Dental treatment planning

EBTISAM EL HAMALAWY

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 History taking
Introduction:

Good morning or (Good afternoon), Mr/Mrs ……… (Surname)…….

My name is DR ………, I am one of the dentists here and will be seeing you.

How are you today? ..............

Personal history:

Can I start my confirming your personal details?

1. What your full name?

2. What’s your date of birth?
3. What’s your Address?
4. What do u do for a living? Do you find it stressful?
Banker/ stressful
5. Are you married or do you have a partner?
Married
6. Do you have any dependents?

No dependents

CHIEF COMPLAIN:

Section: 1. Pain

2. Periodontics

3. Oral medicine

4. Denture

5. Tooth surface loss

6. Restorative (Crowns, bridges, endodontic, oral surgeries)

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Notes:

1. What do you wish from the treatment?

EX: Whiter teeth
Alleviate pain
2. Do you have a specific time frame? Wedding in two weeks
3. Do you have any concerns about the costs of the treatment? No financial
constraints

Dental history:

1. Do you visit your dentist regular? (Regular/ Irregular attendee)

2. When was the last time? 6 month
3. What kind of dental ttt have you had in the past?
Extraction:
A. Why? Always ask about the reason for extraction
B. Have there been any complications when the teeth were taken out?
Bridge:
Denture: a. Do you take it out at night?
b. How often do you clean your denture?

2. How often do you brush your teeth?

Brushes twice
3. Do you floss no use a mouth wash?
Floss occasionally
4. Do you grind on your teeth?
Bruxer / non bruxer
–ve 80% Nocturnal bruxism
(MPDS)
5. Do you have any discomfort on the side of your face early in the morning?
Hallmark of Myofacial pain dysfunction + ve 100%

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 6. Have you noticed any clicking from your jaw joints?
Clicking/ no clicking
TMPDS
Tempromandibular pain dysfunction syndrome

7. Are you anxious going to a dentist?

Anxious/ non- anxious

Social history
SADS
1. Smoking:

I. Do you smoke?

YES

A. How many cigarettes do you smoke a day?

B. For how long?
C. Are you interested in quitting?
D. Do you chew tobacco

II. Have you ever smoked before?

No

2. Alcohol:

A. Do you drink alcohol?

B. What kind of alcohol?

(White/ red wine are highly acidic PH they cause tooth surface loss)

C. How many units do you consume on a weekly basis?

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 3. Diet:

A. Do you take a balanced diet? , Are you a vegetarian?

B. How do you describe it in terms of sugars? Is it high , medium , low
C. Do you take lots of fizzy drinks and fruit juices?

4. Stress:

A. How do you describe your life in terms of stress levels:

B. Is it high/ medium /low

Medical history
Always take a consent prior to embarking on the MEDICAL history
questioners

Can I ask you a few questions about your health just to make sure everything
is okay?

1. Are generally fit and well?

2. Are you currently under the care of a GP or a specialist for any medical
condition?
3. Are YOU CURRENTLY TAKING ANY MEDICATION THAT IS OVER
THE COUNTER OR PERSCRIBED?
4. Do you have any allergies?
5. Do you have any bleeding problem; do you bleed excessively after a cut?
6. Do you have a family history of any medical condition?
7. Have you been to the hospital in the past 10 years?
8. Have you had any operations done in the past
9. Do you carry any warning card
10. Do you have any blood infections (HIV, HCV, and HBV)?

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 11.Have you ever been refused blood donation in UK before?
LADY:
1. Are you pregnant?
2. Are you on any contraceptive pills?
3. How about your periods are they regular?
12.Systems:
a. Do you have any skin, joint, eye trouble?
(Systemic lupus erythromatous, Sjogren syndrome, rheumatoid
artheritis, Behcet syndrome, Lichen planus).
b. Do you have any heart, liver, kidney trouble?
c. Do you have any breathing or lung troubles?
d. Do you have any tummy trouble?
e. Have you had any faints, fits, Blackouts before?

If patients say he is asthmatic?

1. What medication are you using for your asthma?

2. Are you taking any tablets as well as your inhalers?
3. What was the last time you had an asthmatic attack?
4. What triggers your attacks?
5. Have you had any attacks in a dental surgery before?
6. Are you using a nebulized at home?

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 How can I help you today?
Pain cases
Differential diagnosis
Hierarchy of events

1. Dentine hypersensitivity:
Sensitivity/ hot and cold/ air/ last for a few seconds / recent/ restoration/
dental caries

2. Reversible pulpitis:
Non –localized / Pain on hot and cold/ last for less than one minute/ sharp/
intermitted/ doesn’t disturb sleep/ no radiation/ relieved by medication

3. Irreversible pulpitis:

Non -localized/ Pain on hot and cold or (pain on hot and relieved on cold) /
last for more than 1 min/ radiates/ disturb sleep/ not relieved on medication/
no pain on biting/ sever

((Cracked tooth syndrome))

a. reversible pulpitis secondary to fracture

b. Irreversible pulpitis secondary to fracture

4. Apical periodontitis:

Localized/ Pain on hot and cold/ throbbing/ continuous/ pain on biting/

not relieved on medication/ sever / awaken the pt from sleep/ radiated to the
side of the face/ no swelling

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 5. Acute periapical abscess:

Sever/ swelling/ foul taste/ halitosis/ fever/ localized /throbbing pain/ radiated
to the side of the face/ pervious history of infection / previous history of dental
treatment/ pain on biting/ trismus

6. Chronic peripical abscess:

Localized/ dull ach/ foul taste/ parulis/ previous history of treatment/ previous
history of swelling and antibiotics

7. Combined endodontic and periodontal lesion:

Localized/ dull pain/ foul taste/ parulis/ previous history of swelling and
antibiotics/ Mobile tooth/ gingival bleeding localized

8. Combined periodontal and endodontic lesion:

Localized/ dull aching pain/ history of dental treatment / foul taste/

mobility/ generalized bleeding/ history of periodontal problem

9. Myofacial pain dysfunction syndrome :

Non-localized/ pain on the side of the face/ in the morning/ improves through
the day/ bruxism/ clicking from TmJ/ stress? Previous night guard treatment

10. Chronic idiopathic facial pain:

Non localized/ dull pain/ pain crosses the anatomical boundaries/ failure of
previous treatment/ stress/ depression and antidepressant medication/ pain
worsen on evening

11.Pericoronitis:

Localized/ chch of pain depends on the tooth condition/ Acute, throbbing

pain/ foul taste/ halitosis/ food lodgment/ partially erupted/ can present as a
1st, 2nd, ect episode/ fever/ trismus
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 12.Dry socket :

Localized/ sever/ throbbing / non -relieved on medication/ foul taste /

halitosis/ history of recent extraction.

QUESTIONS

Rest assured we will definitely do something for it today, but can I ask you a
couple of questions first

Pain

1. Can u point to the site of pain, is it from a specific tooth (localized/ non-
localized)?

2. Is it the first time or have you had it before?

3. Can you describe the pain is it sharp, throbbing, dull?

Character
Is it the same or getting worse?
Course: (Progressive, Regressive, constant)

4. What causes the pain?

(Continuous, Intermitted)

5. Do you have any pain on biting?

6. How long does the pain last?

Patient answer: continuous
Is it the same or getting worse?
(Constant, regressive, progressive)

7. R u taking any medication, is it helping?

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 8. Do you have any Swelling?

9. Do you have any Salty taste in your mouth?

10.Do you have any boil on your gums next to that tooth?

11.Is that tooth wobbly?

12.Have you had any dental treatment done on that tooth?

13.Do u grind on your teeth ( 80 no)

14.Have anyone told u before that u grind on your teeth?

15. You have any discomfort on the side of your face?

16.When?

17.Have u had any treatment for it before?

18. Do you have any pain when you bend forward?

19.Do you have a congested nose

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 Radiograph

We carry out a radiographic investigation

Examples
1. Confirm a condition
Ex: confirm periapical pathology, caries

OR

2. Rule out a conditions ( periapical pathology, caries, periodontal

involvement)
3. Impacted tooth: sectional OPG to confirm the status of the impacted
tooth( type, angulation, priapicalathology , proximity to the alveolar
nerve
4. Parallax technique : { Impacted canines}
Vertical parallex: Periapical and Dental Treatment Planning
Horizontal parallex: Periapical and Occlusal x-ray
Justification: Help locate the site of impaction

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 Special Investigation

1. Vitality testing To help locate the offending tooth

To confirm pulp states

It’s very important to correlate between the x-ray and vitality

2. Percussion test To rule out periodontal involvement /

Tenderness on percussion

(Vertical or horizontal percussion / Ankylosis (metallic sound)

3. Mobility To rule out periodontal involvement/ alveolar bone

loss

4. Tooth sleuth test Confirm and localize the cracked tooth

5. Muscles of mastication To rule out MPDS

6. TMJ examination Rule out TMJ involvement

7. Articulated study casts Rule out occlusal trauma

8. Body temperature To rule out systemic involvement

9. Dietary chart Diagnostic for causes of dental

caries

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 X-ray report
Please report on……. shown in the box below. You will have the
radiograph in your folder of artifacts

Radiograph

Horizontal bite wing x-ray

Side: (upper and lower right posterior quadrant)

Bone level: no vertical or horizontal alveolar bone loss

Teeth: 7654

7654

Restorations: occlusal restoration in 16, 46

Caries- lower 1 molar is grossly carious

Other- there is periapical radiolucencies at the apices of both the roots.

There is loss of lamina dura at both the apices and bifurcation.

Film Quality 1

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Last page of the treatment planning

1. Medical link:

a. Medical condition affecting the treatment plan

b. Medication affecting oral condition
c. Medical emergency

Patient is type II diabetes on Oral hypoglycemic

1. Ensure that the patient take medication and meal prior to appointment.
2. Stress reduction protocols (short and early morning appointments).
3. Diabetes a risk factor for periodontitis and candida infection.
4. Oral hypoglycemic associated dry mouth/ Lichinoid reaction.
5. Prepadness to deal with a hypoglycemic attack (Oxygen/ Gluo gel/
Glucagon).

Treatment option:

For the chief complains, just enumeration

Presentation points:

1. Med link: diabetes

2. 1st chief complaint: External discoloration
3. 2nd chief complaint : Chronic periodontitis
4. Prevention: ( Dietary chart / fissure sealant/ fluoride application/ partial
erupted/ alcohol advice/ smoking referral)
5. Gingival condition
6. Referrals
7. Incidental findings

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Sheet 7 Green Treatment Plan Form Continued
Considering this patient, briefly describe what has led you into choosing this
overall care plan and the benefits (likely success, cost, time, etc) to the patient.
Describe

Reasons Benefits

1. Young age 1. High success rate 95%

2. Adequate oral hygiene 2. Preserve alveolar bone
3. Regular dental attender 3. Restore esthetic and functions
4. Non- smoker 4. Last for a long time
5. Low carbohydrate diet
6. Non-financial or time constraints

Considering this patient are there any potential disadvantages of this

treatment (complicated, high risk of failure, short life of restoration, etc) for
the patient.

Disadvantage:

1. Multiple visits
2. Expensive
3. Surgical complications ( bleeding/ swelling/ damage to roof of the mouth)
4. Long treatment
5.

Would you provide all or part of the treatment for this patient yourself? If so
which part or parts? (Give your reasons.)

Yes, I will carry out part of the treatment

Would you refer the patient for all or part of the treatment? If so which part
or parts and to which Specialist/s? (Give your reasons.)
Periodontitis:

Reasons:
1. Complexity 3 index on the BPS score

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 Chronic generalized periodontitis

What the treatment:

1. Surgical debridement
2. Regenerative periodontal surgery: ( Guided tissue regeneration/ Bone
graft)

SHEET 7

Immediate/ Emergency Treatment

1. Reassure /Explain to the patient the cause of chief complain

2. General medical practitioner referral
3. Alleviation of any pain condition ( pulp extirpation / Pocket
debridement
4. Prescription of Analgesics
5. Prescriptions of antibiotics
6. Local management of Swelling/ Periocoronitis

Initial/ Stabilisation Treatment

1. Explain to the patients ……………………..

2. Oral hygiene instruction/ tooth brushing/ mouth wash/ interdental
brushes
3. Supra-gingival scaling, sub-gingival scaling, root surface
debridement, removal of plaques retentive factor.
4. Referral to a periodontist
5. Referral (smoking, stress management, orthodontic treatment…)
6. Monitoring: periodontal condition with a 6 point pocket chart
TSL: BEWE, silicon index, study models, pictures
Diet: Dietary chart
7. Explanation of the treatment option for the main chief complain

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Preferred Definitive Treatment

Whatever you think as a clinician is right as long as you can justify it

Long Term & Maintenance Treatment: 3Rs

1. Recall every ……………….. month ( depending on the NICE

GUIDELINES
2. Review and reinforce oral hygiene
3. Review restorations/ smoking statues/ diet/ alcohol consumption

Explanation
Myofacial pain dysfunction syndrome
Dentist:
Mr…………. as for the discomfort on the side of your face that’s because you
have been grinding on your teeth so you ut too much pressure on the muscles on
the side of your face .

Is it clear so far?

So for the discomfort to go away you will have to stop the grinding, it will take
you some time to improve you need to be patient and give the treatment some time
to work.

For now

1. Stick to a soft diet

2. 2. Avoid any hard or sticky food
3. Cut food into small pieces and chew on your back teeth
4. Don’t cut food with your front teeth
5. I will give you some analgesics to use

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 6. Apply warm towels on the side of your face to reduce the discomfort, it will
help massage the area

7. I will give you a leaflet of some jaw relaxation to use to help with ypur
muscle ach
I will be seeing you regularly if the muscle ach still persists we will give you
a plastic plate that goes between the teeth to keep them apart and decrease
the pressure from your muscles.

Is everything clear so far?

If anfter 3 month things dont improve I will be referring to you to a
specialist.

IRREVERSABLE PULPITIS

Thank you for waiting Mr. ………….. I have the results of your
investigations we will go through it together and I will be explaining to you
the treatment plan available and what options we have for it.
How does that sound??
Patient: sounds okay
Dentist: Because your diabetic don’t forget to take a proper meal and your
medication before you come to see me and if there is anything about the
treatment that makes you stressed or uncomfortable let me know about it.
Is that’s alright?

Patient: yes thank you.

Dentist: for the pain you’re having it’s from your big back tooth.
Unfortunately you have tooth decay that has reached the tooth nerve and
now the nerve is irritated beyond repair.

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 Is it clear Mr.…………….?

Patient: yes

Dentist: What I am going to do today is to numb that tooth and have the
nerve taken out, I will give you some pain killers to use.
That will relieve your pain.
How does that sound?
Patient: Thanks
Dentist: In the future you have one of two options to think about regarding
that tooth. You can either save it or take it out.
If you are to save the tooth we will need to do a nerve treatment, have you
heard about it before?
Patient: Not really
Dentist: It entails cleaning the inside of the tooth and putting a filling in
place. The advantages are: you will end up saving the tooth but on the down
side: it requires multiple appointments and when we are done I have to give
you a cap that goes on top of that tooth to protect it. That will cost more
money.

Is everything clear so far?

Patient: Yes

Dentist: the second option is having the tooth taken out, have you had any
tooth taken out before?

Patient: yes

Dentist:
It’s the same procedure the advantages are: it’s a simple one appointment
procedure on the downside: you will end up losing a big back tooth and have
a gap instead if its not restored with an artificial tooth teeth nxt to the space
will drift in and you will end up with more gaps between your that will cause
more problem in the future.

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 Is everything clear Mr………………….
I will give you leaflets that discuss the treatment options available
Take them home have a read and whatever you decide we will take it from
there.

COMBINED ENDODONTIC AND PERIODONTAL

LESION

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Periodontology
Differential diagnosis:
1. Periodontitis
2. Gingivitis
3. Aggressive gingivitis / periodontitis

A. positive family history

b. No predisposing factor (perfect oral hygiene/ regular dental attender/ non-
stressed / medically fit and well/ non-smoker)
Localized
Incisors and molars plus not more than 2 other teeth
Patients at the age of puberty, more common in female, Afrocarebians

Generalized
Affect all the teeth
30-40 old

4. Pyogenic granuloma: ( lump in my mouth)

1. Where exactly is it? Is it on your gums?

Center ( torus palatinus) , on the gum ( pyogenic granuloma)
2. Since when have you had it?
Birth ( torus paltinus), 3 years ago ( any soft or hard tissue swelling)
3. Is it painful? Any condition if infected and torus if ulcerated
4. Is it increasing in size? Constant ( torus), increase in size ( sof or hard
tissue swelling )
5. Is it hard or soft?
6. Does it bleed? All soft tissue swelling bleeds
7. Is there any tingling sensation in your mouth?
(Minor salivary gland tumor)
8. Have you had any trauma to the teeth next to it?
(Rule out dental abscess)
9. Have you had any dental treatment on the teeth next to it?

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  Poor oral hygiene / irregular dental attender
 plus local predisposing factors ( inadequate restoration , composite
filling, over hanged amalgam, overcontured crowns)
 Occlusion : Deep bite ( class2 division 2)

Pyogenic granuloma:

Gingival swelling / bleeding when provoked/ non-painful / no tingling

sensation/ gradual increasing in size

Pregnant patient:
Pregnancy epulis/ granuloma

Gingival swelling / bleeding when provoked/ non-painful / no tingling

sensation/ gradual increasing in size/ Pregnant

5. Acute necrotizing ulcerative periodontitis/ gingivitis

Predisposing factors:
1. Stress
2. Smoking
3. Malnutrition
4. AIDS
5. Poor oral hygiene

Treatment:

1. Metronidazole
2. H2o2 mouthwash / chlorohexiden

6. Periodontal abscess:
Dull pain, throbbing pain/ localized/ no pain on hot and cold/ no history
of dental treatment/ predisposing factors (Iatrogenic due to calculus from
recent subgingival scaling, hard food).

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 In a previously diseased periodontium.

 Three words:

1. Acute or chronic
Since when have you had it?

2. Localized or generalized

3. Type of the disease

Ex: chronic generalized gingivitis

History questions:

1. Do your gums bleed? What cases it bleed?

(Bleeding on brushing)
2. Since when? ( acute/ chronic)
3. Is it overall or it’s a specific area? ( localized / generalized)
4. Does anyone in your family have gum problem?
(Positive family history)
5. Have you notices any gaps forming between teeth?
6. Have you notices your gums been shrinking down? Gingival recession
7. Have you noticed any sensitivity in your teeth? sensitivity
8. Are your teeth wobbly? Mobile
9. Have you noticed any bad taste in your mouth? Foul taste
10. Are you happy with the appearance of your teeth

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 BASIC PERIODONTAL INDEX

Diagnosis Description Treatment

No bleeding, no calculus, no
0 Healthy overhang, the black band on a Reinforce oral
periodontium who probe is completely hygiene measure
visible
1 Gingivitis Bleeding on probing, no
calculus, no overhang, black
band is completely visible Oral hygiene
instruction
2 Gingivitis Bleeding on probing, calculus,
overhang, black band is Oral hygiene
completely visible ( probing instructions, supra
depth is less than 3.5mm) and sub gingival
scaling.

Oral hygiene
Bleeding on probing, calculus, instructions, supra
Mild-moderate overhang, black band is gingival, sub
3 periodontitis partially visible ( probing depth gingival scaling,
is more than 3.5- but less than root surface
5.5 mm) debridement

Oral hygiene
instructions, supra
gingival, sub
Sever periodontitis Bleeding on probing, calculus, gingival scaling,
4,* overhang, black band is root surface
completely invisible ( probing debridement
depth is more than 5.5 mm) +
Referral to a
specialist

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BPE:

If 2 sextants are involved then the condition is localized, if more then

it’s generalized.

Ex: Generalized periodontitis with localized gingivitis

Ex: Localized periodontitis with generalized gingivitis

Radiograph:

3, 4, * (you have to ask for an x-ray)

If one sextant is involved IOPA

1. IOPA per quadrant

2. Full mouth periapical To confirm the severity and type of
alveolar bone loss

1. Degree of bone loss: % if apex is visible then bone loss is

measured as a percentage.
2. Type of loss : horizontal/ vertical
3. Other features: endo-period lesions, widening in the periodontal
membrane space, calclus, overhanged restoration.

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Investigations:

Plaque index Plaque is a risk factor for periodontitis

Bleeding index confirm the presence of active periodontal disease

6 point pocket chart confirm clinical attachment loss

Mobility test rule out alveolar bone loss/ periodontal involvement

Percussion test rule out alveolar bone loss/ periodontal involvement

Furcation involvement confirm amount of alveolar bone loss

Blood investigation To rule out diabetes

Medical link: the patient is asthmatic

1. Ensure that patient brings his inhaler during the appointment.

2. Stress reduction protocol (short/ early morning appointment).
3. Salbutamol associated dry mouth, risk factor for dental caries
4. Corticosteroid inhaler associated candida infection
5. Risk of an acute asthmatic attack ( salbutamol/ oxygen/ spacer)

SHEET 7

Immediate/ Emergency Treatment

1. ANUG: manage it
Explain the condition/ Prescribe mouthwash (chlorohexidine) /
Antibiotics (Metronidazole)/ Analgesic

2. Periodontal abscess: Sub gingival drainage / prescription of a

mouthwash/ prescribe antibiotics if there is systemic involvement.
Localized/ dull pain/ pain on biting/ no previous ttt

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 3. Periodontitis / Gingivitis : Oral hygiene instruction
4. Pericoronitis: Explain condition/ Local irrigation (saline/chlorohexidine)/
Analgesics ( Paracetamol/ Ibuprofen) / Antibiotics ( systemic signs of
infection) { fever, lymphadenopathy, Malaise }

Initial/ Stabilisation Treatment

1. Oral hygiene instruction/ mouthwash/ TEPE brushes

2. Supra-gingival, sub-gingival scaling, removal of plaque retentive factors,
root surface debridement.
3. Monitor periodontal condition ( x-ray, 6 point pocket chart)

Preferred Definitive Treatment

Refer to a periodontist

Long Term & Maintenance Treatment

1. Recall every 3m, 6m

2. Review and reinforce oral hygiene
3. Review restoration/ smoking status

Sheet 7 Green Treatment Plan Form Continued

Considering this patient, briefly describe what has led you into choosing this
overall care plan and the benefits (likely success, cost, time, etc) to the patient.

Reasons Benefits

1. Irregular dental attender 1. Conservative

2. Poor oral hygiene 2.Adequate management GDP and referral
3. High carbohydrate diet 3. Not expensive
4. Family history of periodontits
5. Stress

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 6. Smoking
7. Not expensive

Considering this patient are there any potential disadvantages of this

treatment (complicated, high risk of failure, short life of restoration, etc) for
the patient.

Disadvantage:

1. Long treatment
2. Multiple appointment
3. Questionable prognosis

Would you provide all or part of the treatment for this patient yourself? If so
which part or parts? (Give your reasons.)
Yes part:

 Explanation the condition

 Rectify oral hygiene care
 Preventive treatment
 Long term follow up
 Initial periodontal treatment

Would you refer the patient for all or part of the treatment? If so which part
or parts and to which Specialist/s? (Give your reasons.)
Yes, refer

1. Beyond the scope of a GDP

2. INDICATED FOR REFERAL ON A BPE score

Periodontist

1. Surgical debridement
2. Regenerative periodontal surgery ( bone grafts/ membrane)

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