hi guys welcome back i'm Zoh i'm a foundation dentist working here in london and i'm ali
a finally a dental student studying at newcastle in this part of the educational
series we're going to show you how to turn all the information from your history and
examination into a well-structured treatment plan that you can follow
this video will follow the order which we think you should write your treatment plan
and its time stamps on screen and in the description if you want to
skip around those following treatment planning is the acute phase prevention
stabilization definitive treatment and finally maintenance we've taken and adapted a lot of
the content from this video from a book called diagnosis and treatment planning
in dentistry and we recommend you check it out your uni might name things slightly
differently so just bear that in mind and as you watch this video it will all make sense
the first phase of any treatment plan should be the acute phase where you basically get
the patient out of pain and you address any emergency or urgent problems they might have so
some problems may need immediate attention and you will need to treat them on the same day and these
are emergency problems like severe dental pain or swelling or systemic infections or trauma to
the face or the jaw whereas some problems don't need the media attention but you or the patient
think they should be attended to now or soon and these are the urgent problems like multi-moderate
pain without active infection asymptomatic broken tooth loss restorations and other purely aesthetic
problems like a small enamel fracture of the upper right one these are treatments which
postponing won't cause the patient any unnecessary pain or risk of systemic illness for example
this part of the treatment plan is often overlooked because when we're treatment
planning we tend to start thinking about all the different restorative or perio problems but the
acute phase is especially important when it comes to building a good rapport with your patients
sometimes patients will come to your practice or your hospital because they have no choice because
they're in pain they might have been kept up by the pain and be really moody and may be fearful
because they don't know what treatment that they might need now if you take a nice empathetic
approach find out which treatments are emergency or urgent and you get them out of pain or fix
their broken tooth then you might have just turned that anxious patient who would only have come in
for the emergency and someone who's willing to come back to the hospital or the practice for
completing the rest of the treatment plan this can be a massive way of attracting new patients to the
practice and can help dental students get patients coming back so they can get their totals done
there's loads of different emergency and acute problems and we're not going to bore you by
going through all of them in this video but there's a table for you guys in the document
in the description listing out all the most common acute problems and some treatment options for the
short term and their long-term implications so check out the link in the description
after the acute phase of the treatment plan you need to look at prevention prevention needs to be
in nearly all treatment plans that you write it should include oral hygiene instructions
fluoride and diet diary and advice there's a public health england document called delivering
better oral health and every dentist and every dental student needs to have read this at some
point it covers everything you need to know for prevention and you can find it in a link in the
description in the modern age of dentistry we want to move away from having to constantly
treat caries to focusing on preventing caries from happening in the first place
this is why prevention comes before stabilization or definitive treatment you don't want to start
doing any perio treatment or fillings if the patient is still not brushing their teeth properly
or using the correct toothpaste because your period treatment or filling might
actually fail so get it in as early as possible ideally in the first appointment
the next phase is the stabilization phase and is kind of connected to prevention in the sense
that we want to stabilize their dentition to prevent any of their current diseases from
getting worse the only time you don't need the stabilization phase is in a diseased patient
when the definitive treatment phase will eliminate the diseases anyways like her full mouth clearance
on someone who has carious teeth who needs an upper lower complete denture so there would be
no point in filling all the teeth in the main sections you want to stabilize are caries perio
pulpal or periapical and extractions of hopeless teeth with immediate gap replacement if needed now
if your patient requires all of those things you can't just do them all at the same time because
let's say you just do perio then the carriers might advance further this is where the difficult
part of treatment planning comes in and we'll explain later how you can handle this but for
now let's explain each section in the order in which you should write them in your treatment
plan so you have a better understanding of what they include and then we'll explain how
to manage multiple sections at the same time so the first section to mention is perio and
the main thing you want to look for when writing out your period treatment is the patient's bpe
if your patient's bps is zeros and ones they don't have periodontal disease and the treatment
is covered by the oral hygiene instructions you would have given in your prevention stage but you
will still need to consider the risk factors for having periodontal diseases in the future
there's a whole list of risk factors but the main ones are smoking alcohol and diabetes you
need to assess and manage these risk factors for all patients not just the ones with bps of zeros
and ones if your patient's highest bpe score is a two you would need to write remove plaque
retentive factors and note down their locations if it's an overhanging restoration or a ledge but
you don't need to note down every tooth that has calculus because you would remove all the
calculus when you do a super gingival skill now if your patient's highest bp score is a 3 you need
to write initial periodontal therapy including super gingival scale oral hygiene instructions
and a review 8 to 12 weeks you could stop there and to be honest most people do but ideally in
your treatment plan you should also know what happens at the review so you could add at review
if bpe remains three or four carry out six point pocket chart and rsd of pockets larger or equal to
four millimeters under local anaesthetic once oral hygiene is adequate plus three months review if
your patient's highest bp score is a four you should write six point pocket chart plus rsd
pockets more than or equal to four millimeters under local anesthetic once oral hygiene is
adequate plus three month review i know this sounds really long but you can use abbreviations
and it'll be much faster to write on clinic the reason you do period before you do any definitive
treatment is because there's no point putting in some beautiful crowns and then later down the line
the patient doesn't clean the margins and the period gets worse at the same time you need to
use some common sense of what is achievable for a particular patient if someone's oral hygiene won't
improve more than its current status maybe because they have arthritis in their hands for example
then you should continue on with your treatment but possibly consider a less damaging option
the next section to include is checking uncertainty look at your chart and ask yourself
are there any teeth which were unsure of their restorability these are teeth which would have to
investigate further by removing carries and then assessing the options options might be a filling
root canal treatment and a crown or an extraction if you find that the tooth is completely
unrestorable but you will only find this out after you've removed all of the carries and you can see
the extent of it you can explain all of this to your patient and let them know of the plan
next up is carries you have to look at the chart and ask yourself which teeth have carries on one
tooth it might have just started and be really early stages which has become a white spot lesion
it could have become cavitated and be adjusted to enamel or just into dentine or it could be
deep into dentine and be encroaching on the pulp each of these require different treatments and you
need to know which would be the most appropriate treatment and this is based on the extent of the
caries now if you see a non-cavitated caries lesion you would just treat that by applying
fluoride varnish and monitor it to make sure it's not getting any worse however if it was a larger
krs legion into dentine you would need to drill away the carriers and fill it in at this stage you
need to decide what you will fill it in with and this can be a temporary material like gic or resin
modified gic or a more mid to long term material like composite or a amalgam if the patient has
lots of carries you want to stabilize them as soon as possible so you can choose to stabilize them
with a temporary filling material like gic because you can stabilize all the carries quicker in fewer
appointments in that case in your treatment plan you would write stabilize with the gic
and note down which teeth trying to fill all those teeth with composite and amalgam would
take too long and in that time the carries might get much worse and then suddenly one
tooth might need a root canal treatment for example however if the patient doesn't have
a lot of carriers and it's only a few teeth you can place a mid to long term restoration like
composite or amalgam so in your notes you could write direct restoration and note which teeth
next on the list is purple and periapical tissues this is where you need to look at the chart and
radiographs and see which teeth near the root canal treatments for example on your chart you
might have seen carious lower right six and on your radiograph a big ape core radiolucency
and the tooth was non-responsive to sensibility testing all of this points to the need for a root
canal treatment in your treatment plan you would write upper right 6 root canal treatment or xla
and then explain the two treatment options to the patient and decide which they want
next up is planning for extractions of hopeless teeth and this might be a retained root or a
grade 3 mobile tooth with over 90 bone loss and lastly you want to provide temporary solutions
to any gaps that they might have this could be because they have a missing upper central
incisor or they struggle to eat because they don't have enough teeth in the arch
these kind of problems can be temporarily fixed with denture additions to an existing denture
or if they don't have a denture ask in your lab to make a temporary partial denture
so now we've covered all the sections of stabilization and there were quite a few
so how do you actually carry out all of this and which ones do you do first one way of doing this
is by carrying out quadrant dentistry and this is where you look at all the stabilization that
is needed and you do it one or two quadrants at a time per appointment now you might think well
which quadrant shall i start with and that's where you can decide as a dentist by prioritizing which
section needs to be attended to sooner rather than later in general treatment of deep carious lesions
in vital teeth symptomatic pulpal problems and acute oral infections take precedence for example
let's say you have a patient who has perio and also needs a filling and an extraction of
a retained root out of all of these the main one that can be a problem if left untreated would be
carries if you have a tooth that has deep carries then you should prioritize the quadrant with that
tooth because if you leave it for too long the carriers might reach the pulp and the tooth might
then need a root canal treatment so you start in that quadrant and in that appointment you can do
all the fillings in that quadrant and carry out rsd in the deep pockets the next appointment you
pick the second worst quadrant and then you do the same and as you're carrying out the period
and the fillings you can talk to the oral surgery department to plan a date for the extraction of
that retained route once you have a date for the extraction you can talk to the prosthodontic lab
to have an immediate denture ready to be fitted after the extraction you can
see how multiple sections of stabilization are handled at the same time to ensure they
happen in as few appointments as possible in a way that you don't neglect any section the
key is to prioritize and see which tooth needs attending to first and start with that quadrant
the next phase of the treatment plan is the definitive phase or as others might call it the
restorative phase in this phase you're looking to carry out any direct restorations which might have
previously been stabilized with gic any indirect restorations like onlays or crowns and you'll also
treat any missing spaces with bridges dentures or implants so let's start with direct restorations
and the main ones are composite amalgam and gic composites were first made to be used as anterior
fillings but since they've gotten better and better each year they're now used as posterior
fillings as well especially outside of the uk but under the nhs the first go-to material for
posterior fillings would still be amalgam however at your uni you might be given the flexibility
to use amalgam or composite and we usually use composite just to practice but it's also important
to use amalgam amalgams are good in posterior fillings because they're stronger and more
resistant to fracture and the studies actually show that they tend to last longer than composites
now let's say there's no nhs limiting your choice of material what do you use for a
posterior filling let's go through some things that you should consider one of the main factors
is patient preference no matter how much you tell the patient of all the advantages of amalgam and
that the risk factor to mercury is actually quite low if they don't want the silver filling or to be
fair they have a metal allergy then the choices being made you use composite if the patient
doesn't mind having a sore filling then you need to see how big the cavity is if the cavity is
quite small then you're going to struggle getting retention with amalgam so your best bet would be
composite if you have a larger cavity to fill and maybe even a cusp to replace then you might
want to think about amalgam however saying that composites are getting better and better and
many dentists will argue that composites are just as strong and even better than amalgams so you can
use composites for even larger restorations now moving on to indirect restorations we have inlays
onlays and crowns indirect restorations are lab made and need to be bonded or cemented to the
tooth the first one is inlays which just covers the pits and fissures and to be honest you rarely
do them the idea is that they're more resistant to abrasion and occlusal wear compared to doing
a direct composite but they're more expensive they require more chair time from the patients
multiple appointments and they're quite fiddly to bond to the tooth because they're so small
now onlays on the other hand have a lot more use they basically cover one or more
cusps of the posterior teeth and in the book the official definition is that it covers up to five
eighths of the tooth and any more than that would be a crown onlays are a more minimally invasive
option to crowns and are used to provide cuspal coverage to strengthen the tooth for example if
he has a crack or after root canal treatment they're better than doing a direct composite
because a lab made only will be stronger and have better contours and contacts sometimes however
there's so much to structure that has been lost from caries for example that your only option
would be to do a crown here we talked a bit about each of the options but check the link in
the description for the document where we have a table for the treatment options of the main tooth
conditions now after indirect restorations you need to look at replacing any gaps the typical
options are bridges dentures or implants which one you go for here massively depends on budget
size of the gap and patient preference bridges can be a great option for smaller gaps dentures can be
a great option for larger gaps and implants can be a great option if the patient can afford them
again there's a table in the document in the description which lays out all the different
treatment options for different gaps so how do you write all of this in your treatment plan well
if there are multiple restorative treatments you can use grids and list them out start with direct
restorations write all of the teeth that you plan to fill and maybe annotate with materials you
plan to use then note indirect restorations and annotate what the indirect restorations will be
and finally any gap replacements and again what the gap replacements you plan to put in
so after the definitive phase comes the maintenance phase where you'll see the patient in
regular intervals to monitor their oral health and to prevent any disease like carries from happening
the general advice is to have checkups with your patients every six months but
you might need to see them more frequently if they are a perio patient or if you feel
like they haven't fixed their diet or their oral hygiene regime in those cases you might choose
to review them every three months this kind of thing changes case by case and is usually up to
the dentist to look at the patient as a whole and decide how often the patient needs to be seen in
these appointments you're looking at recharging reinforcing oral hygiene instructions giving
diet advice re-prescribing fluoride toothpaste rechecking bpe or redoing six point pocket charts
giving their scale and polish if they need it and take an updated bitewings according to the fgdp
guidelines you'll also need to monitor anything else that you might have noted previously for
example if there was a tooth where you were unsure if it has carries or not you'll need to check
that every appointment and document it thanks for making this far guys we hope you found this video
useful and if you did we really appreciate if you hit the like button and subscribed
you might also enjoy some of our other videos that we have on the channel so feel free to check out
some of the suggestions here if your uni teaches you treatment planning any differently then we'd
love to learn about it so throw it in the comments section below and we'll see you next thursday