| 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.
Return to Top Parameters
Adopted 1996, Revised 1997
The key element in the design of this set of parameters
for temporomandibular (TM) disorders 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 TM disorders 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 TM disorders.
The dentist should consider that TM disorders are characterized
by craniofacial, musculoskeletal, stomatognathic and/or dental
interrelationships, and/or psychological influences that are
dynamic throughout life and that the etiology of TM disorders
may be multifactorial.
The dentist should consider a differential disease classification
that may include neuromuscular pain, myofascial pain, neurogenic
pain, neurovascular pain, sympathetic and/or referred pain involving
the trigeminal and/or oropharyngeal systems, or other medical
conditions, which may contribute to or mimic TM disorders.
Following oral evaluation (see limited, comprehensive, periodic,
and detailed and extensive evaluation parameters) and consideration
of the patient’s needs, the dentist is responsible for
providing the patient with information about the nature of TM
disorders prior to obtaining consent for treatment.
The dentist should consider that TM disorders may be self-limiting,
episodic and/or progressive and 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, and the nature and severity of the patient’s
disorder.
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.
Craniofacial relationships, musculoskeletal relationships, and
the status of the temporomandibular joints, should be considered
by the dentist in developing a treatment plan.
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.
The dentist should counsel the patient that TM disorders are often
managed, rather than resolved, and that symptoms of TM disorders
may persist, change, or recur intermittently.
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.
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 Antibiotic
Prophylaxis for Dental Patients With
Total Joint Replacements.)
After consideration of the individual circumstances, the dentist
should decide whether the TM disorders 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 treat patients for TM disorder only when there
is associated craniomaxillofacial pain and/or functional impairment.
Initially the dentist should select the least invasive and most
reversible therapy that may ameliorate the patient’s pain
and/or functional impairment.
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 evaluate the effectiveness of initial therapy
prior to considering more invasive and/or irreversible therapy.
Before initiating invasive and/or irreversible therapy, the dentist
should attempt to determine the likelihood of its therapeutic
success.
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.
The dentist should consider the individual needs and desires 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.
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
the increased difficulty of maintaining good oral hygiene when
TM disorders limit the range of jaw motion, and for instruction
in methods to achieve an appropriate level of oral hygiene.
The dentist should be responsible for educating the patient concerning
self-management and the elimination of behaviors that may contribute
to TM disorders.
The dentist should consider, and inform the patient, that treatment
for TM disorders may include multiple phases of treatment and
multiple health care disciplines.
The dentist should consider that TM disorders requiring treatment
may develop at any time during an individual’s lifetime,
regardless of the patient’s previous treatment history.
The dentist may prescribe or administer physical medicine (therapy)
modalities.
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 articular derangement and/or condylar dislocation has been
determined to be the etiology of the patient’s pain and/or
functional impairment, manual manipulation of the mandible may
be performed by the dentist.
The dentist may prescribe and/or administer pharmacological agents.
The dentist should periodically evaluate the patient’s medication
regimen to determine the effectiveness and appropriateness of
continued pharmacological therapy.
Oral orthotics (guards/splints) may be used by the dentist to
enhance diagnosis, facilitate treatment or reduce symptoms.
The dentist should periodically evaluate oral orthotics (guards/splints)
for their effectiveness, appropriateness and possible risks associated
with continued use.
Before restorative and/or occlusal therapy is performed, the dentist
should attempt to reduce, through the use of reversible modalities,
the neuromuscular, myofascial and temporomandibular joint symptoms.
The dentist may replace teeth, alter tooth morphology and/or position
by modifying occluding, articulating, adjacent or approximating
surfaces, and by placing or replacing restorations (prostheses)
to facilitate treatment.
Transitional or provisional restorations (prostheses) may be utilized
by the dentist to facilitate treatment.
Intracapsular and/or intramuscular injection, and/or arthrocentesis
may be performed for diagnostic and/or therapeutic purposes.
Orthodontic therapy may be utilized to facilitate treatment.
Orthognathic surgery may be performed to facilitate treatment.
When internal derangement or pathosis has been determined to be
the cause of the patient’s pain and/or functional impairment,
arthroscopic or open resective or reconstructive surgical procedures
may be performed by the dentist.
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 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 the TM disorder.
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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