Recommended use pattern for many-to-one treatment-to-problem

[alkhaef]

Hi all.

Conceptual question here...

I've looked through some threads as well as contacted support for some good answers to this, but couldn't really find any. I see some references to "conditions" which sounds right for what I'm looking for, but it doesn't appear to be. Anyway, I decided to throw this question out for any input from the forums.

There are many cases where one problem can have many potential treatments to solve it. During diagnosis, it hasn't yet been determined which road will be taken (often because it depends on what the patient will accept after presentation of their diagnosis). Examples of this include:
- Veneers vs clear aligners for spacing in some cases
- Different types of fillings for cavities
- Different types of crowns
- Bridge vs implant
...and many many more... on channel four...

Does anyone have any insight on how to best handle this? What I mean is...
- What's done during charting?
- How are treatment plan options generated based on that?
- How is any residue (if any) cleaned up?
- (Planned) appointments...
- When does what get done?

What we're currently doing isn't very methodical. Sometimes both options are thrown in during charting, with one to be deleted later... Sometimes just one...

I'd like to develop some strict policies for everyone to follow to make this a lot smoother.

Thanks in advance!

[jordansparks]

This is covered on some other threads which I would have to dig for. Our recommendation is to discuss it orally with the patient and get a feel for which way they are leaning. Otherwise, you waste a lot of time entering procedures that will never be done.

Now, if you really want to create alternate TPs. You can enter all the procs, then save 2 different TP with just some of the procs on each TP. Once the patient makes a decision, you delete the declined procs. There are some feature requests to enhance this process, such as by adding a declined or alternate status for procs so that you don't have to delete the extra procs. Another request is to show both alternates on one page instead of having to print out the two different alternates.

[Pruce Dental]

Jordan...

Not trying to be a pain in the butt here but...

I know that you can guess which way a patient is leaning many times when writing a treatment plan or make multiple treatment plans etc. but what about the patient's that choose no treatment? What about the ones that just stare at you with a duh look on their face when asking if they want an endo or extraction because they say they cannot decide?..what about the ones that are not grown up enough to say they are not interested in treatment and the ones that come right out and say no to treatment?...

I asked in a different thread about conditions recently...I wish you would develop this further. So how do you document your diagnosis of the patient that doesn't accept treatment if you just use a single diagnosis code of caries on the treatment plan (not even charting the surfaces with caries)...after they don't accept the treatment plan eventually your just going to delete the treatment plan and lose the diagnosis right? I though that charting pathology and conditions was a legal requirement of dentists?

Reason I ask is I recently had a mother and two kids as new patient's. The son and daughter both had 4 carious lesions. The mom needed almost every tooth in her head crowned. Mom said that they didn't have any money for even the kids $50 deductible for their restorations that were covered then at 100%...this is after I listened to the kids tell me that the daughter goes to gymnastics 3 times per week, the brother plays baseball on two different summer leagues, he plays hockey twice weekly and has money for ice time, the family was going to the beach in a real nice expensive area for a week next week and they went last month on a 10 day cruise...so when mom says no to the expensive $50 deductible now the kids charts have no treatment plan..how do I record the caries?

[jordansparks]

The ones that chose no treatment get a priority on the procedure that says declined. It would be set to show a light gray text so it was obvious. Then they get reminded about it at every visit because it remains on the TP and it becomes a barrier to further treatment planning.

If they cannot decide, they get left in the room for 5 or 10 minutes while the assistant explains all the options one more time. Clearly, they do not yet understand the options well enough so they need more one-on-one discussion rather than a piece of paper and a rush out the door. After repeated review of the options, it is very rare for someone to still not be able to decide. Asking them point blank if they can afford the extra $1000 for the RCT is one quick way to help them decide.

If the tooth requires treatment, they do walk out the door with a TP showing that they need treatment on that tooth. Even if they can't decide or decline.

So, using your example, the mom says she has no money for herself or her kids. In every such situation, the TPs for the children should show all treatment required, each with a diagnosis. This is not something that she should be able to "decline". It always stays on the TP in bright red. For her, you clearly would not TP every crown. A good way of handling this is in the box right below the 3D chart, type something like this:
Phase 1, #2,3,5,6,7,8,9,11,12,14 caries. A phase 1 patient typically doesn't get a full TP. They get a TP showing what can reasonably be done in 6 months. So after extensive discussion with her, you might decide to do composites on some of the anteriors and a few extractions in the back to prevent infection.

[jordansparks]

After rereading your post, you might have meant that the mom had extensive failing/at-risk restorations rather than meth mouth. She's been like that for years and many dentists have told her she needs crowns. So you would TP the 4 teeth that were actively failing and make the following note below the 3D tooth chart: Phase 1. Most teeth need crowns.
So she's still a phase 1, but just of a different type. Putting 20 crowns on her TP isn't going to help her.

[Pruce Dental]

Thanks Jordan...

My trial conversion does not have the declined option..I assume that I can just go into the definitions and add a "decline" option and then set the text to light gray...I assume that I do not set the paint type for the surfaces to gray correct?

The thing that bothers me is that maybe someone has an open margin on a crown...they don't get it replaced..I treatment plan it..I save a declined treatment plan...after three years have passed I forget to read through all the historical saved treatment plans...maybe that crown margin was slighly open and in a gray area if it should be replaced or not to begin with...then three years later I look at it and it doesn't look any worse and I accidently tell them that everything was good and document that no problems were found and no treatment was needed in my progress notes.


another quick question...if i do not set up charting conditions I will only be able to record one diagnosis correct?...If a tooth has caries and open margins do you just manually type the secondary condition like open margins in the "notes" field positioned about the Topez signing filed on the "procedure info" screen or is there a better quicker way to access this info?

I guess I am just going to have to retrain my brain...between dental school and the past 15 years of charting caries on paper or in Sofdent...my brain looks at a treatment plan in Open Dental and sees a two surface OL composite is treatment planned on tooth #2 with an exisiting old amalgam with a diagnosis of caries...then my brain says are the caries on the lingual or the occlusal or both? ....I know that I am going to prep both surfaces and it probably doesn't make any clinical difference but my brains says this is not right..maybe I need therapy...

[jordansparks]

"decline" would be a TP priority that you add in definitions, right. It would still be visible on the default TP as well, so you won't forget it. I agree that it would be better to document where the caries is on recurrent. The more information the better. But OD just isn't optimized to make that fast. You can do it if you take extra steps, but I don't feel it's currently worth the effort for you. If you think you will forget why you are redoing the filling, you could make a quick note in the procedure note of the TP item. Especially for a crown.

[Pruce Dental]

Jordan...

more examples of why I can't move beyond charting conditions...

If I treatment plan a patient for a posterior composite (MO) then the patient returns a few weeks later for treatment...I can see the mesial caries on the radiograph but I will have to stop and rediagnose the occlusal surface to decide if a proximal box preparation is enough or if the complete occlusal needs done.. since I have no record of what surfaces have caries

Now what happens if a tooth has occlusal caries and an incepient proximal lesion...most times you would just include the incepient lesion while taking out the occlusal caries but if there were no occlusal caries you would watch the lesion right?...so again there is no record of which surface had the caries...so what happens if some insurance company like United Concordia decides your statistically doing .001% more posterior composites than other dentists..if they audit that chart they are going to say that you treated an incepient lesion that did not require treatment and your chart has no documentation that there was occlusal caries and they will pick a sample of 10 charts and then say you did 10% too many posterior composites so they want a check for $25,000.

It sounds like with OD I am going to still want to use conditions. I was wondering if there was anyway to convince you to add a conditions paint type that consisted of some lines or pattern in black (or some other unused color) that we can select for caries and maybe another pattern or color that could be selected for defective restorations. It would be great if there were some lines or patterns that could be superimposed over the existing restorations or treatment planned items so the existing restorations or treatment planned items were still visible and the caries pattern disappeared once a new restoration was charted on the tooth. Would also be great if you could chart caries and open margins graphics on the same tooth and have both conditions show. Any chance I can convince you to add this feature?

Anybody else want Jordan to do this with conditions?

[drtech]

I already do this and you can already do it too:

Set up a procedure coded called "cavity" or "decay" or whatever you want. Set the override color to something clearly visible (i use light pink) and the paint type to surface. Make a procedure button in your chart with this code and then use this for recording decay. In fact you can set up all kinds of diagnostic codes (like "tender," " incipient decay," "hopeless tooth," "wear on tooth," "cavity to the nerve," "TMJ problems," etc...) to use in your charting. This code then stays with the tooth, but get overwritten graphically when you tx plan the filling and subsequently complete it.

Is this what you are looking for?

[DavidWolf]

I use this same system.....

One thing that I just noticed is if you try to test it the graphic of the condition stays on the chart when you add the treatment planned procedure and also stays painted like the condition when you complete it.

I don't think that OD expects you to do them all on the same day and may be confusing which procedure wins the paint battle.

[drtech]

I think if jordan changed it to included paint priorities for TIME of entry that would solve the problem

[Pruce Dental]

I already do this and you can already do it too:

Set up a procedure coded called "cavity" or "decay" or whatever you want. Set the override color to something clearly visible (i use light pink) and the paint type to surface. Make a procedure button in your chart with this code and then use this for recording decay. In fact you can set up all kinds of diagnostic codes (like "tender," " incipient decay," "hopeless tooth," "wear on tooth," "cavity to the nerve," "TMJ problems," etc...) to use in your charting. This code then stays with the tooth, but get overwritten graphically when you tx plan the filling and subsequently complete it.

Is this what you are looking for?

Yes..I have placed with that with my trial conversion but if I set one condition like caries to pink and another condition like open margins to purple for example the last one entered shows only...it would be better if both conditions would show until the conditions were covered with a new restoration...If Jordan made a color in the form of slash lines that would superimpose over a restoration for caries and maybe some different pattern for open margins you could look at a tooth and see that there was an exisiting amalgam, know what surfaces were open and know what surfaces had caries all in one glance at the graphical picture...the conditions could even be set to show thru on treatment planned items or if somebody wants to see the exisiting chart only they can go in the "show" area and uncheck the treatment plan option. As it is now if you are charting more than a single condition (ie both caries and open margins) you know that there is a condition on the graphical chart but there might be two conditions on that tooth for all you know so you have to manually check thru the progness notes side of the chart to see what is actually going on in the chart.

[jordansparks]

Off topic, but it's not just me doing the programming. We have 5 programmers, and I'm seriously debating hiring a 6th within a day or two. Now back to the issue.

One thing we've been planning is outlines around regions on the tooth. This is harder than it sounds because it involves defining a narrow strip in 3D, dividing the strip into segments, and then using logic to decide when to draw each strip segment. But if it all works out, then the user could cause the line segment in a very specific area to show a different color than the restoration. This would beautifully show recurrent caries.

As for multiple conditions at the same location where graphics is not enough, that could be solved by hover text.

[Pruce Dental]

Thanks Jordan...!!!

[jordansparks]

Make that 6 programmers.