The Fixed Prosthodontic Treatment Plan Worksheet is to be printed and filled out following the format shown in the completed example form below. This form can be completed when the patient is seen in Oral Diagnosis. It should certainly be completed by the student before the patient is brought to the clinic for fixed prosthodontic treatment planning. If there is more than one reasonable treatment option possible, i.e. a fixed bridge versus a partial, or substitution of either of these with implant(s), then a separate worksheet should be filled out for each option. This will allow the faculty to evaluate the treatment options, and help the student present all the possible treatment options to the patient for acceptance of one final treatment plan to be entered in the electronic patient record (EPR). All Fixed Prosthodontic treatment will be done in phase III of the treatment process, after all routine disease control, operative, endodontics, and periodontal treatment stabilization is completed. Treatment only in phase III, though, can be overridden by faculty if fixed treatment would stabilize a tooth or more than one teeth. A good example of this would be for a provisional restoration that can be done in phase II, before endodontic treatment, or to provide a cast dowel-core and temporization after endodontics to protect the tooth from fracture.

Each tooth involved in the treatment planning worksheet needs to be listed on a separate line. If a tooth is to receive both a cast dowel-core and crown, then each procedure would be listed separately.

Enter for each line on the form:

1. In the first column enter the SEQUENCE ORDER OF TREATMENT for each tooth listed. This will probably not be in the same order as in column two.
2. In the second column enter the TOOTH TO RECEIVE TREATMENT. These teeth are listed in numerical order.
3. In the third column provide a brief description of the proposed FIXED PROCEDURE (MCR, FGC, Cast Dowel-Core) to be done on that tooth.
4. In the fourth column provide the specific axiUm PROCEDURE CODE (6792 etc.) for the proposed treatment.
5. In the fifth column provide a brief description of the REASON FOR FIXED TREATMENT (FPD retainer, Caries MOD).
6. In the sixth column enter the ENDODONTIC STATUS OF THE TOOTH to be treated by entering either vital (V) or non-vital (NV). (Test to confirm vitality-do not assume vitality just because there is an absence of guta-percha!)
7. In the seventh column enter any PRE-FIXED PROSTHODONTIC TREATMENT REQUIREMENTS (e.g. periodontal treatment to stabilize patient, crown lengthening, endodontics, extraction, or an amalgam core). If insufficient space is available, write additional information in the comments section below.
8. In the eighth column enter if this treatment will be an RPD ABUTMENT with a yes (Y) or no (N).
9. In the ninth column enter a brief assessment of the PERIODONTAL CONDITION of the tooth or teeth to be restored (e.g. out of the ordinary findings, e.g. furcations, 4.0 mm or greater pocketing).
10. No completion date will be entered on this form, since the worksheet will be used only to organize and determine a set of proposed Fixed Treatment Plans to ascertain a final treatment plan that the patient selects and approves to be entered into their Electronic Patient Record in axiUm. Instead this column would be a convenient place to enter the fees for each procedure.

Bring the completed worksheet(s) to your fixed appointment so these preliminary treatment plan options for your patient can be evaluated by your treatment planning faculty, or to your Group Practice Director to coordinate this proposed fixed treatment, after one treatment plan is selected and has been accepted by the patient. If cost is a decisive factor for the patient's decision process on fixed treatment, it would be advisable to have the axiUm Treatment Procedure codes and respective costs estimates for these proposed procedure(s) available to help your patient to select a single desired treatment plan for the EPR. There can be only one active treatment plan approved by the patient in the EPR.

Remember that the optimum treatment plan will be selected through consultation with faculty, and the patient. Any factors that might complicate this treatment should be noted in the comments section of the form. Also any significant conditions from the patient's medical history that could influence the treatment plan should also be noted in the comments portion of the form. Proposed need for any Diagnostic Wax-ups should be noted on the worksheet by the student.

Click on the following example of a completed Fixed Prosthodontics Treatment Planning Worksheet, and a blank worksheet form will appear in a new window that is opened. This blank form is a printable form that can be printed on any available printer in the clinic, which will allow you to obtain as many forms as you need for your patient's potential treatment options.