| 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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