Development of treatment plan

1. Development of treatment plan Subject code 692-421 4th - year dental student Academic year 2011 Lecture note-Dr. Kanokporn Pangsomboon 22/9/2012

2. Learning topics Priorities of treatment and sequencing of the treatment Patient case process

3. Details Phase of the treatment plan Informed consent

4. Setting priorities: the optimal treatment sequence Phase I: Pretreatment phase or Systemic phase Phase II : Acute phase Phase III : Disease control phase Phase IV : Definitive phase Phase V: Maintenance phase ??????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????? ?????????? ???????????????????? ??????????????????????? ?????????????????? ??????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????? ?????????? ???????????????????? ??????????????????????? ??????????????????

5. Patient�s perspective Chief complaint The patient�s dental expectation, desire and awareness Financial limitations The patient�s dental attitudes influence of personal, social and economic history effects of past dental treatment patient age The patient�s dental condition medical or psychiatric conditions Potential complications of dental treatment Referral for specialty treatment Financial considerations significance of the disease process and its etiology

6. Systemic phase Prevent medical emergencies in the dental office Provide dental care in safe and efficient manner Make appropriate accommodation for the patient�s physical, mental, behaviour limitation in the planning and delivery dental care

7. Emergency treatment in dental clinic Allergic reactions Poisoning or toxicity including drug overdose Respiratory difficulty, aspiration Asthma Chronic obstructive pulmonary disease Hyperventilation syndrome Angina pectoris Acute myocardial infarction Cerebral vascular accident (stroke) epilepsy

8. Emergency treatment in dental clinic(cont.) Vasovagal syncope, Orthostatic syncope, cardiac syncope Hypertensive crisis Bleeding Shock convulsive disorder adrenal crisis hypoglycemic shock , hyperglycemic shock (diabetic ketoacidosis) Hyperthyroid crisis (thyrotoxicosis), myxedema coma

9. Acute phase Diagnosis process as routine dental patients but accommodation with patient�s specific physical or cognitive limitations The timing and setting vary ???????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ???????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ????????????????

10. Urgency treatment for acute problem Hypersensitivity of dentin or cementum Pulpal hyperemia Acute pulpitis Acute suppurative pulpitis Non-vital pulp with periapical inflammation Acute periapical diseases (alveolar abscess) Maxillary sinusitis with referred pain to teeth Coronal fracture (fracture/ cracked tooth syndrome) Dental pain associated with tooth eruption or pericoronitis Dental pain associated with previos dental treatment Dental pain of other origin

11. Urgency treatment for acute problem Acute periodontal abscess Acute periapical diseases Necrotizing ulcerative gingivitis or periodontitis Herpes simplex infection Primary herpectic gingivostomatitis (diffuse) Recurrent herpes (diffuse) Major aphthous ulcers Erosive lichen planus Burn Human bites

12. Urgency treatment for acute problem Esthetic complaints If the patient�s appearance or ability to speak is affected adversly

13. Solutions/Treatment for Chief complaints Importance of the chief complaint pain, discomfort, inflammation, expectation For the chief complaint such as pain, acute infection, bleeding, and traumatic injury require immediate attention Palliative Treatment Curative Treatment

14. ????? ????????????????? ????????????????? ??????????????? ???????????????? ???????????? ?????????????????????? ?????? ????????????????? ???????? ??????????????????? ???????????????????????? ????????????? ?????????????

15. Disease control phase Treatment option Depending on the patient�s condition and ability to cooperate

16. Definitive phase Reserved for patients who have excellent oral home care Patients are sufficiently cooperative for comprehensive dental procedures (Exception for request of interested family members or caregivers) Phase IV : Definitive phase (Restoration of esthetics and function, reconstruction and rehability) Phase IV : Definitive phase (Restoration of esthetics and function, reconstruction and rehability)

17. Maintenance phase Help patient establish and maintain pain-free, well functioning, clean, and healthy oral condition in accordance with his or her wishes, circumstances, and abilities Inform and educate the realistic diagnosis and prognosis information Changes, need to adjust the approach and modify the preventive program Susceptibility to specific oral disease and problem will need the attention Some techniques and methods for particular application Proper diet or oral home care Specific oral health care strategies and techniques for overcome the patient� limitation

18. Solutions/Treatment for general health problems Diagnosed medical conditions Medications Allergic/idiosyncratic drug reaction Undiagnosed condition suspected ???????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ????????????????????????????????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ?????????????????????????

19. Solutions/Treatment optionsfor systemic diseases Consideration of past and present systemic disease Evaluation of the influence of systemic treatment on the dental treatment plan Special consideration patient being treated with anticoagulants/ hypertension/ cardiac diseases Prevention of oral infection for patient with diabetes mellitus Serious complications from surgery for patients with bleeding disorders Recognition and reminder of a history of bleeding disorders rheumatic fever congenital heart diseases

20. Solutions/Treatment for in systemic phase Premedication with antibiotics or sedatives as indicated by the history Anxiolytic premedication Avoid medication Precautions must be taken when prescribing or administering analgesics, antibiotics or sedative agents that may have an adverse interaction with the psychiatric medications Corrective therapy for oral infection Monitor systemic condition Oral antibiotic rinse Special patient positioning Other medication Refer patient to physician ??????????????????????????????????????????????????????????????????????????????????????????? ????????????????????????????????????????? ??????????????????????????????????????????????? ???????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????????? ???????????? ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????? ??????????????? ???? ?????????? ?????????? ????????????? ??????? ?????????????????????????????? ???????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????? ???????????????????????????????????????????????? ???????????? ??????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????????? ????????????????????????????????????????? ??????????????????????????????????????????????? ???????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????????? ???????????? ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????? ??????????????? ???? ?????????? ?????????? ????????????? ??????? ?????????????????????????????? ???????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????? ???????????????????????????????????????????????? ???????????? ???????????????????????????????????????????????????

21. Solutions/Treatment for Dental health problems Grouping of treatment Oral surgery Endodontic therapy Caries control Periodontal therapy Orthodontic therapy Occlusal adjustment Operative dentistry Prosthodontic therapy Periodic recall examinations and maintenance treatment

22. Solutions/Treatment for Behavioral problems Tobacco cessation counseling Betel nut chewing cessation counseling Alcohol cessation counseling Substance abuse cessation counseling Etc.

23. Sequencing/summary of treatment plan Systemic phase Treatment and prevention Emergency treatment in dental clinic Urgency treatment for acute problems Treatment for disease control Treatment of orofacial pain/ TMD Treatment of oral lesions Prevention oral hygiene instruction Caries control protocol Pit and fissure sealant Athletic mouthguard/Occlusal splint Tobacco/drug abuse/substance abuse cessation counseling others Scaling and root planing Operative treatment Endodontic treatment. Extraction/surgery Minor occlusal adjustment others: polishing/recontour, periodontal reevaluation, incision/drainage abscess, systemic/localized antibiotic agents, etc. ???????????????????????????????????????????????????? ?????????????????????????????????????????????????????????? ??????

24. Sequencing/summary of treatment plan (cont.) Reconstruction & Rehability for definitive phase Bleaching Operative treatment Removable prostheses Fixed prostheses Periodontal surgery Orthodontic treatment Occlusion Maintenance phase Observed Incipient caries Pathological lesion Restoration/ tooth/ area Chronic oral soft tissue diseases Recheck Evaluation Recall: 3, 6 months, 1 year ??????????????????????? ???????????????????????????????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????????? ?????? ??????????????????? ???????????????????????????????????????????????? ???????? ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????? ??? 3 ????? 6 ????? ???? 1 ?? ?????????????????????????????? ??????????? ?????????? ???????????????????????????????? Others: periodontal reevaluation, incision/drainage abscess, systemic/localized antibiotic agents, ??????????????????????? ???????????????????????????????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????????? ?????? ??????????????????? ???????????????????????????????????????????????? ???????? ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????? ??? 3 ????? 6 ????? ???? 1 ?? ?????????????????????????????? ??????????? ?????????? ???????????????????????????????? Others: periodontal reevaluation, incision/drainage abscess, systemic/localized antibiotic agents,

25. Treatment plan documentation Clearly written plan Sequence of care Fee estimate to be charged In case of disease control only or limitation treatment planning should clearly state �the need for reevaluation and further definitive care�

26. Informed consent ?????????????????????????????? �???????????????????????????... ????????????????????????????????????????????? ???????????????? ???????????????????????????????????� ?????????????????????????????/????????? (Informed consent) ????????????????? ???? 18 ???????? ???????????????????? ??? 3 ????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????? ???????????????????????????????????????????? 18 ???????? ???????????????????? ??? 3 ????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????? ????????????????????????????????????????

27. ????????????????? Informed consent 1. ????????????????????????????? ?????????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????? ??????????????????????????????????????? ????????????????????????????????????????????????????????? ???? ???????????????? ???????????/?????????? ????????? ??????? 2. ?????????????????????????????????????????? ????????????????????????????????????????????????????????????????? 3. ?????????????????????????????????????????? ???? ?????????????????????????????????? 2 ?????????? ??????????????????????????????????? ??????????????????????????????????????????????????????????????????????????? ????????????????????????????????????????????????????????????????????????????

28. Informed consent When Detail the nature of the condition being treated the proposed treatment any risk involved in undergoing the proposed treatment any potential complications or side effect any consequences or risks of not undergoing the proposed treatment any alternative procedures that might be employed the prognosis for the treatment Other helpfully explanation

29. ??????? PARQ note Procedure ?????????????????????????? ??????? ?????? ?????????? ????? ??????? ?????????? Alternatives ?????????????????????? Risks ???????????????????????????????????????? ?????????????????? ?????????????????????????? ?????????????????????????????? Question ?????????????????? ?????????????????????

30. Further reading Colemean GC: Referrals and consultations. In , Coleman GC, Nelson JF, editors: Principles of oral diagnosis, ed 1, St Louis, 2002, Mosby-Year book. Lockhart PB: Dental emergencies. In, Dental care of the medially complex patient, ed 5, Edinburgh, 2004, Wright, 200-209. Lockhart PB: Medical emergencies. In, Dental care of the medially complex patient, ed 5, Edinburgh, 2004, Wright, 200-209, 263-292. Stefanac SJ. Treatment planning in dentistry, ed 2, Missouri, Mosby Elsevier, 2007. Navarro CM,Onofre MA, Sposto M: Referral letters in oral medicine: an approach for the general practicioner. Int J Oral Maxillofac Surg 2001; 30: 448-51.

31. Elective definitive care Crowns Implants Fixed partial dentures Preprosthetic surgery

32. Solutions/Treatment optionsfor Chief complaints Palliative Treatment Curative Treatment

33. ????? ??????????????????????  ??????????????????? ?????????????????????????????????????  ???? ????????????????????????????? ??????????????? ?????? ???????????????? ????????????????? ??????????? ?????????? ?????????????????????????????

34. ????????? ????????????????????????? ??????????????? ??????????????????????????????? ???????????????????????????????????????????????? ????????????????????????????? ??????????????? ??????????????????????????????? ????????????????????? ???????????????????????????? ???????????????????? ????????????????????? ?????????????????? ???????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ????????????????????????? ???????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ?????????????????????????

36. Solutions/Treatment for Dental health problems Nondental lesions of the oral cavity Gingivitis/periodontitis Reversible pulpitis Irreversible pulpitis and pulp necrosis Carious lesions Malalignment/malocclusion Ectopic eruption and impaction of teeth Missing teeth ???????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ????????????????????????????????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????? ???????????????? ?????????????????????????

37. Type of treatment plan Comprehensive treatment plan ?????????????????????? Limited treatment pan ????????????????????? Tentative treatment plan ??????????????????? Alternative treatment plan ???????????????????

38. Solutions/Treatment for Dental health problems Grouping of dental health problems Nondental lesions of the oral cavity (e.g. exostosis, bruxism, cemento-osseous dysplasia, mandiblular fracture, lichen planus, etc.) Periodontal diseases (e.g. gingivitis, periodontitis, peridontal abscess, etc.) Carious lesions Pulpal diseases (reversible pulpitis, irreversible pulpitis, pulp necrosis) Periapical diseases (e.g. chronic apical periodontitis, periapical abscess, condensing osteitis, etc.) Malalignment/malocclusion (e.g. Angle�s class II malocclusion, openbite, tooth sized-arch sized discrepancy, etc.) Ectopic eruption and impaction of teeth Missing teeth/ replacing missing teeth Tooth abnormalities Restoration troubles Esthetic concerns ??????????????????????????????????????????????????

39. Listing possible solutions for patient problems Chief complaint General health problems Dental health problems Behavioral problems