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Orofacial Pain of Non-Dental Origin

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 1996, Revised 1997

The key element in the design of this set of parameters for orofacial pain of non-dental origin 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 pain of non-dental origin 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 orofacial pain of non-dental origin.

The dentist should consider that orofacial pain of non-dental origin may be influenced by craniofacial, musculoskeletal, stomatognathic, neurological, vascular, and/or psychological factors that are dynamic throughout life and that the etiology of orofacial pain of non-dental origin may be multifactorial.

The dentist should consider a differential disease classification of orofacial pain that may include neurogenic pain, neurovascular pain, neuromuscular, and sympathetic and/or referred pain involving the trigeminal and oropharyngeal systems, when developing a treatment plan.

The dentist should consider that orofacial pain of non-dental origin may be the result of medical conditions which contribute to or mimic other disorders.

The dentist should consider the possibility that the patient may be the victim of physical abuse and/or neglect.

The dentist should consider that orofacial pain of non-dental origin may be self-limiting, and 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 orofacial pain.

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.

The dentist may counsel the patient concerning the potential effects of the patient's health condition, medication use and behaviors on oral health.

The dentist should counsel the patient that orofacial pain situations are often managed, rather than resolved, and that symptoms may persist 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 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 and A-Z Topic: Antibiotic Prophylaxis.)

After consideration of the individual circumstances, the dentist should decide whether the orofacial pain 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.

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 and inform the patient of the likelihood of its therapeutic success, and expected and/or potential side effects.

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 may emphasize the prevention and early detection of oral diseases through patient education in preventive oral health practices.

The dentist should be responsible for educating the patient about maintaining good oral hygiene when orofacial pain and/or treatment limits the patient's ability 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 orofacial pain of non-dental origin.

The dentist should consider, and inform the patient, that treatment for orofacial pain of non-dental origin may include multiple phases of treatment.

The dentist should consider that orofacial pain of non-dental origin 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 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.)

The dentist may prescribe and/or administer pharmacological agents.

Anesthetic injections may be performed for diagnostic and/or therapeutic purposes.

The dentist should periodically evaluate the patient's medication regimen to determine the effectiveness and appropriateness of continued pharmacological therapy.

Following diagnosis of orofacial pain of non-dental origin, the treatment of dental conditions may be performed.

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

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 stint(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 orofacial pain.

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.