Referrals and treatment planning Flashcards
Treatment planning - approach
History and examination Preliminary investigation Differential diagnosis Specific investigations e.g. mouth swab sent to microbiology lab to confirm infectious bacteria. Definitive diagnosis- ideally !! List in a logical progression – strategy Carry out treatment
Preliminary data
Patient demographics must be assembled
Name, address, DOB, telephone numbers
Arrange patients to come earlier to do paperwork
You should convey that the team is caring, working in a calm, unhurried and clean environment
History taking
Chief complaint and wishes
Medical history
Dental history
Social history
Chief complaint and history
Open questions “what is the main reason for you coming to see me today?” rather than “Are you having any problems?”
Open questions “is there anything that bothers you about the teeth?”
“If there was one thing you could change about your teeth (mouth) what would it be?”
Medical history
You should ensure the patients understands why this information is necessary
Often standard forms are used, ensure they ask pertinent questions
Dental history
Insight into pts’ attitudes to dentistry
Regular or irregular attender?
Warning signs patient who has seen several dentists over the past few years
E.g. Bad debts, holding dentists /DCP in low regard
Patients with unrealistic time expectations
Patients who just know you can do something for them
Care should be taken before accepting a patient for any complex treatment
Patients who cannot remember the names of past dentists
Value of previous dental records. You only examine a patient at one point in time.
Old records: Radiographs and study casts can provide an insight into the rate of progression of disease.
Change or lack of change in bone levels, enamel caries, wear facets and recession.
Social history
Smoking habits Ask have you previously smoked Alcohol consumption-precipitating factor for oral cancer in smokers; excessive alcohol consumption, particularly binge drinking associated with erosive dental problems Occupation (educational and intelligence) level, potential levels of stress and availability for treatment. Personal situation- marital status Family contacts Stress history e.g. CO..sore ulcers Family history
Clinical examination
Extraoral aspects
Intraoral structures
Screening to assess needs for specialised examination and tests
General dental examination – Preliminary extra-oral observations (eye contact, breathless, sweating, complexion healthy? Are they clean and neat?)
Extraoral head and neck exam
Symmetry
Muscles
Glands
TMJ
Glands - nodes
Submental nodes
Submandibular nodes
Middle jugular nodes
Lower jugular nodes
Intraoral examination
A systematic approach recommended. These should consist of:
Soft tissues
Teeth
Periodontium
Soft tissues
Lips Cheeks Lateral border of tongue Hard and soft palate (throat) Floor of mouth
Floor of mouth
With tongue elevated inspect floor of mouth for -changes in colour, texture -swelling -other surface abnormalities All abnormalities should be palpated
Concerns intra-orally
Cancer of the tongue
Hairy leukoplakia
Teeth
Missing teeth Tipping Over-eruption Spacing Existing restorations Defective restorations Caries Excessive non-carious structure loss (occlusal wear, abrasion, erosion or trauma
Periodontium
Periodontal probing depths Assessment of mobilities Assessment of recession >1mm Bleeding on probing Fremitus (functional contact mobilities)
Special examinations - what radiographs?
Not good practice to prescribe a standard series of radiographs for every new patient prior to carrying out a proper clinical examination
BW/PA
DPT
Digital radiography
Special examinations - what do you need to see from radiographs?
Enamel decalcifications depth/penetration Proximity to the pulp Bone topography Root length and apices Endentulous areas/retained roots Root canal fillings Bone support Status and proximity of large existing restorations
Active problems
Active problem is the one that will be addressed within the present treatment plan E.g. Missing tooth Fractured tooth Unhappy with aesthetics Localised gingivitis
Inactive problems
An inactive problem is a variance from the norm, which is to be monitored but does not need active treatment within the present treatment plan
E.g. Bilateral TMJ joint click
Unerupted wisdom teeth
Treatment options
Clinicians obligation to present all the options outlining the ‘pros’ & ‘cons’ Likely longevity (Evidence based) Cost Invasiveness/reversibility Success rates (EBD) Possible complications/treatment time Time involved number of visits Influence on quality of life
Sequence of treatment: a phased approach
- Relief of pain and other emergencies
- Cause-related therapy (diet advice, OHI)
- Reassessment
- Basic corrective care (Placement of plastic restorations)
- Reassessment
- Preconstructive therapy (crown lengthening)
- Reconstructive therapy (crowns & Bridges)
- Recall and maintenance
Treatment may include (DCP/ Hygienist and therapist scope of practice 2013)
- Clinical examination
2.Diagnose and treatment
plan within their competence - OHI and Scaling/indices
- RSD & review
- Restorations as per chart
- Review
Referral to dentist or specialist
- Crowns
- Endodontic treatment
- Bridge UL4-UL6 replacing the UL5
- Extraction of the LL8 surgically
- Referral to specialist for Orthodontic opinion re: Ectopic canine
- Refer to specialist implant dentist for treatment of missing upper left central
- Review
Medico-legal issues
Negligence – duty of care The degree of skill the law requires Skills & experience Accepting referrals & referral of patients The nature of the contract Consent Risk management (resisting claims) Dental records/retention of records
Written referrals
Ensure you have addressee info Who the letter is from Date of letter Ensure you include patient details, DOB, contact address, hospital number if available Brief clear summary of problem/why you are referring Sign and date appropriately Include MH, SH, Medications GP contacts/telephone numbers
