THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry,...

THE ODTP THE ODTP PROCESSPROCESS

A Case-Based OverviewA Case-Based OverviewOrientation to the Clinical Practice of Orientation to the Clinical Practice of

General Dentistry, Fall Quarter General Dentistry, Fall Quarter

Alan W. Budenz, MS, DDS, MBAAlan W. Budenz, MS, DDS, MBA

Heather – a new patientHeather – a new patient Screened by faculty September 26, Screened by faculty September 26,

20052005 Designated as a 2Designated as a 2ndnd Year teaching Year teaching

casecase

Chief Concern (CC):Chief Concern (CC):I would like a bridge for my I would like a bridge for my

lower front teethlower front teeth

The ODTP Process: Step 1The ODTP Process: Step 1PreparationPreparation

Pre-appointment preparationPre-appointment preparation Review chartReview chart

Read screening and/or treatment Read screening and/or treatment notesnotes

Review health historyReview health history Review radiographsReview radiographs

Make notesMake notes Plan out the first appointmentPlan out the first appointment

The Pacific The Pacific Health History Health History Questionnaire Questionnaire

FormForm

-- Comprehensive Comprehensive

-- Standardized Standardized

-- Translations Translations

The Pacific Health History The Pacific Health History Questionnaire FormQuestionnaire Form

Section 1: General QuestionsSection 1: General Questions Designed to elicit general information Designed to elicit general information

about the patient’s health, and whether about the patient’s health, and whether they have seen a physician recently, they have seen a physician recently, are currently in pain, or have had any are currently in pain, or have had any problems with prior dental treatment.problems with prior dental treatment.


Section 2: Signs and SymptomsSection 2: Signs and Symptoms Focuses on various signs and symptoms Focuses on various signs and symptoms

that are indicative of medical problems.that are indicative of medical problems. Signs = indications of disease that can be Signs = indications of disease that can be

observed by the practitioner.observed by the practitioner. Symptoms = problems associated with a Symptoms = problems associated with a

disease that are experienced by the patient, disease that are experienced by the patient, but cannot be seen by the practitioner.but cannot be seen by the practitioner.


Section 2: Signs and SymptomsSection 2: Signs and Symptoms Note: No time frame is specified for any Note: No time frame is specified for any

of these signs or symptoms.of these signs or symptoms. Determining the relevance of the time Determining the relevance of the time

frame is the responsibility of the frame is the responsibility of the practitioner.practitioner.


Section 3: Specific DiseasesSection 3: Specific Diseases Concentrates on specific diseases which Concentrates on specific diseases which

have been previously diagnosed by a have been previously diagnosed by a physician.physician.

All of these diseases have a systemic All of these diseases have a systemic effect.effect.

Therefore, all of these diseases have Therefore, all of these diseases have potential ramifications on dental care potential ramifications on dental care delivery.delivery.


Section 3: Specific DiseasesSection 3: Specific Diseases The patient’s physiology is compromised The patient’s physiology is compromised

by their medical problems, and many by their medical problems, and many dental procedures have a significant dental procedures have a significant physiologic impact.physiologic impact.

Therefore, the dental procedure may Therefore, the dental procedure may need to be modified to insure patient need to be modified to insure patient safety.safety.


Section 4: TreatmentsSection 4: Treatments Discusses medical treatments and Discusses medical treatments and

prosthetic devices which may have a prosthetic devices which may have a bearing on dental management of the bearing on dental management of the patient.patient.

Decisions regarding dental management Decisions regarding dental management depend on the patient’s specific situation depend on the patient’s specific situation and the extent of the treatment and/or and the extent of the treatment and/or resultant outcome.resultant outcome.


Section 5: Medications and DrugsSection 5: Medications and Drugs Elicits important information on Elicits important information on

prescription drugs, over-the-counter prescription drugs, over-the-counter medications, natural remedies, and any medications, natural remedies, and any other drugs the patient might be taking.other drugs the patient might be taking.

Documents the extent of any problems Documents the extent of any problems noted on other parts of the health noted on other parts of the health history, or possibly problems history, or possibly problems notnot identified by the patient.identified by the patient.


Section 6: Women OnlySection 6: Women Only Elicits specific information relative to Elicits specific information relative to

women uniquely.women uniquely. Pregnancy and the use of birth control Pregnancy and the use of birth control

pills are especially pertinent to dental pills are especially pertinent to dental care delivery.care delivery.


Section 7: All PatientsSection 7: All Patients Consists of a catch-all question Consists of a catch-all question

designed to elicit information the designed to elicit information the patient feels is appropriate to provide, patient feels is appropriate to provide, but which has not been otherwise but which has not been otherwise directly queried.directly queried.


Patients should sign and date the health Patients should sign and date the health history after initially completing it.history after initially completing it.

The patient should review, update, and re-The patient should review, update, and re-sign the form at each recall visit.sign the form at each recall visit.

At start of each appointment, ask “Have At start of each appointment, ask “Have there been any changes in your health?” there been any changes in your health?”

Note response in the Note response in the treatment record.treatment record.

The Health History FormThe Health History Form

In our clinic, the patient fills out a In our clinic, the patient fills out a medical questionnaire when they first medical questionnaire when they first register.register.

This must be followed up with a This must be followed up with a verbal verbal interview by the student doctorinterview by the student doctor To insure that the patient properly To insure that the patient properly

understood the questionsunderstood the questions To ask about and obtain a history about any To ask about and obtain a history about any

positive responsespositive responses To insure that a negative response was what To insure that a negative response was what

the patient intended for certain questions.the patient intended for certain questions.

The Pacific The Pacific Health Health History History

Interview Interview SheetSheet

The Health History Interview FormThe Health History Interview Form The separate interview sheet provides a The separate interview sheet provides a

location location for notation of any significant for notation of any significant findings and a description of any dental findings and a description of any dental management considerations.management considerations.

It is best not to alter or make notations It is best not to alter or make notations on the patient’s Health Questionnaire on the patient’s Health Questionnaire form.form.

The interview sheet is used to ensure The interview sheet is used to ensure that any positive questionnaire that any positive questionnaire responses are followed up and responses are followed up and appropriately documented.appropriately documented.

The Pacific Health History Interview The Pacific Health History Interview FormForm

Includes 6 questions that need to be Includes 6 questions that need to be verbally asked of every patient: verbally asked of every patient: Do you have any…Do you have any… Cardiovascular problems?Cardiovascular problems? Infectious diseases? Infectious diseases? Allergies to medicines (or latex)?Allergies to medicines (or latex)? Bleeding problems?Bleeding problems? Take any medications?Take any medications? Other medical problems not asked Other medical problems not asked

about?about?


Cardiovascular Cardiovascular problems?problems?

Infectious diseases? Infectious diseases? Allergies to Allergies to

medicines (or latex)?medicines (or latex)? Bleeding problems?Bleeding problems? Take any Take any

medications?medications? Other medical Other medical

problems not asked problems not asked about?about?

The six areas covered The six areas covered by these questions are by these questions are extremely important to extremely important to the dentist and it is the dentist and it is appropriate to ask appropriate to ask them again to insure them again to insure that the patient that the patient properly understands properly understands and correctly answers and correctly answers the questions.the questions.


Cardiovascular problems?Cardiovascular problems? Comprise the bulk of medical problems Comprise the bulk of medical problems

that require dental management that require dental management considerations.considerations.

51% of patients with medical complexities 51% of patients with medical complexities have CV problems with the incidence have CV problems with the incidence rapidly increasing with age. rapidly increasing with age. (Smeets et al, Preventative (Smeets et al, Preventative Medicine 1998)Medicine 1998)

Heart disease is the leading cause of Heart disease is the leading cause of adult deaths in the U.S.adult deaths in the U.S.

Stroke is the third leading cause of death Stroke is the third leading cause of death in adults in the U.S.in adults in the U.S.

Most specifically, patients should be Most specifically, patients should be asked if they have any history of “heart asked if they have any history of “heart

problems or heart murmurs”.problems or heart murmurs”.

If “yes”, questions to ask:If “yes”, questions to ask: When was the problem first diagnosed?When was the problem first diagnosed? Did your doctor ever say you should take Did your doctor ever say you should take

antibiotics before dental treatment?antibiotics before dental treatment? Did your doctor ever say you Did your doctor ever say you don’tdon’t need to need to

take antibiotics before dental treatment?take antibiotics before dental treatment? For heart murmurs specifically: Was it For heart murmurs specifically: Was it

termed functional or organic? Is there termed functional or organic? Is there regurgitation?regurgitation?


Infectious diseases?Infectious diseases? Hepatitis is the most common infectious Hepatitis is the most common infectious

disease with implications for dental disease with implications for dental complications.complications.

HIV+ and AIDS often produce significant HIV+ and AIDS often produce significant oral and systemic changes.oral and systemic changes.

Note: All patients should be treated as Note: All patients should be treated as though they are infectious, i.e. though they are infectious, i.e. universal universal precautionsprecautions are the standard infection are the standard infection control protocol for all patients, with control protocol for all patients, with oneone exception...exception...


Infectious diseases?Infectious diseases? The The oneone exception... exception...

Active tuberculosisActive tuberculosis requires additional requires additional precautions, and these patients should precautions, and these patients should generally be treated only in a hospital generally be treated only in a hospital isolation facility.isolation facility.


Allergies to medicines (or latex)?Allergies to medicines (or latex)? Patients should be asked about allergies Patients should be asked about allergies

to any medications in general, and to any medications in general, and specifically about possible allergies to:specifically about possible allergies to:

AntibioticsAntibiotics Pain medications, including aspirinPain medications, including aspirin NarcoticsNarcotics Local anestheticsLocal anesthetics LatexLatex


Hematologic, bleeding problems?Hematologic, bleeding problems? Has the patient ever had any bleeding Has the patient ever had any bleeding

problems or do they bruise easily?problems or do they bruise easily? Positive responses may be indicative of Positive responses may be indicative of

undiagnosed hematologic disease.undiagnosed hematologic disease. Referral to or consultation with the Referral to or consultation with the

patient’s physician may be indicated.patient’s physician may be indicated.


Take any medications?Take any medications? Indicates that the patient’s medical Indicates that the patient’s medical

problems are severe enough to require problems are severe enough to require medical treatment.medical treatment.

Knowing any medications that the patient Knowing any medications that the patient may be taking allows the dentist to be may be taking allows the dentist to be alert to possible side effects, toxicity, or alert to possible side effects, toxicity, or drug interactions that may occur during drug interactions that may occur during dental care.dental care.


Take any medications?Take any medications? The increasing use of over-the-counter, The increasing use of over-the-counter,

natural, and herbal medications and natural, and herbal medications and supplements may have a significant supplements may have a significant impact on the delivery of dental care.impact on the delivery of dental care.

Patients often fail to disclose these Patients often fail to disclose these medications unless specifically asked medications unless specifically asked about them.about them.


Other medical problems not asked Other medical problems not asked about?about? This catch-all question asked in a one-on-This catch-all question asked in a one-on-

one confidential setting may elicit one confidential setting may elicit significant information that a patient may significant information that a patient may be reluctant to write down on a form.be reluctant to write down on a form.

May also induce the patient to discuss May also induce the patient to discuss anxieties and concerns they may have anxieties and concerns they may have regarding dental treatment.regarding dental treatment.

Allows dentists to establish a thoughtful Allows dentists to establish a thoughtful and caring rapport with their patients.and caring rapport with their patients.

The ODTP Process: The ODTP Process: Step 1Step 1

Medical History ReviewMedical History Review

““Yes” answer to Yes” answer to #3: Hospitalized or serious illness #3: Hospitalized or serious illness

(3yrs)(3yrs)Listed: Lung problemListed: Lung problem

What questions do What questions do youyou want to want to ask?ask?



““Yes” answers to Yes” answers to

#4: Being treated by physician#4: Being treated by physician

Listed: Anemia, GERDListed: Anemia, GERD





#37: Stomach problems, ulcer#37: Stomach problems, ulcer





#62: Taking medications#62: Taking medications

Listed: Warfarin, PrevacidListed: Warfarin, Prevacid




““Yes” answers to Yes” answers to #63: Tobacco#63: Tobacco


Health History ReviewHealth History Review

From your analysis of the medical From your analysis of the medical history:history:

Is the patient’s medical condition Is the patient’s medical condition controlled and stabilizedcontrolled and stabilized under the under the supervision of a physician?supervision of a physician?

Do you need to make any care Do you need to make any care deliverydelivery accommodations because accommodations because of the of the patient’s health status?patient’s health status?

Dental Management of Medically Dental Management of Medically Complex PatientsComplex Patients

Good sources for information on this Good sources for information on this subject:subject: From the UOP web site: From the UOP web site:

www.dental.pacific.eduwww.dental.pacific.edu Protocols for the Dental Management of Medically Protocols for the Dental Management of Medically

Complex PatientsComplex Patients Protocols for the Dental Management of Patients Protocols for the Dental Management of Patients

with HIV Diseasewith HIV Disease Little, Falace, Miller & Rhodus, Little, Falace, Miller & Rhodus, Dental Dental

Management of the Medically Compromised Management of the Medically Compromised PatientPatient, 6, 6thth Edition, Mosby-Year Book, Inc., Edition, Mosby-Year Book, Inc., 2002 (will get in 22002 (will get in 2ndnd Year Student kit) Year Student kit)


Radiographic InterpretationRadiographic InterpretationPatient has brought in an FMX Patient has brought in an FMX

dated 4/20/99. Do we need a new dated 4/20/99. Do we need a new FMX?FMX?


Radiographic InterpretationRadiographic Interpretation

Complete a Complete a Radiographic Radiographic

Diagnosis Diagnosis Worksheet Worksheet

(available in (available in Radiology)Radiology)


Radiographic InterpretationRadiographic Interpretation

Radiographic Findings:Radiographic Findings:#2: possible mesial caries#2: possible mesial caries#3: gross distal caries w/ apical #3: gross distal caries w/ apical radiolucenciesradiolucencies#13, 24, 25: severe vertical bone loss#13, 24, 25: severe vertical bone loss#14: gross mesial caries w/ apical #14: gross mesial caries w/ apical radiolucenciesradiolucencies#4, 17, 30, 32: missing#4, 17, 30, 32: missing


All of this should be done BEFORE All of this should be done BEFORE your first appointment with your first appointment with

Heather.Heather.

The better prepared you are, the The better prepared you are, the smoother and faster the smoother and faster the

appointment will go, and the better appointment will go, and the better the impression you will make upon the impression you will make upon

the patient.the patient.

The First Appointment:The First Appointment:D0150 Initial Oral D0150 Initial Oral

ExaminationExamination

Greet Heather in the waiting room Greet Heather in the waiting room and introduce yourself. Ask her how and introduce yourself. Ask her how

she is today. Does she have any she is today. Does she have any tooth pain?tooth pain?

Give her a brief overview of what Give her a brief overview of what you are going to do during this you are going to do during this

appointment.appointment.

The First Appointment:The First Appointment:D0150 Initial Oral D0150 Initial Oral

ExaminationExaminationGive her a brief overview of what you Give her a brief overview of what you

are going to do this appointment:are going to do this appointment:

““Today I’m going to do a very thorough Today I’m going to do a very thorough examination of all of your teeth and examination of all of your teeth and

gums, and then I’ll be able to discuss gums, and then I’ll be able to discuss with you what dental care you need with you what dental care you need

and what treatment options you have. I and what treatment options you have. I particularly want to evaluate your lower particularly want to evaluate your lower

front teeth.”front teeth.”


Medical History Interview/ Medical History Interview/ Physical Exam/Vital SignsPhysical Exam/Vital Signs

1.1. Review the health history with the Review the health history with the patient (MH)patient (MH)

2.2. Take vital signs (VS)Take vital signs (VS)

3.3. Perform intra- and extraoral exams Perform intra- and extraoral exams (EOE & IOE)(EOE & IOE)

4.4. Take diagnostic casts if neededTake diagnostic casts if needed



Health History: Ask your questions Health History: Ask your questions from your Step 1 review of the from your Step 1 review of the completed form and record completed form and record Heather’s responses to your Heather’s responses to your questions on the Health History questions on the Health History Interview Sheet.Interview Sheet.



What is significant in Heather’s What is significant in Heather’s health history for safe delivery of health history for safe delivery of

dental treatment? dental treatment?

Where do you record this Where do you record this information?information?



Do Do youyou still have questions about still have questions about Heather’s health?Heather’s health?

If so, how do you get them If so, how do you get them answered?answered?



Physical exam (PE) findings:Physical exam (PE) findings:

VS: BP 105/70 – R, pulse 77 VS: BP 105/70 – R, pulse 77 reg.reg.

EOE & IOE: all WNLEOE & IOE: all WNL



This is a good time to start This is a good time to start gathering a dental and social gathering a dental and social

history of Heather.history of Heather.

What questions do you want to What questions do you want to ask?ask?

Dental History:Dental History:HCC: currently asymptomatic. HCC: currently asymptomatic.

DH: Last dental appt. for delivery of a DH: Last dental appt. for delivery of a maxillary partial denture, June 2000.maxillary partial denture, June 2000.

Has had sporadic dental care most of her Has had sporadic dental care most of her life.life.

Perio: “deep cleanings” occasionallyPerio: “deep cleanings” occasionally

Ortho and Endo : noneOrtho and Endo : none

OS: #1,3,13,14,16 ext. at UOP in 1999;OS: #1,3,13,14,16 ext. at UOP in 1999;

#4,19,30,32 ext. prior, different #4,19,30,32 ext. prior, different timestimes

Restorative: moderate restorations: Restorative: moderate restorations: amalgams, amalgams, crowns, bridge #29 – 31, crowns, bridge #29 – 31, maxillary removable maxillary removable partial denture partial denture (RPD).(RPD).

Social History:Social History:Grew up in Ireland, lived in Berlin, Grew up in Ireland, lived in Berlin,

moved to Arizona in 1985, moved to Arizona in 1985, moved to LA in 1989, moved to moved to LA in 1989, moved to SF in 1998.SF in 1998.

Parents deceased; 2 sisters, 1 Parents deceased; 2 sisters, 1 brother living in Ireland.brother living in Ireland.

Separated from husband who lives Separated from husband who lives in Arizona with their 19 y.o. son.in Arizona with their 19 y.o. son.

Lives with 3 roommates in SF.Lives with 3 roommates in SF.

Enjoys reading and furniture Enjoys reading and furniture restoration.restoration.



After completing Step 2, “present” your After completing Step 2, “present” your patient to the ODTP instructor patient to the ODTP instructor beforebefore proceeding to any invasive proceeding to any invasive examination, i.e. perio probing.examination, i.e. perio probing.

Faculty will sign your paperwork and Faculty will sign your paperwork and “grade” the steps in the computer.“grade” the steps in the computer.

The ODTP Process The ODTP Process

Use any waiting time during the ODTP Use any waiting time during the ODTP appointment to take clinical appointment to take clinical photographs of Heather.photographs of Heather.

Basic patient intake photographs for chart record (7) Basic patient intake photographs for chart record (7) Full frontal faceFull frontal face Profile faceProfile face Full frontal teeth occludedFull frontal teeth occluded Right lateral teeth occludedRight lateral teeth occluded Left lateral teeth occludedLeft lateral teeth occluded Full upper archFull upper arch Full lower archFull lower arch Additional images as needed for unique conditions or Additional images as needed for unique conditions or

needsneeds


Periodontal ExaminationPeriodontal Examination

1.1. Review x-rays, complete full mouth Review x-rays, complete full mouth probing and comprehensive probing and comprehensive periodontal examinationperiodontal examination

2.2. Diagnose periodontal disease Diagnose periodontal disease status status

3.3. Plan periodontal treatment therapyPlan periodontal treatment therapy

4.4. Plan follow-up/maintenance carePlan follow-up/maintenance care



Chart all findings in Chart all findings in the computer the computer and on the buff-and on the buff-colored Baseline colored Baseline Clinical Clinical Examination Examination formform



Periodontal Findings:Periodontal Findings:

Recession: generalized 2 – 4 mm w/ 8 mm #25 Recession: generalized 2 – 4 mm w/ 8 mm #25 facialfacial

Pockets: generalized 3 – 4 mm w/ localized 5 – 7 Pockets: generalized 3 – 4 mm w/ localized 5 – 7 mmmm

Plaque index: 1 – 2Plaque index: 1 – 2

Mobilities: #23 – 25 Class 2, severe vertical Mobilities: #23 – 25 Class 2, severe vertical bone lossbone loss

Furcations: Class I & II on all remaining molars, Furcations: Class I & II on all remaining molars, Class I on #5 & 12Class I on #5 & 12



What is your periodontal diagnosis? What is your periodontal diagnosis? Does Heather have active or Does Heather have active or

stabilized disease?stabilized disease?

Since we have x-rays from 1999 and Since we have x-rays from 1999 and now from 2005, we can compare now from 2005, we can compare bone levels, furcas, and defects.bone levels, furcas, and defects.


Periodontal ExaminationPeriodontal ExaminationWhat is your periodontal What is your periodontal

diagnosis? diagnosis?

Generalized moderate chronic Generalized moderate chronic periodontitis with localized periodontitis with localized severe chronic periodontitissevere chronic periodontitis

What is the etiology?What is the etiology?

Moderate generalized bacterial Moderate generalized bacterial plaque and calculus; heavy plaque and calculus; heavy smoker and moderate alcohol smoker and moderate alcohol intake.intake.



What is Heather’s prognosis?What is Heather’s prognosis?

Generally fair as is, good if she Generally fair as is, good if she quits smoking and improves her quits smoking and improves her oral hygiene; prognosis poor for oral hygiene; prognosis poor for 23 – 25.23 – 25.

Treatment plan: 4 quads root Treatment plan: 4 quads root planing, ITE, recall interval to be planing, ITE, recall interval to be determined.determined.


Oral Hygiene InstructionOral Hygiene InstructionFull instruction customized to your Full instruction customized to your

patient’s individual needs.patient’s individual needs.

After completing Steps 3 and 4, After completing Steps 3 and 4, “present” your patient to the “present” your patient to the

Perio instructor.Perio instructor.

Faculty will sign your paperwork and Faculty will sign your paperwork and “grade” the steps in the “grade” the steps in the

computer.computer.


Dental & Occlusal Exam/Dental & Occlusal Exam/Problem ListingProblem Listing

1.1. Charting of restorations, caries, Charting of restorations, caries, pathologypathology

2.2. Ortho/occlusion screeningOrtho/occlusion screening

3.3. Caries risk assessmentCaries risk assessment

4.4. List all findings and tentative List all findings and tentative solutionssolutions



1.1. Charting of restorations, caries, Charting of restorations, caries, pathology: in the computerpathology: in the computer

2.2. Ortho/occlusion screening: in the Ortho/occlusion screening: in the computer and on Orthodontic computer and on Orthodontic Screening formScreening form



3.3. Caries risk assessment: on Caries Caries risk assessment: on Caries Risk Assessment form. Risk Assessment form.

What is the patient’s risk level and What is the patient’s risk level and how will we, the patient and you how will we, the patient and you together, manage their caries risk together, manage their caries risk level?level?



4.4. List all hard tissue findings and List all hard tissue findings and tentative solutions: on ODTP tentative solutions: on ODTP Dental Examination Worksheet Dental Examination Worksheet in in detaildetail. .

List List allall restorations: if no problem, restorations: if no problem, write WNL; if problem, describe write WNL; if problem, describe exactly what it is and where.exactly what it is and where.


Dental & Occlusal ExamDental & Occlusal ExamView of Heather’s maxillary arch:View of Heather’s maxillary arch:


Dental & Occlusal ExamDental & Occlusal ExamView of Heather’s mandibular arch:View of Heather’s mandibular arch:


Dental & Occlusal ExamDental & Occlusal ExamAnterior view of Heather’s dentition:Anterior view of Heather’s dentition:


Dental & Occlusal ExamDental & Occlusal ExamView of Heather’s right lateral side:View of Heather’s right lateral side:


Dental & Occlusal ExamDental & Occlusal ExamView of Heather’s left lateral side:View of Heather’s left lateral side:


Dental & Occlusal ExamDental & Occlusal ExamClinical Findings:Clinical Findings:#1,3,4,13,14,16,17,19,30,32: missing#1,3,4,13,14,16,17,19,30,32: missing#2: MO amalgam with mesial recurrent caries at #2: MO amalgam with mesial recurrent caries at

ginigival marginginigival margin#5: MOD amalgam – WNL #5: MOD amalgam – WNL #12: PFM crown – WNL#12: PFM crown – WNL#15: FVC crown – WNL#15: FVC crown – WNL#18: PFM crown – WNL #18: PFM crown – WNL #21: DO amalgam – WNL #21: DO amalgam – WNL #23, 24, & 25: guarded/poor perio prognosis #23, 24, & 25: guarded/poor perio prognosis #28: DO amalgam – WNL #28: DO amalgam – WNL #29 – 31: FVC 3-unit bridge – WNL #29 – 31: FVC 3-unit bridge – WNL


Tentative Treatment PlanTentative Treatment Plan1.1. Determine the ideal treatment Determine the ideal treatment

options for the various dental options for the various dental problems found.problems found.

2.2. Determine appropriate alternative Determine appropriate alternative treatment choices for the dental treatment choices for the dental problems found.problems found.

3.3. Discuss treatment goals with the Discuss treatment goals with the patient.patient.


Tentative Treatment PlanTentative Treatment PlanIn Heather’s case, her dental problems In Heather’s case, her dental problems

are:are:

1.1. Moderate generalized periodontitis Moderate generalized periodontitis disease with localized severe disease with localized severe diseasedisease

2.2. Caries on the Mesial of #2Caries on the Mesial of #2

3.3. Severe bone loss & mobility #23, 24, Severe bone loss & mobility #23, 24, & 25& 25

What treatment options does she have?What treatment options does she have?


Tentative Treatment PlanTentative Treatment Plan• Moderate to severe periodontitisModerate to severe periodontitis

What treatment options does she What treatment options does she have?have?

1.1. 4 quadrants of root planing4 quadrants of root planing

2.2. No treatmentNo treatment

What are the risks, benefits, and What are the risks, benefits, and alternatives (RBAs) of each alternatives (RBAs) of each option?option?


Tentative Treatment PlanTentative Treatment Plan• Caries on the Mesial of #2Caries on the Mesial of #2


1.1. M or MOL amalgamM or MOL amalgam

2.2. Full veneer crown (FVC)Full veneer crown (FVC)


What are the risks, benefits, and What are the risks, benefits, and alternatives (RBAs) of each option?alternatives (RBAs) of each option?


Tentative Treatment PlanTentative Treatment Plan• Severe bone loss & mobility #23 – Severe bone loss & mobility #23 –

2525


1.1. Re-evaluate following perio Re-evaluate following perio therapytherapy

2.2. Extract and replace teeth with…?Extract and replace teeth with…?


What are the risks, benefits, and What are the risks, benefits, and alternatives (RBAs) of each alternatives (RBAs) of each option?option?


Tentative Treatment PlanTentative Treatment Plan

After completing your hard tissue After completing your hard tissue examination and formulating a examination and formulating a

tentative treatment plan, tentative treatment plan, “present” your patient to the “present” your patient to the

ODTP instructor.ODTP instructor.

Discuss findings and treatment Discuss findings and treatment options with the instructor and options with the instructor and

the patient.the patient.



After “presenting”, reviewing, and After “presenting”, reviewing, and discussing your findings and discussing your findings and

treatment options with the ODTP treatment options with the ODTP instructor and your patient, instructor and your patient,

The ODTP instructor will decide if The ODTP instructor will decide if specialist consultations are specialist consultations are

needed.needed.



After completing your hard tissue After completing your hard tissue examination and formulating a examination and formulating a

tentative treatment plan with your tentative treatment plan with your patient and the ODTP instructor,patient and the ODTP instructor,

The faculty will sign your paperwork The faculty will sign your paperwork and “grade” the steps in the and “grade” the steps in the

computer.computer.


Treatment Prioritizing/ContractTreatment Prioritizing/Contract1.1. Prioritize and finalize the treatment Prioritize and finalize the treatment

plan with the patient and review it plan with the patient and review it with the ODTP instructor.with the ODTP instructor.

2.2. Enter the treatment into the computer Enter the treatment into the computer in prioritized sequencein prioritized sequence, print it out , print it out and have the patient sign the and have the patient sign the printout.printout.

3.3. Have the ODTP instructor Have the ODTP instructor clinically clinically approveapprove your treatment plan in the your treatment plan in the computer.computer.


Treatment Prioritizing/ContractTreatment Prioritizing/Contract

For Heather’s case, the priorities are:For Heather’s case, the priorities are:

1.1. 4 quadrants of root planing4 quadrants of root planing

2.2. M amalgam on #2M amalgam on #2

3.3. Re-evaluate perio health for status of Re-evaluate perio health for status of #24 & 25. Are these teeth #24 & 25. Are these teeth salvageable? If not, what salvageable? If not, what replacement options does she have?replacement options does she have?

The ODTP Process: The ODTP Process: The Final StepThe Final Step

At the completion of your appointment, At the completion of your appointment, or during “down” times during the or during “down” times during the

appointment, appointment,

Write up your treatment record.Write up your treatment record.

Treatment RecordsTreatment Records The quantity of information gathered The quantity of information gathered

from the comprehensive patient from the comprehensive patient examination process can be examination process can be overwhelming.overwhelming.

It is therefore essential to have a It is therefore essential to have a systematic method for recording and systematic method for recording and organizing all of the data.organizing all of the data.

Treatment RecordsTreatment Records Paperwork can be viewed as a burden, Paperwork can be viewed as a burden,

but it is also a necessary fact of life in but it is also a necessary fact of life in every practice.every practice.

Just do it, and get used to it!Just do it, and get used to it!(It’s only going to get worse!)(It’s only going to get worse!)

Learn how to make the paperwork Learn how to make the paperwork serve serve youryour needs. needs.

““The palest ink is stronger than the best The palest ink is stronger than the best memory.”memory.”

Treatment RecordsTreatment Records The treatment record is perhaps the The treatment record is perhaps the

single most important document in the single most important document in the patient chart.patient chart.

It is essential that every aspect of patient It is essential that every aspect of patient care be fully documented.care be fully documented.

““If it isn’t written down, it didn’t If it isn’t written down, it didn’t happen.”happen.”

Treatment RecordsTreatment Records ““The complete record contains a description The complete record contains a description

of of the patient’s original condition, your the patient’s original condition, your diagnosis and treatment plan, progress diagnosis and treatment plan, progress notes on the treatment performed and the notes on the treatment performed and the results of that treatmentresults of that treatment. It should also . It should also contain the patient’s personal data, health contain the patient’s personal data, health history information, and informed consent history information, and informed consent documentation. The record should be documentation. The record should be organized logically and in language that is organized logically and in language that is comprehensible to all who use it.”comprehensible to all who use it.”

((Dentist’s Guide to Keeping Patient Records: Strategies & SolutionsDentist’s Guide to Keeping Patient Records: Strategies & Solutions, ,

California Dental Association, 1996)California Dental Association, 1996)

Treatment RecordsTreatment Records The patient treatment record is The patient treatment record is

perhaps the single most important perhaps the single most important document in the patient chart. It document in the patient chart. It forms a running narrative of the forms a running narrative of the diagnostic process, the treatment diagnostic process, the treatment plan derivation, the delivery of care, plan derivation, the delivery of care, care outcomes, and the patient’s care outcomes, and the patient’s involvement in care. involvement in care.

This ongoing record is the practicing This ongoing record is the practicing dentist’s first reference at every dentist’s first reference at every subsequent patient visit.subsequent patient visit.

Treatment RecordsTreatment Records ““The patient record not only serves as the The patient record not only serves as the

history of the therapeutic and business history of the therapeutic and business relationship between dentist and patient, relationship between dentist and patient, but also but also it is the most reliable – and most it is the most reliable – and most relied upon – defense against a relied upon – defense against a malpractice allegationmalpractice allegation. Malpractice . Malpractice allegations remain subjective until they allegations remain subjective until they can be substantiated, and sound records can be substantiated, and sound records are an objective and factual measure of are an objective and factual measure of the actual treatment provided.”the actual treatment provided.”

(Liability Lifeline, TDIC, California Dental Association, 1994)(Liability Lifeline, TDIC, California Dental Association, 1994)

Treatment RecordsTreatment Records The patient treatment record is perhaps the The patient treatment record is perhaps the

single most important document in the single most important document in the patient chart. It forms a running narrative of patient chart. It forms a running narrative of the diagnostic process, the treatment plan the diagnostic process, the treatment plan derivation, the delivery of care, care derivation, the delivery of care, care outcomes, and the patient’s involvement in outcomes, and the patient’s involvement in care. care.

From a legal standpoint the patient From a legal standpoint the patient treatment record has the greatest treatment record has the greatest credibility, and when properly filled out, credibility, and when properly filled out, offers the best defense against offers the best defense against litigation.litigation.

Treatment RecordsTreatment Records Document all treatment visits by Document all treatment visits by

chronological order, what services were chronological order, what services were performed, details of the procedures performed, details of the procedures including what materials were used, and including what materials were used, and note any complications.note any complications.

Document all instructions, referrals, and Document all instructions, referrals, and recommendations given to the patient recommendations given to the patient with notation of all RBAs discussed.with notation of all RBAs discussed.

Treatment RecordsTreatment Records Document the informed consent Document the informed consent

process and any significant questions process and any significant questions and comments made by the patient. and comments made by the patient.

Document all patient contacts: Document all patient contacts: appointments, telephone calls, letters, appointments, telephone calls, letters, etc.etc.

Document all failed and cancelled Document all failed and cancelled appointments, late arrivals, etc.appointments, late arrivals, etc.

Treatment RecordsTreatment Records Ten rules for complete patient records:Ten rules for complete patient records:1.1. Use a consistent style and standard Use a consistent style and standard

abbreviations for all entries to foster your abbreviations for all entries to foster your professionalism, and thereby your credibility.professionalism, and thereby your credibility.

2.2. Use blue or black ink only – colors do not Use blue or black ink only – colors do not copy well, and pencil smears and fades over copy well, and pencil smears and fades over time and can be too easily altered, reducing time and can be too easily altered, reducing the credibility of your records.the credibility of your records.

Treatment RecordsTreatment Records Ten rules for complete patient Ten rules for complete patient

records:records:3.3. Use a single line to cross out errors.Use a single line to cross out errors.

4.4. Do not use whiteout – not only is it messy, Do not use whiteout – not only is it messy, but it may be construed as an effort to but it may be construed as an effort to conceal information.conceal information.

5.5. Date and explain any corrections, making Date and explain any corrections, making corrections as they happen with the true corrections as they happen with the true date of the correction entry.date of the correction entry.

Treatment RecordsTreatment Records Ten rules for complete patient records:Ten rules for complete patient records:6.6. Write legibly – an illegible record can lead to Write legibly – an illegible record can lead to

inappropriate guesswork and suggests a inappropriate guesswork and suggests a careless, disorganized attitude.careless, disorganized attitude.

7.7. Note discussions of treatment options Note discussions of treatment options including the risks, benefits, and including the risks, benefits, and alternatives (RBAs) – list all options alternatives (RBAs) – list all options discussed.discussed.

A handy abbreviation: DWP = discussed with patientA handy abbreviation: DWP = discussed with patient

Treatment RecordsTreatment Records Ten rules for complete patient records:Ten rules for complete patient records:8.8. Express your honest concerns about patient Express your honest concerns about patient

needs – this reflects an understanding of the needs – this reflects an understanding of the patient’s needs and documents that the patient’s needs and documents that the dentist listened to, noted, and possibly dentist listened to, noted, and possibly addressed the patient’s expressed needs.addressed the patient’s expressed needs.

9.9. Record missed appointments and failure to Record missed appointments and failure to follow instructions, and record your attempts follow instructions, and record your attempts to educate and change patient behavior. This to educate and change patient behavior. This information can be vital for documenting your information can be vital for documenting your due diligence in caring for the patient.due diligence in caring for the patient.

Treatment RecordsTreatment Records Ten rules for complete patient Ten rules for complete patient

records:records:10.10. Never write derogatory remarks in the Never write derogatory remarks in the

record – this does not mean you should not record – this does not mean you should not record negative information, such as a record negative information, such as a patient’s failure to follow treatment advice, patient’s failure to follow treatment advice, but record all remarks in a dispassionate but record all remarks in a dispassionate and objective manner.and objective manner.

Adapted from the June/July 1995 Adapted from the June/July 1995 New York State Dental JournalNew York State Dental Journal

Treatment RecordsTreatment Records The SOAP note entry formatThe SOAP note entry format

A clear, concise, and standardized form A clear, concise, and standardized form for recording all patient information for recording all patient information and treatmentand treatment

Forms the basis for analyzing all Forms the basis for analyzing all patient data including treatment patient data including treatment outcomesoutcomes

Is a universal format for discussing Is a universal format for discussing your patient with physicians or your patient with physicians or specialty practitioners, and for case specialty practitioners, and for case reports in the dental/medical literaturereports in the dental/medical literature


S = SubjectiveS = Subjective

O = ObjectiveO = Objective

A = AssessmentA = Assessment

P = Plan/ProcedureP = Plan/Procedure


S = SubjectiveS = SubjectiveWhat does the patient tell What does the patient tell

you?you?

Includes Includes CC = Chief Concern CC = Chief Concern HCC = History of Chief ConcernHCC = History of Chief Concern MH = Medical HistoryMH = Medical History DH = Dental HistoryDH = Dental History SH = Social HistorySH = Social History


O = ObjectiveO = Objective

What are your observations?What are your observations?

Includes Includes PE/VS = Physical Exam & Vital SignsPE/VS = Physical Exam & Vital Signs EOE & IOE = Extra- & Intraoral ExamsEOE & IOE = Extra- & Intraoral Exams Summary of appearance of both soft Summary of appearance of both soft

and hard tissuesand hard tissues RE = Radiographic ExamRE = Radiographic Exam


A = AssessmentA = Assessment

What is your diagnosis?What is your diagnosis?

Includes Includes Periodontal diagnosisPeriodontal diagnosis Caries risk assessmentCaries risk assessment Restorative diagnosisRestorative diagnosis Addresses patient’s chief concernAddresses patient’s chief concern


P = Plan/ProcedureP = Plan/Procedure

What treatment did you or What treatment did you or will will you provide?you provide?

Includes complete notes onIncludes complete notes on Treatment plan discussionTreatment plan discussion Procedures done or plannedProcedures done or planned Instructions, recommendations, Instructions, recommendations,

referralsreferrals Prescriptions Prescriptions DWP: RBAsDWP: RBAs

The Treatment Record: The Treatment Record: S.O.A.P. NotesS.O.A.P. Notes

For ALL procedures:For ALL procedures:

First line: the date and procedure code First line: the date and procedure code and descriptionand description


For ODTP we use an For ODTP we use an extendedextended SOAP note: SOAP note:

10/3/05 D0150 Initial oral exam10/3/05 D0150 Initial oral exam(S: Subjective)(S: Subjective)

1.1. ID: Patient age, sex, etc.ID: Patient age, sex, etc.2.2. CC: Chief ConcernCC: Chief Concern3.3. HCC: History of Chief ConcernHCC: History of Chief Concern4.4. MH: Medical HistoryMH: Medical History5.5. DH: Dental HistoryDH: Dental History6.6. SH: Social HistorySH: Social History


For ODTP we use an For ODTP we use an extendedextended SOAP SOAP note:note:

(O: Objective)(O: Objective)

7.7. PE: Physical Exam (VS, EOE, IOE, PE: Physical Exam (VS, EOE, IOE, TMJ)TMJ)

8.8. Perio Dx: Periodontal Exam Perio Dx: Periodontal Exam findingsfindings

9.9. RE: Radiographic Exam findingsRE: Radiographic Exam findings

10.10. Hard Tissue Exam findingsHard Tissue Exam findings



(A: Assessment)(A: Assessment)

11.11. Periodontal DiagnosisPeriodontal Diagnosis

12.12. Hard Tissue “Diagnosis”Hard Tissue “Diagnosis”

13.13. Caries Risk AssessmentCaries Risk Assessment

Make sure the patient’s CC is Make sure the patient’s CC is addressed!addressed!



(P: Plan/Procedure)(P: Plan/Procedure)Includes complete notes onIncludes complete notes on14.14. DWP: Treatment plan discussion: DWP: Treatment plan discussion:

RBAs – options and decisions RBAs – options and decisions 15.15. Treatment plan or procedures doneTreatment plan or procedures done16.16. Instructions, recommendations, Instructions, recommendations,

referrals, prescriptions referrals, prescriptions 17.17. NA or NV: Next Appointment or VisitNA or NV: Next Appointment or Visit


For restorative appts., etc., use abbreviated For restorative appts., etc., use abbreviated SOAP note:SOAP note:

(P: Plan/Procedure)(P: Plan/Procedure)

Treatment progress notes include:Treatment progress notes include: Tooth/region and procedureTooth/region and procedure Type, dose, location of anestheticsType, dose, location of anesthetics Isolation techniqueIsolation technique All materials and medications usedAll materials and medications used Shade, occlusion, lab prescriptionShade, occlusion, lab prescription Post-operative instructions givenPost-operative instructions given Treatment outcomesTreatment outcomes

Treatment RecordsTreatment Records Patient privacy (HIPPA)Patient privacy (HIPPA)

Patient privacy must be respected at all Patient privacy must be respected at all timestimes

Charts must be regarded as confidential, Charts must be regarded as confidential, privileged informationprivileged information

Patient’s have Patient’s have entrustedentrusted their personal their personal information to usinformation to us

We, as doctors, are We, as doctors, are privilegedprivileged to have access to have access to this confidential patient informationto this confidential patient information

Therefore, we must make every effort to Therefore, we must make every effort to preserve chart, and thereby patient, preserve chart, and thereby patient, confidentiality at all timesconfidentiality at all times

Patient PresentationPatient Presentation A derivative of the SOAP note A derivative of the SOAP note

formatformat The presentation should be a brief The presentation should be a brief

summation of significant findings summation of significant findings and history.and history.

The SOAP note format helps The SOAP note format helps practitioners to organize their practitioners to organize their thoughtsthoughts

Analyze patient dataAnalyze patient data Frame in an standard sequenceFrame in an standard sequence

Patient PresentationPatient Presentation Example:Example:

Mary is a 42 y.o. African-American female with a Mary is a 42 y.o. African-American female with a chief concern to have her teeth cleaned and chief concern to have her teeth cleaned and bleached. She has a medical history significant for bleached. She has a medical history significant for hypertension controlled with the beta-adrenergic hypertension controlled with the beta-adrenergic blocker Propanolol and for use of the antidepressant blocker Propanolol and for use of the antidepressant medication Zoloft. medication Zoloft.

Her initial oral exam was completed Sept. 1, 2005 Her initial oral exam was completed Sept. 1, 2005 and her perio treatment of 4 quadrants of root and her perio treatment of 4 quadrants of root planing was completed on Sept. 15planing was completed on Sept. 15thth. Her . Her hypertension is controlled today with blood pressure hypertension is controlled today with blood pressure measured at 134/88 on her right arm, and a strong, measured at 134/88 on her right arm, and a strong, regular pulse of 72. regular pulse of 72.

Tooth #12 has a distal carious lesion with a good Tooth #12 has a distal carious lesion with a good restorative prognosis.restorative prognosis.

Today I’m treating #12 with a DO amalgam. I will Today I’m treating #12 with a DO amalgam. I will minimize the use of vasoconstrictor containing local minimize the use of vasoconstrictor containing local anesthetic in this patient due to the use of non-anesthetic in this patient due to the use of non-specific beta-blocker and CNS depressant specific beta-blocker and CNS depressant medications.medications.

S

O

A

P

The ODTP Process:The ODTP Process:Points to remember:Points to remember:•Yes, the ODTP process is time Yes, the ODTP process is time consuming.consuming.

•A well done examination and A well done examination and treatment plan are the key to treatment plan are the key to successful patient care.successful patient care.

The ODTP Process:The ODTP Process:Points to remember:Points to remember:•The ODTP appointment is an The ODTP appointment is an excellent excellent time to build patient time to build patient rapport.rapport.•The better prepared you are, the The better prepared you are, the smoother and faster the appointmentsmoother and faster the appointment

will go, and the better the will go, and the better the impressionimpression you will have upon the you will have upon the patient.patient.

Unless…

THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry,...

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