Interdisciplinary Treatment Planning

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Summary

This summary is used with permission and is partially abstracted from:

Berkey DB, Shay K, Holm-Pedersen P: Clinical Decision-Making for the Elderly Dental Patient. In Textbook of Geriatric Dentistry. P Holm-Pedersen and H Löe (eds), 2nd Edition, Munksgaard, 319-337, 1996.

There is great variety and diversity in older adult populations (e.g., health status, income, racial/ethnic composition, expectations, cultural values, etc). These attributes may play a significant role in the treatment planning process. Increasing numbers of older adults place higher value on improving chewing function, eliminating or reducing oral symptoms, and enhancing aesthetics. Weighing the subjective concerns of patients along with their multidimensional systemic, psychosocial and clinical dental problems and then subsequently identifying the best dental treatment planning approach can be a formidable task.

Basic challenges that the dental clinician faces include:

a. Identifying important medical, psychosocial, behavioral factors and other mitigating factors and their impact;
b. correctly diagnosing the patient's oral problem
c. recognizing likely etiological factors
d. identifying reasonable treatment options
e. predicting the short-term and long-term outcomes associated with these proposed treatment options;
f. selecting an effective, appropriate, and agreeable option in collaboration with the patient and involved caregiver (if appropriate);
g. establishing a vitally important effectual maintenance program.

An organized and systematic approach can help provide some clarity to the complexity of clinical decision making for older adults. The sequence below highlights that before proceeding with a specific treatment, true etiologies should be determined, treatment goals determined collaboratively, and contingency as well as prevention plans established.

	Action 1 Determine Cause	Action 2 Choose an action	Action 3 Plan implementation
A.	Define problem	Establish goals	Anticipate problems
B.	Consider possible causes	Examine alternatives	Take preventive actions
C.	Test possible causes	Consider adverse outcomes	Set up contingency plans

Determine Cause

A. Define the problem
The identification of oral diseases and disorders and their concomitant etiological factors may be difficult. Many times, an elderly patient does not present with a chief complaint or have any acute symptoms associated with any of a variety of dental and oral maladies. Data on oral symptoms in the United States demonstrate that older adults are much less likely than younger adults to report orofacial pain. Depression can also affect symptom reports and treatment outcomes. Similarly, elderly patients with early clinical dementia may be unable to report and interpret symptoms adequately. To compensate for the tendency to underreport oral problems, a closed-ended question format is recommended. Specific inquiry should be directed toward identifying a history of oral discomfort or dysfunctions. Additional information should also be sought regarding a patient's perceived needs, aesthetic concerns and expectations. Another important consideration understands the link between oral problems and medical, psychosocial and medication status. Clinical signs and symptoms of over 100 diseases may be seen in the oral cavity. Medication may cause mouth dryness, caries, gingival inflammation, mucosal changes (such as lichenoid reactions, erosion, etc.) and /or fungal infections and may ultimately cause the loss of teeth and/or function.

B. Consider possible causes
Once a potential oral problem has been identified through patient report and/or clinical examination, the practitioner should try to identify possible causes. For example, the existence of multiple dental caries lesions should lead the dentist to suspect lack of regular dental care as well as contributing factors associated with dry mouth, dietary changes and/or reduced ability to perform oral hygiene. In contrast, loss of denture stability or retention might be associated with alveolar ridge atrophy, mucosal disease, dry mouth, dehydration and/or impaired neuromuscular control mechanisms. Identifying contributing causes is essential in considering treatments directed toward problem eradication.

C. Test possible causes
The correct identification of contributing etiologies to oral problems should be pursued through questioning of the patient and detailed clinical evaluations, radiographs, and other diagnostic tests. The dentist should look for tongue papillary atrophy and oral tissue dryness, seek patient complaints for dryness and examine the patient's lists of medicines for likely causative agents. In the same way, Plaque Index score, identification of deficits in performing independent activities of daily living (bathing, dressing, toileting, oral hygiene techniques, etc.) and food selection by the patient should also be evaluated to provide important clues to the possible associated etiologies.

Choose an action

A. Establish goals
The existence of an oral health problem does not generally mandate a single prescribed course of action. It is therefore essential to determine the chief complaint(s), the perceptions and expectations of both the patient and family, oral health history and personal history. Helpful information might include determining the degree of bother or concern the specific oral problem generates for the patient or whether this problem stops the patient from doing anything. Yet this is not the only indication for treatment, as serious, significant oral disease and disability may not generate significant symptoms. Ultimately, agreement on the treatment objectives should be sought with the patient and, with the patient's permission, with family members or others. Consensus may be relatively easy to accomplish for less complicated oral health issues.

Options for removing, restoring and replacing teeth, however, may be based on a variety of factors, including:

1. the chief complaint
2. the restoration size
3. the risk of later fracture of the restoration or tooth
4. chewing comfort
5. the dentist's preference and skills
6. patient aesthetic concerns
7. the costs (in terms of money, time, and discomfort)

Such factors should be differentially valued and may lead to a number of reasonable treatment or non-treatment options. For substantial oral problems that are not perceived by the patient to be important (for example, asymptomatic periapical disease in patients at risk for subacute bacterial endocarditis), thorough and frank discussion of the benefits of the suggested treatment as well as the associated risks of non-treatment must be pursued. The patient's autonomy (the patient's choice of treatment or non-treatment consistent with his or her needs and values) should be honored unless medical or legal determination has established the patient's decision-making ability to be lacking. In such a case, the patient should still be informed of the intended course of care, and consent is obtained from a third party. The ethical and moral principles below must be integral in the treatment planning process.

Autonomy - individuals should be treated as national and thus have the freedom to decide and act on their own behalf;

Nonmaleficence - it is the dentist's duty to "do no harm" to the patient (this principle usually takes precedence over "doing good");

Beneficence - "doing good": dentists should use all their skills, knowledge, and abilities to benefit patients;

Truth telling - Sharing accurately with patient the state and prognosis of the patient's health, the risks and benefits of proposed treatment, and the results of withholding those treatments.

B. Examine Alternatives
A number of options may be available to address the oral problems successfully. Fixed and removable prostheses are available to compensate for tooth loss, and dental caries may be treated using a number of different approaches, materials (alloy, composite, glass ionomers, cast restorations, and full or partial veneer coverage) and techniques (pins, chemical bonding, etc.). Periodontal intervention may involve surgical, nonsurgical, medication and combination options.

Treatment planning decisions and alternatives should be consistent with the ethical and moral concepts mentioned above. There may be several appropriate actions to be considered and decided by preference, convenience, etc. Where conflicts to exist, appeal should be made to higher level rules (for example, nonmaleficence over beneficence) or weighing the relative merits of each approach.

C. Consider adverse consequences
Treatment planning is truly a dynamic process. Certain types of interventions may lead to adverse outcomes. Complications may arise that are anticipated as well as those that were presumed unlikely. These may include: 1) biological complications (for example, recurrence and progression of periodontitis, etc.); and 2) technical complications (for example, fracture of bridge, etc.). Understanding these potential problems is important for maximizing treatment success. The determination of prognosis involves a number of aspects including:

• Concurrent diseases
• Seriousness of problem
• Patient' attitude
• Previous adverse reactions
• Ability for compliance
• Weighing benefits vs. costs and risks

Consideration of possible treatment benefits and weighing these against the risks and costs of proposed interventions could be very helpful. Expected oral benefits include improved function, comfort, aesthetics and/or elimination or reduction of pathology. Short-term systemic health risks are associated with dental treatment stresses, whereas longer-term risks include such oral complications as postoperative discomfort, periapical or periodontal breakdown, progressive natural tooth mobility, resorption of alveolar ridge and difficulty accommodating to prostheses.

The costs are not only financial but may also involve time and discomfort components. And the costs are not all related to the mouth: there may be considerable systemic risks involved in delaying or foregoing care, such as bacteremia, sepsis, abscess, metastatic infection, spread of local oral disease and progression of restorable oral disease to nonrestorability.

Implement the Plan

A. Anticipate potential problems
During specific oral treatment implementation, a number of undesirable incidents may take place as predicted during the stage of choosing an action and considering adverse consequences. During the implementation phase of treatment, it is very important to then plan to address these possible negative outcomes. Examples might include: 1) untoward medical complications associated with invasive dental therapies (for example, angina, diabetic crisis, or postoperative infection); 2) changes in treatment approach due to clinical difficulty (for example, a key abutment proves to be nonrestorable; irremediable gagging, etc.); and 3) the decline of health status with untoward oral impact (for example, exacerbation of dry mouth, heightened depression interfering with oral hygiene, impaired diabetic control contribution to recurrent periodontal disease, etc.).

B. Take preventive actions
Understanding the issues associated with prognosis should lead the practitioner to intervene with preventive action. This approach helps to reduce the probability of future problems. Careful medical management and stress reduction for medically compromised patients is essential. Judicious use of local anesthetic is important, although arbitrary use when unnecessary or the use of excessive amounts can be needlessly risky. In complex cases, the dentist must discuss with the patient and family, prior to the initial intervention, the likelihood that the treatment plan needs to be modified during treatment. A maintenance care program may assume the most importance for good prognosis. The use or fluoride, chlorhexidine, xylitol gum, and scheduling more frequent recall appointments is often advantageous. Other possible preventive approaches might include chemotherapeutic intervention, diagnostic wax-ups, occlusal splints, night guards, stress-breakers on fixed and removable appliances, multiple abutments on bridges, the use of bonding for restoration retention and endodontic therapy on asymptomatic nonvital teeth, use of overdenture abutments and the use of immediate dentures, treatment partials or conditional prostheses.

C. Set up contingency plans
The use of contingency plans helps to minimize the effects of a problem once it has arisen. The skillful dental practitioner should consider fallback options if dental approaches are only partially successful. The use of segmented bridges allows the dentist options to maintain a portion of fixed bridgework when certain abutments fail due to periodontal or periapical causes. Partial dentures can be designed with clasps and frameworks to accommodate (with minor modification) future tooth loss without compromising function. Including several teeth for overdenture abutments provides a basis for continued alveolar support if certain teeth fail over time or the use of hard tissue replacement materials into extraction sites helps to maintain alveolar bone height.

Pitfalls that endanger success
Although this treatment planning model is not complicated, it is frequently underused. Instead, a number of initially more expeditious alternative approaches are used. Too often these ultimately lead to failure due to:

1. jumping to a cause - a diagnosis is rendered too quickly; sufficient assessment data have not been collected and/or correctly analyzed
2. jumping to an immediate solution - given the severity of the problems (for example, oral pain or swelling, etc.), an inaccurate diagnosis is generated and proposed solution is flawed
3. taking permanent interim action - not enough time is invested to find the true problem cause or to identify an appropriate corrective approach; interim action lasts only a short period of time before another manifestation of the real problem occurs
4. "missing the forest for the trees" - not recognizing other oral problems that may be potentially more serious than the chief complaint but may not be symptomatic or perceived as important.

Summary
The clinical decision-making process for older adults must be a multidimensional process. Practitioners are most successful when they:

1. synthesize diverse assessment data to understand the causes and effects of oral problems
2. effectively choose an action that appropriately considers patient desires, alternatives and consequence; and then
3. efficiently implement the plan while anticipating potential problems and using preventive or contingent actions as necessary.

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