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Appendix
N
THSteps Dental Guidelines
N.1 American Academy of Pediatric Dentistry Periodicity Guidelines . . . . . . . . . . . . . . . . . . N-2
N.2 American Dental Association Guidelines for Prescribing Dental Radiographs. . . . . . . . . N-5
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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 assessment11 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 2005 American Medical Association. All rights reserved.
THSteps Dental Guidelines
Reference Manual 2005-2006
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.
CPT only copyright 2005 American Medical Association. All rights reserved.
Clinical Guidelines
85
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.
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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.
Age
6–12 months
12–24 months
2–6 years
6–12 years
Clinical oral examination
•
•
•
•
•
Assess oral growth
and development2
•
•
•
•
•
Caries-risk assessment3
•
•
•
•
•
•
•
•
•
1
Prophylaxis and topical
fluoride treatment4
12 years and older
Fluoride supplementation5,6
•
•
•
•
•
Anticipatory guidance7
•
•
•
•
•
Parents/guardians/
caregivers
Parents/guardians/
caregivers
•
•
•
•
•
Injury prevention counseling
•
•
•
•
•
Counseling for
nonnutritive habits11
•
•
•
•
•
Substance abuse counseling
•
•
Counseling for intraoral/
perioral piercing
•
•
•
•
•
•
•
•
Assessment and treatment
of developing malocclusion
•
•
•
Pit and fissure sealants13
•
•
•
Oral hygiene
counseling8
Dietary counseling9
10
Radiographic assessment12
Treatment of dental
disease/injury
•
•
Patient/parents/
Patient/parents/
guardians/caregivers guardians/caregivers
Patient
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.
N–4
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.
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.
CPT only copyright 2005 American Medical Association. All rights reserved.
CPT only copyright 2005 American Medical Association. All rights reserved.
Copyright © American Dental Association. Reprinted by permission
Document created: November 2004
Recall patient* with
clinical caries or at
increased risk for caries**
Recall patient* with no
clinical caries and not at
increased risk for caries**
New patient*
being evaluated for dental
diseases and dental
development
TYPE OF ENCOUNTER
PATIENT AGE AND DENTAL D EVELOPMENTAL S TAGE
Adult, Dentate or
Adolescent with
Child with
Child with Primary
Partially Edentulous
Permanent Dentition
Transitional Dentition
Dentition (prior to
(prior to eruption of
(after eruption of first
eruption of first
third molars)
permanent tooth)
permanent tooth)
Individualized radiographic exam consisting of
Individualized
Individualized
posterior bitewings with panoramic exam or
radiographic exam
radiographic exam
posterior bitewings and selected periapical images.
consisting of posterior
consisting of selected
A full mouth intraoral radiographic exam is
bitewings with
periapical/occlusal
preferred when the patient has clinical evidence of
panoramic exam or
views and/or posterior
generalized dental disease or a history of extensive
posterior bitewings and
bitewings if proximal
dental treatment.
selected periapical
surfaces cannot be
images.
visualized or probed.
Patients without
evidence of disease and
with open proximal
contacts may not
require a radiographic
exam at this time.
Posterior bitewing exam at 6-12 month intervals if proximal surfaces cannot
Posterior bitewing
be examined visually or with a probe
exam at 6-18 month
intervals
Posterior bitewing
Posterior bitewing
Posterior bitewing exam at 12-24 month intervals
exam at 24-36 month
exam at 18-36 month
if proximal surfaces cannot be examined visually
intervals
intervals
or with a probe
Not applicable
Not applicable
Individualized
radiographic exam,
based on clinical signs
and symptoms.
Adult, Edentulous
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.
G UIDELINES FOR PRESCRIBING D ENTAL RADIOGRAPHS
N.2 American Dental Association Guidelines for Prescribing Dental Radiographs
THSteps Dental Guidelines
N
N–5
N–6
PATIENT AGE AND DENTAL D EVELOPMENTAL S TAGE
Adult Dentate and
Adult Edentulous
Adolescent with
Child with
Child with Primary
Partially Edentulous
Permanent Dentition
Transitional Dentition
Dentition (prior to
(prior to eruption of
(after eruption of first
eruption of first
third molars)
permanent tooth)
permanent tooth)
Not applicable
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
Clinical judgment as to Usually not indicated
radiographic images for evaluation and/or
need for and type of
monitoring of dentofacial growth and development radiographic images for
evaluation and/or
monitoring of
dentofacial growth and
development.
Panoramic or periapical
exam to assess
developing third molars
Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these circumstances.
Document created: November 2004
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
*Clinical situations for which radiographs may be
indicated include but are not limited to:
Patient with other
circumstances including,
but not limited to,
proposed or existing
implants, pathology,
restorative/endodontic
needs, treated periodontal
disease and caries
remineralization
Patient for monitoring of
growth and development
Recall patient* with
periodontal disease
TYPE OF ENCOUNTER
G UIDELINES FOR PRESCRIBING D ENTAL RADIOGRAPHS , cont’d.
Appendix N
CPT only copyright 2005 American Medical Association. All rights reserved.
Remineralization monitoring
Presence of implants or evaluation for implant placement
CPT only copyright 2005 American Medical Association. All rights reserved.
Document created: November 2004
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
5.
6.
THSteps Dental Guidelines
N
N–7
N–8
Developmental or acquired disability
Xerostomia
Genetic abnormality of teeth
Many multisurface restorations
Chemo/radiation therapy
Eating disorders
Drug/alcohol abuse
Irregular dental care
Document created: November 2004
11.
12.
13.
14.
15.
16.
17.
18.
Appendix N
CPT only copyright 2005 American Medical Association. All rights reserved.