20.1 Treatment Planning and Sequencing

Why Sequencing Is Examined

Paper B frequently gives a complex case and asks what should be done first. The expected answer almost always follows the same hierarchy, because building restorations on active disease guarantees failure and because the GDC requires a written treatment plan and cost estimate before treatment begins.

The Standard Sequence

1. IMMEDIATE / EMERGENCY      Relief of pain, drainage of infection, management of trauma,
                              treatment of acute conditions
             ▼
2. STABILISATION / INITIAL    Caries stabilisation, extraction of unsalvageable teeth,
                              oral hygiene instruction and behaviour change, dietary advice,
                              smoking cessation, non-surgical periodontal therapy,
                              endodontic treatment where needed
             ▼
3. RE-EVALUATION              Periodontal re-assessment at 8 to 12 weeks, review of
                              plaque and bleeding scores, reassessment of prognosis
             ▼
4. DEFINITIVE / RECONSTRUCTIVE  Definitive restorations, crowns, bridges, dentures, implants,
                              orthodontics
             ▼
5. MAINTENANCE                Supportive periodontal care, risk-based recall, ongoing
                              prevention

Four rules follow from this and are tested repeatedly:

1. Never place a definitive indirect restoration on a tooth with active periodontal disease or an unresolved pulpal diagnosis.
2. Never plan around a tooth of hopeless prognosis. Decide its fate before designing the restoration, bridge or denture that would depend on it.
3. Stabilise before you reconstruct. Caries stabilisation with glass ionomer or a provisional restoration is a legitimate and often correct intermediate step.
4. Periodontal re-evaluation happens at 8 to 12 weeks, not at the next available appointment.

Prognosis and Deciding to Extract

Prognosis is assigned tooth by tooth and drives the plan. Factors that worsen it include:

• Periodontal — attachment loss beyond about 70% of root length, mobility grade 3, through-and-through furcation involvement, residual deep pockets after therapy
• Endodontic — untreatable canal anatomy, perforation, vertical root fracture
• Restorative — inadequate ferrule that cannot be created, subcrestal caries, insufficient remaining coronal tissue
• Patient — inability to maintain the restoration, high caries rate, smoking, uncontrolled diabetes

A tooth may be technically restorable and still be the wrong tooth to restore, and explaining that distinction to the patient is part of valid consent.

Options and Consent

Every plan must present the realistic options, including the option of no treatment with its consequences. Montgomery requires disclosure of material risks for each option, and GDC Standards Principle 2 requires a written treatment plan and an itemised cost estimate before treatment begins, with a revised plan and estimate if the plan changes materially.

For a single missing posterior tooth the options presented would normally be:

Multidisciplinary and Referral Decisions

Preparing for Practice outcome 1.5.5 requires referral "when and where appropriate", and outcome 1.7.9 requires understanding of referral networks. A referral letter should state the reason for referral, the relevant history and findings, the treatment already provided, the urgency and what is being asked of the recipient. Common referral triggers include suspected malignancy under the urgent suspected cancer pathway, complex surgical extractions with nerve injury risk, periodontitis not responding to properly executed therapy, and patients whose medical complexity exceeds the primary care setting.

Exam link. A stem describing a patient with generalised bleeding on probing, 6 mm pockets and a request for anterior crowns is testing sequence. The correct first step is periodontal therapy and re-evaluation, not crown preparation, because crown margins placed in inflamed tissue will fail and may violate the supracrestal attachment.

Stabilisation Before Reconstruction

The sequencing principle that examiners test repeatedly is that disease is controlled before function and aesthetics are restored. A patient with active caries, untreated periodontitis and a failing dentition does not receive crowns and bridges first; they receive emergency relief of pain, then caries control with provisional restorations, then periodontal therapy and prevention, then re-evaluation, and only then definitive restorative work. Building fixed prosthodontics on an unstable foundation is the classic wrong answer, because the substrate for the restoration — the tooth and its periodontium — will continue to deteriorate beneath it.

Re-evaluation is an explicit stage, not an afterthought. After initial periodontal therapy, the patient is reassessed at eight to twelve weeks; after caries control, the response to prevention is assessed before deciding which teeth are restorable. Prognosis assigned at the first visit is provisional, and teeth of questionable prognosis are often retained through the stabilisation phase so that the response to treatment informs the final decision.

Deciding Between Restoration, Extraction and Monitoring

Every plan involves the choice between doing something, doing nothing and doing something less. The examinable factors in deciding whether a tooth is restorable are the amount and distribution of remaining sound tooth tissue, the availability of a ferrule, the periodontal support and mobility, endodontic status and the accessibility of the canal system, the tooth's strategic value in the arch, and the patient's ability to maintain it. Strategic value is often decisive: a heavily broken-down second molar in a patient with an otherwise intact dentition and a stable occlusion may reasonably be extracted, whereas the same tooth as the sole posterior abutment on that side would justify complex treatment.

The shortened dental arch concept is directly examinable as the evidence-based alternative to replacing every missing tooth: for many adults, a dentition of anterior and premolar teeth in occlusion provides adequate function, comfort and aesthetics without distal extension prostheses, and this is a legitimate planned endpoint rather than neglect.