5.2 Treatment Planning & Patient Management

The Structured Treatment Plan

A defensible treatment plan follows a repeatable, auditable structure rather than a list of procedures. The canonical sequence taught for MFDS is:

1. Problem list — every diagnosed problem, including disease, aesthetic and functional concerns, and patient expectations.
2. Goals — what success looks like for each problem, agreed with the patient.
3. Options — the reasonable alternatives for each goal, including no treatment, with their risks, benefits and costs.
4. Sequencing — the order in which treatment will be delivered.
5. Recall and maintenance — ongoing review and prevention.

Phased Sequencing

The stabilisation phase is particularly important for the high-caries-risk patient: active disease must be controlled (caries removal, diet analysis, fluoride prescription, oral hygiene instruction) before definitive restorations are placed, otherwise new restorations will fail at the margins. Stabilisation also gives the clinician an opportunity to assess the patient's compliance and motivation before committing to complex, irreversible treatment.

Risk Assessment & the High-Caries-Risk Patient

A risk assessment informs every part of the plan: the disease control strategy, the recall interval, the preventive prescription and the choice of restorative materials. The NICE CG19 Dental Recall and SDCEP Oral Health Assessment and Review (OHAR) both use a risk-based approach rather than a blanket six-month recall.

Modifying Factors for Caries Risk

• Previous caries experience — the single best predictor of future caries.
• Diet — frequency of sugar intake is more important than total amount.
• Fluoride exposure — use of fluoride toothpaste and water fluoridation status.
• Saliva — xerostomia (medication, Sjogren's, radiotherapy) dramatically increases risk.
• Medical history — diabetes, eating disorders, gastro-oesophageal reflux, learning disability.
• Social history — socio-economic deprivation, limited access to care, family caries history.
• Plaque and oral hygiene — visible plaque and bleeding on probing.

Planning for the High-Caries-Risk Patient

A high-caries-risk plan weaves prevention through every phase:

1. Diet analysis — identify sugar frequency, agree realistic reductions, recommend sugar-free snacks.
2. Fluoride — prescribe 2,800 ppm or 5,000 ppm toothpaste (see Section 4.3), recommend 2.26% sodium fluoride varnish two to four times a year.
3. Oral hygiene instruction — tailored to the patient's dexterity and dentition; interdental cleaning for periodontal disease.
4. Stabilisation — remove caries, place well-sealed temporaries (e.g. glass ionomer), reassess at a short interval.
5. Definitive restoration — only when the patient demonstrates disease control.
6. Recall — 3-6 monthly while risk remains high.

Informed Consent & Shared Decision-Making

Informed consent is a process, not a form. Since Montgomery v Lanarkshire Health Board (2015), the legal standard in the UK requires the clinician to:

• Take reasonable care to ensure the patient is aware of any material risks of the proposed treatment.
• Take reasonable care to ensure the patient is aware of reasonable alternatives (including no treatment).
• Tailor the discussion to the individual patient, not to a notional reasonable patient alone.

A risk is material if a reasonable person in the patient's position would be likely to attach significance to it, or the clinician is or should be aware that this particular patient would. A quoted percentage is not sufficient on its own; the clinician must contextualise the risk by its nature, its effect on the patient's life, and the alternatives available.

Shared Decision-Making

Shared decision-making is the practical expression of Montgomery. The clinician brings professional knowledge of the diagnosis, the options and their risks; the patient brings their values, preferences and circumstances. The two are weighed together. For example, a singer may decline a lingual-flap lower third molar surgery because even a small risk of lingual nerve injury threatens their livelihood; an anxious patient may prefer a root canal under sedation over extraction and an implant.

Exceptions and Limits

• If a patient expressly does not wish to be told of risks, the clinician is not obliged to have the discussion, but should record the patient's wish.
• Far-fetched or fanciful risks need not be disclosed.
• The less urgent or more elective the procedure, the greater the duty to disclose risk.
• Capacity must be assessed under the Mental Capacity Act 2005; if a patient lacks capacity, treatment must be in their best interests under the Act.

Record-Keeping Standards

The FGDP(UK)/RCS England Clinical Examination and Record-Keeping guidance (formerly Good Practice Guidelines) sets the standard expected of a dental professional and is the benchmark used by the GDC and indemnity organisations when reviewing complaints or claims.

Minimum Content of a Clinical Record

• Medical history — updated at every course of treatment, including medications, allergies and relevant social history (smoking, alcohol, recreational drug use).
• History of the presenting complaint — in the patient's words where possible.
• Examination findings — extra-oral, intra-oral, soft tissue, periodontal (BPE), caries, restorations, occlusion.
• Special investigations — radiographs with justification (IRMER), sensibility testing, study models.
• Diagnosis — stated explicitly, not implied.
• Treatment options discussed — including no treatment, with risks and benefits.
• Consent — valid, patient-specific, and what the patient was told, not merely that a form was signed.
• Treatment carried out — including materials, batches (for implants), local anaesthetic type and batch, and any complications.
• Advice and prescriptions — drugs, doses, and written advice given.
• Follow-up and recall — the agreed recall interval and any review arrangements.

Records should be contemporaneous (made at the time or as soon as practicable afterwards), legible, accurate, and unchanged once written; any correction should be struck through with a single line, dated and signed. Records are a legal document and the clinician's principal defence in a complaint or claim.

Managing Patient Expectations

Patients may enter with expectations shaped by advertising, family advice or social media. Managing expectations is part of valid consent: the clinician should clarify what is realistically achievable, the maintenance required, the longevity of restorations, and the cost and time commitment. For complex plans, a written estimate and treatment plan summary, with risks and alternatives, helps align expectations and provides documentary evidence of the discussion.