approaches to treatment planning
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M d l d G id liModels and Guidelines
Follow a sequence of guidelinesTreatment planning is naturally based on a complete and thorough history and examinationexaminationMedicalDental Social
Information gatheringDental examination should include
Full charting: dentition, soft tissue, periodontalOPG, BW’s, PA’s as required, , qPhotographs if indicatedStudy models for any complex restorative, prosthetic, TMJ, orthodontic treatmentsMounted on semi‐adjustable articulator
Systemic considerationsAddress the general medical health status of the patientDentist 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 signsSuspected hypertensive condition
Coordination: treatment of oral disease with medical treatment
ExamplesBeing cognisant of drug interactionsDentist performing biopsy – suspected malignancy referred to Maxillo‐facial surgeon or to physicianPhobic patients referred to specialist consultants for assistance in accepting necessary dental treatment
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The Role of Dental Screening in Prevention of Systemic Disease
ExamplesAntibiotic prophylaxis
Heart valve replacementArtificial joints (recently placed)
Pre‐surgical antibiotic and anti‐bacterial regimesDiabeticsImmune compromisedHistory of poor resistance to infection
Early detection of head, neck & oral neoplasias before metastasis can occur
PhasesEmergency/investigativePreparatoryPreparatoryCorrectiveMaintenance
Emergency / Investigative PhasePatient’s chief complaint????????Relief of pain
Antibiotic/analgesiaPalliative treatments – Sed. Dressing (Exo/Endo?)
Definitive immediate treatments Extraction of hopeless painful toothRestoration of a fractured toothAdjust a denture sore‐spot
More involved treatmentsThese should await proper examination, investigation, diagnosisTreatment then follows a designated Treatment then follows a designated sequence that has been developedWorking towards final goal
Established by dentist in consultation with the patient
Preparatory TreatmentHygiene phase
OHIPerio. therapyPerio. therapyCleaningSurgery‐pocket elimination, guided tissue regeneration
Fluoride
Dietary counsellingOral surgery
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Continued:
Caries controlGeneral restorativeMore advance fixed pros will await completion of the preparatory phase p p y p
Endodontic therapy‐strategic teethOcclusal modification
Ortho. – single teeth, comprehensive treatmentOcclusal adjustmentTrial restoration of lost vertical dimension
Alleviate symptomsFacilitate later reconstruction
Corrective TreatmentRestoration of form, function, aesthetics
Form & FunctionRestorative treatmentFixed prosthodonticsRemovable partial prosthodonticsRemovable full prosthodonticsCombinations of any or all of the above
AestheticsAesthetic considerations are made during all of the corrective phase treatments abovetreatments aboveAesthetic treatments may stand alone using any of the treatment modalities above
Maintenance Treatment
Treatment aimed at ensuring a continuing healthy environmentBegins as soon as healthy environment is establishedMay begin during the corrective phaseTailored to suit the patient’s needs
Maintenance may include:
Review and modification (tailoring) of patient’s home care routinePeriodic review and reinforcement of thisPeriodic examination radiographsPeriodic examination, radiographs
Monitor status of restorations, prosthesesDetect incipient diseasePeriodic scaling/cleaningFluoride treatmentModification, adjustment, repair, replacement of restorative and prosthetic hardware
Many ways to skin a cat
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Optimal PlanEstablished with patient’s agreementMay be instituted and carried to completion immediatelyimmediatelyMay be phased over time
Treatment considerationsWait for successful outcomes of corrective treatment before proceeding further
Financial considerations
Acceptable Alternative PlanIf the optimal plan is not able to be instituted for whatever reason – cost, time factor, biasOne or more possible alternatives to offer the patient
Example:Lost single anterior tooth
Partial dentureBridgeImplant
Each will have indications and contra‐indications depending on the situation and the patients requirements
Tilly: a Lancashire Mill Worker
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An example of preparatory & corrective treatment required
Full denture patientwith oral candidiasis
l f f ll d d b
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poorly fitting full upper denture opposed by only lower anterior teeth ‐ TBA’s, periodontallycompromised, sharpulcer on tip of tongueflabby upper residual ridge
History
Lives alone estranged from familySocially awkward
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AnxiousEmbarrassedTaking “nerve pills”Diabetic – Poorly controlled Type Two
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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
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Surgical procedure to reduce the flabby tissue – upper ridge – refer to oral surgeonHealing period – soft liningAnti‐fungal treatment for candidiasis
Continued: Other considerationsPatient does not wish to wear a lower full dentureTending towards dementia (arrives once a year seeking new dentures with a bag full
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year seeking new dentures, with a bag full of previous dentures to illustrate her requirements)Eventually confined to nursing homeExperiences 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 TreatmentConsult with patient regarding an overdenture rather than exo. of all remaining lower teeth
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gExtraction of all lowers with exception of 33 & 43Root canal treatment, decoronate 33 & 43 in preparation for full lower overdenture
Overdenture 2
Reasonable residual ridge
height and shapeA more retentive, wearable form of full lower denture
Bone preserved
Decoronated Canines
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Construct Full / Full OverdentureEstablish the aesthetic requirements of patientDentist: 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 teethAfter reasonable consultation with patient, dentist will need to try to meet the patients aesthetic requirements
The Maintenance Phase for TillyOHI with regard to caring for her dentures and her mouthRemoval of dentures at night – aimed at Removal of dentures at night aimed at prevention of candidiasisOHI with partic. reference to retained 33, 43Regular recall for examination and OH coaching
Follow‐up treatment for TillyPt’s dementia has progressedConfined to nursing homeDentist is called out to visit the nursing Dentist is called out to visit the nursing homeTilly keeps losing her denturesWhat can the dentist offer to the nursing home carers
The Treatment Planning ProcessThe general practitioner’s role is to coordinate
Director of careSequencing integration continuity of careSequencing, integration, continuity of careInvolvement of specialist treatments in the overall plan
An effective treatment plan1. Involves the patient early in the process2. Is comprehensive3. Is directed towards goals derived by
interaction between practitioner & patient
The patient is the Involve the patient as early as possibleWhat is the patient’s perception of their need or wantWhat is their perception of your ability to provide the serviceEarly involvement engenders confidence and trustAcceptance of treatments offered
Communication ‐Involve the patient Educate the patientPresent the diagnosis or planPresent the diagnosis or planSet a mutually recognized goal for treatment Obtain informed consent to proceed
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to proceedThe 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 ogreWelcome and foster the kind of patient that sees the value in comprehensive, excellent, contemporary treatment
SimpleMore 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/failureAttempt to close apex with CaOH2 may not succeedNeed for MTA therapy to seal open apex –Need for MTA therapy to seal open apex may not succeedNeed to orthodontically extrude tooth or perform crown lengthening procedureLength of remaining root for retention of post/core (crown root ratio)
Key Tooth ConceptCreate a Problem List (4) based on the information gathered
Local, generalC t T th I t Create a Tooth Inventory (1)
Grading each tooth+ Stable and favourable(+) Potential – needs some mod. of position or stability0 Sound retainable – will stand on its own(0) Same as 0 – needs treatment or mod._ Tooth to be eliminated from treatment plan
Key tooth conceptEstablish which are key teeth in overall dental planStability, favourable arch position, distribution ‐
lexamples1. Single tooth missing in otherwise intact arch2. Single remaining molar in a partial denture
case3. Upper canines and molars – partial denture
case4. Lower canines – full lower overdenture case
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1. Single tooth damaged in otherwise intact arch
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Continued:
Temporary crown
Orthodontic extrusion
Final Crown1
2.Single remaining molar in a partial denture case
Stability & Favourable Arch PositionDistribution
Tooth supported more desirable than free-end saddle
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Favourable distribution?
Better situation with canine here
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Stability & Retention
Milled Cro ns
Retentive FittingsMilled Crowns
Ball Retainers
Upper canines and molars – partial denture case
Another example of strategic p gteeth for stability and retentionFavourable distribution
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Maintain Molars and Canines – Stability, Retention, Favourable Distribution
Attaining stability1. Perio therapy
Fill of osseous defects combined with guided i itissue regenerationEnhance stability of teeth
2. Clinical crown reductionImproves the crown‐root ratio (decoronationfor overdenture abutment)
3. SplintingCrown 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
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Creating favourable arch position
OrthodonticsAugmenting natural tooth distribution with implants
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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