DENTAL HEALTH SERVICES VICTORIA

Continuing Professional Development Program

Treatment planning in general

dental practice: an overview

Dr Kevin Nicholson

Treatment planning in general

dental practice
History & Clinical Examination
Case Assessment

Treatment Planning

Treatment planning in general

dental practice
History
Examination

Case Assessment

Data
collection/recording

Evaluation of input data

Diagnosis/aetiology
Risk assessment
Prognosis
Treatment options
Treatment risk
factors
Provisional treatment
plan(s)

Primary input
Medical History
Dental History
Clinical examination
Additional
investigations

Treatment planning in general

dental practice
History
Examination
Secondary input
Training &
experience
Clinical interests
Patient expectations
Patient motivation

Case Assessment

Treatment planning in general

dental practice
History
Medical History
Dental History

Examination

Case Assessment

Treatment Plan

Treatment planning in general

dental practice
The agreed course of treatment
should satisfy the patients expectations
meet the patients treatment needs
must fall within the dentists range of skills &
abilities
Patient needs must be met while meeting
professional & contemporary standards in clinical
care

Treatment planning in general

dental practice
Treatment should improve oral health
Include prevention of disease
pain management & provision of comfort
Patient motivation is a necessary prerequisite to
effective dental care
Irregular attenders must become regular
attenders

WHY PLAN TREATMENT?

Strategy for dental care should:
meet patients realistic expectations
be based on knowledge/understanding of patients
medical & dental history
personal & social history

provide goals & treatment options

provide knowledge of ongoing needs & costs

WHY PLAN TREATMENT?

Strategy for dental care should:
be appropriate to dentists knowledge, training &
experience
enhance patient confidence & well-being

educate re ongoing care & maintenance

minimise post-operative problems & patient
dissatisfaction

WHY PLAN TREATMENT?

The treatment plan should:
be based on an informed & comprehensive
approach

include all feasible treatment options

ensure an appropriate order & time-span
resolve the patients presenting complaint
provide for optimal long-term outcomes

WHY PLAN TREATMENT?

The treatment plan should:
estimate the prognosis, including possible
sequelae & complications
minimise the risk of misunderstandings & adverse
legal consequences
encourage the patients continuing confidence
facilitate ongoing monitoring & maintenance

INITIAL APPOINTMENT
Patient interview

INITIAL APPOINTMENT
Recording General Information
Date of examination
Consulting dentist
Patient referred by
Patient name
Date of birth
Home address
Contact details
Emergency contact

INITIAL APPOINTMENT
Medical History
Medical History Questionnaire
Current & past medical history
Systems review

Medication review

INITIAL APPOINTMENT
Medical History
General health?
Seeing physician for any health reasons?
Taking any medicines, tablets, injections?
Previously in hospital for any illness, operations,
medical procedures?
Any known allergies/smoker?
Pregnant?

INITIAL APPOINTMENT
Medical History
Assessment of medical history
Antibiotic cover required for any reason?
Does medical history affect diagnosis?
Does medical history affect treatment in any way?
Does current medication require change for dental
treatment?
Will medical consultation be required?

INITIAL APPOINTMENT
Medical History
Medical /specialist referral required for combined
management?
Any change in medical status during course of dental
care?

Appropriate record-keeping

INITIAL APPOINTMENT
Psychological status
History of:

neurosis
psychosis
anxiety
depression
personality traits/disorders
current medical management; other care

INITIAL APPOINTMENT
Habits
Smoking
Sucrose drinks
Substance abuse

Parafunction, Bruxism

INITIAL APPOINTMENT
Personal, Family & Social history
Occupation
Employment status
Economic/social status
Recreation, sports activities
Patient expectations & attitude
Availability to attend for treatment & maintenance
Special requirements, eg wind instrument players,
singers, film/television actors

INITIAL APPOINTMENT
Personal, Family & Social history
Patient expectations & attitude
Value of patient knowledge & experience of
treatment
Feedback from patients post-treatment
Value of patient questionnaires relating to
expectations

INITIAL APPOINTMENT
Dental History

INITIAL APPOINTMENT
Dental History
Presenting Complaint
History PC
Past Dental History
Reasons for tooth loss
Denture history, past
experience
Attendance pattern

Past dental experience

Restorative
Endodontics
Orthodontics
Periodontics
Past extractions, surgery

CLINICAL EXAMINATION
Recording Clinical Information
Odontogram

Clinical Notes

CLINICAL EXAMINATION

Extra-oral examination (Head & Neck)

General morphology
Skeletal base
Skin lesions
Lymph glands
Neck & facial muscles

Lip support/seal
TMJ

CLINICAL EXAMINATION
Intra-oral examination

Soft tissues/oral mucosa

Underlying bony structures
Masticatory muscles
Dental examination
Periodontal examination
Occlusal examination
Existing prostheses
Oral hygiene/Saliva

CLINICAL EXAMINATION
Soft tissues/Oral mucosa
Tonsils, fauces, fossae
Posterior pharyngeal
wall
Soft palate
Lips
Cheeks
Tongue
Floor of mouth

CLINICAL EXAMINATION
Soft tissues/Oral mucosa
Site
Size
Shape
Colour
Surface
Surroundings
Texture
Bleeding on gentle
wiping?

Description, drawing,
photograph in clinical notes

CLINICAL EXAMINATION
Underlying bony structures
Maxillary, mandibular
Arch size, form
Residual ridge contour
Palatal vault
Maxillary tuberosities

Tori
Bony undercuts
Muscle & frenum
attachments

CLINICAL EXAMINATION
Masticatory muscles
Elevators
Masseter, temporalis, int. pterygoid

Depressors
Mylohyoid, geniohyoid, ext. pterygoid, digastric

Tenderness on gentle palpation?

Attachment relationship to residual ridge

CLINICAL EXAMINATION
Oral hygiene
Halitosis
Tongue surface
stains/debris
Dental plaque

Dental calculus

CLINICAL EXAMINATION
Saliva

Quantity
Quality

CLINICAL EXAMINATION
Dental

Teeth present, missing

(Count, account)

Attrition
Abrasion
Abfraction
Erosion/Corrosion
Caries

CLINICAL EXAMINATION
Dental

Hypomineralisation
Staining, discoloration
Gingival recession,
exposed root surfaces
Dentine hypersensitivity
Enamel faceting
Dentine cupping

CLINICAL EXAMINATION
Dental

Open contact areas,

food impaction
Plunger cusps
Restorations
adequate
inadequate
fractured
gingival overhangs

CLINICAL EXAMINATION
Dental Trauma
Crown infraction
Uncomplicated crown
fracture, complicated
crown fracture
Uncomplicated crownroot fracture,
complicated crown-root
fracture
Root fracture

CLINICAL EXAMINATION
Dental Trauma
Periodontal tissues
Concussion
Subluxation (loosening)
Intrusive luxation
(intrusion)
Extrusive luxation
(extrusion)
Lateral luxation
Exarticulation (avulsion)

CLINICAL EXAMINATION
Dental Trauma
Supporting bone
Comminution of alveolar
socket
Fracture of alveolar
socket wall
Fracture of the alveolar
process
Fracture of mandible or
maxilla

CLINICAL EXAMINATION
Periodontal
Oral hygiene
procedures

brushing
interspace brush
flossing
superfloss
other

Oral hygiene
Plaque index (date/score)

CLINICAL EXAMINATION
Gingival, Periodontal
Gingival tissue

Colour
Swelling
Bleeding
Ulceration
Exudate
Suppuration

Papillae
Marginal gingivae
Attached gingivae

CLINICAL EXAMINATION
Gingival, Periodontal
Psuedo-pocketing
gingival swelling?
gingival hyperplasia?

Gingival tone

soft, spongy
firm
friable
ulceration
desaquamation

CLINICAL EXAMINATION
Gingival, Periodontal
Attached gingiva

Adequate width
Diminished width
Mucogingival lesion
Frenal attachments

Gingival recession
Dentine
hypersensitivity

CLINICAL EXAMINATION
Periodontal

Gingival recession
6 sites per tooth

Pocket probing depths

6 sites per tooth
bleeding on probing

CLINICAL EXAMINATION
Periodontal
Suppuration
Furcation sites
Fremitis
Mobility
Gr I
GrII
GrIII

CLINICAL EXAMINATION
Occlusion

Arrangement &
position of teeth
Drifting
Tilting/inclination
Rotation
Supra-eruption
Crowding/imbrication

CLINICAL EXAMINATION
Occlusion

Arrangement & position of teeth

Contact areas/open contacts
Diastemas
Cuspal inclines
Wear facets

CLINICAL EXAMINATION
Occlusion

Angle classification
Overbite/overjet
Anterior/posterior open bite
Rest vertical dimension/occlusal vertical dimension
Freeway space

CLINICAL EXAMINATION
Occlusion

Occlusion & articulation

Intercuspal position (ICP, CO)
Retruded contact position (RCP, CRO)
ICP coincides with RCP?
Premature contacts in RCP?
Mandibular shift from initial point of
contact in RCP?
Mandibular deviation on opening/closing?

CLINICAL EXAMINATION
Occlusion

Occlusion & articulation

Fremitus

Mandibular excursions; excursive contacts

Working/balancing sides; protrusion
Cuspid rise; group function; balanced
occlusion?
Working side interfering contacts?
Balancing side contacts?
Posterior disclusion?

CLINICAL EXAMINATION
Occlusion

Occlusion & articulation

Faceting/wear of occlusal surfaces?
Parafunction; clenching, bruxism?

CLINICAL EXAMINATION
Occlusion

CLINICAL EXAMINATION
Existing prostheses
Removable
Fixed
Implant retained
prostheses
Provisional prostheses
Occlusal splints

General comments;
finish, form, contour
Fit
Retention
Extensions
Stability
Aesthetics
Comfort,function,
speech
Occlusion/occlusal
analysis

CLINICAL EXAMINATION
Further investigations

Pulpal response tests

Plaque/gingival indices
Saliva testing
Radiographic
examination
Study casts
Clinical photographs

CLINICAL EXAMINATION
Further investigations
Dietary analysis
Medical investigations
Biopsy procedures
Referral to
physician/medical
specialist
Referral to
dentist/dental specialist

Further Investigations:
Extra oral Radiographs

Further Investigations:
Intra oral Radiographs

Further Investigations:
Intra oral Radiographs

EXAMINATION & TREATMENT PLANNING

IN GENERAL DENTAL PRACTICE

HISTORY TAKING
CLINICAL EXAMINATION/RECORDING
CLINICAL DATA

CASE ASSESSMENT
TREATMENT PLANNING
PATIENT CONSULTATION

CASE ASSESSMENT

Evaluation of all information obtained

Existing problems? (Diagnosis)
Aetiological/ risk factors evident?
Long term outcome both with & without
treatment? (Prognosis)
Treatment goals?
Treatment risk factors?
Strategy for management? (Treatment
options)
Formulation of a treatment plan

CASE ASSESSMENT

Evaluation of all information obtained

Considering treatment goals
Overall treatment goals
Goals of individual treatment procedures

Considering treatment options

Considering treatment risk factors
Concept of the phased treatment plan
Concept of the provisional treatment plan

TREATMENT PLANNING
Phased treatment plan
Provides for:
appropriate sequential order of treatment
procedures
effective & efficient treatment needs

customised & optimal treatment needs

TREATMENT PLANNING
Phased treatment plan

Allows the patient to participate in:

their own treatment needs & dental health
maintenance
flexibility within and between phases of
management
not all patients require treatment within all
phases of management

TREATMENT PLANNING
Phased treatment plan

Phase 1 (Preliminary phase)

Phase 2 (Interim phase)
Phase 3 (Restorative/prosthetic phase)
Phase 4 (recall/review/maintenance)

TREATMENT PLANNING
Phase 1 (Preliminary phase)
Treatment goals
Resolution of acute problems
Stabilisation/elimination of active disease

TREATMENT PLANNING
Phase 1

Treatment procedures
Relieving pain & discomfort

Managing risk factors; local, systemic

Elimination active carious lesions
Extraction of teeth with hopeless prognosis

TREATMENT PLANNING
Phase 1

Treatment procedures
Instituting effective plaque control

Initial periodontal therapy

Scaling & root planing

Direct restorations
Temporary or provisional prostheses

TREATMENT PLANNING
Phase 1

Reassessment of Phase 1
Addressed patient's presenting complaint?
Comfortable, stable dentition?

Control of risk factors; systemic, local?

TREATMENT PLANNING
Phase 1

Tissue response to periodontal treatment?

Patient motivation to continue treatment?

Review phase 2 & 3 treatment goals

TREATMENT PLANNING
Phase 2 (Interim phase)
Phase 2 treatment goals
Elimination of active disease sites

Maintenance of gingival/periodontal health

Periodontal pocket elimination

TREATMENT PLANNING
Phase 2 (Interim phase
Phase 2 treatment goals
Regeneration of periodontal attachment
loss
Infrabony defects
Furcation sites

Stabilisation of gingival position, contours

Management of localised gingival recession

TREATMENT PLANNING
Phase 2 (Interim phase)

Phase 2 treatment procedures

Periodontal surgery
Pocket elimination; periodontal plastic surgery
Regeneration of periodontal attachment loss
Infrabony defects
Furcation sites

TREATMENT PLANNING
Phase 2 (Interim phase)

Phase 2 treatment procedures

Direct (non-complex) restorations
Repairs/relines to existing prostheses
Oral surgery, complex extractions eg 8's

Endodontics
Orthodontics

TREATMENT PLANNING
Phase 2
Phase 2 treatment procedures
Periodontal, osseous & mucogingival surgery

Flap procedures, open debridement

Crown-lengthening procedures
Gingivectomy, gingivoplasty
GTR, bone grafting/ridge augmentation
Crown-lengthening procedures
Soft tissue grafting, gingival, ridge
Implant placement procedures

TREATMENT PLANNING
Phase 2
Phase 2 treatment procedures
Provisional prostheses

TREATMENT PLANNING
Phase 2
Reassessment of Phase 2
Active disease sites?
Plaque score acceptable to proceed to
Phase 3?
Acceptable gingival contours/aesthetics?
Patient interest/motivation?
Review Phase 3 treatment goals

TREATMENT PLANNING
Phase 3 (Restorative/prosthetic phase)

Phase 3 treatment goals

Maintenance of gingival/periodontal health
Restoration of function & aesthetics
Occlusal stability
Establishing a determined occlusal scheme
Establishing a new occlusal vertical
dimension

TREATMENT PLANNING
Phase 3

Phase 3 treatment procedures

Occlusal analysis/diagnostic wax up
Direct & indirect restorative procedures
Fixed prosthodontics
Removable prosthodontics
Implants/prostheses
Provision of protective night guards

TREATMENT PLANNING
Phase 3

Reassessment on completion of Phase 3

Phase 3 treatment goals met?
Review treatment outcomes Phase 1, 2, 3

TREATMENT PLANNING

Phase 4 (Recall, review, maintenance)

Phase 4 management goals

Disease free long-term maintenance
Maintenance of gingival/periodontal health
Long term comfort, function, aesthetics
Occlusal stability
Maintaining patient motivation &
participation, responsibility
Overall patient well-being

TREATMENT PLANNING
Phase 4

Phase 4 management procedures

Check appointments, 48 hrs, 7 days, 10 days
Address concerns

Short term, 6 12 weeks

Short term recall, review/reassessment

Longer term, 3 mths 12 mths

Longer term recall, review/reassessment
Maintenance program

PATIENT CONSULTATION
Presentation & discussion of treatment plan
Patient consent
Appointments; fees & financial arrangements

Confirmation of treatment plan

PATIENT CONSULTATION
Presentation/discussion of treatment
plan
Dentist provides adequate information
Questions & answers
Patient makes informed decision
Patient expectations may differ from that
of dentist
Provisional/definitive treatment plan

PATIENT CONSULTATION
Patient consent
Dentist must assist patient to make well-informed
decisions about treatment procedures

For complex procedures, expressed consent,

verbal or written is required
For valid consent, information about the risks &
consequences of the proposed procedures must
be provided
Patient must understand what is consented to!

PATIENT CONSULTATION
Appointments
No. of appointments
Duration of appointments
Time frame to complete treatment plan/phases

Fees & financial arrangements

PATIENT CONSULTATION
Follow up letter confirming:
Diagnosis/es, prognosis, treatment plan

Any referrals as discussed

Time lines, fees, financial arrangements

Treatment planning in general

dental practice: an overview
History & Clinical Examination
Case Assessment

Treatment Planning

Treatment Planning in General

Dental Practice
Clinicians must:
Continue to develop & enhance diagnostic skills,
including aetiology, risk factors & prognosis
Provide a comprehensive treatment plan for
appropriate, effective & efficient treatment, referring
to specialists where necessary for advice or
management
Evaluate all treatment outcomes and provide
appropriate long term management

EXAMINATION & TREATMENT PLANNING

References

Dental Practice Board of Victoria (2007). Dental Records Code

of Practice No. C003.

See also DPBV 1001 Information on Dental Records & 1002
Consent: Assisting patients to make well-informed decisions
Ibbetson, R (1999). Treatment planning. BDJ 186:11, 552-558.
McLeod, DE (2000). A practical approach to the diagnosis &
treatment of periodontal disease, JADA 131:4, 483-491.
Palmer, R & Howe, L (1999). Assessment of the dentition &
treatment options for the replacement of missing teeth.
BDJ 187:5, 245-255.
Renvert, S & Persson, GR (2000). Supportive periodontal
therapy, Periodontology Vol 36, 179-195.

Treatment Planning in General

Dental Practice: case study

Treatment planning in general

dental practice: case study

Treatment planning in general

dental practice: case study

Treatment planning in general

dental practice: case study
General Information:
65 yr old male

MH:

Generally healthy
History of high bp, sees medico 1/12
Coversyl 4 mg /day last two years
Smoker 10+ per day
No family history diabetes
No allergies
No CVD, no rh fever, no kidney disease, no Hep/HIV

PC:
Broken filling upper right back tooth

Treatment planning in general

dental practice: case study
HPC:
Many restorations placed & broken over last few years
No pain, sensitivity, no tenderness/swelling

PDH:
Last dental treatment (Xn 16) 9 mths ago - no
complications
Previous Xns (35, 36, 37, 46) 3-4 yrs ago
Previous fillings over last few years
RCTs (25, 45) > 5 yrs ago
Tooth coloured veneers (11, 21) 5 yrs ago
Previous scalings over last appointments

Treatment planning in general

dental practice: case study
OE:
Extra-oral:
No skin lesions, no lymph node swelling/tenderness, No TMJ
tenderness/clicking; mandibular movements OK

Intra-oral

Mucosa/Bony structures
Dental
Gingival/periodontal
Occlusion
Existing prostheses
Oral hygiene
Saliva

Treatment planning in general

dental practice: case study
Dental
Missing 18, 16, 28, 35, 36, 37, 46, (48)
Recurrent caries 12MD, 13D, 26M, 44D, 45D
Heavily restored 14, 15, 11, 21, 24, 25, 45
RCT 25, 45 (adequate?)
Gingival/periodontal
Gingivae pink, firm; papillae blunted 15 - 27, 35 - 45
PPD 2-4mm all sites, except 24 - 27 proximal PPD 4 6mm
26 DP furcation GrII, 6+ mm 26 D, 27 M
Bleeding on probing all proximal sites
No mobility

Treatment planning in general

dental practice: case study
Occlusion
Angle Cl I; loss of posterior occlusion R & L
Existing prostheses
none
Oral hygiene
Subgingival calculus all segments ++
Plaque Index 70%

Additional investigations:
Radiographic Report
Radiographic report
Panoramic radiograph of partially dentate maxilla/mandible
Intraoral periapical radiograph 24, 25, 26, 27; male patient 65
yrs old

Dental structures
Teeth missing:
Restorations:
RCT:
Dental caries:
Calculus:

18, 16, 28, 35, 36, 37, 46,

48 u/e (mes. angular impaction)
Amalgam 17,13, 24, 26, 27, 38, 44, 45,
47; Resin/GIC 15, 14, 12, 11, 21, 25
25, 45 (short of apex), 25 parallel post
12MD, 13D, 26M, 44D, 45D
27M

Additional investigations:
Radiographic Report
Supporting structures

Early horizontal bone loss all segments

Vertical bone loss:15D, 25D, 26M, 27M, 38M, 25D, 47M
Furcation bone loss: 26DP
Residual ridge bone loss: 16, 35, 36, 37

Adjacent structures: TMJ disc space regular, well-defined

Diagnoses

Missing teeth:
U/E impacted:
Recurrent caries?:
Inadequate RCT?:

18, 16, 28, 35, 36, 37, 46

48 mes-angular impaction
12MD, 13D, 26M, 44D, 45D
25, 45

Additional investigations:
Radiographic Report
Diagnoses
? Generalised chronic periodontitis with early horizontal bone
loss; irregular vertical bone loss 25, 26, 27
Furcation bone loss 26DP
Heavily restored teeth 15, 14, 11, 21, 25, 45

Additional information?
FM periapical radiographs, long cone technique
Review dental history; aesthetics?, function?, comfort?
Review examination data re caries, restorations/residual tooth
structure 15, 14, 11, 21, 25, 45
Full periodontal charting /assessment if not completed

Additional investigations:
Pulp sensibility
CO2 test:
15, 14, -ve

Study casts
Clinical photographs
anterior, R & L lateral views of gingivae/dentition

Case Assessment
Diagnosis

Missing teeth as charted

Recurrent caries
Heavily restored GIC 15, 14, 25
14, 15, non-vital pulp response
Poor aesthetics 11, 21, RC veneers
Generalised chronic periodontitis (early to moderate)
all sites, except
Chronic periodontitis 25 - 27 ( mod to severe), with
Gr II furcation bone loss 26D

Case Assessment
Aetiology/Risk factors
Local factors; dental plaque, recurrent caries,
irregular bone loss/furcation Gr II
Other factors; smoking

Prognosis for overall dentition

Fair to good

Prognosis for 26
without treatment long term prognosis poor
with management, guarded (furcation II)

Case Assessment
Prognosis 15, 14, 25
Poor (non-vital, lack of tooth structure)

Patient motivation
Good

Treatment goals

Restore comfort, function, aesthetics

Eliminate caries activity
Control, eliminate active periodontitis
Long term dental & periodontal health
Long term patient motivation, attendance

Treatment Plan
Phase I
Scale & root plane all teeth, F application
Oral hygiene instructions; toothbrushing,
interspace brush, superfloss, home disclosing
solution
Management of dentine hypersensitivity?
Restoration 12MD, 13D, 26M, 44D, 45D
Extraction 14, 15, 25
Provisional P/- acrylic denture (aesthetics)
Refer 48 Xn

Treatment Plan
Phase 2
Review all Phase 1, 6/52
Review OH
Gingival/periodontal status, PPD

Rescale perio sites as required, eg 26D

Reassess prognosis of 26
Refer periodontist advice 26?
PPD not reduced, bleeding, cleanability?

Treatment Plan
Phase 3
Review specialist management 26 as required
26 for Xn if required
Review OH
Patient motivation

Restore 11, 21
Ceramic labial veneers

P/P Co-Cr removable dentures

Treatment Plan
Phase 4
Review all treatment carried out 12/52
Review OH
Review gingival/perio status, PPD

Scale & polish all teeth, F application

Assess re ongoing maintenance
Recall examination 3 -6 months
Regular SRP (3 - 6 months?)
Reline P/P 6/12

Treatment Planning in General Dental practice