Dental Treatment Planning Considerations For Complex Patients Paul Glassman DDS, MA, MBA 1
TREATMENT PLAN WORKSHEET Age I. Medical Information A. What is the disability? B. How severe? C. What is the long and short term prognosis? D. What treatment is being or will be given and what are the side effects? E. What medications are being taken and what are the side effects? II. Social/Personal Information A. What is the effect of the disability on the patient's life? B. What are the effects of the dental problems on the patients life? C. What would the effect of dental treatment be on the patient's life? 2
D. What is person's ability to understand, communicate, and perform procedures? E. What support persons are available? F. What are the expectations of the patient and support persons? G. What financial support is available? III. Dental Information A. What dental abnormalities are associated with the disability? 1. Do the abnormalities need treatment? 2. What considerations are there in treating these abnormalities? B. What other dental problems exist? 3
C. How does the disability affect the delivery of dental services? 1. What patient management considerations are there? 2. What position modifications are necessary? 3. What precautions or special procedures need to be employed? D. How does the disability and associated problems affect the maintenance of dental health? 1. What oral hygiene procedures can and will be performed? 2. How will dental appliances be tolerated and cared for? 3. Will it be possible to establish a schedule of recall appointments which can be kept? 4
E. What is the prognosis for the future? 1. What is the prognosis for dental health and/or dental problems with and without treatment? 2. What is the risk and benefit of each procedure which might be indicated? IV. Treatment Plan A. What, when and how and who for each of the following: 1. Emergency treatment 2. Preventive program 3. Initial treatment 4. Future maintenance treatment 5
Dental Treatment Planning Considerations For Complex Patients Sample Case History Paul Glassman DDS, MA, MBA
Patient History 1. Identifying data: This 93 year old white female comes to your dental office by herself for dental treatment 2. Chief Complaint: She is complaining of a broken front tooth. 3. History of Present Illness The tooth broke about 4 weeks ago. She has not experienced any pain. She went to another dentist who tried to attach a false tooth in the space. It didn't last. She has now been without the tooth for 3 weeks and is very embarrassed about how it looks. She had a root canal and crown on this tooth about 7 years ago at the same time as other anterior crown and bridge work. 4. Past Dental History: She has had extensive dental treatment in the past including extensive crown and bridge, endos, and other restorations done 7 to 10 years ago. About 25 years ago she had periodontal surgery in all areas of her mouth. She has been having cleanings every 6 months, although her last dental treatment before this tooth broke was about 18 months ago. She had a "check up and cleaning" at that time. She has delayed coming in for treatment the last 18 months because of her fatigue. 5. Past Medical History: a. General Health: She gets tired very easily. This has gotten markedly worse in the last year. She has lost considerable weight in the last year and has spent weeks at a time in bed recovering from several URI's. b. Infectious Diseases: She has had a number of childhood diseases including measles, mumps, and chicken pox. She had pneumonia 20 years ago which resolved with antibiotics. She had "infectious" hepatitis 30 years ago and was hospitalized for 4 months recovering. c. Operations and Hospitalizations: 6 years old - tonsillectomy 14 years old - appendectomy 35 years old - fracture femur 61 years old - hysterectomy 63 years old - hepatitis in hospital for 4 months 73 years old - Pneumonia 75 years old - Myocardial Infarction 76 years old - placement of pacemaker 86 years old - CHF (congestive heart failure) - in hospital for 2 months 1
d. Chemotherapy: current medications are: digoxin -.2mg tid haldol - 200mg HS Insulin - NPH (intermediate acting), before breakfast and dinner Lasix (a diuretic) - 30mg bid e. Review of Systems i. Integument - recent hair loss, easy bruising, brittle nails ii. Lymph nodes - no enlargement, pain iii. Musculoskeletal - Fracture femur in automobile accident 48 years ago iv. Hematopoietic System - history of anemia in last 10 years. Needed blood transfusion one time 4 years ago v. Endocrine system - Diabetes Mellitus - She is has been Insulin dependent for the past 10 years. She was previously treated with diet and then oral hypoglycemics. vi. Immune system - history of eczema - she has used steroid cream for this but does not use it at present. vii. Head - occasional severe headaches and dizziness. No history of head trauma, seizures. viii. Eyes - wears glasses ix. Ears - mild hearing loss - occasional vertigo. x. Nose - no history of dryness, bleeding, or obstruction xi. Mouth - mouth feels dry. has had extensive dental treatment. xii. Throat - tonsils removed at age 6. No hoarseness or voice changes. xiii. xiv. xv. xvi. xvii. Neck - no swelling, nodes or stiffness. Respiratory system - hospitalized at age 73 with pneumonia. She recovered with antibiotics. Now occasional episodes of shortness of breath upon exertion. Can walk a block with no problem. Can't climb a flight of stairs without stopping once or twice. Cardiovascular system - history of MI, CHF, and placement of pacemaker. Cardiac arrhythmias are now controlled with pacemaker and medication. Genitourinary system - no history of nocturia, hematuria. Hysterectomy at age 61. Neuro-Psychiatric - fatigues easily recently. Sometimes becomes confused. Memory for recent events is noticeably worse in last few years. 2
6. Medical Prognosis: Her Physician feels that she could survive 5 years or more in spite of her extensive medical history although the severity of her illnesses may increase during that time. 7. Social History: Lives at her own home by herself. Has a daughter in the city who visits her about once per week. Her husband died 15 years ago. She hires a driver when she wants to go out. Her daughter feels that she may need to be in a more protected environment in the next few years. She has enough money to pay for whatever dental care is indicated. 8. Dental Findings: i. Extraoral examination and intraoral soft tissues are within normal limits. ii. gingival tissues are slightly inflamed with mild plaque and a little calculus behind the lower anterior teeth. There are scattered 4 to 5 mm pockets in the molar region and 2 to 3 mm of recession around the lower anterior teeth. iii. Tooth # 10 is broken at gum line. This tooth has had a root canal, and now has about 2 mm of decay at coronal surface of the root. There is a porcelain and gold crown on tooth # 9 and there is a porcelain and gold bridge from tooth # 11 to 13. Tooth # 12 is missing. iv. Tooth # 16 is impacted and has a moth eaten appearance to the crown radiographically. v. Teeth #'s 4 and 5 both have MOD gold onlays and root caries interproximally on the mesial and distal roots apical to the gold restoration. vi. vii. Her oral hygiene is good. All intraoral structures not mentioned above are in good condition. 3