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1. Dental treatment
planning

2. The goal of dental treatment plan is the formulation
of a strategy to solve the patients dental complaints
and problems depending on diagnostic data base or
problem list of the patient
Effective dental treatment planning is one of the
most challenging aspects of dentistry

3. Aims and objectives of treatment
plan:
•Manage the emergency or urgent complaint. e.g. Relief of pain
•Prioritize the treatment needs in the interest of the patient
•Restore function and esthetic
•Achieve the highest standard of care
•Prevent any further deterioration of patient oral health

4. Steps to reach treatment plan:
•Collection of data
•Proper diagnosis of chief complaint
•Listing the dental problems of the patient
•Determine the medical status of the patient
•Determination of management options

5. Decision making process:
•It is mutual decision
•Explain the options: advantages, disadvantages, limitations
•Listing possible solutions for patient problems:
•Some of the patient’s problems can only be solved by specific procedures
•Others have alternative solutions
•The ideal treatment plan might not be feasible
•The agreed treatment plan is documented in patient’s file

6. The patient problems may include:
•Chief complaint problem
•Problems related to medical conditions:
•Previously diagnosed
•Discovered through systemic review and clinical examination
•Problems related to other oral conditions (dental or non dental) that
patient may not be aware of them e.g. white patch or nasty
appearing ulcer

7. The chief complains may be:
•Urgent
•Pain
•Acute infection
•Bleeding
•Traumatic injury
•Less urgent:
•Lost restoration
•Mild symptoms of pulpitis and carious lesions
•May be treated by temporary restorations
•Non urgent:
•Routine checkup
•Oral prophylaxis
•Replacement of missing teeth
•Can be delayed until a definitive TP is formulated

8. •The C.C and reason for attendance must be clearly taken and
recorded
•If communication problem exist due to age or language barriers
ask for help (parents or interpreter)
•The TP will depend on whether the patient is attending for an
emergency relief of pain or for routine checkup

9. I.THE CHIEF COMPLAINT PROBLEM:
•Should be managed first whenever possible to show the
patient that you care and makes him/her accept the
comprehensive treatment planunless:
•There is more serious or urgent conditions
•There is a need for some treatment to be done before
dealing with chief complaint (oral prophylaxis before
implant and fixed prosthodontics)

10. The management of urgent C.C may include:
•Palliative treatment to control symptoms of the diagnosed problems
•Analgesics & antibiotic
•incision and draining (I & D)
•Pulp extirpation
•Temporary restoration
•Curative treatment:
•Directed towards elimination of the problem e.g. extraction or
RCT.
•It is an optimal goal whenever possible

11. •The emergency treatment need to be followed by definitive
treatment if patient agreed
•If the patient is not interested in definitive or
comprehensive treatment record that in his/her file in clear
terms

12. II.PROBLEMS RELATED TO POTENTIAL MEDICAL CONDITIONS
•Recognition of medical problems and prevention of their potential
complications by modifications of dental procedures is of high
importance
•This may include:
•Previously diagnosed medical conditions (PMH)
•Discovered medical conditions (systemic review and clinical
examination)

13. Previously diagnosed medical conditions:
•The effectiveness of current medications used in their treatment need to be
assessed
•The need for medical consultations in such cases is often indicated in:
•Poor patient understanding of the nature of the problem
•Poor records
•Failure to comply with medical treatment
•Long duration since the condition was evaluated
•Features suggestive of ineffective treatment (systemic review finding)
•The effect of the expected physiological or emotional stress of the
procedure on the patient

14. Current medical condition & medications that may
necessitate certain modifications include:
•Prophylactic antibiotic as in patients with rheumatic heart disease
•Early morning appointment for diabetic patients
•Dental consideration for dialysis patient
•Dental considerations for patients with H/O heart attack
•Dental considerations for patients on anticoagulants: prove to be threat
in surgical procedures

15. Current medical
condition &
medications
•Dental considerations for patients with epilepsy
•Dental considerations for patients with hemophilia
•Dental considerations for pregnant patient
•Dental considerations for terminally ill patients
•Hypersensitivity: allergic or idiosyncratic

16. Discovered medical conditions:
•Any undiagnosed disease revealed by the history, review of
systems or clinical examinations put a moral and ethical
responsibility on practicing dentist for proper referral or
consultations of his or her patient
•Must be listed in patient problems
•Don’t put patient on stress
•You may ask for basic investigation e.g. DM, anemia
•Always remember that you are not a medical doctor !!

17. III.ORAL DISEASE AND CONDITIONS:
•Gingivitis and Periodontitis
•Caries, Pulpitis and its sequel
•Complications of eruption
•Missing teeth
•Non dental oral lesion
•Others

18. Gingivitis and Peridontitis:
•OHI and plaque control
•Scaling & root planning
•Surgical elimination of tissue defects
•Extraction of poorly prognosed teeth

19. Pulp related problems:
Reversible pulpitis:
Excavation of deep caries
Placement of calcium hydroxide and temporary restoration
Wait and see for 7-10 days:
Symptom free: restore as usual
Symptom persisted or increased: deal as irreversible
pulpitis
Irreversible pulpitis: RCT or Extraction

20. •If in doubt to distinguish between
reversible and irreversible pulpitis,
deal with the case as reversible
pulpitis until proven otherwise
(periodic checkup)

21. Management of carious teeth:
•Carious teeth treatment should be prioritized on the basis of
greatest axial extension of the lesion
•Heavily restored teeth with suspected recurrent caries may
necessitate complete removal of the old filling

22. •Incipient caries:
•It is reversible
•No need for cavity preparation
•Managed by:
•Improvement of OH
•Less cariogenic food
•Fluoride application
•The exception to this role is when other surface of the tooth
require conventional restoration e.g. occlusal cavity with incipient
proximal or smooth surface caries

23. Carious cavity lesions:
•Prepare and restore
•Select proper filling material:
•Composite
•Amalgam
•Glass ionomerrestoration
•Compomers
•Heavy filled and RCT teeth will be weakened on long-term and
may need to be
•Ceramic crowned
•Porcelain-fused to metal crowned
•Cast gold crowned

24. Eruption problems:
•Buccally or palatally placed canine
•Crowding
•Impacted third molars
•Others
•Optimal solutions are dependent on clinical situation and
guidelines:
•Extraction
•Orthodontic
•Extraction and orthodontic
•Leave as it is

25. Buccally
placed
canines
and
crowding

26. Impacte
d
canines

27. Consultations with the followings are essentials:
•Orthodontist
•Pedodontist
•Oral surgeon
•Oral medicine

28. Treatment options for replacement
of missing teeth:
•Fixed prosthesis:
•Short span: three unit
bridge
•Long span:
•a double a abutment
design
•Cantilever bridge
•Acid etch or “Maryland
“ bridges
•Dental Implant
•Removable prosthesis:
•Immediate partial
•Transitional denture
•Complete denture

29. •Always take into account the implications and
consequences of specific treatment options:
•Most treatment options create additional treatment
needs or definite consequences in the treatment
planning procedures (Treatment complications)
e.g. treatment of badly carious lower first molar →
extraction→space→drift→3 unit bridge

30. •Ideal treatment plan is not always achievable and a
compromised plan may be the best option
•The final step in treatment plan is to rearrange all the
treatment procedures necessary to solve the patient
problems and needs in the most logical treatment sequence
(prioritizing the treatment)

31. Factors that affect or determine the
treatment goals and treatment plan
I.The patient perspective
II.Dentists perspective

32. I.The patient perspective:
1.The patient dental expectation
2.Financial limitations
3.Patient dental attitude
4.Self image
5.Age of the patient
6.Patient occupation
7.Prognosis of the proposed dental treatment
8.Existing dental conditions

33. The patient perspective:
•The patient chief complaint should become the
dentist’s treatment priority but more urgent
problems should not be ignored while treating chief
complaint

34. The patient perspective
The patient dental expectations: Which can be ranged
from:
•Care limited to treatment of painful tooth
•Patient who wants to retain teeth regardless of
treatment complexity
•Past dental history may be regarded as reliable
indicator of the patient real attitude
•The dentist must be suspicious of the high patient
expectations

35. The patient perspective
Financial limitations:
•It is a challenge for the dentist to convince the patient to pay for
painless dental problem with long term adverse effects
•It is an ethical dentist responsibility to provide the best treatment
possible although the high cost may be an obstacle
•Financial limitation may reflect:
•Inadequate income
•Adequate income with preference to spend for other things
•Policies dictated by third party

36. The patient perspective
•The financial problem can be overcome by payment planes,
delaying most expensive restorative treatment, omitting
elective procedures and giving priority to disease control
procedures
•Unfortunately, there are times, when even minimal care is
beyond the patient ability

37. The patient perspective
Patient dental attitude:
•May reflect a complex mixture of inaccurate
knowledge, misinformation and impression of past
bad experiences
•Asymptomatic patient may not be interested in
comprehensive plan
•Negative attitude towards dentistry can be
changed by gaining confidence of the patient and
establishment of good dentist-patient relationship

38. The patient perspective
Existing dental conditions and status:
•Caries risk and susceptibility
•Location and number of missing teeth
•Condition of alveolar bone
•Others

39. The patient perspective
Self image:
•Some expectations are unrealistic or unattainable
Age of the patient:
Patient occupation:
Prognosis of the proposed dental treatment:
•The prognosis for any dental reconstruction should be at
least 5 years

40. Dentists perspective: is affected by:
1.The patient’s dental condition
2.Prognosis
3.Operator’s knowledge and updating
4.Experience and technical skills
5.Treatment plan philosophy
6.Potential complications of dental treatment
7.Referral for specialty treatment
8.Public or private services

41. The patient’s dental condition:
•This is the most important factor that influence the
treatment plan
•The dentist obligation is to give high priority to
chief complaint and active disease/s
•Any diagnostic uncertainty must be solved before
treatment plan is formulated

42. Prognosis:
•Dentist will always be blamed for unsuccessful or failed
treatment (implant now)
•The procedure with high expectation for success should
be offered for the patient and to let him or her decide
•The selected treatment plan may be affected by
expected life span of the patient

43. Operator’s knowledge:
•New graduated GDP may adopt an ideal treatment plan giving
no account to patients desires and modifying factors
•GDP in practice for many years with substantial clinical
experience may not improve his knowledge and not in line
with new techniques or treatments options
•The good dentist is a lifelong learner, keeping up with
current development in the profession (continuing education
courses, critical reading of literature)

44. Experience and technical skills:
•The GDP may have no experience with RCT of multi-
rooted teeth. This treatment may not be offered to
the patient unless the dentist is interested in
referring the patient to a colleague
•Referral option should always be available for
second opinion or for full or partial management of
the case

45. Treatment plan philosophy:
•Treatment plan adopted by experienced dentist always
reflect his or her philosophy:
•Removal of wisdom teeth
•Unwarranted removal of sound amalgam restoration and
replacement with gold or composite restoration
•Giving the choices between two or more treatment
alternatives, the dentist is most likely to chose the option
that is consistent with his/her philosophy of dental care or
experience

46. Potential complications of dental treatment:
•Treatment planning options are occasionally selected
specifically to avoid the possibility of certain
treatment complications as in treatment plan for a
patient at risk of infective endocaraditis or patient
with hereditary bleeding disorders

47. •Referral for specialty treatment: depends on
•Availability of the specialist
•Acceptance of the patient to be referred
•Public or private services

48. Types of treatment plans
•Emergency dental treatment
•Limited treatment plan
•Tentative or provisional dental plan
•Comprehensive dental treatment plan

49. Limited dental treatment:
•Treatment solutions for specific problem that is not
urgent e.g. Patient may request
treatment of anterior teeth before marriage
•Planning on the basis of limited treatment goals
should represent exceptional situations rather than
a routine method of dental practice
•The temptation to adopt tooth by tooth problem
solving approach should be avoided

50. Tentative or provisional dental plan:
•Some dental diagnoses and prognoses are so complex that
no definitive or complete treatment can be planned until
the results of intermediate therapy is determined (the
outcome of the initial treatment can not be confidentially
predicted)
•The specification of additional treatment decisions is
deferred or listed in general terms until the
effectiveness of initial treatment can be assessed

51. Tentative or provisional dental plan:
•An example of such a tentative plan may be
adopted for a patient with advanced Peridontitis,
with questionable prognoses on several potential
abutment teeth. If all teeth are retained, a fixed
prosthesis would be indicated, the loss of one
tooth may indicate a removable partial denture,
and loss of more teeth may indicate a complete
denture or implant.

52. Comprehensive dental treatment (holistic):
•Plan decided by the patient and dentist to solve all
the patient oral and dental problems
•It is the preferred approach as all aspects of care
are targeted
•Referral for specialty is part of comprehensive
treatment and delaying of certain elective
procedures are consistent with comprehensive
procedure as long as the plan will eliminate all
patient problems

53. Comprehensive TP:
•Definitive treatment phases: this would be adopted for those
who seek routine dental treatment or who have had successful
emergency treatment and wants to have total oral care

54. Phases of comprehensive treatment plan
I. Pretreatment phase:
•Pretreatment phase: may need to be done before commencement of active treatment
•Specialized radiographs CT, MRI
•Study models
•Medical or dental consultations
II. Treatment phases:
Phase I: Treatment of acute problems
Phase II: Disease control and stabilization phase
Phase III: Restoration of esthetic and function
Phase IV: Re-evaluation of treatment
Phase V: Maintenance care phase (Recall phase)

55. •Phase I: Treatment of acute problems:
to control pain or acute infections
•Extraction of painful tooth
•I&D of an abscess
•Management of traumatic injuries
•Pulpectomy
•Excavation of deep caries lesions
•Sedative temporary restoration
•Pulp capping
•Biopsy of a lesion

56. •Phase II: Disease control and stabilization phase:
•Only well motivated patients will go to this stage
•The purpose of this phase is to:
Control active oral disease and infection
Stop occlusal and esthetic deterioration
Management any risk factors that cause oral
problems ( e.g. preventive measures).

57. •Common procedures during Disease control and stabilization phase include:
•Periodontal treatment:
•OHI
•Curettage
•Scaling and root planning
•Surgical periodontal therapy
•Conservative treatment:
•Composite and amalgam restorations of carious lesions
•Caries risk assessment and prevention
•Management of non carious tooth loss (erosion, attrition and abrasion)
•Endodontic therapy
•Oral and maxillofacial surgery:
•Extraction of hopeless teeth
•Treatment of any soft tissue pathology

58. Phase III (Restoration of esthetic and function (Oral
rehabilitation)
•Aims to rehabilitate the patient’s oral conditions and include
procedures thatimprove appearance and function like:
•Additional periodontal therapy including periodontal surgery
•Orthodontic treatment and occlusal therapy
•OS: preprosthetic & orthognathic surgery
•Replacement of missing teeth with fixed or removable
appliances (including implants)

59. Phase IV: Re-evaluation of treatment): the goal is to
confirm that:
•All treatment has been adequately completed with
no omission
•No new lesion have developed
•Patient adapted to any appliance provided
•Patient has adhered to home care advise

60. Phase V: Maintenance care phase (Recall phase):
•It depends on patient motivation
•To maintain optimum treatment results achieved
•Prevent relapses and disease recurrences
•Support the patient
•Monitor the level of disease control
•Assess and maintain treatment previously carried out
•Reinforce patient motivation and responsibility for
his/her oral health
•Early identification of new dental or oral lesions
•The success depends on regular recall system

61. Setting priorities (the optimal treatment sequences)
•The final step in formulating the dental treatment plan is to
rearrange all the treatment procedures necessary to solve
the patient’s problems in the most logical treatment
sequence.
•The order in which dental procedures are completed is
determined by consideration of the priorities from the
perspective of both the patient and the practitioner.
•Unfortunately, esthetic problems are of high priority to the
patient may seen rather secondary to the dentist compared
with extensive decay affecting several molars.
•Despite this divergence of opinion, planning the sequence of
the procedures, should allow high priority problems to be
solved early in treatment and prevent complication resulting
from delaying treatment or poor sequencing e.g. Fabrication
of a ceramic metal crown before completing periodontal
therapy

62. Please note that:
•Treatment plan for the patient is an opinion of
what the dentist thinks is best for the patient
“treatment plans are to large extent are opinions”
•The dentist should not be offended if the patients
seek a second opinion (in fact reluctant patient
should be encouraged to do so)

63. •More than one way may exist to plan treatment for
a patient and several plans may be acceptable
•Most treatment plans are compromises, few are
ideal.
•Several “best” treatment plans may exist and they
are the ones that are closest to ideal yet practical
for a particular patient.

64. •Best treatment plan is defined “as the plan that
represent the most effective practical treatment
approach for a given patient, taking into account all
factors affecting formulation of treatment plan
including availability of delivery” and accepted by
the patient.

65. •Every patient deserves to know the best treatment
plan possible for him or her and it is the
responsibility of the dentist to offer such treatment.
If a certain part of the care is not within the
dentist’s usual practice or experience , the patient
should be referred for that therapy. If the patient
refuses such referral , an appropriate treatment plan
modification or a compromise may be made

66. •In summery, patient treatment priorities generally
include attentions to chief complaint, solving the
patient perceived problems within the financial
resources and obtaining reasonable prognosis which
minimizing inconvenience, pain and complications

67. Case presentation
•Case presentation is the process of explaining the
diagnostic findings, the necessary dental treatment and
the possible complications of dental treatment to the
patient and obtaining the patient’s consent to begin
treatment
•This process started once the dentist has build up
relationship of trust
•The dentist has to use his communication skills to reach
consensus on treatment plan

68. Case presentation
•If handled poorly, the patient may perceive the
dentist as uncertain, lacking confidence, self
serving, arrogant or even incompetent
•Use simple language and avoid technical terms to
convey your massage

69. Case presentation
•Use radiographs, photographs, study models and
pamphlets to educate patient and visualize their problems
•Encourage patient to ask questions and clarify any doubts
•Educate the patient about the nature of his chief
complaint and other existing problems
•Inform the patient about the short and long term
prognoses

70. Case presentation
•Explain treatment options with advantages and disadvantages
of each
•Explain the possible complications, why they might occur and
how can be solved
•Record the patient-dentist agreement on the best approach
to solve the patient problem
•The barriers that may prevent the patient from accepting
treatment (pain, cost, time, phobia …etc.) must be clearly
addressed