 5. No more than a total of 10 existing crown and bridge units (intact or defective). Replacement of multiple defective crowns is not predictable; can take an excessive amount of time; and, is not a good teaching experience. 6. Extensive root caries (more than 3-4 teeth). 7. Multiple implants. More than 2 in the same quadrant. Final approval to be made by Dr. Kronstrom or implant advisor. 8. Crown and bridge units will not be covered by DSHS. Patients should be advised before assignment to student for comprehensive care. 2
  3. 3. Page 3 9. Patients “demanding” that specific treatments be accomplished or who have unrealistic expectations. (I want “caps” on all of my teeth to make me look younger”, or, “I want all of my amalgam fillings replaced with white fillings”) Common Problems During the Treatment Phase 1. Conditions that are so extensive that caries control cannot keep up with continued deterioration of the dentition. Students are only able to work on one or two teeth at a time. Teeth are lost – possibly unnecessarily. Patient complaints. 2. Patients do not understand that there are many things that we cannot or will not do, despite treatment plans generated by “outside” dentists. For example, we will not attempt to place a crown on what we consider to be a non-restorable tooth. 3. Patients do not understand that although our fees are lower, we cannot propose a logical treatment plan that would meet all of their needs and still be affordable to them. (Patients desire all edentulous spaces restored with bridges, and will not accept a removable prosthesis.) 4. Patients expect that all teeth can be restored. Not all teeth are restorable. Many teeth might only be restorable with expensive specialty care – and then with an unpredictable prognosis. It is not practical to spend time and money on one tooth while the rest of the dentition is ignored. UG students cannot be expected to spend all of their time with one patient, while others are neglected. 5. Many teeth with radiographically identified deep caries may be non-restorable. A referral to the Department of Endodontics does not guarantee that RCT will be performed or that the Department of Restorative Dentistry will place a crown. 6. The restorative treatment plan is determined to be too complex. This may include: too many defective crown and bridge units; severe occlusal wear necessitating extensive occlusal rehabilitation or increase in the vertical dimension of occlusion; extensive root caries on more than a few teeth; medical or behavioral conditions that would be best treated in Fears, DECOD, GPR, or Faculty Practice. Very few patients are accepted to Graduate Prosthodontics. Removable Prosthodontics General Guidelines 1. Be sure that patient is available for many lengthy appointments and in some cases treatment may take up to a full year. 2. Be sure financing is available. 3. We need relatively healthy patients; patients with compromised health are too difficult for undergrads. 4. We need patients with a relatively good occlusion and interarch relationship where students will not struggle to set denture teeth. 5. Patients who want or need many implants should be referred to Grad Pros, Faculty Pros or to PP. 6. Be sure the patient is truly interested in a removable treatment option. Ask them directly “Are you interested in a removable appliance to replace your missing teeth?” 7. If the patient has large Tori/Exostosis that will interfere with the fabrication of a CD or RPD be sure the patient is healthy enough and willing to undergo surgical removal. 3
  4. 4. Page 4 Complete Dentures 1. Excessive resorption of ridges is OK, if patient has reasonable expectations. Ask yourself, are patient’s expectations reasonable? Ask patient if they will consider and if they can afford 2 mandibular implants for retention. 2. Good ridges but unrealistic expectations, the patient is not a good candidate. Ask yourself, “Do I want this person as a patient?” 3. ICD patients that require general anesthesia should be referred to Hospital Dentistry for both the extractions and the dentures. Removable Partial Dentures 1. Patient may first have to undergo initial care and take care of urgent needs, perio, and caries control before we can commit to treat the patient. 2. CONTRAINDICATION: Patient with rampant caries who will not or can not improve home care. 3. CONTRAINDICATION: Kennedy Class IV with large edentulous area. 4. CONTRAINDICATION: RPD patient with supra-erupted teeth and inadequate room for denture teeth. 5. EXPECTATION: Food will collect under a RPD. This is a sure thing when chewing food. 6. Swinglock RPD’s may not be possible if less than 5 anterior teeth remaining, should have at least 1 canine and patient should accept the appearance and possibly showing the bar. Also patient must be able to lock and unlock RPD bar. 7. RPD’s designs with attachments should be referred to Grad Pros, Faculty Pros or to PP. 8. RPD patients who will need an Increase in Vertical Dimension should be referred to Grad Pros, Faculty Pros or to PP. 4
  5. 5. Page 5 Appendix B-Patient Oral Conditions Requiring Advising System Management (2009- 0123*) Oral Condition/Treatment involves: Comment Fixed partial dentures. **All bridges (regardless of # of units). Specific check points at discretion of advising group. **More than 4 individual crowns or more than 2 adjacent individual crowns. **Failing crowns or bridges. **Involves change in or restoration of excursive mandibular guidance. Note, cannot involve change in vertical dimension. **Single crowns as abutments for removable partial dentures. **PFM crowns in upper anterior, any number of units. Implants **All treatments involving new or existing implants. Note: specific advisor in each advising group must manage these treatments. Esthetic cases, particularly in the upper anterior, and particularly **All in-house bleaching. Note: specific adivosr those that cross the mid-line in each advising group must manage these treatments. **All-ceramic crowns, any number of units. **All veneers, ceramic or composite Complete dentures **All types. Removable Partial dentures **All types. Periodontal conditions that complicate restorative treatment **Note: may require coordination of advising group with a perio faculty member. Patients with Special Problems **Systemic disease (physical or mental) that complicates treatment or increases risk of treatment failure. *Note: Exceptions may occur and will be determined by the advising group and the Chair/Vice Chair(s) of the Department. A conservative approach (error on the side of closer student advisement is encouraged), particularly for less experienced students. Advising faculty may give more experience greater latitude in independently managing cases, depending on the student’s past performance, the patient’s needs, and the best judgment of the 5