| 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 1996, Revised 1997
The key element in the design of this set of parameters
for orofacial osseous lesions 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 orofacial osseous lesions 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 (a) orofacial
osseous lesion(s).
The dentist should utilize a process of differential diagnosis
when evaluating orofacial osseous lesion(s) and developing a
treatment plan.
In developing a treatment plan, the dentist should consider that
the etiology of osseous lesions can be multifactorial, and that
these lesions could be benign, premalignant or malignant.
The dentist should consider that orofacial osseous lesion(s) may
be self-limiting, and episodic and/or progressive and may recommend
that the patient return for further evaluation.
The dentist should consider that clinical manifestations of orofacial
osseous lesion(s) may not coincide with cytological changes.
The dentist should inform the patient that an osseous lesion has
the potential for cytological change and should be monitored
and/or evaluated through diagnostic procedures.
The dentist should determine the need for, and/or type of diagnostic
procedure(s), including, but not limited to, biopsy or cytological
evaluation.
When an osseous lesion has been diagnosed as malignant, the dentist
should consider that malignant lesions have the potential for
rapid growth and metastasis, and may be primary or metastatic.
When the dentist considers it necessary, (an)other health care
professional(s) should be consulted to acquire additional information.
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.
After consideration of the individual circumstances, including
microscopic evaluation, if any, the dentist should decide whether
the orofacial osseous lesion should be monitored or treated.
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 a 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 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, and Antibiotic Prophylaxis
for Dental Patients With Total Joint Replacements.)
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 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.
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 emphasize the prevention and early detection
of oral diseases through patient education in preventive oral
health practices.
The dentist should determine the frequency and type of preventive
treatment based on the patient’s risk factors or presence
of oral disease(s).
The dentist should be responsible for educating the patient about
maintaining good oral hygiene when the orofacial osseous lesion(s)
and/or treatment limits the patient’s ability to achieve
an appropriate level of oral hygiene.
The dentist should consider, and inform the patient, that treatment
for orofacial osseous lesions may include multiple phases of
treatment.
The dentist should consider that orofacial osseous lesions requiring
treatment may develop at any time during an individual’s
lifetime, regardless of the patient’s previous treatment
history.
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 Conscious Sedation, Deep Sedation, and General Anesthesia
in Dentistry and Guidelines for the Use of Conscious Sedation,
Deep Sedation, and General Anesthesia for Dentists.)
When chemotherapy and/or radiotherapy are used in treating orofacial
osseous lesion(s), the sequencing, frequency and type of palliative
and/or preventive dental treatment should be determined by the
dentist.
Relevant and appropriate information about the patient and any
necessary coordinated treatment should be communicated between
the referring dentist and the health professional(s) accepting
the referral.
Surgical management of this condition may include removal of teeth,
and other intra-oral and extra-oral surgical approaches. The
patient should be informed of appropriate treatments to maintain
space and/or replace teeth.
The dentist may resect or ablate the orofacial osseous lesions
with or without associated structures.
Surgical reconstruction may be performed primarily or secondarily
by the dentist.
Maxillofacial restoration(s) (prostheses), including implant-supported
restoration(s) (prostheses), may be used for therapy and reconstructive
purposes.
Fixed, removable and implant-supported restoration(s) (prostheses)
may be placed, repaired, modified or replaced, as determined
by the dentist.
Endodontic therapy and/or root resection may be performed by the
dentist.
Local etiologic factors may be removed.
Periodontal procedures may be performed by the dentist to facilitate
treatment.
The dentist may alter tooth morphology and/or position by modifying
occluding, articulating, adjacent or approximating teeth to facilitate
treatment or reduce symptoms.
Placement of restoration(s) (prostheses), and modification or
replacement of restoration(s) (prostheses) may be performed to
facilitate treatment or reduce symptoms.
Transitional or provisional restorations (prostheses) may be utilized
by the dentist to facilitate treatment.
When the dentist removes an osseous lesion, a microscopic evaluation
must be considered.
The dentist may prescribe and/or administer pharmacological agents.
The dentist should consider the characteristics and requirements
of each patient in selecting material(s) and treatment(s).
The dentist should communicate, by prescription, necessary information
and authorization 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 accuracy and delivery of the appliance(s) or prosthesis(es).
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.
Documentation of findings, 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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