The dental treatment plan represents many observations, judgments and decisions on the part of the dentist. But – YOU need to be intimately involved in this decision-making process as well. YOUR future is at stake!
Your exploration of this site allows you to have enough knowledge of every aspect of the treatment plan – cause, consequences and therapies. The ORDER in which these things is of paramount importance – as doing things in the wrong order can greatly compromise the overall achievement of goals.
Bear in mind, that ALTERNATIVE plans can often be considered – as discussed in the next Chapter.
Also, an article has been published that details some of the same considerations I discuss here, with ample references to the primary literature that will benefit those of you that want to explore this topic more thoroughly.
Organization of this Chapter
You May Skip to Whatever Subject Interests You Now
The Problem List
Typical Sequence of Treatment Steps
1. Emergency Treatment – Getting Out of Pain
2. Disease Control – Avoiding Pain
Temporary Fillings and Pulp Capping
3. Chief Complaint – What the Patient Wants
4. Endodontic Therapy
5. Periodontal Therapy
6. Definitive Operative Dentistry – fillings
7. Periodontal Reevaluation
9. Crown, Bridge, Implants and Cosmetic Dentistry
10. Removable Partial Dentures
Bottom Line for Treatment Plan Sequencing
The Dental Treatment Plan: Basics
In general, when a new patient comes to a dental office – a lot of information is collected about them, their health, and their oral condition before anything is actually done. A detailed treatment plan is developed that is customized to get their oral health and appearance back on track, and this plan is made with the awareness and agreement of the patient at every step.
On the other hand, it is possible that they come in because they are in pain – and the first visit or two are scheduled around getting them out of pain. Possibly it is an existing patient in the practice that develops a painful condition due to inattention, or a patient that comes to you for the first time simply because they hurt. Either way, the focus at this point is only on getting them out of pain – after that comes careful consideration about how to make that pain-free condition permanent, and how to avoid any future painful situations.
We would like if at all possible to have a plan for every patient that will keep their mouth in such a healthy state that uncontrolled pain is not likely. And, of course, we want to evaluate a patient on a regular basis so that if anything goes awry it is discovered and dealt with before a painful condition develops.
In the sections below will be described the basic concepts of treatment planning, in ORDER. This is assuming a new patient comes to us with many issues that need resolution. Certain things need to be done before other things, or it is possible that what HAS been done will have to be done again.
For instance, if the patient comes in and they have a periodontal condition that is affecting their gingival tissues adversely and visibly – for instance the appearance of the gums for the front teeth is puffy and red – this needs to be dealt with before cosmetic things are done. Let’s say that the patient and dentist are eager to have some cosmetic procedures done on these teeth – crowns or veneers for example – and they are done BEFORE the gingival condition is corrected. Once the gingival condition is managed by cleaning, root planing perhaps, and improved home care, the puffiness and swelling and color of these tissues is much improved and the tissues have shrunk back tighter against the teeth, which looks much more healthy. Unfortunately, the gingival tissue shrinkage may have exposed to view the margins of those new crowns that were just done – and the cosmetic situation is poor.
Great thought needs to be given to planning a sequence of treatment for any patient and sometimes plans are fairly simple, and sometimes they are extremely complex. Of course consideration needs to be given to the patient’s ability to afford a complex and expensive treatment plan, and what their insurance plan might cover – in relation to their actual needs and vision for their comfort, health and appearance further down the road.
The Dental Treatment Plan: The Problem List
As we saw in Section IV – we collect information from the patient in many areas, so that we will know EVERYTHING that is wrong, or CAN go wrong with the patient. This includes their oral condition, their overall health condition, their appearance and their stress and anxiety levels.
From all of these observations we form a list of everything that is wrong, and this is called the PROBLEM LIST. There may well be things on this list that are not the job of the dentist to fix – medical issues perhaps, but they may need to be taken into account for whatever the dentist does.
It is from the problem list that the dentist formulates the final TREATMENT PLAN. Everything that the treatment plan needs to correct must show up on the problem list. And, everything on the problem list must be accounted for in the design of the treatment plan.
The Dental Treatment Plan: The Typical Sequence of Steps
As we develop the ideal, best dental treatment plan for a particular patient, irrespective of cost, there is a basic order involved, and the headings below are presented pretty much in the nominal sequence desired.
1. Emergency Treatment – Getting Out of Pain
There are many possible causes of pain, as outlined in Chapter IV.1. But for now we will consider that the pain is the result of decay that has exposed the pulp of the tooth. The initial discomfort and sensitivity may have been ignored until the infection of the pulp tissue is advanced, and perhaps even progressed into the bone past the apex of the root. If the situation has not progressed to the point where the tooth is necrotic (dead), then the patient probably has a throbbing pain that doesn’t simply go away in a minute or two, but is persistent, what we call pain of DURATION.
For this situation, we make room for them in our office schedule so that they can come right in and get taken care of. Now, what is NOT done is simply to open the pulp chamber of the tooth – because we MIGHT NOT KNOW WHAT TOOTH IS HURTING! Sometimes what the patient says is the tooth that hurts is actually wrong. Pain from one tooth can feel like it is coming from another. Even a tooth that looks badly decayed may not be the one that hurts, so the dentist should avoid making assumptions based on simple observation and the patient’s statement. Evaluation of the tooth by X-ray, palpation (pushing and tapping on the tooth), and possibly pulp vitality testing should indicate clearly where the problem lies.
Of course, this is done quickly, so that we may anesthetize the patient as soon as possible and get them out of pain.
Then, and only then, can we proceed to open the offending tooth. It may be discovered that even with what usually would be an effective blocking of the nerves that connect to this tooth, there is pain as the pulp chamber is opened even just a little with the bur. This situation arrises due to the acidity of infected tissues, which tend to deactivate the anesthetic – making it hard to “numb” the tooth. In this instance the dentist would be best advised to let some of the anesthetic fluid go directly into the pulp chamber by pushing it gently in with the needle on the syringe. If he/she lets the anesthetic sit there for a minute it may numb that immediate area, and then more can be put in a little deeper. Eventually the whole pulp chamber may be pain-free and the tissue can be removed.
It is unlikely with such an infected situation that the dentist can extend his tissue removal down into the canals as would most be desired, but at least the dentist can remove all tissue from the pulp chamber and place a medication which will “cauterize” if you will the rest of the tissue in the tooth between this visit and the next one. This procedure is called “open and med”. The tooth is sealed up temporarily at this point, the patient put on an antibiotic to help resolve any bacterial infection into the bone, and then an appointment for later in the week scheduled.
For the next appointment a full root canal therapy can be done, but if the charge is prohibitive for that and the required crown afterward, a “partial” root canal can be done where the tissue is removed down into each canal to the apex, but a thorough cleaning and shaping is not performed, nor is the canal system obturated. This Pulpectomy is just a temporary procedure, which will keep the patient pain free and comfortable for months, until the plan of what to do next can be approved.
Other Kinds of Emergency Visits
There are other kinds of emergency visits, of course – perhaps involving periodontal abscesses, teeth that have been fractured down the root, broken cusps, or even tortilla chips that have become embedded into the palatal tissues and refuse to come out with the patient’s best efforts.
Often the best approach for a given patient that has a problem with a particular tooth is to EXTRACT that tooth. It is certainly cost-effective in the short term, but may not be the least expensive way to go in the long term. If the dentist extracts a tooth and leaves a space, that space will have consequences farther down the line that need to be considered – perhaps esthetically, functionally or both.
Every situation that is causing the patient pain or discomfort is an emergency, and will be dealt with immediately, if not permanently.
2. Disease Control – Avoiding Pain
Here we have the situation where the patient is NOT in pain, but is perhaps a new patient to the practice and the X-rays and other observations make it clear that they are ABOUT to be in pain.
Perhaps it is clear that there are 5 or 6 teeth that are decayed CLOSE to the pulp chamber. Perhaps there is a periodontal pocket that is badly infected, or showing signs of an abscess that is draining into the mouth but not hurting. The patient may be aware of a fowl taste but not notice much else. Perhaps there is a tooth with a lot of recession that is showing signs of decay in a furcation area that is unrestorable but not penetrating to the pulp chamber yet, and there are other teeth that are susceptible to this same pattern of decay.
In each of these cases the dentist can do something that will potentially stave off the continuing development of a condition that will inevitably lead to pain, expense or tooth loss.
Temporary Fillings and Pulp Capping
For example, when the patient has many teeth with decay approaching the pulp, ALL of these teeth must be managed in ONE appointment. The dentist will anesthetize as much of the mouth as is necessary, and remove decay from every tooth. No attempt is made to do a preparation that will be appropriate for filling the tooth with amalgam or composite – the goal is simply to remove the decay. The tooth can be restored definitively another day. As the dentist is removing the decay he/she carefully monitors how close they are approaching the pulp chamber.
IF they determine that all of the decay has been removed, but there is little healthy tooth structure left between their excavation site and the pulp, they may decide to place a little medication that will help stimulate the production of more dentin inside the pulp chamber and increase the thickness.
IF they discover that there is still some decay left – a little leathery dentin or slightly soft dentin – and it is clear that the removal of this would likely expose the pulp, then it is temporarily left there, with the pulp-stimulating medication placed atop. Later when the tooth is reopened in a few months, it is possible that the final bit of decay can be removed and there will be enough new dentin formed to protect the pulp from exposure – this is called an INDIRECT PULP CAPPING procedure.
IF they discover that when the decay on a tooth is so far advanced that they can ALMOST remove it all, but when the last little bit is removed there is an exposure of the pulp with the instrument used, it is likely that no infectious material went into the pulp. Then a medication is placed over the exposure site and the tooth sealed up for a few months to see if the pulp will wall off this exposure from the inside – this is called a DIRECT PULP CAP.
When a patient with rampant decay comes to the office, their first treatment visit may involve many teeth where decay is removed and a temporary filling is placed – and some of these could well be direct and indirect pulp capping procedures as well as those teeth from which the decay has been removed completely without exposure.
When a suitable time has gone by, the patient is scheduled for a series of visits where each tooth accessed on that first DISEASE CONTROL visit will be definitively or permanently restored. Whereas the first visit could have taken a couple of hours to temporize 6 or 8 teeth, it may require an hour or more per tooth to effect the final restorations.
But, we know after a disease control appointment that we are in NO HURRY to deal with each tooth individually because all of the teeth are being managed.
3. Chief Complaint – what the patient wants
I’ve put this section third because we really don’t know where to put it! If the chief complaint is PAIN – then it is FIRST. If the chief complaint is appearance, it may be last. If pain is not involved, the decision as to WHEN the chief complaint is addressed is made with careful consideration and planning.
On the other hand, there are certainly times when a patient comes into a dentist’s office and wants cosmetic dentistry. The dentist may know that there are some things that should be done first – perhaps they really need to get their periodontal condition under control first, or perhaps there are some areas of decay that are not pressing but should be addressed first. BUT – if the patient is a new patient and comes in for cosmetic treatment and is willing to pay $10,000 for it, if it can get done SOON – you can see that the temptations for the dentist are going to be extreme.
It is really important under the circumstances described above that the dentist does an effective job educating the patient as to what is the best way to proceed, and the PROBLEMS that can arise from doing things OUT OF ORDER!
The BEST way to educate a patient is VISUALLY!
If the dentist has an album of pictures he can show the patient, and some of these pictures illustrate their exact situation and what can happen if things are NOT done the right way, and it is obviously a bad cosmetic situation – the point gets made far more clearly than a simple discussion.
One can assume that the patient will go “down the street” to another dentist to ask them for their opinion on whether this cosmetic procedure can be done now. The patient is armed with the clear knowledge that their first dentist has given them regarding the consequences of doing it out of order, but doesn’t tell the second dentist what they know. They wait for him/her to tell them. Perhaps they find that the second dentist says the cosmetic treatment can be started TODAY! With the graphic education given to them by the first dentist, it is likely that they will walk out from dentist number two, even if he charges less, and come back to number one.
So – the Chef Complaint can be addressed early on or after some preliminary work, totally depending on what it is, and the condition of the mouth otherwise. This is a variable that must be considered carefully, and often involves careful education of the patient.
4. Endodontic Therapy.
Visit Chapter III.3 for a discussion of pulpal infection. Chapter V.10 discusses root canal therapy.
It may be that during the disease control of a treatment plan there were several teeth left that clearly need full root canal therapy, but had to be delayed due to other considerations. This may be a good time in the sequence to get the definitive therapy completed.
After the RCT is accomplished for any teeth needed, they will have to be crowned, but some period of time should pass after the RCT to make sure it has been successful before the tooth is prepared for the crown and the crown delivered.
5. Periodontal Therapy
Visit Chapter III.12 for a review of periodontal therapies.
Any periodontal therapy should also be completed before delivery of any crown and bridge restorations. So this, as well as the root canal therapy, should be scheduled in the early portion of the sequence of treatment.
Several months need to pass after endodontic therapy and periodontal therapies before fixed indirect restorations are performed. In both instances we need to make sure that the response to the therapy is as needed before performing procedures that depend on this success.
If the patient doesn’t require anything more than a simple cleaning, then no waiting is required for this – their gingival tissues were probably of good health to start. But if root planing was required to resolve subgingival infections and get the tissues back into a healthy configuration, a reevaluation needs to be done later.
6. Definitive Operative Dentistry
Visit Chapters V.2 and V.3 for a review of filling teeth.
During any healing/resolution process after endodontic or periodontal therapies, the dentist can proceed to do direct restorations that are required. It may be that the dentist has already done disease control procedures and left a number of temporary fillings that need to be replaced, or it may be there are a number of less deep decay areas on a variety of teeth that can now be restored.
Whether it is best to do amalgam or composite restorations is to be determined by the particular situation, but IF decay extends far down on the sides of a back, posterior, tooth it may well involve placing a margin for that restoration underneath the gingiva. If it is necessary to place a margin deeply under the gingiva, the isolation of that area will be more difficult, and there will be more bleeding involved if the periodontal condition is not under control yet. Since amalgam restorations tend to be less sensitive to contamination than do composites, it would be best to either select an amalgam to do now, or wait somewhat longer for the composite restoration.
In any event, operative dentistry, involving primarily direct restorations, can be done without risk at this stage.
7. Periodontal Reevaluation
This is where the results of periodontal therapies are evaulated a few months down the road. What the dentist is looking for is that the periodontal pocket depths have gotten smaller – a sign that the swelling of the tissues due to infection, has decreased – meaning that the infection is less or gone. As long as the removal of calculus deposits in the areas underneath the gumline has been done effectively, the bacteria which cause periodontal disease will have no place to stay.
This also depends on whether the patient is keeping things clean at home – regular brushing and flossing perhaps, or using other means to keep plaque from building up on any tooth surface. Remember that when plaque, which is the gummy stuff that contains bacteria, is allowed to accumulate around a tooth, some of the bacteria will deposit hard substances, called calculus or tartar, on the sides of the teeth. These hard mineral deposits shelter the bacteria, and cannot be removed by normal home care. Visit Chapter III.2 for a review of periodontal issues.
So, IF the home care has been adequate and the periodontal therapy was successful in removing all previous calculus deposits, then the tissue should be healthy and subsequent restorations that depend on the health of these tissues can be done.
Visit Chapter V.17 for a discussion of orthodontic procedures, particularly for adults.
Possibly at this point, even for an adult patient, some orthodontic procedure might be started. It is possible that it is planned to do a bridge or two which may involve a second or third molar that has become tipped because of the missing neighbor. In order to secure a bridge on this tooth, it needs to be tipped back, so it is in alignment with the other tooth that will support the bridge. It may be that the upper front teeth are leaning outward because of unbalanced pressure from the tongue.
It may even be necessary to move a tooth in order to be able to place an implant in the bone. Either one tooth is tipped so that the space between the crowns of the teeth is too small for an implant and subsequent crown, or the space between the roots is too small to place the threaded part of the implant without hitting the roots of the adjacent teeth.
In either of these situations and more, to correct alignment or orientation may be necessary to put the patient in brackets and wires. Of course the presence of brackets and wires in the mouth makes home care far more challenging, and if there is a periodontal condition that has yet to be resolved, this would be a bad time to make the situation worse.
So, we will generally wait until the periodontal condition is under control – cleaning or root planing as necessary, followed by the confirmation that the patient is doing thorough home care, before making it more difficult for them.
9. Crown, Bridge, Implants and Cosmetic Dentistry
Now, after we have positioned teeth where they need to be, and have gotten the periodontal condition under control, and have done any root canals and restorations and buildups (visit Chapter V.9) that are necessary, it is time to consider fixed prosthodontics – crowns and bridges.
Review Crown and Bridge in Chapter V.6 for gold crowns, V.7 for all porcelain crowns, V.8 for porcelain-fused-to-metal, V.13 for tooth replacement, V.14 for the use of implants, and V.18 for a discussion of cosmetic dentistry.
Given that Cosmetic Dentistry often involves indirect restorations, i.e. crowns and veneers, these esthetic procedures are best saved toward the end of the treatment plan. If the patient’s teeth are aligned in an unpleasing way, and the gingival tissue is swollen and inflamed, it doesn’t make sense to do the final phase of cosmetic dentistry.
And we certainly don’t want to be placing implants in the mouth if the patient hasn’t learned to take REALLY good care of their teeth. With poor home care, periimplantitis is not an unusual thing, and certainly compromises the longevity of implants in the bone – which jeopardizes everything that they support!
Typically, for each quadrant we must decide what is the basic plan of action. Are there any missing teeth? If so, how should we replace them? Is there enough bone to place an implant? Do the teeth adjacent to the missing tooth (edentulous area) need crowns also? How much of the occlusion in that part of the mouth will be replaced? Should all of the crowns be placed at the same time, or should they be done in stages? Do we have to take into account the hinging of the jaw and where they joint wants the occlusion to be?
These are some of the many questions that we need to consider for this part of the treatment plan, and most of these issues have been discussed in earlier chapters, but this is where decisions need to be made about WHAT to do, and in what order.
10. Partial Dentures
I don’t include full dentures in this ordered list of procedures, as there are ultimately NO natural teeth to deal with. Of course for a full denture treatment plan, it may involve a carefully sequenced removal of teeth so that an immediate denture (visit Chapter V.16) can be designed and delivered with no more discomfort than necessary – but a detailed plan involving perio and endo, etc is not involved.
For partial dentures, as we’ve seen before, we are simply replacing teeth as easily as possible. In Chapter V.13 we went over the possibilities as far as patterns of missing teeth are concerned, and various strategies for their replacement with a removable appliance. We learned that in some cases it is necessary to crown teeth adjacent to open spaces so that the partial denture will be more secure in its connection. We may also need to upright certain orthodontically to make it possible to design a partial denture in the most effective manner.
But, for all treatment plans, if a partial denture is needed, it is always the LAST procedure done. Everything done previously will weigh in on the success or failure of the partial denture – direct and indirect restorations on non-vital or vital teeth, periodontal therapy and successful home care by the patient, alignment of the supporting teeth as necessary, and placement of crowns to help support the denture.
The Bottom Line for the Dental Treatment Plan
Every patient is totally different in every respect. I’ve never seen two patients that had the same needs in their mouth, let alone had the same ability to afford to have it done. I’ve never seen two patients that had the same sense of their appearance – some really don’t mind if some gold shows, for example, or if the margin of a crown is showing conversationally, and others totally freak if anything in their mouth shows that looks unnatural (to their eye).
Every patient needs something different, and every patient wants something different – which is what makes the “world go round”, as they say. This is one of the things that makes the profession of dentistry so enjoyable to those practitioners whose motivations are to give each patient the best service possible. The field of dentistry is certainly not boring!
But, whatever needs to be done, it needs to be done with a very well-conceived strategy, and the most important thing about that strategy is the ORDER in which things are done.
In this chapter we’ve seen many aspects of various procedures that determine the point at which they should be done relative to other procedures. These are the determinants of the SEQUENCING of a treatment plan.