DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION I

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DIAGNOSIS, TREATMENT PLANNING, AND CASE
CONSULTATION I

• CLINICAL DECISION-MAKING

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SCENARIO

• 330 P.M., September 16, 2000
• Commonwealth Stadium
• Roar over the stadium as the CATS have just
  completed a short pass.
• Score is 17-14 in favor of Indiana.
• It is now 4th down and the football is on the 4
  yard line of Indiana with 1 yard to go for a
  first down.
• Quarterback Lorensen looks at Coach Mumme.
• What does Coach Mumme do?

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A Data-Based, Phased, Problem-Oriented,Scientifi
c System for Making Treatment Decisions
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Clinical Decision-Making,Treatment Planning,
andCase Consultation Are The...

• Essence of clinical practice.
• Sun of the solar system of clinical practice.
• Core of the planet of clinical practice.
• Heart of the organism of clinical practice.
• Soul of the life of clinical practice.
• Hub of the wheel of clinical practice.
• Nucleus of the atom of clinical practice.
• and/or any other metaphor you want to employ to
  recognize their centrality in practice.

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Decisions . . .
Decisions . . .
Decisions . . .

• We all make them and most of the time it seems
  like a straight-forward process.
• How do we learn to make decisions? Mostly by
  trial and error.
• While this may be a functional way to learn, it
  means many poor decisions are made while learning
  proceeds.
• Additionally, inappropriate decisions may be made
  later because learning did not proceed far enough
  or fast enough.

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Clinical Decision Making

• Treatment planning is a basic component of the
  clinical practice of dentistry.
• Observations during examination focus on problems
  for which therapy must be planned.
• Treatment planning is the vital link between
  diagnosis and treatment.
• Frequently, however, treatment is devised from a
  simplistic, mechanistic perspective.

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Intention...

• To present a model for thinking about clinical
  decisions which can provide a conceptual
  framework for understanding the multifaceted,
  interactive nature of the process, as well as
  provide a means of applying systematic,
  analytical scientific decision- making skills.
• The system is characterized as being data-based,
  phased, problem-oriented, incorporating a
  scientific decision style.

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• There is nothing morepractical than a good
  theory.

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Science Is A Way of Knowing, Thinking,
Understanding, and Creating

• Thinking Critically (Scientifically) About
  Clinical Decision-Making In Dentistry

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Living As Problem Solving

• Regularly and frequently (daily) in life we
  confront circumstances in which we must make a
  decision. The necessity of making such a decision
  is, in its essence, the presentation of a
  problem a problem which we now must solve.
• No one thinks unless presented with a
  problem.
  John Dewey

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Gathering Information

• The problem that has presented itself to us is
  the result of some information that has come to
  our awareness.
• No doubt the information we have is inadequate to
  deliberate comprehensively about the matter, so
  the first step in a scientific decision making
  process is to gather (more) information.
• We may call the facts we discover in our
  gathering of information our FINDINGS.

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Identifying or Stating the Problem

• Our FINDINGS of fact should now enable us to
  identify or state the problem more explicitly.
• We can say that the additional information we
  gathered allows us to interpret the situation or
  circumstance we had encountered into an explicit
  STATEMENT OF THE PROBLEM.

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State the Basic GOAL or OBJECTIVE

• A problem is really only a problem if it is a
  circumstance that in some way impedes the
  achievement or fulfillment of a need or desire.
• Not infrequently we are not sure what the need or
  desire we have that is being thwarted really is.
  Therefore, we must work to make explicit in our
  minds specifically what our goal is in this
  circumstance.
• The PROBLEM STATEMENT must be translated into a
  GOAL STATEMENT.

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Identify the Basic Facts, Assumptions, and
Constraints

• Facts are statements of things that are known.
• Assumptions are applied to factors which can be
  changed to simplify the problem and make it
  solvable.
• Constraints are factors which affect the outcome
  of the situation and cannot be changed.

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Generate Possible SOLUTIONS

• This is the time for creative thinking.
• Dont prejudge ideas as they are generated.
• Identify all the different potential ideas that
  may resolve the problem and achieve the desired
  goal. These are your TREATMENT ALTERNATIVES.

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Analyze ALTERNATIVES

• Analyze the various ALTERNATIVES to evaluate
  which of them holds the most promise of achieving
  the desired goal, and can do so with the most
  advantageous cost/benefit result.

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Synthesize Elements of the SOLUTION

• Most any SOLUTION to a PROBLEM will have more
  than one element.
• Separate the chosen SOLUTION into meaningful
  elements.
• Gather additional information you may need to
  further develop each element.
• Combine/Synthesize the elements to create a
  detailed SOLUTION.

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Critique the SOLUTION

• Does it satisfy the basic GOAL or OBJECTIVE?
• Is it feasible, practical, economical, safe?
• Is it moral/legal?

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Communicate the Result of Decision-Making

• Report to appropriate individuals the result of
  what you have considered, and decided (or are
  recommending).
• Determine the information needs of the person to
  whom you are reporting the decision.
• Communicate only that information to others that
  they need to know. Dont overwhelm.

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Implement the Decision

• What should be done now, what is the next step?
• What is required logistically to resolve the
  PROBLEM and achieve the GOAL?
• Are there any impediments to implementation, and
  if so, how can they be removed?

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Evaluate the RESULTS

• Did the SOLUTION work?
• Was the PROBLEM resolved?
• Was the GOAL or OBJECTIVE achieved?

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The Butterfly

• A Model forClinicalDecision-Making

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Scientific Decision-Making in Clinical Dentistry

• Gather Information
• Identify the Problem(s)
• State the Goal(s) of Therapy
• Identify the Basic Facts, Assumptions,
  Constraints
• Generate Alternatives
• Analyze Alternatives
• Make Decision/Recommendation
• Critique the Decision/Recommendation
• Communicate The Decision/Recommendation
• Synthesize Components of Decision Into Detailed
  Solution
• Implement Therapy
• Evaluate the Results of Therapy

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Office Dynamics

• Diagnosis Appointment
• Consultation Appointment
• Treatment Appointments
• Post Treatment Appointment
• Recall Appointment
• ------------------------------
• Emergency Appointment

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The Dental Record

• Registration Record
• Case History Record
• Health History
• Dental History
• Clinical Examination Record
• Radiographic Record
• Problem/Plan Record (If Utilized)
• Treatment Plan Record
• Written Consultation Record
• Parents Notes Page
• Supplemental Records, (When Necessary)
• Such as, Space Analysis Record
• Treatment Record/Progress Notes

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Diagnosis Appointment

• Defined Data Base
• Data Analysis
• Supplemental Data Base

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Defined Data Base for the Child Patient

• Case History
• Health History
• Dental History
• Clinical Examination
• Behavior Assessment

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Analysis

• Analysis refers to examining the information
  learned from the defined data base to determine
  if the information is adequate and complete for
  identifying all problems or potential problems.
• Questions such as what, when, where and how are
  appropriately asked.
• Analysis may result in an appreciation that all
  relevant information required for a thorough
  diagnosis is not available and additional
  information must be gained.

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Supplemental Data Base

• Radiographs
• Diagnostic Casts
• Clinical Photographs
• Space Analysis
• Dietary Analysis
• Pulpal Vitality Tests
• Water Analysis for Fluoride Content
• Laboratory Blood Studies
• Consultation with other Health Care
  Professionals

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FINDINGS

• The results of all of the information gathered
  through the defined and supplemental data bases
  is referred to as the FINDINGS.
• FINDINGS have been called the focal point of
  oral diagnosis.

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Four Dimensions of Oral Health Problems

• FINDINGS from the information gained patients
  data bases are interpreted into problems of
  oral health in one of four dimensions
• Immediate Problems
• Problems of Prevention
• Problems of Rehabilitation
• Problems of Maintenance

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Immediate Problems

• Health Constraints
• Parental Concerns
• Critical/Emergency Circumstances
• Problems of Diagnostic Evaluation
• Management of Behavior

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Problems of Prevention

• These problems relate specifically to the
  etiologic factors of dental pathology
• host
• microflora
• substrate
• education/motivation

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Problems of Pathology, Development and
Reconstruction

• Dental Caries
• Pulpal Pathology
• Periodontal Disease
• Craniofacial/Occusal Disharmonies
• Oral Pathoses
• Developmental Anomalies

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Problems of Maintenance

• Oral health must be maintained, once gained.
  Key concepts at this level of problem definition
  and resolution are
• Review
• Education/Motivation
• Periodic Evaluation
• Monitoring Unresolved Problems

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Explicating the Process

• PROCESS PRODUCT
• Data Collection FINDINGS
• Interpret STATEMENT OF
  PROBLEM(S)
• Translate STATEMENT OF
  GOAL(S)
• Define SPECIFIC
  LISTING OF PROBLEM(S)
• Generate TREATMENT
  ALTERNATIVES
• Analyze TREATMENT
  JUSTIFICATION
• Interpret SPECIFIC PLAN
• Criticize OPERATIONAL
  TREATMENT PLAN
• Communicate
  CONSULTATION/INFORMED CONSENT
• Implement TREATMENT
• Evaluate NEW FINDINGS