2014 Cllinical Practice Guidelines PDF

ATTACHMENT A
2
3
5 Clinical Practice Guidelines

6 for
7 Orthodontics and
8 Dentofacial Orthopedics 2008
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14
15 This document may not be copied or reproduced without the
16 express written permission of the AAO
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31
32
33 2008 2012 American Association of Orthodontists
34 Created: 1996
35 Amended: 2001, 2009, 2010, 2012, 2014
36 Date: September 9, 2008; Adopted May 2009
37 Amended May 2010
38 Amended May 2012
39
1
ATTACHMENT A
1 TABLE OF CONTENTS
2
3 Clinical Practice Guidelines for Orthodontics and 1
4 Dentofacial Orthopedics 2008 1
5 This document may not be copied or reproduced without the 1
6 express written permission of the AAO 1
7 Introduction. 3
8 Pretreatment Considerations... 4
9 Examination 4
10 Diagnostic Records.. 5
11 Referral... 5
12 Diagnosis and Treatment... 5
13 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and Dental
14 Alveolus.. 6
15 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length. 9
16 Abnormalities of Tooth Number Morphology, and Eruption Pattern.10
17 Dentofacial Functional Abnormalities12
18 Craniofacial Anomalies, Cleft Lip and Palate...13
19 Treatment Objectives and Limiting Factors..14
20 Goals...14
21 Limiting Factors.14
22 Treatment Consultation and Informed Consent...14
23 Risks Associated with Orthodontic Treatment.15
24 Risks Associated with Adjunctive Procedures in Orthodontics.16
25 Post Treatment Evaluation and Outcomes Assessment16
26 Post Treatment Records..16
27 Positive Outcomes of Treatment16
28 Negative Outcomes of Treatment..17
29 Retention17
30 Record Keeping.17
31 Transfer of Orthodontic Patients.18
32 Recommendations to the Transferring Practitioner.18
33 Recommendations to the Accepting Practitioner.18
34 Patients Who Wish to Transfer because of Dissatisfaction with Current Orthodontist..19
35 Recommendations to the Transferring Practitioner..19
36 Recommended Procedures for Accepting Orthodontist...19
37 Evidence-Based Dentistry...19
38 Definition.19
39 Levels of Evidence20
40 Best Evidence20
41 Evidence-Based Clinical Recommendations20
42 HIPAA.20
43 Appendix A: Historical Development ...22
44 Appendix B: Updating of Clinical Practice Guidelines23
45 Appendix C: Clinical Practice Guidelines Members...25
46 Selected References25
47
2
ATTACHMENT A
1 Introduction
2
3 Orthodontics and Dentofacial Orthopedics is a the specialty area of dentistry concerned with the
4 supervision, guidance and correction of the growing or mature dentofacial structures, including
5 those conditions that require movement of teeth or correction of malrelationships and
6 malformations of their related structures and the adjustment of relationships between and among
7 teeth and facial bones by the application of forces and/or the stimulation and redirection of
8 functional forces within the craniofacial complex. Major responsibilities of orthodontic practice
9 include the diagnosis, prevention, interception, and treatment of all forms of malocclusion of the
10 teeth and associated alterations of their surrounding structures; the design, application, and
11 control of functional and corrective appliances; and the guidance of the dentition and its supporting
12 structures to attain and maintain optimal occlusal relations and physiologic and esthetic harmony
13 among facial and cranial structures.
14
15 A specialist in orthodontics and dentofacial orthopedics meets educational standards established
16 by the Commission on Dental Accreditation of the American Dental Association (ADA) and must
17 possess advanced knowledge in biomedical, clinical, and basic sciences. This knowledge includes
18 the biology of tooth movement, cephalometrics, orthodontic diagnosis, treatment planning, surgical
19 orthodontics, biomechanical principles, the effects of growth and development on tooth movement,
20 application of orthopedic forces to dentofacial structures, and patient management and motivation.
21
22 The American Association of Orthodontists (AAO) is the leading national organization of dentists
23 who limit their practice to orthodontics and dentofacial orthopedics and is recognized by the ADA
24 as the sponsoring organization of the national certifying board, the American Board of
25 Orthodontics. The membership of the AAO includes approximately 94% of practicing orthodontists
26 in the United States. The AAO has the background, expertise, and professional responsibility to
27 assist the dental profession and the public by developing clinical practice guidelines for
28 orthodontics and dentofacial orthopedics. The AAO recognizes its role in upholding the public trust
29 granted to it by presenting these clinical practice guidelines to help practitioners develop
30 judgments on diagnosis, treatment planning, and timing of orthodontic and dentofacial orthopedic
31 therapy. The primary concern of the AAO is the provision of high quality orthodontic care and the
32 protection of the public.
33
34 Practice guidelines, as defined by the Institute of Medicine, are systematically developed
35 statements to assist practitioner and patient decisions about appropriate health care for specific
36 clinical circumstances.
37
38 The Orthodontic Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics
39 presented in this document are condition based and are related to the International Classification
40 of Diseases, Clinical Modification, 9th Edition (ICD-9Codes). This approach recognizes the need
41 for integrated treatment of oral and dentofacial conditions rather than isolated treatment
42 procedures. These guidelines are also directed toward the process of patient care and outline
43 considerations related to diagnosis, treatment, and quality of care.
44
45 These guidelines were derived from a professional consensus, based on a review of relevant
46 clinical and scientific literature, the expert opinion of educators, and the clinical experience of
47 practicing orthodontists. Similar documents written by other organizations and publications related
48 to guideline development were also reviewed.
49
50 There are various professionally accepted philosophies regarding orthodontic diagnosis,
51 treatment, and retention. Because of the nature of the doctor-patient relationship, the practitioner,
3
ATTACHMENT A
1 who is actively engaged in treating the patient, is in the best position to evaluate and interpret the
2 complexities, timing, and potential efficacy from among different the many treatment philosophies
3 and systems available. Deviations from these guidelines may be appropriate based on
4 professional judgment and individual patient needs. Where a practitioner chooses to deviate from
5 these guidelines (based on the circumstances of a particular patient or for any other reason) the
6 practitioner is advised to note in the patient's record the reason for the procedure followed. Finally,
7 it should be understood that adherence to these guidelines does not guarantee a successful
8 treatment outcome.
9
10 The AAO recognizes that these guidelines may be used by insurance carriers and other payers,
11 attorneys in malpractice litigation, and various entities with an interest in orthodontics. The
12 Association encourages all interested persons to become familiar with the Guidelines. This
13 document was not developed to establish standards of care or to be used for reimbursement or
14 litigation purposes. The AAO cautions that these uses involve considerations that are beyond the
15 scope of the Guidelines.
16
17 The professional conduct of members of the AAO is governed by the Principles of Ethics and
18 Code of Professional Conduct of the AAO and the ADA.
19
20 Pretreatment Considerations
21
22 A screening examination may be performed to determine the nature of the orthodontic problem,
23 and to determine if and when treatment is indicated. When treatment is indicated, a
24 comprehensive examination must be performed that should include:
25
26 Examination
27
28 A. Chief Complaint
29 The chief complaint or the reason for seeking treatment should be recorded as described
30 by the patient, parent or legal guardian.
31 B. Medical and Dental History
32 An appropriate medical and dental history must be obtained as a part of the initial
33 evaluation of the patient. If treatment is to be delayed until a future date, an updated history
34 may be necessary. Patients/parents/legal guardians should be requested to advise the
35 orthodontist of any change in the patient's health history.
36
37 C. Clinical Examination
38 A comprehensive clinical examination should include the following with all findings
39 recorded in the patient's record:
40
41 1. An extraoral facial assessment to determine facial form, symmetry, soft-tissue
42 harmony, and status of the perioral musculature. This determines deviations from
43 normal regarding a patient's sagittal, vertical, and transverse maxillofacial
44 relationships and to assess the relationship of the dentition to the facial structures.
45 2. An intraoral examination to assess the condition of the hard and soft tissues of the
46 mouth, (including the periodontium) and the static and functional status of the
47 patient's occlusion.
48 3. An evaluation of the temporomandibular joint and associated musculature to
49 assess function and disease.
50
4
ATTACHMENT A
1 Diagnostic Records
2
3 Diagnostic records and tests will vary with the nature of the patient's condition but must be
4 sufficient to identify the problems, formulate a diagnosis, and allow the development of an
5 acceptable course of treatment. Where limited orthodontic procedures are anticipated, diagnostic
6 records may vary from those associated with comprehensive care. Pretreatment unaltered
7 diagnostic records for comprehensive orthodontic treatment should include the following to
8 establish a baseline for documenting treatment and/or growth changes:
9
10 1. Extra and intraoral images (may include digital or video images) to supplement the
11 clinical findings.
12 2. Dental casts (or digital models) to assess the inter-arch and intra-arch relationship
13 of the teeth, to help determine arch length and width requirements, and to assess
14 arch symmetry.
15 3. Intraoral and/or panoramic radiographs to assess the condition and developmental
16 status of the teeth and associated structures, and to identify any dental anomalies
17 or pathology.
18 4. Cephalometric radiographs to permit evaluation of the size, shape, and positions of
19 the craniofacial structures and dentition, and to aid in the identification of skeletal
20 anomalies or pathology. Three-dimensional cone-beam computer tomography
21 (CBCT) may be used as an alternate (imaging) source to obtain dentofacial
22 information.
23 5. The AAO recognizes that while there may be clinical situations where a cone-beam
24 computed tomography (CBCT) radiograph may be of value, the use of such
25 technology is not routinely required for orthodontic radiography.
26
27 Referral
28
29 Practitioners must make a recommendation for referral of patients to general dentists, other dental
30 specialists, physicians, or other health care practitioners whenever, in the judgment of a
31 practitioner, referral would be in the best interest of a patient. Technological advances such as
32 CBCT scans fall in this category and should be assessed/read in their entirety by a qualified
33 professional; the entire area encompassed by the scan may be the responsibility of the
34 practitioner.
35
36 Diagnosis and Treatment
37
38 Prior to the initiation of orthodontic treatment, a diagnosis of the patient's oral health condition
39 must be made. A diagnosis allows for the development of a treatment plan that addresses the
40 patient's chief complaint; medical and dental history; and dental, facial, skeletal, functional, and/or
41 psychosocial problems.
42
43 After a diagnosis has been established, a treatment plan must be developed. Such a plan will
44 facilitate coordination of the treatment objectives and the various methods available for addressing
45 them. The plan should include:
46
47 1. A list of the patient's dental, facial, skeletal, functional, and/or psychosocial
48 problems.
49 2. A differential diagnosis which coordinates the patient/parents/legal guardian's chief
50 complaint with the clinical findings.
5
ATTACHMENT A
1 3. A written documented plan for therapy which includes treatment goals, appliance
2 selection, sequencing and timing of treatment, coordination with other health care
3 providers, and retention.
4
5 The treatment plan should be periodically reassessed throughout treatment. This reassessment
6 should take into consideration various limiting factors and establish short- and/or long-term
7 objectives.
8
9 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and
10 Dental Alveolus
11
12 The following conditions may indicate the need for orthodontic or dentofacial orthopedic treatment.
13 These conditions may be structural or functional, may appear in various combinations, and are not
14 limited to the following. Frequently used treatment options, which may include the removal of
15 primary or permanent teeth, are listed for each condition. Moreover, devices including headgear,
16 osseointegrated implants, mini-screw implants, miniplates and other temporary anchorage devices
17 may be used as adjuncts to improve facilitate the treatment outcome, in particular where maximum
18 anchorage would be beneficial.
19
20 I. Maxillary/Dentoalveolar Hyperplasia (Large Maxilla)
21
22 A. Diagnostic Considerations
23
24 1. Anteroposterior
25 a. Excess Overjet
26 b. Distoclusion
27 c. Asymmetry
28 d. Mid-Face Protrusion
29 2. Vertical
30 a. Long Face Height
31 b. Deep Overbite
32 c. Open Bite
33 d. Lip Incompetency
34 e. Asymmetry
35 3. Transverse
36 a. Buccal Maxillary Cross-bite (unilateral or bilateral; functional or
37 structural)
38 b. Asymmetry
39
40 B. Treatment Options
41
42 1. Primary Dentition - Treatment Indicated Under Certain Circumstances,
43 Appliances Vary
44 2. Mixed Dentition
45 a. Functional/Orthopedic Appliances
46 b. Fixed or Removable Orthodontic Appliances
47 3. Adolescent Dentition
48 a. Functional/Orthopedic Appliances
49 b. Fixed or Removable Orthodontic Appliances
50 c. Fixed Orthodontic Appliances Adjunctive to Orthognathic Surgery
51 (surgery usually performed after majority of growth completed)
6
ATTACHMENT A
1 4. Adult Dentition
2 a. Fixed or Removable Orthodontic Appliances
3 b. Fixed Orthodontic Appliances Adjunctive to Orthognathic Surgery
4
5 II. Maxillary/Dentoalveolar Hypoplasia (Small Maxilla)
6
8
10 a. Mesiocclusion
11 b. Anterior Cross-bite (functional or structural)
12 c. Asymmetry
13 d. Mid-Face Deficiency
14 2. Vertical
15 a. Short Face Height
16 b. Deep Overbite
17 c. Open Bite
18 d. Lip Redundancy
19 e. Asymmetry
20 3. Transverse
21 a. Lingual Posterior Cross-bite (unilateral or bilateral; functional or
22 structural)
23 b. Asymmetry
24
26
27 1. Primary Dentition
28 a. Functional/Orthopedic Appliance
29 b. Fixed or Removable Orthodontic Appliance
37 a. Fixed or Removable Orthodontic Appliance
38 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery
39
40 III. Mandibular/Dentoalveolar Hyperplasia (Large Mandible)
41
43
45 a. Prognathic Facial Pattern
46 b. Mesiocclusion
47 c. Anterior Cross bite (functional or structural)
48 d. Macrogenia
49 e. Asymmetry
50 2. Vertical
51 a. Open Bite
7
ATTACHMENT A
1 b. Deep Overbite
2 c. Long Lower Facial Height
3 d. Asymmetry
4 3. Transverse
5 a. Posterior Cross-bite (unilateral or bilateral; functional or structural)
6 b. Asymmetry
7
9
10 1. Primary Dentition - Treatment Indicated Under Certain Circumstances,
11 Appliances Vary
21
22 IV. Mandibular/Dentoalveolar Hypoplasia (Small Mandible)
23
25
27 a. Mandibular Retrognathic Facial Pattern
28 b. Excess Overjet
29 c. Distoclusion
30 d. Asymmetry
31 2. Vertical
32 a. Open Bite
33 b. Deep Overbite
34 c. Short Lower Face Height
35 d. Long Lower Face Height
36 3. Transverse
37 a. Posterior Cross-bite (unilateral or bilateral; functional or structural)
38 b. Asymmetry
39
41
42 1. Primary Dentition - Functional/Orthopedic Appliance
49 c. Appliance Adjunctive to Orthognathic Surgery (surgery usually
50 performed after majority of growth completed)
8
ATTACHMENT A
3
4 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length
5
6 These conditions may appear in various combinations and are not limited to the following.
7 Frequently used treatment options for these anomalies may include modification of tooth size,
8 surgical exposure, extraction of primary or permanent teeth, and appropriate soft tissue surgery.
9
10 I. Deficient Arch Length (Crowding)
11
13
14 1. Facial-Lingual Displacement
15 2. Supra/Infra Eruption
16 3. Rotations
17 4. Impactions
18 5. Axial Inclination of Teeth (Anterior or Posterior)
19 6. Tooth Size
20 7. Premature Loss of Primary Teeth
21 8. Ankylosis
22
24
25 1. Primary Dentition
26 Fixed or Removable Space Maintainer
30 c. Serial Extraction
33 b. Functional/Orthopedic Appliance
35 Fixed or Removable Orthodontic Appliance
36
37 II. Excessive Arch Length (Spacing)
38
40
41 1. Facial-Lingual Displacement
42 2. Axial Inclination of Teeth
43 3. Fibrous Gingival Hyperplasia
44 4. Frena
45 5. Tooth Size
46
48
49 1. Primary Dentition - Treatment Rarely Indicated
50 2. Mixed Dentition - Fixed or Removable Orthodontic Appliance
51 3. Adolescent Dentition - Fixed or Removable Orthodontic Appliance
9
ATTACHMENT A
1 4. Adult Dentition - Fixed or Removable Orthodontic Appliance
2
3 III. Discrepancies of Arch Form
4
6
7 1. Asymmetry
8 2. Interarch Coordination
9 3. Abnormal Occlusal Planes: Curves of Wilson and Spee
10
12
13 1. Primary Dentition - Fixed or Removable Orthodontic Appliance
23
24 Abnormalities of Tooth Number Morphology, and Eruption Pattern
25
26 Anomalies of tooth number, morphology or eruption pattern should be diagnosed and managed as
27 soon as reasonably practical according to the particular requirements of each clinical situation.
28 These conditions may appear in various combinations, and may indicate the need for orthodontic
29 or dentofacial orthopedic treatment. Some of the frequently used treatment options may require a
30 multidisciplinary approach and may include the extraction of primary or permanent teeth.
31
33
34 1. Supernumerary Teeth
35 2. Missing Teeth
36 a. Congenital (Anodontia)
37 b. Pathologic
38 c. Traumatic
39 d. Extracted
40 3. Ectopic Erupting Teeth
41 4. Impacted Teeth
42 5. Eruption Anomalies
43 6. Over-Retained Primary Teeth
44 7. Ankylosed Teeth
45 8. Transposition
46 9. Atypical Crown Morphology
48 11. Atypical Root Morphology
49 12. Root Resorption
50 13. Carious or Fractured Teeth
51
10
ATTACHMENT A
2
3 1. Supernumerary Teeth
4 a. Surgical Intervention
5 b. Extraction
6 c. Fixed or Removable Orthodontic Appliance
7 2. Missing Teeth
8 a. Space Maintenance
10 c. Prosthetic Replacement of Teeth/Implants
11 d. Transplantation
12 e. Maintenance of Primary Teeth
13 f. Space Closure
14 3. Ectopic Teeth
16 b. Extraction
17 4. Impacted Teeth
19 b. Extraction
21 5. Eruption Anomalies
23 b. Retention with or without Coronal Modification
24 c. Extraction
25 d. Fixed or Removable Orthodontic Appliance
26 e. Referral for Medical Evaluation
27 6. Over-Retained Primary Teeth Extraction
28 a. Extraction
29 7. Ankylosed Teeth
30 a. Extraction
31 b. Surgical Luxation
32 c. Surgical Repositioning
33 d. Fixed or Removable Orthodontic Appliance
34 e. Retention with or without Coronal Modification
35 8. Transposition
37 b. Extraction
38 c. Retention with or without Coronal Modification
39 d. Transplantation
40 9. Atypical Tooth Morphology
41 a. Retention with or without Coronal Modification
42 b. Extraction
45 a. Space Maintenance
47 11. Atypical Root Morphology
48 a. Monitor Radiographically
49 b. Extraction
50 12. Root Resorption
51 a. Monitor Radiographically
11
ATTACHMENT A
1 b. Extraction
2 c. Stabilization
3 13. Carious or Fractured Teeth
4 a. Reposition Tooth or Root
6
7 Dentofacial Functional Abnormalities
8
9 55 Dentofacial functional abnormalities may occur in combination with other dentofacial conditions
10 and should be diagnosed and managed according to the particular requirements of each clinical
11 situation. Correction or control of functional problems may involve alteration of behavior patterns,
12 may require orthodontic/dentofacial orthopedic treatment, or multidisciplinary treatment. The
13 influence of functional abnormalities on dentofacial development is variable, and cause and effect
14 relationships are difficult to determine.
15
17
18 1. Lip Size and Function
19 2. Tongue Size and Function
20 a. Abnormal Tongue Function
21 b. Ankyloglossia
22 c. Microglossia or Macroglossia
23 3. Deleterious Habits
24 a. Thumb, Finger or Lip Sucking
25 b. Pacifier Sucking
26 c. Tongue Thrust/Sucking
27 d. Clenching
28 e. Grinding
29 f. Lip/Cheek Biting
30 g. Nail Biting
31 h. Foreign Objects (e.g., pipes, pens, pencils, musical instruments)
32 4. Airway Obstruction
33 a. Nasopharyngeal Morphology
34 b. Sleep Apnea
35 c. Allergies
36 d. Pathology
37 5. Speech Disorders
38 6. Mandibular Dysfunction
39 a. Dental Interferences
40 b. Skeletal Abnormalities
41 c. Neuromuscular Abnormalities
42 d. Temporomandibular Dysfunction
43 7. Temporomandibular Disorders
44 Temporomandibular disorders represent a broad range of conditions which involve
45 medical, dental, and psychological factors. Such disorders may be associated with
46 stress, habits, emotional disorders, structural malrelationships, trauma to the face
47 or head, occlusal disharmonies, and medical problems associated with
48 osteoarthritis, rheumatoid arthritis, or viral disease. These factors may be
49 associated with temporomandibular disorders in one individual with no
50 symptomatology or pathology in another.
51
12
ATTACHMENT A
2 1. Lip Size and Function
4 b. Therapeutic Exercises
5 c. Functional/Orthopedic Appliance
6 d. Surgery
7 2. Tongue Size and Function
9 b. Therapeutic Exercises
10 c. Functional/Orthopedic Appliance
11 d. Surgical Reduction
12 e. Lingual Frenectomy
13 3. Deleterious Habits
16 c. Behavior Management
17 4. Airway Obstruction
18 a. Medical Evaluation/Treatment
20 c. Orthognathic Surgery
21 5. Speech Disorders
23 b. Referral for Evaluation/Treatment
24 6. Mandibular Dysfunction
25 a. Occlusal Equilibration (Modification of Tooth Form)
27 c. Fixed Orthodontic Appliance Adjunctive to Surgery
28 d. Functional/Orthopedic Appliance
29 7. Temporomandibular Disorders
30 Numerous treatment modalities, including orthodontics, have produced beneficial
31 results in the management of temporomandibular disorders. However, no singular
32 treatment modality may necessarily be definitive for any particular patient. There is
33 no scientific proof that any particular method of orthodontic treatment, whether
34 involving extraction or non-extraction, has any causative effect on
35 temporomandibular disorders. There is no reliable method for predicting or
36 preventing future temporomandibular disorders in any particular individual.
37
38 Craniofacial Anomalies, Cleft Lip and Palate
39
40 Management of patients with these and other anomalies is, in many cases, best provided by a
41 multidisciplinary team of dentists and physicians. The optimal time for the first evaluation of these
42 patients is within the first few days of life, and referral for team evaluation and management is
43 appropriate at any age. Treatment plans should be developed and implemented on the basis of
44 team recommendations. The orthodontist, as a member of the craniofacial defects team, should
45 evaluate those factors that may influence surgical management, assist in treatment planning,
46 obtain baseline diagnostic records and perform orthodontic treatment.
47
48 For patients at risk for developing malocclusion or maxillomandibular discrepancy, diagnostic
49 records should be collected at appropriate intervals. Depending on the goals to be accomplished,
50 periods of treatment and retention may be necessary beginning at birth. For example, patients with
51 cleft lip and cleft palate may require presurgical maxillary orthopedics to improve the position of
13
ATTACHMENT A
1 the maxillary alveolar segments prior to lip and palate closure. Timing of bone grafting of alveolar
2 clefts should be determined by the stage of dental development and with the collaboration of the
3 orthodontist and surgeon.
4
5 Treatment Objectives and Limiting Factors
6
7 Goals
8
9 The goals of orthodontic treatment are optimum dentofacial function, health, stability and esthetics.
10 While these goals are desirable, it should be recognized that individual patients have problems,
11 concerns and conditions which may prevent the attainment of optimal results in every case, and
12 that the non-attainment of some of the goals of orthodontic treatment in a particular patient is no
13 indication of negligence by the orthodontist even when no limiting factors are present. Some
14 patients may simply wish to pursue more limited treatment goals.
15
16 Limiting Factors
17
18 Orthodontic treatment results may be affected by extenuating circumstances beyond the
19 practitioner's control. These limiting factors should be documented in the patient's record when
20 they occur and the patient/guardian should be informed. The following are some of the more
21 common limiting factors affecting orthodontic therapy:
22
23 1. Severity of the pretreatment condition
24 2. Pretreatment agreement to pursue limited objectives
25 3. Abnormal skeletal morphology or growth, during or after treatment
26 4. Abnormal size, shape, or number of teeth
27 5. Aberrant tooth eruption patterns
28 6. Patient's failure to initiate timely treatment, continue or complete treatment
29 7. Compromised periodontal tissues
30 8. Persistent deleterious habits or abnormalities of muscle function relating to the
31 dentofacial complex
32 9. Inability or unwillingness of the patient to cooperate with treatment (e.g., the wear
33 and/or care of appliances, oral hygiene measures, diet, or keeping appointments)
34 10. Failure to complete all recommended aspects of treatment
35 11. Poor quality, untimely or inappropriate integration of other recommended or
36 required dental and/or medical services
37 12. Medical complications or underlying systemic conditions
38 13. Patient transferring to another provider during orthodontic treatment
39 14. Patient transferring from another provider where the previous treatment plan limits
40 the quality of outcome
41 15. Incomplete correction or relapse of orthognathic surgical procedures
42
43 Treatment Consultation and Informed Consent
44
45 A discussion must be held with the patient/parents/legal guardian utilizing lay terminology to
46 provide sufficient information for the responsible party to accept or reject the proposed treatment
47 plan. This discussion must be documented and should include:
48
49 1. A description of the diagnosis and treatment plan.
50 2. A discussion of reasonable alternative treatments.
14
ATTACHMENT A
1 3. The relevant risks, compromises, and limitations associated with the proposed
2 treatment plan and alternative treatments.
3 4. A discussion of any portion of the treatment plan that will require the services of
4 other dental or medical health care providers and the anticipated effects of such
5 services on the orthodontic treatment plan.
6 5. The prognosis related to all treatment plans, including the option of no treatment.
7 6. A discussion of the patient's responsibility relating to the care (e.g., maintaining
8 periodic recall visits with their general dentist).
9 7. An estimate of the duration of active treatment and retention.
10 8. A signed agreement regarding informed consent and the financial arrangements
11 may be considered.
12
13 Risks Associated with Orthodontic Treatment
14
15 All forms of medical and dental treatment, including orthodontics, involve some risks and/or
16 limitations. Fortunately, in orthodontics, serious complications are infrequent. The orthodontist
17 should determine which potential risks to disclose to the patient in the exercise of sound
18 professional judgment given the clinical condition of the patient. Due to the length of orthodontic
19 treatment, conditions may arise which are coincident, but not caused by orthodontic treatment.
20 Some of the risks associated with orthodontic treatment include:
21
22 1. Tooth decay, or permanent markings (decalcification deca1cification).
23 2. The length of the roots of teeth may become shortened. This may be of no clinical
24 significance or may require the discontinuance of orthodontic treatment with
25 subsequent interdisciplinary treatment to stabilize the teeth. In some cases root
26 shortening may be pre-existing.
27 3. The health of the bone and periodontal support of the teeth may be affected.
28 4. The teeth and/or jaws have a tendency to change their positions after treatment.
29 5. Temporomandibular joint problems may appear concurrently with
30 orthodontic treatment, but may not be related to the treatment.
31 6. The vitality of a tooth may be compromised.
32 7. Orthodontic appliances may irritate or damage the oral tissues and may cause
33 injury if accidentally swallowed or aspirated.
34 8. Dental materials, instruments, and equipment may result in damage or injury to
35 the oral tissues, face and/or eyes.
36 9. Accidents during treatment or patient misuse of orthodontic appliances may result
37 in injury to the oral tissues, face and/or eyes.
38 10. Oral surgery, orthognathic surgery or other adjunctive medical, surgical or
39 dental procedures may be necessary in conjunction with orthodontic treatment.
40 Associated treatments carry additional risks which must be discussed with the
41 patient/parents/legal guardian by the health care practitioner providing the service.
42 11. Orthodontic appliances may cause attrition, flaking or fracturing of tooth
43 structure.
44 12. When orthodontic appliances are removed, fracture and/or damage to the teeth
45 may result.
46 13. Medical or psychosocial conditions may result in compromised results or
47 dissatisfaction with treatment.
48 14. Orthodontic materials may cause allergic reactions in some individuals.
49 15. Patients may be dissatisfied with their dental or facial esthetics at the conclusion
50 of treatment due to unrealistic expectations or perceptions.
51 16. Abnormal growth during or after treatment may produce undesirable results.
15
ATTACHMENT A
1 17. Treatment time may be extended and results compromised due to unforeseen
2 circumstances and poor patient cooperation.
3 18. Tooth movement during orthodontics may be adversely affected for patients
4 receiving bisphosphonates. Bisphosphonates have the potential to slow tooth
5 movement and may lengthen treatment time. The effects of these medications may
6 be severe enough to stop tooth movement which may result in removal of
7 appliances regardless of tooth positions. The effects of bisphosphonates on an
8 individual are not predictable. Long-term bisphosphonate use has been observed to
9 decrease bone healing. It is possible that tooth movement and any surgery
10 procedures within the jaws or bone surrounding the teeth may be difficult, and in
11 some cases may result in osteonecrosis of the jaws.
12 19. The use of orally applied drugs, especially certain drugs of abuse such as cocaine
13 or amphetamines, may seriously compromise the gums and bone tissue around
14 teeth which can be exacerbated by orthodontic treatment.
15
16 Risks Associated with Adjunctive Procedures in Orthodontics
17
18 The orthodontist may recommend certain procedures that are intended to enhance or
19 facilitate the positive outcome of orthodontic therapy (i.e. temporary anchorage devices
20 devises, soft tissue laser treatment, etc.). These procedures may involve certain risks and
21 limitations, all of which may involve additional informed consent issues.
22
23 Post Treatment Evaluation and Outcomes Assessment
24
25 The effects of orthodontic treatment should be evaluated retrospectively with reference to the
26 pretreatment condition. Consistent re-evaluation of treatment results along with continued review
27 of treatment modalities and their effectiveness will serve to provide the public with the highest
28 quality of orthodontic care. Assessing the outcome of treatment is dependent upon the treatment
29 goals and objectives, the condition being treated, the stage of the patient's dentofacial
30 development, and the treatment provided. Limiting factors must be considered when evaluating
31 treatment and outcomes.
32
33 Post Treatment Records
34
35 Post treatment unaltered records provide information for the quantitative and qualitative
36 assessment of treatment changes as well as for education, research, and quality assurance. Post
37 treatment records may include, but are not limited to:
38
39 1. Extra and intraoral images (digital, still or video images)
40 2. Dental casts (hard copy or digital format)
41 3. Intraoral, panoramic, and/or cephalometric radiographs (CBCT as an alternative)
42 4. Other indicated procedures or tests
43
44 Positive Outcomes of Treatment
45
46 1. Satisfaction of the patient's chief complaint
47 2. Well aligned teeth
48 3. Good or improved occlusal function
49 4. Good or improved dental and facial esthetics
50 5. Good or improved environment for dentofacial development
51 6. Desirable modification of the size, shape, and position of the jaw(s)
16
ATTACHMENT A
1 7. Stability of the treatment results
2 8. Good or improved dental and periodontal health
3 9. Good or improved temporomandibular function
4
5 Negative Outcomes of Treatment
6
7 1. The patient's chief complaint was not satisfied
8 2. Poorly aligned teeth
9 3. Poor or unimproved occlusal function
10 4. Poor or unimproved dental and facial esthetics
11 5. Premature root resorption (primary teeth)
12 6. Excessive root resorption (permanent teeth)
13 7. Loss of periodontal support
14 8. Clinically significant decalcification or dental caries
15 9. Unsatisfactory modification of the size, shape, and position of the jaws
16 10. Instability of the treatment results
17 11. Poor or worsened temporomandibular function
18
19 Retention
20
21 1. A retention plan must be established after reviewing the patient's original
22 condition, treatment objectives, the results achieved, and/or any limiting factors.
23 2. Completion of orthodontic treatment does not ensure the stability of the result.
24 Future treatment may be recommended when post treatment changes occur and
25 may be due to growth, maturation, aging, lack of compliance with the retention
26 protocol, periodontal problems, oral habits and post treatment trauma, among other
27 factors.
28
29 Record Keeping
30
31 The keeping and preserving of a patient's dental record is necessary to the goal of providing high
32 quality orthodontic treatment. Prudent record keeping is the foundation for planning and
33 maintaining the continuity of patient care. It also provides documentary evidence of the evaluation
34 and diagnosis of the patient's condition, the treatment plan, the treatment provided, referrals
35 made, and follow up care. It also documents communications with the patient, other health care
36 providers and any other third parties. The dental record also protects the legal interests of all
37 parties. In addition, a patient's dental record may provide material for continuing education,
38 research, administrative oversight, billing, and quality assurance.
39
40 1. Treatment procedures, changes in the treatment plan, patient compliance,
41 treatment difficulties, and other important aspects of treatment must be recorded
42 and maintained. Copies of related correspondence and appropriate release forms
43 must also be maintained as part of the patient's record.
44 2. Documentation must be written, dictated, or computer annotated; maintained
45 concurrently; and kept chronologically.
46 3. The original records are usually considered the property of the practitioner. Laws
47 regarding patient record access, duplication and transfer vary from state to state.
48 Practitioners can obtain clarification from their state regulatory agency.
49 4. Electronic/digital records have the potential to be altered. Alteration of original
50 electronic/digital records must be avoided. Credible computer software either
51 prevents this or records any alteration of an original electronic/digital record.
17
ATTACHMENT A
1 However, enhancement of images is allowed as long as these are duly labeled and
2 saved as separate images. Enhancement of other electronic/digital records, such
3 as radiographs, to enable better identification of landmarks and/or dentoskeletal
4 anomalies is permissible; however, the original cannot be altered. It is the
5 responsibility of the practitioner to protect the sanctity of all patient records as
6 prescribed by all local, state and federal laws.
7
8 Transfer of Orthodontic Patients
9
10 Because of the time required to complete orthodontic treatment, the transfer of care from one
11 practitioner to another occurs frequently.
12
13 Recommendations to the Transferring Practitioner
14
15 1. Practitioners should attempt to arrange for the continuation of orthodontic treatment
16 of their patients with as little interruption as possible. Regardless of the reason for
17 transfer, reasonable efforts of both the transferring and accepting practitioner are
18 necessary to effect an orderly transfer. It is recommended, and in some states
19 required, to obtain a written release from the patient/parents/legal guardian prior to
20 the transfer of the patient's records. It is preferable to send copies of the pertinent
21 records directly to the new practitioner. The use of electronic media may facilitates
22 this process. It is acceptable, but less desirable, to provide these records to the
23 patient/ parents/legal guardian. A patient's records should not be withheld due to an
24 outstanding balance.
25 2. The transferring practitioner should ensure that all appliances are in good order.
26 The patient/parents/legal guardian should be advised that extended periods of
27 active orthodontic treatment without supervision can be detrimental, and an
28 appointment with the new practitioner should be scheduled as soon as possible.
29 3. The patient/parents/legal guardian should be informed that there may be different
30 approaches to treatment by different practitioners.
31 4. The patient/parents/legal guardian should be informed that there may be different
32 fees with treatment by different practitioners.
33 5. The transferring practitioner should make no statements that would undermine the
34 establishment of a sound doctor-patient relationship with the accepting practitioner.
35 6. The transferring practitioner should be available for consultation by the accepting
36 practitioner.
37 7. The transferring practitioner should provide appropriate financial information in
38 advance or immediately upon request to the accepting practitioner.
39
40 Recommendations to the Accepting Practitioner
41
42 1. The accepting practitioner should review the patient's records, including the
43 previous financial arrangements if available, prior to the development of a plan for
44 continuation of treatment. In addition, the estimated time required to complete
45 treatment and the financial arrangement for continuation of treatment should be
46 discussed as soon as possible. Patients should be informed about their present oral
47 health status without unprofessional comments about prior treatment.
48 2. Appropriate records documenting the status of the case at the time of transfer
49 should be made.
18
ATTACHMENT A
1 3. A practitioner is not obligated to accept an orthodontic transfer patient. If a
2 practitioner is unable or unwilling to accept the transfer patient, the practitioner may
3 assist the patient/parents/legal guardian in finding another practitioner.
4 4. At the patient/parents/legal guardian's request, a practitioner may remove
5 appliances from a patient not of record. If appropriate, previous practitioners
6 should be consulted.
7
8 Patients Who Wish to Transfer because of Dissatisfaction with Current Orthodontist
9
10 Recommendations to the transferring practitioner
11
12 1. If it becomes known that a patient plans to leave an orthodontists practice for
13 another, the orthodontist should provide the name(s) of other orthodontists in the
14 area.
15 2. Upon the patients written request, copies of all treatment records and appropriate
16 financial records should be forwarded to the accepting orthodontist, or to the
17 patient, if requested. The original treating orthodontist should retain all original
18 records. A reasonable and fair fee can be charged for record duplication. Treatment
19 records cannot be withheld because the patient/guardian has an outstanding
20 balance.
21
22 Recommended procedures for accepting orthodontist
23
24 1. Check to verify the patient received a copy of Advice for the transferring
25 orthodontic patient form from the transferring orthodontist. If not, the patient should
26 be given a copy.
27 2. Request copies of all treatment records and appropriate financial records and the
28 AAO transfer form from the referring orthodontist.
29 3. Document thoroughly the patients condition on starting treatment in the practice.
30 4. Be candid in assessing treatment progress to date. The orthodontist should refrain
31 from any unnecessary remarks about the previous treatment that could be
32 construed as negative.
33 5. If unable or unwilling to accept transfer patients, consider referring the patient to
34 another AAO member.
35
36 Members should be aware of the following documents written by the AAO Legal Counsel:
37
38 1. Second Opinions
39 2. Terminating the Doctor/Patient Relationship
40 3. Patient Records and Record Keeping
41
42
43 Evidence-Based Dentistry
44
45 Definition
46
47 Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
48 integration of systematic assessments of clinically relevant scientific evidence, relating to the
49 patients oral and medical condition and history, with the dentists clinical expertise and the
50 patients treatment needs and preferences.
51
19
ATTACHMENT A
1 Levels of Evidence
2
3 Hierarchical rating systems exist to grade individual or multiple studies based on the type of study
4 design and effectiveness in answering a specific question. Evidence levels follow a structured
5 hierarchy of criteria for grading strength of evidence, and some include assessment of the studys
6 methodological quality, precision of statistical data for the population being studied (internal
7 validity), and other considerations.
8
9 Examples of evidence ranging from a high to low-level:
10
11 Meta-analysis
12 Systematic Review
13 Randomized Trial
14 Cohort Study
15 Case/Control Study
16 Case Series
17 Expert Opinion
18
19 Best Evidence
20
21 The highest level of evidence available represents the current best evidence for a specific clinical
22 question. Based on a hierarchy of levels of evidence, meta-analysis and systematic reviews of
23 randomized controlled trials constitute the highest levels of current best evidence, and expert
24 opinion the lowest level of evidence.
25
26 Evidence-Based Clinical Recommendations
27
28 Evidence-Based clinical recommendations are developed through critical evaluation of the
29 collective body of evidence on a particular topic to provide practical applications of scientific
30 information that can assist orthodontists in clinical decision-making. In addition to scientific
31 journals, dental schools, and approved courses, sources of this information may be found in the
32 following locations:
33
34 1. Cochrane Collaboration
35 An international nonprofit organization that develops evidence-based systematic reviews
36 on health care interventions
37 2. MEDLINE
38 The National Library of Medicine's searchable database of over 12 million indexed citations
39 from more than 4,600 medical, dental, health and scientific journals Additional information
40 is available through the AAO Library.
41
42 HIPAA
43
44 The United States Department of Health and Human Services issued comprehensive privacy
45 regulations in December 2000 (modified in 2002 and 2003) which originated in the Health
46 Insurance Portability and Accountability Act of 1996 (HIPAA). The new rules are a set of federal
47 regulations that affects the practice of orthodontics.
48
49 Under the new rules, orthodontists may use and disclose a patients protected health
50 information only as the patient permits or as allowed under the privacy rules. Even where the use
51 and disclosure of such information is permissible, orthodontists must adopt policies and
20
ATTACHMENT A
1 procedures to safeguard and limit the use and disclosure of the information to the minimum
2 necessary level required to accomplish the intended purpose of the use or disclosure.
3
4 In the context of this law, protected health information is individually identifiable information and
5 includes names, dates, phone/fax numbers, email addresses, home addresses, social security
6 numbers, and demographic data. Employment records are excluded from the definition unless
7 used in connection with the provision of treatment.
8
9 The use or disclosure of the information for any purpose requires the patients/guardians prior
10 written permission except for the purpose of the patients treatment, payments activities, and
11 health care operations, for the treatment activities of any health care provider, and for payment
12 activities of other covered entities such as insurance companies.
13
14 The privacy rules also give patients certain rights (amending their protected health information, the
15 right to an accounting of certain disclosures, etc.). According to the rule, the orthodontist needs to
16 appoint a privacy official within the practice and to adopt a privacy policy so internal changes can
17 be implemented and monitored in the practice.
18
19 The new security rules require persons and entities covered by HIPAA to assess the potential
20 risks to, and vulnerabilities of, their computer systems, protect against threats to information
21 security or integrity, implement and maintain security measures, and ensure compliance with
22 these safeguards. The specific security rules can be obtained here. at:
23 http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/HIPAALaw.pdf
24
25
26 The privacy regulations only apply to health care providers who transmit (or authorize third party to
27 transmit on their behalf) protected health information electronically. The new regulations do not
28 apply to AAO members who transmit information in paper form or via facsimile. The new rules
29 require that appropriate administrative, technical and physical safeguards are put in place for
30 patients protection. The orthodontist must designate a privacy official who can develop and
31 implement the privacy procedures and a contact person who is responsible for receiving
32 complaints and can respond on matters concerning privacy. Orthodontists must provide privacy
33 training to their staff members within a reasonable amount of time after commencement of
34 employment and training should be documented. The privacy rules require that orthodontists
35 follow the minimum necessary rule (obligating practitioners to make reasonable efforts to use,
36 disclose, and obtain the minimum amount of protected information reasonably required to achieve
37 the intended purpose) in relation to the use and disclosure of protected patient information, and
38 reasonably safeguard such information to limit incidental uses and disclosures.
39
40 The AAO website provides further details on the need for a written consent to use protected
41 information for treatment, payment or health care operations. The website also details what the
42 consent form should contain, what new rights are given to patients by the new rules, information
43 concerning the extent of the accounting of disclosure that must be given, information about the
44 type of privacy notice that must be given, and when written authorization from the patient/guardian
45 must be obtained. Practitioners are encouraged to consult the AAO HIPAA Compliance Manual
46 found on the AAO website (http://www.aaomembers.org/legal/hipaa).
47
21
ATTACHMENT A
1 Appendix A
2
3 Historical Development
4
5 At its November 1993 meeting, the AAO Board of Trustees directed the AAO Council on
6 Orthodontic Health Care (COHC) to study the feasibility of developing clinical practice guidelines
7 for orthodontics. The council met in January 1994 and proposed a business plan for the
8 development of Guidelines, which was considered at the February 1994 meeting of the AAO
9 Board of Trustees. It was the consensus of the AAO Board of Trustees to develop guidelines
10 utilizing the expertise within the AAO. A task force was appointed. (Appendix A)
11
12 The task force met three times between July 1994 and January 1995 and wrote draft guidelines. A
13 copy of draft guidelines was sent to all active AAO members in April 1995 for review. Open forums
14 were held at the 1995 AAO Annual Session and at the meetings of all eight AAO constituent
15 societies during August-November 1995. The task force met again in December 1995 to revise the
16 draft guidelines based on feedback received in 1995. The December 1995 revised draft guidelines
17 were widely circulated in January 1996 for comment. The task force reviewed the comments and a
18 revised draft of the guidelines was distributed to the AAO House of Delegates members, the Board
19 of Trustees and other leaders of organized orthodontics in April 1996. An open forum was held at
20 the 1996 AAO Annual Session for comments on the revised draft guidelines. The revised draft
21 guidelines were approved by the Board of Trustees, a House of Delegates Reference Committee
22 and by the House of Delegates. The Clinical Practice Guidelines were printed in 1996 and were
23 made available to AAO members.
24
25 A reprint of the 1996 Clinical Practice Guidelines was published in 2001.
26
27 The Board of Trustees decided at their May 2007 meeting to appoint a task force to review and
28 recommend changes to the AAO document Clinical Practice Guidelines for Orthodontics and
29 Dentofacial Orthopedics 2001. The 2008 Guidelines will be made available on the AAO members
30 website so they will be more easily accessible. The task force was also asked to recommend a
31 protocol to regularly update these Guidelines.
32
33 The task force members were assigned in September 2007 (Appendix C). Conference calls and
34 emails between November 2007 and June 2008 were used to make edits and additions to the
35 2001 Clinical Practice Guidelines. When all changes have been fully discussed and agreed upon
36 by the task force members, they will be circulated to all AAO Councils for input. The task force will
37 then consider whether or not any additional changes are to be made prior to approval by legal
38 counsel and the Board of Trustees.
39
40
22
ATTACHMENT A
1 Appendix B
2
3 Updating of Clinical Practice Guidelines
4
5 The American Association of Orthodontists considers its Clinical Practice Guidelines to be a living
6 document. The existence of this document is intended to stimulate improvement in the practice of
7 orthodontics by identifying areas where knowledge is incomplete or inadequate. The AAO
8 recognizes the dynamic nature of orthodontics and dentofacial orthopedics and the necessity for
9 updating the guidelines to reflect the evolving science and art of orthodontics.
10
11 Revisions to the document, with opportunities for AAO member input, will be made to reflect
12 increasing knowledge and experience. This will take into account future practice developments,
13 basic science and clinical research findings, and clinical data on treatment outcomes. In this
14 manner, the guidelines will continue to evolve and serve as an important resource to the dental
15 profession.
16
17 The AAO is committed to revising this document biennially. The AAO President will select an AAO
18 Board member to chair the task force. One council member from three councils will be appointed
19 to the taskforce. Councils providing members to the taskforce will rotate each time the guidelines
20 are updated. An AAO staff member will also be appointed to the task force. The AAO Board of
21 Trustees task force will be authorized to make minor revisions from time to time. The Clinical
22 Practice Guidelines will be an online document only.
23
24
25
23
ATTACHMENT A
1 Appendix C Clinical Practice Guidelines Task Force Members
2
3 1994 Task Force Members
4
5 Dr. Charles S. Tjersland, Chairman
6 Dr. Rolf G. Behrents
7 Dr. Thomas J. Cangialosi
8 Dr. Rodney C. Dubois
9 Dr. Raymond George, Sr.
10 Dr. Arnold J. Hill
11 Dr. Laurance E. Jerrold
12 Dr. Terry R. Pracht
13 Dr. Donald R. Poulton, Trustee Liaison
14 Mr. Terry G. Wolf, Staff Liaison
15
16 2007 Task Force Members
17
18 Dr. David Turpin, Chair and Trustee Liaison
19 Dr. Michael Foy
20 Dr. Jeffery Johnson
21 Dr. Douglas Klein
22 Dr. Gary Opin
23 Dr. Robert Prince
24 Dr. O.H. Rigsbee
25 Dr. Emile Rossouw
26 Dr. Bhavna Shroff
27 Ms. Jackie Hittner, AAO Staff Liaison
28
29 2013 Committee Members
30
31 Dr. Christopher Roberts, Chair and Trustee Liaison
32 Dr. Carolyn Melita (COOP)
33 Dr. Shannon Owens (COSA)
34 Dr. Sheldon Seidel (COE)
35 Ms. Jackie Hittner, AAO Staff Liaison
24
ATTACHMENT A
1 Selected References
2
3 * denotes reference could not be verified.
4
5 Introduction
6
7 American Academy of Periodontology. Guidelines for periodontal therapy. Chicago: American
8 Academy of Periodontology; 1993.
9
10 American Association of Endodontists. Appropriateness of care and quality assurance guidelines
11 of the American Association of Endodontists. Chicago: American Association of Endodontists;
12 1994.
13
14 American Association of Oral and Maxillofacial Surgeons. Parameters of care for oral and
15 maxillofacial surgery. A guide for practice, monitoring and evaluation (AAOMS Parameters of Care
16 92). Journal of Oral and Maxillofacial Surgery 1992;50(7 Suppl 2) : i-xvi, 1-174.
17
18 American Association of Orthodontists. American Association of Orthodontists bylaws and
19 principles of ethics. St. Louis: American Association of Orthodontists; 1994.
20
21 American Association of Orthodontists. Glossary of dentofacial orthopedic terms. St. Louis:
22 American Association of Orthodontists; 1993.
23
24 American Association of Orthodontists. Guidelines for quality assessment of orthodontic care. St.
25 Louis: American Association of Orthodontists; 1988.
26
27 American Dental Association. Standards for advanced specialty education programs in
28 orthodontics. Chicago: American Dental Association; 1991.
29
30 Field MJ, Lohr KN. Guidelines for clinical practice: from development to use. Washington, DC:
31 National Academy Press; 1992.
32
33 ICD-9-CM: the International classification of diseases, 9th revision, clinical modification. 4th ed.
34 New York: McGraw-Hill; 1995.
35
36 Lovelace SE. Guiding the profession. CDA Journa1 of the California Dental Association
37 1993;21:30-6.
38
39 Pretreatment Considerations
40
41 Ackerman JL, Proffit WR. The characteristics of malocclusion: a modern approach to classification
42 and diagnosis. American Journal of Orthodontics 1969;56:443-54.
43
44 *Albino JE. Psychosocial aspects of malocclusion. New York: Behavioral Health; 1984. p. 918-26.
45 Baumrind S, Frantz RC. The reliability of head film measurements. American Journal of
46 Orthodontics 1971;60:111-27.
47
48 Bottomly WK. Patient health status evaluation procedures for the dental profession. Part I -
49 Dental/medical history. Journal of Oral Medicine 1976;Spec. No:5-7.
50
25
ATTACHMENT A
1 Burstone CJ. Application of bioengineering to clinical orthodontics. In: Graber TM, Vanarsdall RL.
2 Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 235-267.
3
4 Dale JG. Interceptive guidance of occlusion, with emphasis on diagnosis. In: Graber TM,
5 Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p.
6 291-379.
7
8 Downs WB. The role of cephalometrics in orthodontic case analysis and diagnosis. American
9 Journal of Orthodontics 1952;38:162-82.
10
11 Forsberg CT, Burstone CJ, Hanley KJ. Diagnosis and treatment planning of skeletal asymmetry
12 with the submental-vertical radiograph. American Journal of Orthodontics 1984;85:224-37.
13
14 Graber TM. Panoramic radiography in orthodontic diagnosis. American Journal of Orthodontics
15 1967;53:799-821.
16
17 Grave KC, Brown T. Carpal radiographs in orthodontic treatment. American Journal of
18 Orthodontics 1979;75:27-45.
19
20 Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. 2nd ed.
21 Stanford, CA: Stanford University Press; 1959.
22
23 Horowitz SL, Hixon EH. The nature of orthodontic diagnosis. St. Louis: C.V. Mosby Co.; 1966.
24
25 Kaplan RG. Standardization for serial intraoral photography. American Journal of Orthodontics
26 1979;75:431-7.
27
28 Kenealy P, Frude N, Shaw W. An evaluation of the psychological and social effects of
29 malocclusion: some implications for dental policy making. Social Science and Medicine
30 1989;28:583-91.
31
32 Kenealy P, Hackett P, Frude N, Lucas P, Shaw W. The psychological benefit of orthodontic
33 treatment. Its relevance to dental health education. New York State Dental Journal 1991;57:32-4.
34
35 Larheim TA, Svanaes DB. Reproducibility of rotational panoramic radiography: mandibular linear
36 dimensions and angles. American Journal of Orthodontics and Dentofacial Orthopedics
37 1986;90:45-51.
38
39 Macgregor FC. Social and psychological implications of dentofacial disfigurement. Angle
40 Orthodontist 1970;40:231-3.
41
42 McLain JB, Proffit WR. Oral health status in the United States: prevalence of malocclusion.
43 Journal of Dental Education 1985;49:386-97.
44
45 Moyers RE. Standards of human occlusal development. Craniofacial growth series No. 5 Ann
46 Arbor, MI: Center for Human Growth and Development, University of Michigan; 1976.
47
48 Proffit WR, Ackerman JL. Diagnosis and treatment planning in orthodontics. In: Graber TM,
50 3-95.
51
26
ATTACHMENT A
1 Richmond S. Recording the dental cast in three dimensions. American Journal of Orthodontics
2 and Dentofacial Orthopedics 1987;92:199-206.
3
4 Ricketts RM. Perspectives in the clinical application of cephalometrics. The first fifty years. Angle
5 Orthodontist 1981;51:115-50.
6
7 Riedel RA. An analysis of dentofacial relationships. American Journal of Orthodontics
8 1957;43:103-19.
9
10 Riolo ML, Moyers RE, McNamara JA Jr, Hunter WS. An Atlas of craniofacial growth. Craniofacial
11 growth series No. 2 Ann Arbor, MI: Center for Human Growth and Development, University of
12 Michigan; 1974.
13
14 Romriell GE, Streeper SN. The medical history. Dental Clinics of North America 1982;26:3-11.
15
16 Shaw WC. The influence of children's dentofacial appearance on their social attractiveness as
17 judged by peers and lay adults. American Journal of Orthodontics 1981;79:399-415.
18
19 Shaw WC, Meek SC, Jones DS. Nicknames, teasing. harassment and the salience of dental
20 features among school children. British Journal of Orthodontics 1980;7:75-80.
21
22 Steiner CC. Cephalometries in clinical practice. Angle Orthodontist 1959;29:8-29.
23
24 Stutts WF. Clinical photography in orthodontic practice. American Journal of Orthodontics
25 1978;74:1-31.
26
27 Terezhalmy GT, Schiff T. The historical profile. Dental Clinics of North America 1986;30:357-68.
28
29 Vanarsdall RL, Musich DR. Adult orthodontics: diagnosis and treatment. In: Graber TM, Vanarsdall
30 RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby;
31 1994. p. 750-834.
32
33 Walker RP. Computer applications in orthodontics. In: Graber TM, Vanarsdall RL. Orthodontics:
34 current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 268-290.
35
36 Diagnosis and Treatment
37
38 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and Dental
39 Alveolus
40
41 Alexander RG, Sinclair PM, Goates LJ. Differential diagnosis and treatment planning for the adult
42 nonsurgical orthodontic patient. American Journal of Orthodontics 1986;89:95-112.
43
44 Arvystas MG. Treatment of anterior skeletal open-bite deformity. American Journal of Orthodontics
45 1977;72:147-64.
46
47 Barrer HG. The adult orthodontic patient. American Journal of Orthodontics 1977;72:617-40.
48
49 Bell WH, Jacobs JD, Legan HL. Treatment of Class II deep bite by orthodontic and surgical
50 means. American Journal of Orthodontics 1984;85:1-20.
51
27
ATTACHMENT A
1 Bell WH, Jacobs JD, Quejada JG. Simultaneous repositioning of the maxilla mandible and chin.
2 Treatment planning and analysis of soft tissues. American Journal of Orthodontics and Dentofacial
3 Orthopedics 1986;89:28-50.
4
5 Bishara SE, Staley RN. Maxillary expansion: clinical implications. American Journal of
6 Orthodontics and Dentofacial Orthopedics 1987;91:3-14.
7
8 Burstone CR. Deep overbite correction by intrusion. American Journal of Orthodontics 1977;72:1-
9 22.
10
11 Cangialosi TJ, Meistrell ME Jr, Leung MA, Ko JY. A cephalometric appraisal of edgewise Class II
12 nonextraction treatment with extraoral force. American Journal of Orthodontics and Dentofacial
13 Orthopedics 1988;93:315-24.
14
15 Cangialosi TJ. Skeletal morphologic features of anterior open bite. American Journal of
16 Orthodontics 1984;85:28-36.
17
18 Carlotti AE, George R. Differential diagnosis and treatment planning of the surgical orthodontic
19 class III malocclusion. American Journal of Orthodontics 1981;79:424-36.
20
21 Case CS. The question of extraction in orthodontia. American Journal Orthodontics 1964;50:660-
22 91.
23
24 Chaconas SJ, de Alba y Levy JA. Orthopedic and orthodontic applications of the quad-helix
25 appliance. American Journal of Orthodontics 1977;72:422-8. American Journal of Orthodontics
26 and Dentofacial Orthopedics
27
28 Epker BN, Fish L. Surgical-orthodontic correction of open-bite deformity. American Journal of
29 Orthodontics 1977;71:278-99.
30
31 Epker BN, Wolford LM, Fish LC. Mandibular deficiency syndrome II. Surgical considerations for
32 mandibular advancement. Oral Surgery, Oral Medicine, and Oral Pathology 1978;45:349-63.
33
34 Frankel R, Frankel C. A functional approach to treatment of skeletal open bite. American Journal
35 of Orthodontics 1983;84:54-68.
36
37 Gianelly AA, Arena SA, Bernstein L. A comparison of Class II treatment changes noted with the
38 light wire, edgewise, and Frankel appliances. American Journal of Orthodontics 1984;86:269-76.
39
40 Glassman AS, Nahigian SJ, Medway JM, Aronowitz HI. Conservative surgical orthodontic adult
41 rapid palatal expansion: sixteen cases. American Journal of Orthodontics 1984;86:207-13.
42
43 Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic therapy: posttreatment dental and
44 skeletal stability. American Journal of Orthodontics and Dentofacial Orthopedics 1987;92:321-8.
45
46 Graber LW. Chin cup therapy for mandibular prognathism. American Journal of Orthodontics
47 1977;72:23-41.
48
49 Graber TM. Functional appliances. In: Graber TM, Vanarsdall RL. Orthodontics: current principles
50 and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 383-436.
51
28
ATTACHMENT A
1 Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning.
2 Part II. American Journal of Orthodontics 1984;85:279-93.
3
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16 Morin DR. The patient's records and the defense of dental malpractice claims. American Journal
17 of Orthodontics and Dentofacial Orthopedics 1992;102:569-70.
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19 Transfer of Orthodontic Patients
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21 American Association of Orthodontists. American Association of Orthodontists bylaws and
22 principles of ethics. St. Louis: American Association of Orthodontists; 1994.
23
24 American Association of Orthodontists. Guidelines for transfer of orthodontic cases. St. Louis:
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