2021

Interdisciplinary
treatment planning

MULTIDISCIPLINARY II

GEHAD BADR SAYED

MOHAMMED AYMAN HAMDY
A patient attending for treatment of a restorative nature may present for a variety of
reasons. The success is built upon careful history taking coupled with a logical
progression to diagnosis of the problem that has been presented. Each stage follows
on from the preceding one. A fitting treatment plan should be formulated and should
involve a holistic approach to what is required.
The purpose of dental treatment is to respond to a patient's needs. Each patient,
however, is as unique as a fingerprint. Treatment therefore should be highly
individualized for the patient as well as the disease.

Development of treatment plan for a patient consists of four steps:

1. Examination and problem identification
2. Decision to recommend intervention
3. Identification of treatment alternatives
4. Selection of the treatment with patient's involvement.

When the database (information) is gathered, three stages must be

established:
1. Generation of the problem list (ranking the order of problems)
2. Tentative treatment plan for each of the problems
3. Synthesis of the tentative treatment plan into a unified detailed treatment plan.
Assessment:

Assessment begins with an initial consultation, which is a mutual evaluation

between the patient and clinician. The information gathering process is divided into
histories, examination and technological tests.

(1) Histories: Medical history, Risk history, Nutritional history and Dental
history.
(2) Examination: Verbal, Visual examination (Extra-oral & Intra-oral).
(3) Technological tests: Articulated study models with jaw relation
records, Articulators and jaw movement/registration analysers,
Diagnostic wax-ups and Radiographs

Analysis

II. Facial analysis (frontal view): interpupillary line is determined by a

straight line that passes through the center of the eyes and represents
III. Lateral view (Profile): Appropriate clinical evaluation of the lateral view
is a determining factor in successful assessment of the patient.
(Normal profile, Convex profile & Concave profile)
IV. Tooth analysis:
1. Maxillary vs. mandibular interincisal lines
2. Tooth type & colour
 V. Gingival analysis: Gingival margin outline, Gingival zenith and Dental
papilla.
VI. Phonetic analysis: the m sound, the e sound, the f/v sound and the s sound.

Treatment Planning

After completing the initial consultation, necessary histories, examination and tests,
the next stage is planning. The planning phase involves diagnosis, risk assessment,
evidence-based decision making and presenting treatment proposals to the patient.

Diagnosis: Depending on the clinician‟s experience, relevant data is highlighted,

while less important information is relegated, allowing commencement of the
diagnostic process. Diagnosis is the premise of planning, preceding any prescribed
treatment. It is not limited merely to current symptomatic signs, but incorporates
etiologic of the prevailing pathology.

Risk assessment: The aim of risk assessment is to tailor treatment plans individually
according to a patient‟s dental profile, and give the 3D diagnosis, thereby moving
away from a „repair model‟ to a „wellness model. This will discourage disease
recurrence and encourage long-term oral health. The using 2D diagnosis (clinical
examination and radiograph) only, all patients will prescribed the same treatment.

Evidence based decision making: The responsibility is on the dentist to choose

appropriate materials, backed by evidence based research, to avoid rebuke or
professional negligence litigation in the event of failure.
Evidence based treatment is succinctly summarized as a combination of: - Clinical
experience. -Sound scientific research: It relies on randomized clinical trials as the
standard goal. -Patients‟ needs and wants.

Presenting treatment plan proposals to the patient:

In fact, treatment can change due to a myriad of reasons, including the patient‟s
ambivalence, prevailing clinical presentations, unforeseen complications, financial
burdens, etc. At the onset, it is the clinician‟s duty to convey the flexibility and
fluidity of the proposed treatment, indicating that as treatment progresses, changes
or alterations may be desirable or mandatory. The presentation should encompass
simple and clear verbal and written communication. Visual aids, such as
radiographs, scans, study models and pictures, add credence to the written and
spoken word.

Treatment
Treatment is influenced by biological, clinical, psychosocial and economic factors.
The biological factors include systemic and nutritional health, as well as local
factors, such as periodontal biotype. Clinical aspects include knowledge,
techniques and manual dexterity of the operator, while economic constraints
determine the degree of sophistication of the proposed treatment.

Phasing of the treatment plan:

1. Systemic Phase.
2. The Acute Phase of Treatment.
3. Disease Control Phase.
4. Definitive Treatment Phase.
5. Maintenance Care Phase.

1. Systemic Phase: Establishment and maintain the best possible state of physical
health for the patient before, during and after treatment. Importance of systemic
phase:
1. To prevent emergencies in the dental office
2. To prevent serious post-operative complications in conjunctions with dental
treatment.
 3. To recognize symptoms and signs of undiagnosed systematic disease and refer
the patient to a physician for medical evaluation.

2. The Acute Phase of Treatment:

Incorporates diagnostic and treatment procedures aimed in solving urgent cases.
Acute care can involve controlling pain and swelling to simply replacing a
missing tooth from a denture Possible lines of treatment include endodontic
therapy, initial periodontal therapy, placement of temporary or permanent
restorations and prosthesis repair.

Common acute problems and diagnoses:

Pain
1-Pain of pulpal or periapical origins
- Reversible and irreversibla pulpitis
- Acute apical periodontisis
- Cracked tooth syndrome
2. Pain associated with periodontal tissue
- Acute marginal periodontitis
- Periodontal abscess
- Acute necrotizing ulcerative gingivitis
3. Pain associated with tooth eruption or pericoronitis
4. Pain associated with previous dental experience
5. Other sources of pain ulcers
- Acute TMJ disorders- Acute sinusitis
- Complaint of swelling
- Swelling of dental origin is almost caused by infection
- Possible sources of swelling not associated with teeth like cysts,
granulomatous diseases, and tumors.
- Esthetic complaint
- Fracture of a tooth or loss of restoration in esthetic area
- Traumatic injury
 - Soft tissue injury (Laceration of lips and check, edema, induration or
swelling)
- Injury of the jaw bones (fractures, displacement)
- Dental injuries: Luxation, intrusion, extrusion, crown or root fractures or
avulsion.

3. Disease Control Phase:

To control active oral disease and infection Stop occlusal and esthetic
deterioration Manage any risk factors that cause oral problems.
Example: Controlling dental caries and arresting periodontal disease before
deciding how to rebuild or replace teeth.
Common procedures:
- Oral hygiene instruction
- Scaling and root planning
- Caries risk assessment and prevention
- Endodontic therapy - Extraction of hopeless teeth
- Conservative treatment (dental caries), reduce or eliminate Para-functional
habits, smoking.

The success or failure: Evaluated with a post-treatment assessment examination

before proceeding with definitive treatment procedures.

4. Definitive Treatment Phase:

To rehabilitate the patient‟s oral condition & includes procedures that improve
appearance and function.
Examples: - Additional periodontal treatment, including periodontal surgery -
Orthodontic treatment and occlusal therapy - Oral surgery (extractions, pre-
prosthetic surgery, and orthognathic surgery) - Cosmetic or esthetic procedures
(composite bonding, veneers, bleaching).
5. Maintenance Care Phase:
- Follow after completion of other treatment. - Without a plan to
periodically reevaluate the patient and provide supportive care, the
patient‟s oral condition may relapse and disease may recur.
- The maintenance phase is more than a “check-up every 6 months”.
Procedures: Periodic examinations, periodontal maintenance treatment,
application of fluoride, and oral hygiene instruction.

These General Guidelines for Sequencing Dental Treatment are:

I. Systemic Treatment
A. Consultation with patient‟s physician
B. Premedication
C. Stress/fear management
D. Any necessary treatment considerations for systemic disease

II. Acute Treatment

A. Emergency treatment for pain or infection
B. Treatment of the urgent chief complaint when possible

III. Disease Control

A. Caries removal to determine restorability of questionable teeth
B. Extraction of hopeless or problematic teeth
C. Periodontal disease control
1. Oral hygiene instruction
2. Initial therapy * Scaling and root planing, prophylaxis * Controlling other
contributing factors Replace defective restorations, remove caries Reduce or
eliminate parafunctional habits, smoking.
D. Caries control
1. Caries risk assessment
2. Provisional (temporary) restorations
 3. Definitive restorations (i.e., amalgam, composite, glass ionomers)
E. Replace defective restorations
F. Endodontic therapy for pathologic pulpal or periapical conditions
G. Stabilization of teeth with provisional or foundation restorations
H. Posttreatment assessment

IV. Definitive Treatment

A. Advanced periodontal therapy
B. Stabilize occlusion (vertical dimension of occlusion, anterior guidance, and
plane of occlusion)
C. Orthodontic, orthognathic surgical treatment
D. Occlusal adjustment
E. Definitive restoration of individual teeth
1. for endodontically treated teeth
2. for key teeth
3. Other teeth
F. Esthetic dentistry (i.e., esthetic restorations, bleaching)
G. Elective extraction of asymptomatic teeth
H. Prosthodontic replacement of missing teeth
1. Fixed partial dentures, implants
2. Removable partial dentures
3. Complete dentures

V. Maintenance Therapy
A. Periodic visits

Interdisciplinary Considerations

Periodontal Therapy:
Initial periodontal therapy often is sequenced first in a treatment plan. Also, the
dentist may decide to begin gross scaling of the teeth to permit visualization and
exploration of tooth surfaces during the examination.

To ensure appropriate care, periodontal therapy should occur as early as possible in

the plan, but it can be delayed for several reasons:
- One frequently encountered justification is the decision to first resolve a
simple complaint, such as replacing a lost restoration or extracting
symptomatic impacted third molars.
- Another example is the patient with large carious lesions, especially those
located subgingivally. Restoring such teeth with a permanent or provisional
filling should make periodontal treatment more comfortable for the patient,
and begin to resolve the gingivitis that accompanies subgingival lesions.
- Lastly, teeth that are nonrestorable or are periodontally hopeless are often
extracted before beginning scaling and root planning procedures.

Caries Control:
For the patient with many carious lesions, treatment consists of restoring lost
or decayed tooth structure and preventing caries from occurring in the future.
Preventive strategies, such as reducing refined carbohydrates, improving the
patient‟s plaque removal technique, and the application of fluorides, should
commence immediately and be regularly reinforced, ideally at every
appointment.
The following guidelines should be followed when triaging treatment for
caries:
• Address any symptomatic teeth first. Extract those that should not be
retained for obvious periodontal restorative reasons. For other
symptomatic teeth, remove all caries, begin endodontic therapy if
necessary, and place a permanent or provisional restoration.
• Treat any asymptomatic carious lesions that may be nearing the pulp
as determined clinically or interpreted on radiographs. The goal is to
 prevent symptoms for the patient and avoid irreversible injury to the
pulp.
• Remove caries to determine restorability. For teeth with caries at or
below the alveolar crest radiographically, remove the caries and decide
whether the tooth can be restored. Endodontic therapy should not be
provided until the tooth is deemed restorable and periodontally sound.
• Finally, remove caries from asymptomatic teeth and when possible
restore with a definitive restoration, such as composite resin or
amalgam. For efficiency, sequence first by severity and then by
quadrant.

Endodontic Therapy:
For patients with many deep carious lesions or pulpal pain, simply removing
the caries and pulpal tissue followed by rudimentary filing and shaping and
placement of a provisional, sedative restoration is preferred. After
establishing some level of disease control, endodontic therapy can then be
completed. To prevent fracture, permanent restorations for endodontically
treated teeth should be sequenced before those for vital teeth if at all possible.

Extraction:
When possible, tooth extractions (all hopeless or nonrestorable teeth) should
be sequenced early in the treatment plan to permit healing to take place,
especially before tooth replacements are fabricated.
It may be necessary to delay the extraction of asymptomatic teeth:
- So that provisional replacements can be fabricated to preserve
appearance. - To maintain the position of opposing and adjacent teeth for
short periods of time.
Sequencing removal of third molars in a treatment plan may vary. When
symptomatic, they should be removed immediately. Asymptomatic or
impacted teeth may be removed at the end of the disease control phase or
during the definitive treatment.
 If the treatment plan includes extracting and fabricating a complex
restoration, such as a crown, for the second molar anterior to it, the third molar
should be removed first because of the potential to damage adjacent teeth
during the oral surgery.

Occlusion:
- Achieving a stable occlusal relationship represents an important goal
when developing a comprehensive treatment plan. During the examination,
the dentist will have identified any occlusal problems, such as malocclusion,
tooth mobility, loss of vertical dimension, malposed teeth, or signs of
parafunctional habits, such as bruxism.
- Study casts mounted in centric relation are essential for evaluating and
planning occlusal relationships, especially if multiple crown and bridge
restorations are planned.
- The practitioner should have a clear vision for what the final occlusion
will be like before beginning definitive care, especially when the plan
involves prosthodontic treatment.
- Treatment for occlusal problems would normally begin after the
disease control phase and may involve orthodontic treatment, comprehensive
occlusal adjustment, or altering the vertical dimension.
In some instances occlusal therapy, such as a limited occlusal adjustment,
may be part of the initial therapy.
When restoring or replacing teeth with crowns, fixed or removable
prosthodontic appliances, procedures should be sequenced to develop the
anterior occlusion first, followed by the posterior occlusion.

Removable Partial Dentures:

- Patients who eventually will need to have teeth replaced with
removable partial dentures typically have several dental problems.
Controlling caries and periodontal disease should begin immediately. - It may
 also be necessary to fabricate provisional partial dentures to satisfy the
esthetic and functional needs of the patient during this interval.

- The practitioner should also begin identifying key teeth during the
disease control phase, particularly those that will serve as abutments for the
removable partial denture. It may be necessary to do a preliminary removable
partial denture design on study casts with the help of a dental surveyor.
- At the same time, the dentist should be evaluating the need for
preprosthetic surgery.
- Key teeth should receive special attention during the posttreatment
assessment, especially their response to disease control procedures and their
suitability as abutments.
- The partial denture design should be finalized before beginning
definitive care. This is particularly important so that the dentist can
incorporate occlusal rests, guide planes, and retentive areas into the
restoration design. - Preprosthetic surgery, endodontic therapy, post and
cores, survey crowns, and fixed partial dentures will precede fabrication of
the removable partial denture.

Treatment Plan Approval

Finally, the practitioner should obtain Informed Consent from the patient and
document the Treatment Plan. Informed consent has become an integral part
of modern day dental practice. One aspect of informed consent is to provide
the patient with the necessary information about the alternative therapies
available to manage their oral conditions. The well-constructed treatment plan
provides a foundation for the long-term relationship between dentist and
patient. A functional treatment plan is dynamic, not static, evolving in
response to changes in the patient‟s oral or general health. In addition to that,
a sound and flexible treatment plan facilitates communication and strengthens
the doctor-patient relationship.