Appendix NTHSteps Dental Guidelines N N.1 American Academy of Pediatric Dentistry Periodicity Guidelines.................. N-2 N.2 American Dental Association Guidelines for Prescribing Dental Radiographs......... N-5 CPT only copyright 2007 American Medical Association. All rights reserved.
Appendix N N.1 American Academy of Pediatric Dentistry Periodicity Guidelines 84 Clinical Guidelines American Academy of Pediatric Dentistry Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children Originating Committee Clinical Affairs Committee Review Council Council on Clinical Affairs Adopted 1991 Revised 1992, 1996, 2000, 2003 Purpose The American Academy of Pediatric Dentistry (AAPD) intends this guideline to help practitioners make clinical decisions concerning preventive oral health care for infants, children, and adolescents. Because each child is unique, these recommendations are designed for the care of children who have no contributory medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from the normal. Methods This guideline is a compilation of pediatric oral health literature and national reports and recommendations, in addition to related policies and guidelines published in the AAPD Reference Manual. 1-24 The related policies and guidelines provide references for individual recommendations. Some recommendations are evidence-based, while others represent best clinical practice and expert opinion. Background The AAPD emphasizes the importance of professional oral health intervention very early in childhood. Caries-risk assessment 11 is an essential element of contemporary clinical care for infants, children, and adolescents. Continuity of care is based on the assessed needs of the individual patient. Although evidenced-based research supporting the benefits of an infant dental intervention is limited, there is sufficient evidence that certain groups of children are at greater risk for development of early childhood caries (ECC) and would benefit from infant oral health care. ECC can be a costly, devastating disease with a lasting detrimental impact on the dentition and systemic health issues. 7 The characteristics of ECC and the availability of preventive methods support anticipatory guidance as an important strategy in addressing this significant pediatric health problem. Major benefits of early intervention, in addition to assessment of risk status, include analysis of fluoride exposure and feeding practices, as well as oral hygiene counseling. The early dental visit should be seen as the foundation upon which a lifetime of preventive education and oral health care can be built. Clinicians must consider each infant s, child s, and adolescent s individual needs and risk indicators to determine the appropriate interval and frequency of dental visits. Recommendations Birth to 12 months 1. Complete the clinical oral examination with appropriate diagnostic tests to assess oral growth and development, pathology, and/or injuries; provide diagnosis. 2. Provide oral hygiene counseling for parents, guardians, and caregivers, including the implications of the oral health of the caregiver. 3. Remove supragingival and subgingival stains or deposits as indicated. 4. Assess the child s systemic and topical fluoride status (including type of infant formula used, if any, and exposure to fluoridated toothpaste) and provide counseling regarding fluoride. Prescribe systemic fluoride supplements, if indicated, following assessment of total fluoride intake from drinking water, diet, and oral hygiene products. 5. Assess appropriateness of feeding practices, including bottle and breast-feeding, and provide counseling as indicated. 6. Provide dietary counseling related to oral health. 7. Provide age-appropriate injury prevention counseling for orofacial trauma. 8. Provide counseling for nonnutritive oral habits (eg, digit, pacifiers). 9. Provide required treatment and/or appropriate referral for any oral diseases or injuries. 10. Provide anticipatory guidance for parent/guardian/ caregiver. 11. Consult with the child s physician as needed. 12. Based on evaluation and history, assess the patient s risk for oral disease. 13. Determine the interval for periodic re-evaluation. Copyright American Association of Pediatric Dentistry. Reprinted by permission. N 2 CPT only copyright 2007 American Medical Association. All rights reserved.
THSteps Dental Guidelines Reference Manual 2005-2006 Clinical Guidelines 85 12 to 24 months 1. Repeat birth to 12-month procedures every 6 months or as indicated by individual patient s risk status/susceptibility to disease. 2. Assess appropriateness of feeding practices, including bottle, breast-feeding, and no-spill training cups, and provide counseling as indicated. 3. Review patient s fluoride status including any childcare arrangements, which may impact systemic fluoride intake and provide parental counseling. 4. Provide topical fluoride treatments every 6 months or as indicated by the individual patient s needs. 2 to 6 years 1. Repeat 12- to 24-month procedures every 6 months or as indicated by individual patient s risk status/susceptibility to disease. Provide age-appropriate oral hygiene instructions. 2. Complete a radiographic assessment of pathology and/or abnormal growth and development, as indicated by individual patient s needs. 3. Scale and clean the teeth every 6 months or as indicated by individual patient s needs. 4. Provide pit and fissure sealants for primary and permanent teeth as indicated by individual patient s needs. 5. Provide counseling and services (athletic mouthguards) as needed for orofacial trauma prevention. 6. Provide assessment/treatment or referral of developing malocclusion as indicated by individual patient s needs. 7. Provide required treatment and/or appropriate referral for any oral diseases, habits, or injuries as indicated. 8. Assess speech and language development and provide appropriate referral as indicated. 6 to 12 years 1. Repeat 2- to 6-year procedures every 6 months or as indicated by individual patient s risk status /susceptibility to disease. 2. Provide substance abuse counseling (eg, smoking, smokeless tobacco). 3. Provide counseling on intraoral and perioral piercing. 12 years and older 1. Repeat 6- to 12-year procedures every 6 months or as indicated by individual patient s risk status/susceptibility to disease. 2. At an age determined by patient, parent/guardian, and pediatric dentist, refer the patient to a general dentist for continuing oral care. References 1. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams and Wilkins; 1996. 2. Lewis DW, Ismail AI. Periodic health examination, 1995 Update: 2. Prevention of dental caries. Canadian Task Force on the Periodic Health Examination. Can Med Assoc J 1995;152:836-846. 3. CDC. Recommendations for using fluoride to prevent and control dental caries in the Unites States. MMWR 2001;50(RR14):1-42. 4. US Dept of Health and Human Services. Oral Health in American: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. 5. American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2003;25(suppl):12. 6. American Academy of Pediatric Dentistry. Clinical guideline on infant oral health care. Pediatr Dent 2003; 25(suppl):54. 7. American Academy of Pediatric Dentistry. Policy on early childhood caries: Classifications, consequences, and preventive strategies. Pediatr Dent 2003;25(suppl):24-26. 8. American Academy of Pediatric Dentistry. Policy on early childhood caries: Unique challenges and treatment options. Pediatr Dent 2003; 25(suppl):27-28. 9. American Academy of Pediatric Dentistry. Policy on dietary recommendations for infants, children, and adolescents. Pediatr Dent 2003;25(suppl):29. 10. American Academy of Pediatric Dentistry. Clinical guideline on the role of prophylaxis in pediatric dentistry. Pediatr Dent 2003;25(suppl):64-66. 11. American Academy of Pediatric Dentistry. Policy on the use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent 2003;25(suppl):18-20. 12. American Academy of Pediatric Dentistry. Clinical guideline on fluoride therapy. Pediatr Dent 2003;25(suppl):67-68. 13. American Academy of Pediatric Dentistry. Policy on breast-feeding. Pediatr Dent 2003;25(suppl):111. 14. American Academy of Pediatric Dentistry. Policy on oral habits. Pediatr Dent 2003; 25(suppl):31. 15. American Academy of Pediatric Dentistry. Clinical guideline on pediatric restorative dentistry. Pediatr Dent 2003;25(suppl):84-86. 16. American Academy of Pediatric Dentistry. Clinical guideline on prescribing dental radiographs. Pediatr Dent. 2003;25(suppl):112-113. 17. American Academy of Pediatric Dentistry. Policy on prevention of sports-related orofacial injuries. Pediatr Dent 2003;25(suppl):37. 18. American Academy of Pediatric Dentistry. Clinical guideline on management of acute dental trauma. Pediatr Dent 2003;25(suppl):92-97. 19. American Academy of Pediatric Dentistry. Clinical guideline on management of the developing dentition in pediatric dentistry. Pediatr Dent 2003;25(suppl):98-101. 20. American Academy of Pediatric Dentistry. Clinical guideline on acquired temporomandibular disorders in infants, children, and adolescents. Pediatr Dent 2003; 25(suppl):102-103. 21. American Academy of Pediatric Dentistry. Policy on tobacco use. Pediatr Dent 2003;25(suppl):33-34. 22. American Academy of Pediatric Dentistry. Clinical guideline on adolescent oral health care. Pediatr Dent 2003;25(suppl):55-60. 23. American Academy of Pediatric Dentistry. Policy on intraoral and perioral piercing. Pediatr Dent 2003; 25(suppl):35. 24. American Academy of Pediatric Dentistry. Policy on oral and maxillofacial surgery for infants, children, and adolescents. Pediatr Dent 2003;25(suppl):116. N CPT only copyright 2007 American Medical Association. All rights reserved. N 3
Appendix N 86 Clinical Guidelines American Academy of Pediatric Dentistry Recommendations for Pediatric Oral Health Care Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. Age 6 12 months 12 24 months 2 6 years 6 12 years 12 years and older Clinical oral examination 1 Assess oral growth and development 2 Caries-risk assessment 3 Prophylaxis and topical fluoride treatment 4 Fluoride supplementation 5,6 Anticipatory guidance 7 Oral hygiene Parents/guardians/ Parents/guardians/ Patient/parents/ Patient/parents/ Patient counseling 8 caregivers caregivers guardians/caregivers guardians/caregivers Dietary counseling 9 Injury prevention counseling 10 Counseling for nonnutritive habits 11 Substance abuse counseling Counseling for intraoral/ perioral piercing Radiographic assessment 12 Treatment of dental disease/injury Assessment and treatment of developing malocclusion Pit and fissure sealants 13 Assessment and/or removal of third molars Referral for regular and periodic dental care 1. First examination at the eruption of the first tooth and no later than 12 months. 2. By clinical examination. 3. As per AAPD Policy on the use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. 4. Especially for children at high risk for caries and periodontal disease. 5. As per American Academy of Pediatrics/American Dental Association guidelines and the water source. 6. Up to at least 16 years. 7. Appropriate discussion and counseling should be an integral part of each visit for care. 8. Initially, responsibility of parent; as child develops, jointly with parents; then, when indicated, only child. 9. At every appointment discuss the role of refined carbohydrates, frequency of snacking. 10. Initially play objects, pacifiers, car seats; then when learning to walk, sports and routine playing. 11. At first discuss the need for additional sucking: digits vs pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism. 12. As per AAPD Clinical guideline on prescribing dental radiographs. 13. For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and/or fissures; placed as soon as possible after eruption. N 4 CPT only copyright 2007 American Medical Association. All rights reserved.
CPT only copyright 2007 American Medical Association. All rights reserved. N 5 N.2 American Dental Association Guidelines for Prescribing Dental Radiographs Document created: November 2004 GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS The recommendations in this chart are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after reviewing the patient s health history and completing a clinical examination. Because every precaution should be taken to minimize radiation exposure, protective thyroid collars and aprons should be used whenever possible. This practice is strongly recommended for children, women of childbearing age and pregnant wo men. TYPE OF ENCOUNTER New patient* being evaluated for dental diseases and dental development Recall patient* with clinical caries or at increased risk for caries** Recall patient* with no clinical caries and not at increased risk for caries** Child with Primary Dentition (prior to eruption of first permanent tooth) Individualized radiographic exam consisting of selected periapical/occlusal views and/or posterior bitewings if proximal surfaces cannot be visualized or probed. Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time. PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE Adolescent with Permanent Dentition (prior to eruption of third molars) Child with Transitional Dentition (after eruption of first permanent tooth) Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images. Posterior bitewing exam at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe Posterior bitewing exam at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe Copyright American Dental Association. Reprinted by permission Adult, Dentate or Partially Edentulous Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images. A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized dental disease or a history of extensive dental treatment. Posterior bitewing exam at 18-36 month intervals Posterior bitewing exam at 6-18 month intervals Posterior bitewing exam at 24-36 month intervals Adult, Edentulous Individualized radiographic exam, based on clinical signs and symptoms. Not applicable Not applicable THSteps Dental Guidelines N
N 6 CPT only copyright 2007 American Medical Association. All rights reserved. GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS, cont d. PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE TYPE OF ENCOUNTER Recall patient* with periodontal disease Patient for monitoring of growth and development Patient with other circumstances including, but not limited to, proposed or existing implants, pathology, restorative/endodontic needs, treated periodontal disease and caries remineralization Document created: November 2004 Child with Primary Dentition (prior to eruption of first permanent tooth) *Clinical situations for which radiographs may be indicated include but are not limited to: A. Positive Historical Findings 1. Previous periodontal or endodontic treatment 2. History of pain or trauma 3. Familial history of dental anomalies 4. Postoperative evaluation of healing Child with Transitional Dentition (after eruption of first permanent tooth) Adolescent with Permanent Dentition (prior to eruption of third molars) Adult Dentate and Partially Edentulous Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be identified clinically. Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development. Panoramic or periapical exam to assess developing third molars Usually not indicated Adult Edentulous Not applicable Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these circumstances. Appendix N
CPT only copyright 2007 American Medical Association. All rights reserved. N 7 5. Remineralization monitoring 6. Presence of implants or evaluation for implant placement B. Positive Clinical Signs/Symptoms 1. Clinical evidence of periodontal disease 2. Large or deep restorations 3. Deep carious lesions 4. Malposed or clinically impacted teeth 5. Swelling 6. Evidence of dental/facial trauma 7. Mobility of teeth 8. Sinus tract ( fistula ) 9. Clinically suspected sinus pathology 10. Growth abnormalities 11. Oral involvement in known or suspected systemic disease 12. Positive neurologic findings in the head and neck 13. Evidence of foreign objects 14. Pain and/or dysfunction of the temporomandibular joint 15. Facial asymmetry 16. Abutment teeth for fixed or removable partial prosthesis 17. Unexplained bleeding 18. Unexplained sensitivity of teeth 19. Unusual eruption, spacing or migration of teeth 20. Unusual tooth morphology, calcification or color 21. Unexplained absence of teeth 22. Clinical erosion Factors increasing risk for caries may include but are not limited to: 1. High level of caries experience or demineralization 2. History of recurrent caries 3. High titers of cariogenic bacteria 4. Existing restoration(s) of poor quality 5. Poor oral hygiene 6. Inadequate fluoride exposure 7. Prolonged nursing (bottle or breast) 8. Frequent high sucrose content in diet 9. Poor family dental health 10. Developmental or acquired enamel defects Document created: November 2004 THSteps Dental Guidelines N
N 8 CPT only copyright 2007 American Medical Association. All rights reserved. 11. Developmental or acquired disability 12. Xerostomia 13. Genetic abnormality of teeth 14. Many multisurface restorations 15. Chemo/radiation therapy 16. Eating disorders 17. Drug/alcohol abuse 18. Irregular dental care Document created: November 2004 Appendix N