Developing the Treatment Plan

Once the examination phase has been completed, a treatment plan will be created based on the patient’s urgent needs and desires. Patients may not be aware of their needs until brought to the attention by their dental provider.

Obvious infections take priority followed by conditions that may create issues in the short-term. A sequenced treatment plan can be created to enable patients to utilize their dental benefits before they are lost. The chronological plan can be established so a patient can take advantage of their benefit plan or plan their dental work accordingly to decrease the amount of future appointments by quadrant treatment planning.

Patients will be made aware of their condition, every option for treating the condition, the consequences of non-treatment and its impact to their overall health. The age of an individual should not determine a patient’s treatment options. Non-treatment can be an option if the patient is made fully aware of all consequences involved. It is our responsibility to educate patients about every option available to them without interjecting our preconceived ideas of what is right for the patient. This treatment plan will be revisited periodically during preventive appointments to assess a patient’s changing needs.

Patients may deny the need for treatment or change the priority we have established for that treatment. Open communication between the patient and dental providers (and eventually their caregivers) will allow for care of the patient’s dental needs and wants. Many patients are motivated to accept treatment based on worsening oral symptoms, deteriorating oral function and their dissatisfaction with their oral health status and chewing ability.17

Table 2. Example of Patient Treatment Options.
Treatment Needed Benefits of Treatment Consequences of Treatment Consequences of Non-treatment
Extraction Relief of pain, if present Space left in place of tooth

Infection

Implant Preserve bone

Preventing deterioration of facial structure

Improving of appearance

Replaces missing tooth
Bone loss

Deterioration of facial structure due to continued bone loss

Space left in place of tooth

Loss of tooth function
Bridge Improving of appearance

Replaces missing tooth

Cuts down on adjacent teeth to attach tooth to

Bone loss occurs where fake tooth is present

Shifting of teeth

Space remains

Loss of tooth function
Denture/Partial Improving of appearance

Replaces missing teeth/tooth
Deterioration of facial structure due to continued bone loss Loss of tooth/teeth function

Deterioration of facial structure due to continued bone loss

A person’s perception of the aging process will motivate them to accept or decline care. Patients who believe dentures are an expected result of aging may not be willing to accept preventive dentistry. Patients whose parents had dentures may feel this is the only option for missing teeth. Implants and bridges may not be in their vocabulary; therefore, visual displays of these options should be available for patient education. Identifying what medications a patient is taking can also affect the compliance of a denture wearer due to the potential xerostomic side effects.

Evaluating the photographs together allows the patient to take ownership of the dental issues and allows the clinician to answer any questions the patient has about what they see. Patients are more motivated to treat conditions they see as the photographs provide information that words cannot convey. The photographs, as a visual tool, will also allow patients to monitor changes in their mouth at recare visits.

The wearing of the teeth, which may have been noted on the photographs, caused by grinding and clenching, is not just a cosmetic issue but can create functional issues in the future. Patients should be made aware that grinding and clenching may result in fractures of teeth and the possibility of needing future expensive and larger restorations. Excessive wear can indicate sleep issues which can be monitored by the patient’s physician.9

Patients’ physicians should be contacted if mouth breathing is noted as this may indicate a more pressing medical condition may be present, such as sleep apnea or high blood pressure. Patients may be prone to high blood pressure due to the blood oxygen levels being lower than those who breathe nasally.18

The radiographs will be read to find areas of decay, abscesses and bone loss. Overhangs and irregular contours creating plaque traps and areas for bacterial overload due to the inability to clean these areas effectively will need to be addressed. More conservative dentistry can be provided to the patient if open margins are found early so expenses to the patient can be kept at a minimum. Bridges need to be evaluated as their failure rate has been found to be 35% due to periodontal disease and caries on abutment teeth.19

If the patient’s periodontal health is less than ideal, further investigation of the infection may be in order. Bacteria from the oral cavity have been found elsewhere in the body, and the inflammation produced by the body’s response to these bacteria has been shown to have a correlation with many systemic illnesses such as heart disease, diabetes, strokes, erectile dysfunction, colon and pancreatic cancers and arthritis, as literature suggests.8,20-24 Consultations with both periodontists and medical physicians may be necessary to create a comprehensive plan if high levels of bacteria and inflammation are present.

Gingival recession will be noted and monitored as root exposure from bone loss may increase the patient’s susceptibility to root caries. The need for gingival grafts to alleviate this problem should be identified, where appropriate, and incorporated into the treatment plan.

A patient with bone loss caused by a previous periodontal infection, that is now controlled, may be a candidate for guided bone regeneration (GBR). This regeneration of bone will create a more solid foundation for a patient’s dentition allowing maintenance of the teeth for a longer period of time decreasing their need for dentures. An evaluation for implants, to replace lost teeth, can be done if the periodontal health is stable.

The home care assessment will help determine a patient’s current at home care regimen. The monitoring of a patient’s ability to adequately remove plaque should be done at every appointment. Overgrowth of plaque, especially on dentures, can lead to inhalation of plaque biofilm that could potentially contribute to aspiration pneumonia.25

A detailed home care plan should be outlined and may include the use of electric toothbrushes, floss, interdental brushes or a water flossing device. Xylitol, in sprays, gum and candy forms, may be incorporated for those to be found with a low pH and dry mouth issues to prevent decay and reduce plaque levels. Changes to home care techniques may need to be modified if the patient develops medical conditions or physical limitations.

It may be necessary to include a third party during treatment planning to facilitate communication during the visit. The caregiver, if one is needed, can assist the patient with decision-making about their care. It is important the caregiver not pressure the patient to make a decision that may not be in their best interest.