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B.13 CARIES STABILIZATION

PURPOSE


According to the American Academy of Pediatric Dentistry and endorsed by the Indian Health Service, caries stabilization using an Interim Therapeutic Restoration is an effective means of treating small carious lesions. Frequently these restorations remain in primary teeth until exfoliation. “The American Academy of Pediatric Dentistry (AAPD) recog­nizes that unique clinical circumstances can result in challenges in restorative care for infants, children, adolescents, and persons with special health care needs. When circumstances do not permit traditional cavity preparation and/or placement of tradi­tional dental restorations or when caries control is necessary prior to placement of definitive restorations, interim therapeutic restorations (ITR)1 may be beneficial and are best utilized as part of comprehensive care in the dental home… The AAPD recognizes ITR as a beneficial provisional technique in contemporary pediatric restorative dentistry. ITR may be used to restore and prevent dental caries in young patients, uncooperative patients, patients with special health care needs, and situations in which traditional cavity preparation and/or placement of traditional dental restorations are not feasible. ITR may be used for caries control in children with multiple carious lesions prior to definitive restoration of the teeth.” (AAPD, 2008, available online at: http://www.aapd.org/media/Policies_Guidelines/P_ITR.pdf )
PROCEDURE:
Goal of Interim Therapeutic Restorations

To provide treatment without local anesthetic using fluoride-releasing glass ionomer on teeth diagnosed with neither necrotic nor irreversible pulpitis. This procedure can be done by general dentists and their staff, often avoiding dental treatment under general anesthesia. (IHS, 2012. Available online at: http://www.ihs.gov/doh/documents/ecc/NewECCPacket/Fillings.pdf )



Indications
Interim Therapeutic Restorations are indicated for infants, children, adolescents and children with special health care needs when conventional restorative care is not available or needs to be deferred. (IHS, 2012)
Placement and Follow Up
The ITR procedure involves removal of caries using hand or slow speed rotary instruments with caution not to expose the pulp. Leakage of the restoration can be minimized with maximum caries removal from the periphery of the lesion. Following preparation, the tooth is restored with an adhesive restorative material such as self-setting or resin-modified glass ionomer cement.11 ITR has the greatest success when applied to single surface or small 2 surface restorations.12,13 Inadequate cavity preparation with subsequent lack of retention and insuf­ficient bulk can lead to failure.12 Follow-up care with topical fluorides and oral hygiene instruction may improve the treat­ment outcome in high caries-risk dental populations. (AAPD, 2008)

B.14 INFORMED CONSENT

PURPOSE


According to the American Dental Association, “A consent form is a document that a patient has knowingly consented to a particular treatment. The key is the discussion between the dentist and the patient during which the treatment, its risks and benefits and alternatives, are all discussed. An informed consent form is evidence this discussion took place. It should be signed and dated by the patient.”

The purpose of this policy is to identify procedures that require informed consent and to establish procedures for obtaining and documenting informed consent.

PROCEDURE

Following a comprehensive examination, the dentist will develop a proposed treatment plan. The dentist will explain the proposed treatment, risks and benefits of treatment, and consequences of non-treatment. The patient or parent/guardian will have the opportunity to ask questions about the proposed treatment. Slight and/or unanticipated protective stabilization may be included in the treatment plan. The patient’s (parent/guardian) signature on the treatment plan form will indicate informed consent for proposed routine treatment.

A separate Informed consent form will be used for cases of:

(List Procedures) IHS recommends consent forms for:

Tooth extraction

Invasive surgical intervention

Endodontics

Protective stabilization (with or without restrictive device)

Nitrous oxide analgesia/anxiolysis

Conscious sedation

Complex pediatric cases (see following section)

Use of extracted teeth or soft tissues to be used for educational or research purposes

Any procedure requiring the need for specific informed consent will use the [form name or number] This form will be explained to the patient by the provider or dental assistant and signed by patient or parent/guardian, provider and a witness.



Treatment of Minors

Informed consent for dental treatment will be obtained in writing from all patients (18 years and older) or from the parent or legal guardian of a minor. In the case of a minor who is not accompanied by a parent or legal guardian, emergency care to treat bleeding, extreme pain, prevent the spread of infection or other severe conditions will be accomplished with minimal medical and/or surgical intervention required to stabilize the patient and prevent permanent injury until legal written consent can be obtained. The forms will be kept in the patient’s dental chart.


INSERT Appropriate Forms

(Informed consent MUST INCLUDE benefits, risks, and alternatives)

B.15 RADIOGRAPHY

PURPOSE


To set general guidelines for prescribing dental radiographs.

PROCEUDRE



General Procedures

  1. All dental radiographs will be taken using appropriate lead aprons with cervical collars.

  2. Non-licensed staff taking radiographs will have documentation of appropriate Radiology training as required by [insert State or IHS].

Type and Frequency of Radiographs
The following radiograph recommendations are consistent with the American Dental Association (ADA) 2004 guidelines for dental radiographic examinations. See http://www.ada.org/sections/professionalResources/pdfs/topics_radiography_examinations.pdf

for the full ADA Guidelines for Prescribing Dental Radiographs document.



The recommendations are subject to clinical judgment and may not apply to every patient.

Type of Encounter

Patient Age and Developmental Stage

Children with Primary Dentition (prior to the eruption of the 1st permanent tooth)

Child with Transitional Dentition

Adolescent Dentition (prior to the eruption of 3rd molars)

Adult Dentate or Partially Edentulous

Edentulous Adult

New Patient* being evaluated for dental disease and/or dental development

1. Selected occlusal or periapical films

2. Posterior bitewings

1. Panoramic film

2. Posterior bitewings

3. Selected periapical

1. Panoramic film

2. Posterior bitewings as needed

3. Selected periapical films

Individual exam based on clinical signs and symptoms

Recall* with clinical caries or increased risk of caries**

1. Posterior bitewings at 6-12 month interval

2. Selected periapical films as needed


Not applicable

Recall with no clinical caries and not at increased risk for caries**

1. Posterior bitewings at 12-36 month intervals

2. Selected periapical films as needed

Not applicable



Type of Encounter

Patient Age and Developmental Stage

Children with Primary Dentition (prior to the eruption of the 1st permanent tooth)

Child with Transitional Dentition

Adolescent Dentition (prior to the eruption of 3rd molars)

Adult Dentate or Partially Edentulous

Edentulous Adult

Recall* with periodontal disease

Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease.


Not applicable

Patient for monitoring growth and development

Clinical judgment as to the type and need of radiographic images to monitor growth and development.

Clinical judgment as to the type and need of radiographic images to monitor growth and development. Panoramic or periapical exam to assess development of third molars.

Usually not indicated

Not applicable

Patients with other circumstances

Clinical judgment as to the type and need of radiographic images for evaluating and/or monitoring specific patient circumstances.

Note: A new patient is an individual who is new to the facility, has not received regular dental care, has had significant changes in medical or dental history, or has not received any dental services in the facility for a significant period of time.

*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

  5. Remineralization monitoring

  6. Presence of implants

B. Positive Clinical Signs and 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 tempopomandibular joint

  15. Facial asymmetry

  16. Abutment for fixed or removable partial prosthesis

  17. Unexplained bleeding

  18. Unexplained sensitivity of teeth

  19. Unusual eruption, spacing, or migration of teeth

  20. Unusual morphology, calcification or color

  21. Unexplained absence of teeth

  22. Clinical erosion

** Factors for increased risk of caries may include but not be 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 dental defects

  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


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