Restoration(s) Needing Replacement or Modification
The American Dental Association developed these dental practice parameters for voluntary use by practicing dentists. The parameters are intended, foremost, as an aid to clinical decision making and thus, they describe clinical considerations in the diagnosis and treatment of oral health conditions. Evaluation in the context of these parameters includes diagnosis.
Additionally, parameters will assist the dental profession by providing the basis on which the profession’s commitment to high-quality care can be demonstrated and can continue to be improved.
The dental practice parameters are condition-based, presenting an array of possible diagnostic and treatment considerations for oral health conditions. Condition-based parameters, rather than procedure-based parameters, were determined to be the most useful because this approach recognizes the need for integrated treatments of oral conditions rather than emphasizing isolated treatment procedures. The parameters are also oriented toward the process of care and describe elements of diagnosis and treatment.
While the parameters describe the common elements of diagnosis and treatment, it is acknowledged that unique clinical circumstances, and individual patient preferences, must be factored into clinical decisions. This requires the dentist’s careful professional judgment. Balancing individual patient needs with scientific soundness is a necessary step in providing care.
It is understood that treatment provided by the dentist may deviate from the parameters, in individual cases, depending on the clinical circumstances presented by the patient. This should be documented and explained to the patient.
The elements of care that are described in the parameters were derived from a consensus of professional opinion. This consensus included expert opinion on the topic and the clinical experience of practicing dentists. In addition, the research literature, and parameters and guidelines of other dental organizations were reviewed.
The American Dental Association recognizes that other interested parties, such as payers, courts, legislators and regulators may also opt to use these parameters. The Association encourages users to become familiar with these parameters as the profession’s statement on the scope of clinical oral health care.
However, these parameters are not designed to address considerations outside of the clinical arena and, therefore, may not be directly applicable to all health policy issues.
Furthermore, these parameters are intended to describe the range of acceptable treatment modalities. They are intended as educational resources, not legal requirements. As such, the parameters are not intended to establish standards of dental care, which are rigid and inflexible, and represent what must be done; nor are they guidelines which are less rigid, but represent what should be done; nor are they intended to undermine or restrict the dentist’s exercise of professional judgment. In this context, considerable thought was given to the use of the verbs "may," "should" and "must." The verb "may" clearly allows the practitioner to decide whether to act.
The verb "should" indicates a degree of preference and differs in meaning from "must" or "shall" (which require the practitioner to act).
Throughout the parameter document, "dentist" refers to the patient’s attending dentist. Additionally, elements of the parameters concerned with patient consent refer to the patient’s parent, guardian or other responsible party, when the patient is a minor or is incompetent.
The Association intends to continually develop, revise and maintain parameters, in order to include all dental conditions and to accommodate advances in dental technology and science.
Adopted 1995, Revised 1997
The key element in the design of this set of parameters for restoration(s) needing replacement or modification is the professional judgment of the attending dentist, for a specific patient, at a specific time.
The patient’s chief complaint, concerns and expectations should be considered by the dentist.
Following oral evaluation (see limited, comprehensive, periodic, detailed and extensive evaluation parameters) and consideration of the patient’s needs, the dentist should provide the patient with information about restoration(s) needing replacement or modification prior to obtaining consent for treatment.
The dental and medical histories should be considered by the dentist to identify medications and predisposing conditions that may affect the prognosis, progression and management of restoration(s) needing replacement or modification.
Factors affecting the patient’s speech, function and orofacial aesthetics should be considered by the dentist in developing a treatment plan.
In developing a treatment plan, the dentist should consider that the etiology of restoration(s) needing replacement or modification may be multifactorial, characterized by craniofacial, musculoskeletal, stomatognathic and/or dental interrelationships that are dynamic throughout life.
The behavioral, psychological, anatomical, developmental and physiological limitations of the patient should be considered by the dentist in developing the treatment plan.
Restorative implications, carious lesions, pulpal/endodontic status, tooth position, and periodontal status and prognosis should be considered in developing a treatment plan.
Following evaluation, treatment priority should be given to the management of pain, infection, traumatic injuries or other emergency conditions.
When the dentist considers it necessary, (an)other health care professional(s) should be consulted to acquire additional information.
The dentist may counsel the patient concerning the potential effects of the patient’s health condition, medication use, and behaviors and/or habits on his or her oral health.
Medications should be prescribed, modified and/or administered for dental patients whose known conditions would affect or be affected by dental treatment provided without the medication or its modification. The dentist should consult with the prescribing health care professional(s) before modifying medications being taken by the patient for known conditions. (See: ADA Statement on Antibiotic Prophylaxis, Prevention of Bacterial Endocarditis: A Statement for the Dental Profession (PDF), and A-Z Topic: Antibiotic Prophylaxis.)
Any treatment performed should be with the concurrence of the patient and the dentist. If the patient insists upon treatment not considered by the dentist to be beneficial for the patient, the dentist may decline to provide treatment. If the patient insists upon treatment considered by the dentist to be harmful to the patient, the dentist should decline to provide treatment.
The dentist should recommend treatment; present treatment options, if any; and discuss the probable benefits, prognosis, limitations and risks associated with treatment, and the probable consequences of no treatment.
The dentist should refer the patient to (an)other health professional(s) when the dentist determines that it is in the best interest of the patient.
Relevant and appropriate information about the patient and any coordinated treatment should be communicated and coordinated between the referring dentist and the health professional(s) accepting the referral.
The dentist may take this opportunity to emphasize the prevention and early detection of oral diseases through patient education in preventive oral health practices, which may include oral hygiene instructions.
The dentist should determine the frequency and type of preventive treatment based on the patient’s risk factors or presence of oral disease. (See: ADA Statement on Sugar-free Foods and Medications)
The dentist should consider the characteristics and requirements of each patient in selecting material(s) and treatment(s).
Soft and hard tissue characteristics and morphology, ridge relationships, occlusion and occlusal forces, aesthetics and parafunctional habits should be considered by the dentist in the design of the restoration (prosthesis).
The dentist should consider the compatibility of the selected treatment with the surrounding oral tissues and should provide an environment accessible for maintenance.
The dentist should attempt to manage the patient’s pain, anxiety and behavior during treatment to facilitate safety, efficiency and patient cooperation. (See: ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists and Guidelines for the Use of Sedation and General Anesthesia by Dentists.)
Endodontic therapy may be performed by the dentist.
Local etiologic factors should be removed.
Periodontal procedures, including surgery, may be performed by the dentist to facilitate treatment.
Counseling and/or therapy for parafunctional behaviors which can contribute to defective restorations may be performed to facilitate treatment.
Occlusal evaluation, adjustments, guards and/or splinting may be used by the dentist to facilitate treatment.
The dentist may modify occluding, articulating, adjacent or approximating teeth or the tooth in question to facilitate treatment.
Alteration of tooth morphology and/or position; placement of restorations; modification or replacement of restorations; and treatment of associated carious lesions may be performed to facilitate treatment.
Fixed, removable, and/or implant-supported restorations (prostheses) may be repaired, modified or replaced, as determined by the dentist.
The dentist should communicate by prescription the necessary information for fabrication of the restoration (prosthesis) to the dental laboratory technician. Although the fabrication may be delegated, the dentist is responsible for the accuracy of the restoration (prosthesis).
Chemotherapeutic agents may be used by the dentist to facilitate treatment.
Pulpal tissue should be protected by the dentist when indicated.
Transitional or provisional restorations may be utilized by the dentist to facilitate treatment.
Teeth may be removed, as determined by the dentist. When appropriate, the patient should be informed of the necessity to replace any removed teeth.
The patient should be informed that the success of treatment is often dependent upon his or her compliance with the instructions, and his or her adaptability to and acceptance and tolerance of the restoration (prosthesis). Lack of compliance should be recorded.
The dentist should inform the patient that he or she should participate in a prescribed program of continuing care to allow the dentist to evaluate the effectiveness of the treatment provided and the status of restoration(s) that were replaced or modified.
Documentation of treatment provided, counseling and recommended preventive measures, as well as consultations with and referrals to other health care professionals, should be included in the patient’s dental record.