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Orofacial Trauma

Preamble

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

The key element in the design of this set of parameters for orofacial trauma is the professional judgment of the attending dentist, for a specific patient, at a specific time.

In a patient presenting with orofacial trauma, medical stabilization takes precedence over dental treatment.

The patient's chief complaint, concerns and expectations should be considered by the dentist.

When possible, the dentist should instruct the patient on the protocol for managing the orofacial trauma prior to evaluation.

The dentist should attempt to manage the patient's pain, anxiety and behavior during examination and 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.)

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 trauma 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 trauma.

The dentist should utilize a process of differential diagnosis when evaluating orofacial trauma.

The dentist should consider that the cause of orofacial trauma may be multifactorial and may affect multiple sites with differing degrees of severity.

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

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.

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 and dental 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 orofacial trauma should be monitored or treated.

Following evaluation, treatment priority should be given to the management of emergency conditions, pain and anxiety.

The dentist, when possible, 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.

When possible, 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.

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 of each patient in selecting material(s) and treatment(s).

The dentist should be responsible for educating the patient about maintaining good oral hygiene, appropriate for the patient's condition.

The dentist should consider, and inform the patient, that treatment for orofacial traumas may include multiple phases of treatment.

The dentist may prescribe and/or administer pharmacological agents.

Foreign matter may be removed from the trauma area.

Lacerations may be repaired.

Alteration of tooth morphology and/or modification or placement of restorations may be performed by the dentist to facilitate treatment or reduce symptoms.

Resective and/or reconstructive surgical procedures may be performed by the dentist.

Endodontic therapy may be performed by the dentist.

Transitional or provisional restorations may be used by the dentist to facilitate treatment.

The dentist may utilize manipulation and/or stabilization techniques to facilitate treatment.

Surgical management of this condition may include the removal, repositioning, and/or reimplantation of teeth, and other intra-oral and extra-oral surgical procedures. The patient should be informed of appropriate treatments to maintain space and/or replace teeth. as determined by the dentist.

The dentist should communicate, by prescription, necessary information and authorization for fabrication of 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 emphasize the prevention of oral trauma through patient education in preventive oral health practices, which may include orofacial protective appliances.

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.

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.