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DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION I

DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION I. “CLINICAL DECISION-MAKING”. SCENARIO. 3:30 P.M., September 16, 2000 Commonwealth Stadium Roar over the stadium as the CATS have just completed a short pass. Score is 17-14 in favor of Indiana.

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DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION I

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  1. DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION I “CLINICAL DECISION-MAKING”

  2. SCENARIO • 3:30 P.M., September 16, 2000 • Commonwealth Stadium • Roar over the stadium as the CATS have just completed a short pass. • Score is 17-14 in favor of Indiana. • It is now 4th down and the football is on the 4 yard line of Indiana; with 1 yard to go for a first down. • Quarterback Lorensen looks at Coach Mumme. • What does Coach Mumme do?

  3. A Data-Based, Phased,Problem-Oriented,Scientific System for Making Treatment Decisions

  4. Clinical Decision-Making,Treatment Planning, andCase Consultation Are The... • Essence of clinical practice. • Sun of the solar system of clinical practice. • Core of the planet of clinical practice. • Heart of the organism of clinical practice. • Soul of the life of clinical practice. • Hub of the wheel of clinical practice. • Nucleus of the atom of clinical practice. …and/or any other metaphor you want to employ to recognize their centrality in practice.

  5. Decisions . . . Decisions . . . Decisions . . . • We all make them and most of the time it seems like a straight-forward process. • How do we learn to make decisions? Mostly by trial and error. • While this may be a functional way to learn, it means many poor decisions are made while learning proceeds. • Additionally, inappropriate decisions may be made later because learning did not proceed far enough or fast enough.

  6. Clinical Decision Making • Treatment planning is a basic component of the clinical practice of dentistry. • Observations during examination focus on problems for which therapy must be planned. • Treatment planning is the vital link between diagnosis and treatment. • Frequently, however, treatment is devised from a simplistic, mechanistic perspective.

  7. Intention... • To present a model for thinking about clinical decisions which can provide a conceptual framework for understanding the multifaceted, interactive nature of the process, as well as provide a means of applying systematic, analytical scientific decision- making skills. • The system is characterized as being data-based, phased, problem-oriented, incorporating a scientific decision style.

  8. “There is nothing morepractical than a good theory.”

  9. Science Is A Way of Knowing, Thinking, Understanding, and Creating Thinking Critically (Scientifically) About Clinical Decision-Making In Dentistry

  10. Living As Problem Solving Regularly and frequently (daily) in life we confront circumstances in which we must make a decision. The necessity of making such a decision is, in its essence, the presentation of a problem; a problem which we now must solve. “No one thinks unless presented with a problem.” John Dewey

  11. Gathering Information • The problem that has presented itself to us is the result of someinformation that has come to our awareness. • No doubt the informationwe have is inadequate to deliberate comprehensively about the matter, so the first step in a scientific decision making process is to gather (more) information. • We may call thefacts we discover in our gathering of information our FINDINGS.

  12. Identifying or Stating the Problem • Our FINDINGS of fact should now enable us to identify or state the problem more explicitly. • We can say that the additional information we gathered allows us to interpret the situation or circumstance we had encountered into an explicit STATEMENT OF THE PROBLEM.

  13. State the Basic GOAL or OBJECTIVE • A problem is really only a problem if it is a circumstance that in some way impedes the achievement or fulfillment of a need or desire. • Not infrequently we are not sure what the need or desire we have that is being thwarted really is. Therefore, we must work to make explicit in our minds specifically what our goal is in this circumstance. • The PROBLEM STATEMENT must be translated into a GOAL STATEMENT.

  14. Identify the Basic Facts, Assumptions, and Constraints • Facts are statements of things that are known. • Assumptions are applied to factors which can be changed to simplify the problem and make it solvable. • Constraints are factors which affect the outcome of the situation and cannot be changed.

  15. Generate Possible SOLUTIONS • This is the time for creative thinking. • Don’t prejudge ideas as they are generated. • Identify all the different potential ideas that may resolve the problem and achieve the desired goal. These are your TREATMENT ALTERNATIVES.

  16. Analyze ALTERNATIVES • Analyze the various ALTERNATIVES to evaluate which of them holds the most promise of achieving the desired goal, and can do so with the most advantageous cost/benefit result.

  17. Synthesize Elements of the SOLUTION • Most any SOLUTION to a PROBLEM will have more than one element. • Separate the chosen SOLUTION into meaningful elements. • Gather additional information you may need to further develop each element. • Combine/Synthesize the elements to create a detailed SOLUTION.

  18. Critique the SOLUTION • Does it satisfy the basic GOAL or OBJECTIVE? • Is it feasible, practical, economical, safe? • Is it moral/legal?

  19. Communicate the Result of Decision-Making • Report to appropriate individuals the result of what you have considered, and decided (or are recommending). • Determine the information needs of the person to whom you are reporting the decision. • Communicate only that information to others that they “need to know.” Don’t overwhelm.

  20. Implement the Decision • What should be done now, what is the “next step?” • What is required logistically to resolve the PROBLEM and achieve the GOAL? • Are there any impediments to implementation, and if so, how can they be removed?

  21. Evaluate the RESULTS • Did the SOLUTION work? • Was the PROBLEM resolved? • Was the GOAL or OBJECTIVE achieved?

  22. “The Butterfly” A Model forClinicalDecision-Making

  23. Scientific Decision-Making in Clinical Dentistry • Gather Information • Identify the Problem(s) • State the Goal(s) of Therapy • Identify the Basic Facts, Assumptions, Constraints • Generate Alternatives • Analyze Alternatives • Make Decision/Recommendation • Critique the Decision/Recommendation • Communicate The Decision/Recommendation • Synthesize Components of Decision Into Detailed Solution • Implement Therapy • Evaluate the Results of Therapy

  24. Office Dynamics • Diagnosis Appointment • Consultation Appointment • Treatment Appointments • Post Treatment Appointment • Recall Appointment ------------------------------ • Emergency Appointment

  25. The Dental Record • Registration Record • Case History Record • Health History • Dental History • Clinical Examination Record • Radiographic Record • Problem/Plan Record (If Utilized) • Treatment Plan Record • Written Consultation Record • Parents’ Notes Page • Supplemental Records, (When Necessary) • Such as, Space Analysis Record • Treatment Record/Progress Notes

  26. Diagnosis Appointment • Defined Data Base • Data Analysis • Supplemental Data Base

  27. Defined Data Base for the Child Patient • Case History • Health History • Dental History • Clinical Examination • Behavior Assessment

  28. Analysis • Analysis refers to examining the information learned from the defined data base to determine if the information is adequate and complete for identifying all problems or potential problems. • Questions such as what, when, where and how are appropriately asked. • Analysis may result in an appreciation that all relevant information required for a thorough diagnosis is not available and additional information must be gained.

  29. Supplemental Data Base • Radiographs • Diagnostic Casts • Clinical Photographs • Space Analysis • Dietary Analysis • Pulpal Vitality Tests • Water Analysis for Fluoride Content • Laboratory Blood Studies • Consultation with other Health Care Professionals

  30. FINDINGS • The results of all of the information gathered through the defined and supplemental data bases is referred to as the FINDINGS. • FINDINGS have been called the “focal point of oral diagnosis.”

  31. Four Dimensions of Oral Health Problems • FINDINGS from the information gained patient’s data bases areinterpreted into problems of oral health in one of four dimensions: • Immediate Problems • Problems of Prevention • Problems of Rehabilitation • Problems of Maintenance

  32. Immediate Problems • Health Constraints • Parental Concerns • Critical/Emergency Circumstances • Problems of Diagnostic Evaluation • Management of Behavior

  33. Problems of Prevention These problems relate specifically to the etiologic factors of dental pathology: • host • microflora • substrate • education/motivation

  34. Problems of Pathology, Development and Reconstruction • Dental Caries • Pulpal Pathology • Periodontal Disease • Craniofacial/Occusal Disharmonies • Oral Pathoses • Developmental Anomalies

  35. Problems of Maintenance Oral health must be maintained, once gained. Key concepts at this level of problem definition and resolution are: • Review • Education/Motivation • Periodic Evaluation • Monitoring Unresolved Problems

  36. Explicating the Process PROCESS PRODUCT • Data Collection FINDINGS • Interpret STATEMENT OF PROBLEM(S) • Translate STATEMENT OF GOAL(S) • Define SPECIFIC LISTING OF PROBLEM(S) • Generate TREATMENT ALTERNATIVES • Analyze TREATMENT JUSTIFICATION • Interpret SPECIFIC PLAN • Criticize OPERATIONAL TREATMENT PLAN • Communicate CONSULTATION/INFORMED CONSENT • Implement TREATMENT • Evaluate NEW FINDINGS

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