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Dental Caries

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.

Parameters

Adopted 1994, Revised 1997

The key element in the design of this set of parameters of dental caries 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.

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 dental caries.

Following oral evaluation of the patient (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 dental caries prior to obtaining consent for further treatment.

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.)

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 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.

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.

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

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

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

Additional diagnostic tests relevant to the dental caries of the patient may be performed and used by the dentist in diagnosis and treatment planning.

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

After consideration of the individual circumstances, the dentist should decide whether the tooth with a carious lesion(s) should be monitored, treated or removed.

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

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

The tooth preparation should be appropriate for the extent of the lesion and/or the choice of the restorative material. (See: FDA Approvals of Laser Systems for Hard Tissue Applications)

All clinically apparent caries should be removed before the restoration is placed, except in some instances where indirect pulp-capping or pulpotomy techniques are used.

Pulpal tissue should be protected by the dentist when indicated.

The restorative material selected should restore form and function, and withstand the forces of occlusion. (See: ADA Statement on Dental Amalgam)

The dentist may modify occluding, articulating, adjacent or approximating teeth to enhance the final restoration's form and function as well as its ability to withstand the forces of occlusion.

Tissues and/or restorations adjacent to the restorative site may be altered by the dentist to facilitate treatment or sustain the tooth being restored.

Orthodontic repositioning may be performed by the dentist to facilitate treatment.

Transitional or provisional restorations may be utilized by the dentist to facilitate treatment or reduce pulpal symptoms.

Dental sealants may be applied as a preventive measure. (See: Bisphenol A and Dental Materials)

Chemotherapeutic agents may be used for caries prevention and the treatment of incipient caries.

Modification of the root surface followed by application of chemotherapeutic agents may be used to treat caries.

Depth and narrowness of pits and fissures may be modified by the dentist for caries prevention.

Dietary fluoride supplements may be prescribed by the dentist. (See: Facts About Fluorides/Dietary Fluoride Supplements)

Topical fluoride may be applied or prescribed as a preventive measure. (See: Facts About Fluoride/Topical Fluorides)

Endodontic therapy and/or root resection may be performed by the dentist in the treatment of caries.

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 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 condition of the oral cavity.

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 Medication)

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.