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Treatment Planning in Esthetic Operative Dentistry- Lect. 3- 2018

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الكلية كلية طب الاسنان     القسم ترميم ومعالجة الاسنان     المرحلة 4
أستاذ المادة امير حمدي حكيم العميدي       09/03/2018 09:18:05
Lect.3 treatment planning in operative dentistry

1. Treatment Planning inTreatment Planning in Esthetic Operative DentistryEsthetic Operative Dentistry
2. Status of Treatment Planning in Private Practice
3. Reasons for the variation in treatment planning Advance in dental research (e.g.) Changes in diagnostic techniques (e.g. pits and fissures caries) Changes in treatment philosophy (e.g. criteria for replacement of existing restorations) Treatment planning will depend on the training background of the dentist
4. Reasons for the variation in treatment planning Changes in disease pattern Years ago dental caries was pandemic Today, dental caries affect a large percentage of the population. Dentists are not busy enough - looking for optional treatments
5. Reasons for the variation in treatment planning Explosion in treatment options/techniques in operative dentistry Treatment planning will depend on dentist’streatment philosophy, clinical judgment/experience, clinical expertise or other reasons…..
6. Example in treatment options A 35 year-old female patient presents to your dental clinic for a routine dental exam CC: none PDH: regular patient (6-12 mo recall) to another dental clinic, reason for switching clinic is because of changes in dental insurance by her employer Clinical exam: conservative occlusal amalgam on her permanent first molars that were placed when she was 18. All the amalgam showed a sign of slight marginal breakdrown. No evidence of any dental diseases.
7. Example in treatment options Treatment Options Replace the “old” Class I amalgam restorations with: Direct composite ($50) Amalgam ($30) Gold inlay ($760) Gold foil ($150) Indirect ceramic inlay ($350) Indirect composite inlay ($60) CAD/CAM inlay ($760) OR No treatment - priceless
8. Reasons for the variation in treatment planning Consumer driven demand Magazine Internet TV Dentist philosophy in treatment may be influenced by the demand of the patients (specific to the location of the practice)
9. Reasons for the variation in treatment planning Type and location of the dental clinic Mall//Park Clinics that advertise heavily in the area of esthetic dentistry Dentist philosophy in treatment may be influenced by the demand of the patients (specific to the location of the practice)
10. Treatment Planning in Operative Dentistry Evidence-based Dentistry American Dental Association definition of “Evidence- based Dentistry” Approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences
11. Evidence Based Treatment Planning Three elements of treatment planning o Best available scientific evidence (diagnosis and treatment options). o Dentist’s clinical expertise. o Patient’s treatment needs and preferences. SUMMARY
12. Identification of best evidence Information obtained from: Randomized controlled clinical trials Nonrandomized controlled clinical trials Cohort studies Case-controlled studies Crossover studies Case studies Systemic reviews (PubMed, Journals, Cochrane) Ismail and Bader, JADA, Vol.135, January 2004
13. Dentist’s Clinical Expertise Relating to what the dentist is comfortable of doing - e.g. offering composite veneers vs porcelain veneers Understand your strengths and weaknesses, be truthful to your patients Understand when you need to refer to specialists
14. Patient’s Needs/Preferences Probably the most neglected aspect in treatment planning by a student Try to incorporate patient’s preferences in formulating your final treatment plan Try to understand and address what are the TRUE “wants” and “needs” of the patient Try to to address the realistic/unrealistic “needs” and “wants” of the patients Challenge: need to understand your patient in a relatively short period of time
15. Challenges in understanding your patient Time Patient may not be telling you the whole truth Remember it is a two-way street; try to LISTEN to your patient - e.g. patient’s true esthetic concern May have to help your patient understand the “needs” and the “wants” of their dental treatments
16. Defining Oral Rehabilitation Levels of Oral Rehabilitation Treatment of Defective Teeth Only Treatment of Defective Teeth with an Esthetic Upgrade Treatment of All Teeth for Therapeutic or Esthetic Reasons The levels are established based on the esthetic preference of the patient JADA Vol. 135 (2004): 215-217
17. Treatment of Defective Teeth Only Patient in general are pleased with their oral appearance, although it may not be perfect by ideal standards. They want long lasting, comfortable dental restoration and a reasonable smile. They are not seeking the glamorous, but often short- lived, esthetic restorative therapy popularized on TV. They may accept bleaching, some will accept tooth- colored restorations
18. Treatment of Defective Teeth with an Esthetic upgrade Majority of patients - they want to look acceptable, have a pleasant smile and be able to eat normally. Most are not interested in having absolutely perfect-appearing teeth that are snow-white. However, usually they will accept a moderate level of esthetic upgrade while receiving therapy for their dental caries or defect restorations. These patients usually involved a phased treatment plans spanning several years. The patients should be well INFORMED of which part of their therapy is mandatory and which part is purely elective Usually involve bleaching, a few veneers or crowns and restoring any obviously displayed metal restorations or darkened teeth with crowns.
19. Treatment of All Teeth For Therapeutic or Esthetic Reasons This level of oral rehabilitation is being promoted in many continuing education courses and routinely is suggested to patients. Usually, crowns, veneers, elective cosmetic periodontal surgery, some occlusal therapy, perhaps elective endodontic therapy or orthodontics and even orthognatic surgery are suggested. Much of the treatment is for esthetic reasons only and is not required for any therapeutic reason. If a patient is INFORMED that the therapy is not required because of disease, and that it is elective and primarily esthetic, the matter of ethics becomes somewhat clearer. However, if the patient is led to believe that the mostly esthetic therapy is needed for therapeutic reasons, including questionable occlusal pathosis, or if the more conservative therapies are not explained to the patient, the practitioner is treading on unethical ground
20. Understand what type of patient you are dealing with May give you some clue on their preferences Will influence what type of treatment/procedure/material used People do not change - try to make small incremental improvement Try to institute phased treatment
21. Types of Patients Patient never been to dentist in Iraq Recent immigrants from village. May have a lot of “unconventional” dentistry done in his/her village. Educate, take care of acute needs first before trying to fix those “unconventional” dentistry.
22. Types of Patients Last trip to dentist - over 5 years Phobic, not health conscience, only go when I have pain Try to understand where they are coming from, and why they are here Usually they have an acute need Take care of their acute needs, then present a phase approach - acute needs (disease that cause pain), take care of larger lesion, debridement, smaller lesion, missing teeth, cosmetic…
23. Types of Patients Last trip to dentist - 2 to 5 years No insurance, feel very uncomfortable going to a dentist Usually have an acute need More aggressive in prescribing treatment - less confidence in monitoring small lesion
24. Types of Patients Patients that come in at least once every 2 years Regular patient More comfortable in monitoring small lesions Still need to understand what they preferences are: Cost conscience I want the best Missing teeth not a concern Value your judgment and recommendation Just take care of my basic needs Esthetically sensitive
25. Treatment Planning Models Treatment oriented model Problem oriented model
26. Treatment Oriented Model Dentist examine the patient Dentist mentally equate the findings to the need for certain form of treatment Examination findings are summarized in the form of a list of treatments -TREATMENT PLAN Useful in simple cases
27. Problem Oriented Model Examination lead to formulation of a list of problem Each problem on the list is then considered in terms of treatment options Informed patients of all the options Formulate the TREATMENT PLAN
28. Problem Oriented Model Problem Lists (Objective findings from oral and radiograph exam) Formulate Treatment Options Patient’s Preferences/factors (Subjective Findings) Caries Risk Assessment Treatment Plan Patient’s Preferences Informed Consent
29. Patient’s Preferences Address patient’s chief complain Ask questions - assess patient’s true preferences Understand what is the treatment objectives for the patient (better function, better esthetic?) Understand what type of patient you are dealing with Preference for the types of restorations/procedures (e.g. fixed vs removable, direct vs indirect restorations) Can the patient afford the procedures he/she desires? Patient’s dental IQ - long term maintenance Esthetic - understand their true concern
30. Caries Risk Assessment Why is it a vital part of Treatment Planning? Dental caries is an infectious disease. It is the most overlook aspect in the treatment planning process. Patient’s caries risk status will affect the treatment (materials and procedures, treatment vs no treatment) you are going to prescribe. Patient’s caries risk will determine recall intervals and radiograph exposure intervals. For the high risk patients (caries active or caries prone), a strategy to control the disease should be formulated and documented in the treatment plan. Review- Dr. Hildebrandt’s Fall semester manual - Current Concepts in Caries Control
31. Dental Caries - an Infectious Disease Etiologic agent - specific pathogens (Specific Plaque Hypothesis) Signs and symptoms of the disease - localized dissolution and destruction of calcified tissue. It is very easy to focus narrowly on treating the signs and symptoms ONLY (restorative needs); thus failed to identify the underlying cause of the disease. Failure to address the underlying cause of the disease will allow the disease to continue. Restoration alone do not and will not treat the disease
32. High Caries Risk Patients Must identify the underlying reason(s) for the high risk. Not been to a dentist for years or poor oral hygiene are seldom the ONLY factor Salivary flow? Diet? MUST educate and formulate a control measures plan
33. Problem Oriented Model Problem Lists (Objective findings from oral and radiograph exam) Formulate Treatment Options Patient Preferences/factors (Subjective Findings) Caries Risk Assessment
34. Problem List Dental caries - rampant caries Poor oral hygiene
35. Caries Risk Assessment Caries active identify the underlying reason(s) Poor oral hygiene and not been to dentist since high school should not be taken as the “convenient” reason.
36. Caries Risk Assessment Goals Identify the underlying reason(s) - EDUCATE the patient. FORMULATE control measures. ASSESSING patient’s ability to change (habits). These goals are as important if not more important than the restorative part of your treatment plan. Success/failure of the restorative phase will depend on whether you can achieve the goals stated above.
37. Patient’s Preference/Factor Goals Formulate a preliminary plan based on patient’s preferences and the overall treatment goal. Narrow down options
38. Overall Treatment Scheme Initial treatment phase - treating the symptoms of the disease (massive tooth morbidity). Therapeutic Phase Evaluation -evaluate the success/failure of therapeutic phase Final Restorative Phase Therapeutic Phase - control measures
39. Initial Restorative Phase Options available for dealing with massive tooth morbidity Direct Restoration RCT Extraction Treatment options Extract all teeth Extract teeth that are unrestorable only Extract teeth that will need RCT Extract teeth that are unsuitable/unnecessary to support a removable partial denture. E.g. do you want to save all the Mx anterior teeth (assuming they all have extensive lesions) if your treatment plan will involve a Mx partial denture? Immediate removable appliances
40. Therapeutic Phase Evaluation Was the control measures prescribed successfully change the patient from high caries risk to low caries risk, or at least have the disease under control. No final treatment phase should be initiated until the risk is under control
41. Final Restorative Phase Indirect restorations Crowns and bridges Removable appliances


المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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