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Preamble

Adopted 1994

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.

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Parameters

Adopted 1995, Revised 1997

The key element in the design of this set of parameters for malocclusion is the professional judgment of the attending dentist, for a specific patient, at a specific time.

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 malocclusion prior to obtaining consent for treatment.

The patient’s chief complaint, concerns and expectations should be considered by the dentist.

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 malocclusion.

In developing a treatment plan, the dentist should consider that the etiology of malocclusion may be hereditary and/or multifactorial, and may be characterized by craniofacial, musculoskeletal, stomatognathic and/or dental interrelationships that are dynamic throughout life.

The dentist should consider that malocclusion requiring treatment may develop at any time during an individual’s lifetime, regardless of the patient’s previous treatment history.

When possible, a family health history should be obtained in addition to a general health history to assist in understanding the growth pattern of the patient.

The dentist may recommend that the patient return for further evaluation. The frequency and type of evaluation(s) should be determined by the dentist, based on the patient’s risk factors.

When the dentist considers it necessary, (an) other health care professional(s) should be consulted to acquire additional information.

Factors affecting the patient’s speech, function and orofacial aesthetics should be considered by the dentist in developing a treatment plan.

The behavioral, psychological, anatomical, developmental and physiological limitations of the patient should be considered by the dentist in developing the treatment plan.

Restorative implications, pulpal/endodontic status, tooth position, and periodontal status and prognosis should be considered in developing a treatment plan.

The dentist may counsel the patient concerning the potential effects of the patient’s health condition, medication use and behaviors 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.)

After consideration of the individual circumstances, the dentist should decide whether the malocclusion should be monitored or treated.

Following evaluation, treatment priority should be given to the management of pain, infection, traumatic injuries or other emergency conditions.

The dentist should recommend treatment; present treatment options, if any; and discuss the probable benefits, limitations and risks associated with treatment, and the probable consequences of no treatment.

The dentist should recommend and discuss post-treatment retention options, when indicated.

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 patient should be referred 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 necessary coordinated treatment should be communicated and coordinated between the referring dentist and the health professional(s) accepting the referral.

The dentist should consider the characteristics and requirements of each patient in selecting material(s) and treatment(s).

The dentist should 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.

The dentist may reposition teeth orthodontically.

The dentist should be responsible for instructing the patient in oral hygiene methods appropriate for the patient’s malocclusion treatment.

The dentist should be responsible for informing the patient about the effects of dietary habits in maintaining oral hygiene and the integrity of any orthodontic appliances.

In orthodontic treatment, the treatment appliance(s) should be as non-irritating to the surrounding tissues as is practical.

The patient should be informed that the success of treatment is often dependent upon patient compliance with prescribed treatment and recommendations for behavioral modifications. Lack of compliance should be recorded.

The dentist should evaluate the treatment progress and modify the treatment plan if indicated.

The dentist should consider, and inform the patient, that orthodontic treatment may include multiple phases of treatment, with periods of observation, stabilization and/or retention between phases of active treatment.

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.)

When periodontal diseases are present, the dentist should initiate treatment before orthodontic appliances are placed. During orthodontic treatment, the periodontal condition should be monitored and treated. Some aspects of periodontal therapy may be delayed until after the malocclusion is resolved.

Occlusal guards may be used by the dentist to facilitate and maintain treatment.

The dentist should periodically evaluate occlusal guards and/or appliances for their effectiveness and appropriateness.

When necessary, the dentist should modify, replace or discontinue the use of occlusal guards or appliances.

The dentist may modify occluding, articulating, adjacent or approximating teeth to facilitate treatment.

The dentist may alter tooth morphology and/or position by placing restorations to facilitate treatment.

The dentist may modify or replace existing restorations.

Transitional or provisional restorations (prostheses) may be utilized by the dentist to facilitate treatment.

Oral and maxillofacial surgical procedures may be performed.

Presurgical orthodontic treatment may be utilized in preparation for oral and maxillofacial surgery, and a modified orthodontic appliance may be utilized for post-surgical fixation.

When appliances or prostheses are to be used, the patient should be informed about the potential for injury (e.g. soft tissue injury or aspiration).

When appropriate, the dentist should recommend that oral protective appliances be used during occupational, recreational and sporting activities.

The dentist should communicate by prescription the necessary information for the fabrication of the appliance(s) or prosthesis(es) to the dental laboratory technician. Although the fabrication may be delegated, the dentist is responsible for the appliance(s) or prosthesis(es).

The dentist should evaluate the treated occlusion and, based upon the needs of the individual patient, should implement a maintenance and retention plan at the completion of active treatment.

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 malocclusion.

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.

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