Make a Treatment Plan

1. Make a Treatment Plan UNCLASSIFIED//REL TO NATO/ISAF

2. Objective of Treatment Planning 1. Do no harm 2. Address patient’s chief complaint 3. Resolve active disease 4. Prevent recurrent disease 5. Provide optimum comfort, esthetics, and function 6. Treatment that, if maintained, will provide the patient many years of trouble-free service CFHSTC Clin Perio Crse 0013

3. Steps to Treatment Planning • Examination • List the problems • Make a diagnosis • Determine the prognosis • Develop treatment options • Finalize treatment plan with patient • Have patient sign consent for treatment CFHSTC Clin Perio Crse 0013

4. Make a Problem List • Grouping related problems from problem list • Systematic approach • Record in patient’s record Chief complaint • Remember what brought the patient in for treatment • TRY to give the patient what they want – not always possible Medical history • Consult? • Modify treatment?

5. Problem List Clinic Findings Oral Pathology • Evident soft-tissue abnormalities (lumps, bumps, discolourations, etc.) • Radiographic findings • If it does not look normal… investigate further • Consult/referral CFHSTC Clin Perio Crse 0013

6. Make a Problem List Clinical Findings Restorative • Caries risk • Caries • Defective restorations • Oral hygiene • Pulp status (see diagram below) • Crowding • Strategic importance of tooth • Esthetics? • Chewing? • Posterior support?

7. Make aProblem List Clinical findings Endodontics • Non-vital teeth • Root canal – refer • Extraction – DT or refer • Hyper responsive to cold testing • Root canal – refer • Extraction – DT or refer • Cracked tooth • Restorable? • Normal response • Restorable • Non-restorable - extraction CFHSTC Clin Perio Crse 0013

8. Make a Problem List Clinical Findings Periodontics • PSR • Mobility • Abscess • Bone levels • Oral hygiene • Crowding

9. Make a Problem List Clinical Findings Oral Surgery • Non-restorable teeth • Soft/hard tissue pathology • Potential extraction problems • proximity to sinus or neurovascular bundle • medical concerns s/p surgery • Residual roots • Endo treated teeth

10. Diagnosis • “the act or art of identifying a disease by its signs and symptoms” CFHSTC Clin Perio Crse 0013

11. Diagnosis • The main purpose of a diagnosis is to guide treatment planning CFHSTC Clin Perio Crse 0013

12. Diagnosis • Diagnosis for Dental Therapist: • Caries • Cracked tooth • Defective restoration • Pulpal (see next slide) CFHSTC Clin Perio Crse 0013

13. Diagnosis PULPAL • Normal pulp • Reversible Pulpitis • Irreversible Pulpitis • Symptomatic or Asymptomatic • Pulp necrosis • Previously treated • Previously Initiated therapy

14. Diagnosis PULPAL • Normal pulp • No complaint • Responds to cold +/+++ • Test several teeth to determine normal for that patient

15. Diagnosis PULPAL • Reversible Pulpitis • Pulp is inflamed but can recover is proper treatment is given • Patient response: • Sensitive to cold, hot, sweets, air, etc. • Brief and not too painful • Recent restoration, caries, root exposure, cracked tooth

16. Diagnosis PULPAL • Irreversible Pulpitis • Pulp is inflamed and can not be healed • Patient will usually complain: • Spontaneous pain • Very painful to cold • Very painful to hot • Caries or restoration • Cold testing: • ++ or +++ / +++ • Lingering pain – 15 seconds or more

17. Diagnosis PULPAL • Pulp necrosis • Dead pulp • Patient response: • Asymptomatic • Pain to biting • Swelling • No response to cold but it can for multirooted teeth • Should have obvious signs of disease, such as caries • Often will have periapical lesion

18. Diagnosis PULPAL • Previously treated • Previously Initiated therapy • These situations need to be referred to Stomatologist

19. PROGNOSIS 1.“The likely course of a disease or ailment.” 2.“The forecast of the probable result of a regimen of treatment.” CFHSTC Clin Perio Crse 0013

20. Prognosis • A forecast which is used: • For the clinician to determine which treatment options are available • For the patient to determine if the treatment is worthwhile CFHSTC Clin Perio Crse 0013

21. Prognosis • What determines the functionality of a tooth? • “The health and vitality of the PERIODONTIUM.” • What is the Px of tooth 17? TX options?

22. Prognosis • Overall prognosis • Look at all the teeth • Dental Therapist should consult with Stomatologist • Individual teeth • Several criteria to consider • Keep overall prognosis in mind

23. Percentage of bone loss Probing depth Mobility Root form Pulpal involvement Caries Strategic value Therapist knowledge and skill Periodontal Factors forIndividual Tooth Prognosis

24. Prognosis- bone loss • To determine if bone has been lost: • Draw a line between Cementoenamel Junctions • Healthy bone should have solid white line 2mm below that line CEJs connected CFHSTC Clin Perio Crse 0013

25. Prognosis • Many different prognoses used • Some prognoses used in dentistry: • Good • Fair • Poor • Questionable • Hopeless CFHSTC Clin Perio Crse 0013

26. Prognosis • Prognoses suggested for Dental Therapists • Restorable • Dental therapist • Refer • Hopeless • Non-restorable • Extraction: • Dental therapist • Refer CFHSTC Clin Perio Crse 0013

27. Prognosis • Hopeless prognosis • Inadequate attachment to maintain tooth in health, comfort, and function Over 90% attachment loss!

28.   PROGNOSIS-perio • Hopelessprognosis according to Becker, Becker, Berg – need 2 or more of the following • Greater than 75% bone loss • Greater than 8 mm probing depth • Class III furcation • Class III mobility * • Poor C:R ratio • History of repeated periodontal abscess • Close root proximity with minimal interproximal bone and evidence of horizontal bone loss

29. Prognosis This is very difficult! As concluded by McGuire (1991): “…it was found that projections were ineffective in predicting any prognosis other than good, and that prognoses tended to be more accurate for single rooted teeth than for multi-rooted teeth.”

30. Periodontal Prognosis • 88.2% (209 of 237) of questionable and 59.5% (22 of 37) of hopeless teeth survived 15 years during regular SPT in a dental school department. Graetz C, et al • J of ClinPerio 2011 Aug;38(8):707-14.

31. Sequenced / Phased Comprehensive Treatment Plan Treatment compartmentalized in phases: 1. Emergency / Urgent care 2. Systemic problems management 3. Preparatory/ hygienic/ diagnostic work-up/ disease control 4. Re-evaluation 5. Corrective restorative 6. Maintenance

32. Sequenced / Phased Comprehensive Treatment Plan • Emergency Treatment focuses on: • Bleeding • Swelling • Pain • Trauma • Majority of treatment for Dental Therapist will be Emergency Treatment

33. Sequenced / Phased Comprehensive Treatment Plan Systemic Management A. Review of past medical history B. Determination of medical risk status C. Impact of health on treatment D. Need for medical consultation E. Drug interactions and side effects F. Consider stress reduction protocol CFHSTC Clin Perio Crse 0013

34. Sequenced / Phased Comprehensive Treatment Plan Disease Control A. Extract non-restorable teeth B. Restore carious teeth and replace defective restorations DT to REFER C. Endodontics to rectify disease process • defer elective/pre-emptive endo (i.e., for pros expediency) CFHSTC Clin Perio Crse 0013

35. Sequenced / Phased Comprehensive Treatment Plan Disease Control DT to REFER D. Periodontal disease arrested - scaling and root planing, re-eval and possibly surgery (pocket reduction) E. Address other pathologic conditions • biopsy prn, candidarx, etc CFHSTC Clin Perio Crse 0013

36. Sequenced / Phased Comprehensive Treatment Plan • Steps 4 to 6 beyond scope of this course CFHSTC Clin Perio Crse 0013

37. سوالات؟ Questions? UNCLASSIFIED//REL TO NATO/ISAF