DIAGNOSIS AND TREATMENT PLANNING

Introduction.

If the patient attends his family general practitioner for orthodontic advice, the dentist because he knows the patient's dental background - will already be acquainted with a number of relevant matters such as dental mindedness, cooperation, family relations and financial circumstances.
On the other hand if the general practitioner is being consulted by a patient he has never seen before the consultation is divided into three visits. A first consultation is when the patient presents himself at the office, during which such matters that the family dentist normally knows are discussed. A separate visit is arranged for a full examination such as the collection of administration data, taking a history the external and intra - oral examination, diagnostic aids such as taking impressions and request for panaromic and cephalomatric radiographs. A through study of all the facts collected is done and a third visit is planned to present the case to the patient and parent and a decision is taken whether to treat or not to treat the patient.


DIAGNOSTIC TREATMENT CHART

A good comprehensive examination is carried out by having a check list of points that may need investigation. Relevant finds should be recorded and all information obtained from the various diagnostic aids be collected before a decision is made. A Diagnostic treatment chart serves as a record into which all the diagnostic data are entered. This aids in the diagnosis, treatment planning and presentation of the particular case. Notations are made in the record as the treatment is carried through. At the completion of the treatment the Diagnostic treatment chart is filed complete with all the finishing data recorded along with initial and final photographs and cephalomatric tracings.
(The Diagnostic treatment chart used for the patient is the one used by the members of The Alexander Discipline Study Club of Malaysia.) For the convenience of the reader, a loose-leaf version is added which can be perused in conjunction with the text that follows in the remainder of this book.

ADMINISTRATIVE DATA.

Administrative data are generally entered by the dentist's chair side assistant. Most of the points are self explanatory.


Informed Consent: The purpose of this section is to enlighten the practitioner with a basic understanding of the concept of informed consent and why this must become an essential part of the orthodontic records. At the end of this section a sample of customized document entitled, “Information and Informed Consent", is added.

Definition of Informed Consent: This is consents obtained after disclosure of all information which are sufficiently complete and accurate so that a reasonable, competent person can make an intelligent decision on their future treatment The patient must be given sufficient information to make a informed decision regarding his treatment No treatment should commence without the patient's or parent's total agreement and cooperation.


Criteria for informed consent

Following are some of the information that must be given to the orthodontic patient in order for him to make an intelligent decision regarding the giving of consent of treatment.

1. The diagnosis and treatment plan must be thoroughly explained.
2. Discuss the benefits of the treatment.
3. Inform the risks involved.
4. Alternate treatment plan if any
5. The prognosis of the case if no treatment is done.
6. Information must be presented in an organized, systematic manner and easily understood by the patient.
7. Document must be signed by the patient or parent.


Diagnosis and treatment plan

Orthodontic is a time consuming treatment which can take several years or months. All details of the diagnosis, prognosis and the treatment plan must be explained to the patient. It is also important to discuss with the patient the different phases of the treatment and what the practitioner intents to accomplish at the end of each phase. It is also essential to discuss the treatment charges for each phase


Benefits of treatment

A pleasing smile, straight teeth, less TMJ symptoms, improved nasal breathing, improved profile, pleasing appearance, improved self esteem etc. are some of the benefits of treatment. These should be conveyed to the patient.


Risk of Orthodontic Treatment.

Possible risk associated with orthodontic treatment to be discussed with the patient is one of the essential parts of the informed consent procedure. Some of the associated risks are:-

1. Increase incidence of caries.
2. Periodontal diseases.
3. Decalcification due to poor oral hygiene.
4. Loss of tooth vitality especially when the tooth has been previously traumatized.
5. Occurrence of TMJ problems.
6. Relapse.
7. Need for further treatment such as orthognathic surgery.
8. Difficulty in the management of functional problems such as persistent anterior tongue which could result in anterior open bite.


Limitation of treatment.

Patient must emphasized that orthodontic is not a perfect science and the result may not last a life time. Limitation to the success of treatment can be due to several factors such as.
1. Compliance problems.
2. Severe skeletal problem
3. Relapse problem.
4. Severity of malocclusion.


Alternate treatment plan.

There are always different options to treat an orthodontic case. It could be the conventional approach, functional approach, a combination, extraction or non extraction approach. Whichever approach is chosen. All treatment philosophies and treatment techniques must be discussed with the patient prior to the commencement of treatment.


Prognosis if no treatment is done.

The patient must be informed frankly and honestly the consequences of not undergoing treatment. This could depend on the severity of the malocclusions.


Patient asks questions.

At the end of the procedure the patient is encouraged to ask questions and communicate freely with the doctor regarding his future treatment. Hence it is ideal to set this appointment at the end of the day when there will be no interruptions.


Conclusion

The importance of informed consent is discussed. This procedure does not end with the patient signing the document Infect this is only the beginning of the Doctor patient relationship which must continue throughout the entire treatment. Dentist by training and by patient expectation, are primarily therapists and so they often launch into action before rendering a complete diagnosis. For many patients, the etiologies and remedies of problems are obvious, and the ensuring progress of treatment and management causes few problems. But whenever the diagnosis is obscure or difficult, patients will suffer from our haste and the practitioner is often baffled about ineffective regimens. The most grievous mistake one can make is that from misdiagnosis. One can easily overcome errors of mechanics, but have much more trouble correcting a wrong diagnosis. Nevertheless, a sound diagnosis remains the foundation of all successful therapy, and it remains the primary responsibility of conscientious clinicians


Patient History

Orthodontic treatment must only be iniciated on patients who are in good health. It is unwise to subject an unhealthy patient to the demands of the orthodontic treatment as there bound to be compliance problems broken appointments due to illness and at times neglected oral hygiene.

At this point it is also essential to note if the patient is on any medication or if he is undergoing any treatment. it ia appropiate to throughly discuss the situation with the patients parant and his physician


Medical History

In this section, the practitioner should note any existing medical condition such as allergies , tonsillitis or sinus related condition that may hinder orthodontic treatment. The severity of the condition should be noted and it is a good habit to consult the patient's physician before iniciating any treatment.


Dental History

A through dental history is essential for the success of the orthodontic treatment. It is important to look into the possibilities of existing habits such as mouth breathing, tongue thrust, thumb or finger sucking, lip sucking or biting , use of dummies abnormal lip position and activity and other habits.


TMJ Analysis.

Look for the existence of TMJ signs and symptoms. It is essential to note the presence of pain trigger spots clicking of the joints or the presence of crepidus. Deviation of the mandible on closing is noted and recorded. The maximum opening of the jaws is measured and noted.It is essential to inquire the presence of tension headache and whether the patient is under treatment or otherwise.


Panaromic Radiographs.

The applications of panaromic x - ray are as follows:
· Determination of the dentition present.
· Teeth that will be erupting.
· Missing teeth and supernumerary dentition noted.
· Impacted teeth usually upper cuspids or upper and lower third molars.
· The current status of the third molars is evaluated.
· The root apex of each tooth is examined in order to analyze possible potential for root resorption.
· Pre - treatment bone loss espcially in adult patients who might be having periodontal conditions.
· Any other patholigical conditions.