PROSTHODONTICS - American College of Prosthodontists

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICSAMERICAN DENTAL ASSOCIATIONChicago, Illinois2010 CDEL Re-recognition of the Specialty Report 1 of 279

Purpose of the ReviewThe American College of ProsthodontistsIn 1992, the ADA House of Delegates adopted Resolution 144H-1992 which directed theperiodic (every 10 years) review of dental specialty education and practice beginning in 2001.In 2001, the Council on Dental Education and Licensure forwarded its recommendations fromthis review to the House of Delegates for its consideration. The 2001 House accepted thereport and adopted the following resolutions:20H-2001Resolved, that the appropriate Association agency continue to conduct a periodicreview of dental specialty education and practice at ten-year intervals, and be it furtherResolved, that the next periodic review of dental specialty education and practice bepresented to the 2011 ADA House of Delegates.21H-2001Resolved, that the sponsoring dental specialty organizations and ADA recognizeddental specialty certifying boards be urged to continue to monitor the number ofspecialists who are board certified and identify ways to increase the percentage ofspecialists who see and achieve board certification in light of dental specialty facultyshortages and the Commission on Dental Accreditation’s standard requiring thatprogram directors of advanced dental specialty education programs be board certified.In carrying out the House directive for such periodic reviews, the Council hopes to gatherstrategic information that will be of value to the Association, the specialty organizations, theprofession and the public. The review should clearly focus on changes occurring within thespecialty education and practice environments, e.g., disease trends, technology, scope ofpractice, program enrollments, and demographics. It should address the current environmentas well as potential trends for the future and how these will impact the public and the profession.The Council believes that the input and self-assessment of each of the specialty organizations isessential in providing an accurate report to the House of Delegates.Instructions to the Specialty Organizations: Each specialty organization is being providedwith all information and data available from ADA agencies relevant to the review. A copy of theorganization’s 2001 submission is also provided for reference.Where existing data is available, specialty organizations are asked to analyze the data andcomment on trends that have and/or may impact the specialty and the profession. The Councilseeks succinct but thoughtful responses to study items to provide a broad assessment of keyissues. Each item includes a suggested length for a response. However, the length and natureof responses may vary according to the unique characteristics of the specialty.The current environment as well as potential trends for the future and how these may impact thepublic, the profession and practice should be addressed.Prosthodontics - 32010 CDEL Re-recognition of the Specialty Report 3 of 279

A. General InformationThe American College of Prosthodontists1. Provide a copy of the sponsoring organization’s strategic plan. Provide a brief summaryhighlighting specific areas of the strategic plan that the specialty wishes to call to theCouncil’s attention as it relates to this review. Briefly comment on efforts the specialty hasundertaken to promote quality in the discipline over the past 10 years (e.g., continuingcompetence, parameters of care, continuing education).In June 2006, the leadership of the American College of Prosthodontists invited selectProsthodontists representing the spectrum of the specialty, as well as select leadership from thecommunities of interest for “Reframing the Future of Prosthodontics: An Invitational LeadershipSummit”. Through this effort, the core purpose of the American College of Prosthodontists wasredefined as “to improve the quality of life through the advancement of Prosthodontics”, acompelling statement that underscores the importance of the discipline and specialty. The fivegoals are stated as appended in the “ACP Strategic Plan” focuses on 1) the value ofprosthodontic care, 2) advocacy for prosthodontic care, 3) emphasis on discovery throughstrong science, technology and research, 4) growth of the workforce and 5) partnership at alllevels for strong dental education.The ACP has focused resources on the areas of growth, education, and science andtechnology. In the area of growth, the ACP Education Foundation invested resources todevelop “A Guide for Creating an Advanced Educational Program in Prosthodontics” to helpsupport creation of new advanced education programs in Prosthodontics and in particular, theACP Education Foundation provided resources to assist a new program. Local efforts ofadvocacy included outreach to Deans and leaders of dental schools without programs todiscuss and implement creation of new advanced education programs in Prosthodontics. TheACP has promoted change in the CODA standards for predoctoral education includingcompetence in oral cancer screening and assessment, as well as increased knowledge andexposure to emerging technologies that will affect prosthodontists in practice.The ACP developed the Prosthopedia®, an on-line resource of educational informationto include all areas in Prosthodontics for practitioners, educators, and residents. The ACP hasdeveloped a number of digital educational resources including Oral Cancer Screening, Colorand Shade Selection, Implant Dentistry, TM Disorders, Occlusion, Tooth Preparation,Prosthodontic Diagnostic Index and Private Practice DVD/CDs. In addition, new educationalbrochures on esthetics, veneers, fixed, removable and implant prosthodontics, TMD andxerostomia have been developed for patients. In the past 10 years, the ACP has hosted morethan 47 continuing education programs providing approximately 1,000 credit hours serving morethan 13,000 prosthodontists in attendance. Course objectives are required of faculty as well asassessment by delegates in attendance with debriefing and reporting assessment by thescientific program committee to the ACP Board of Directors as well as to the educational faculty.The ACP has taken a leadership role in oral cancer screening and education throughproduction of a comprehensive oral cancer educational document and an Oral CancerScreening DVD, ultimately to benefit our patients. The Oral Cancer DVD was distributed to theentire membership and also made available through the Prosthopedia® in an effort to addressthis public health issue. Importantly, this achievement serves as model educational content forour predoctoral and advanced education faculty. National Prosthodontics Awareness Week,new in 2010, represents a landmark “value” statement for Prosthodontics. These are greatexamples of Advocacy. [Reference documents appended, A-E]Science and technology has been addressed thematically through programs foreducators and clinicians. Specific forums have been supported by our ACP EducationFoundation and particular efforts to promote careful evaluation followed by early adoption oftechnology are ongoing throughout the membership. The CODA Standards for AdvancedEducation Prosthodontics reflect this emphasis. The ACP engages its industrial partners inachieving growth in science and technology by interaction in educational venues and symposiasuch as the 2009 Technology Forum at the University of North Carolina.Prosthodontics - 42010 CDEL Re-recognition of the Specialty Report 4 of 279

The American College of Prosthodontists2. Complete the table below and provide overview comments on past and futuremembership trends forecast for the next 10 years. Comment on how changes inmembership will impact public and the profession. (suggested response – up to twopages including the table)The ACP reports that in 2010 allmembership classes of the ACPtotaled 3,305 individuals. Thistotal includes 2428 (73%) USeducationally qualifiedprosthodontists (Members +Fellows) and 193 InternationalMembers and Fellows (5.8%)along with 877 (26.5%) noneducationallyqualified nonprosthodontiststhe majority ofwhich are Prosthodontic PGStudents, other dentists anddental laboratory technicians. Anincrease in membership hasoccurred as seen in the adjacentgraph, Figure 1. This trendrepresents a 33% increase inmembership in just 6 years.Figure 1.Table 1. MEMBERSHIP CATEGORIESProsthodonticsYEARACTIVEASSOCIATE AFFILIATE(Students) (Alliance)LIFE OTHER2001 1979 419 0 307 132002 1879 259 21 326 142003 1948 279 75 322 172004 1879 216 106 320 142005 1970 298 133 361 172006 1970 327 120 378 172007 2013 503 108 384 172008 1980 547 213 386 152009 2185 447* 203 443 14*There has been a transition of student members to active members which shows a decreasefrom 2008; however, for 2010, there are over 600 associate members.If available, please provide information on the gender and ethnicity of members.Limited data as presented in Table 2.Table 2. MEMBERSHIP/Gender and Ethnicity, ProsthodontistsYEAR Male Female White Black Hispanic20052006200720082009 2678 612AmericanIndianProsthodontics - 52010 CDEL Re-recognition of the Specialty Report 5 of 279AsianUnknown

The American College of Prosthodontists3. Review the following summary of certification and examination data from the CDEL’sAnnual Reports of the ADA-Recognized Dental Specialty Certifying Boards, 2000-2009.In collaboration with the recognized certifying board, provide overview comments onsignificant trends for the future. (suggested response - up to one page including thetable)Table 3. CERTIFICATION AND EXAMINATION DATA: 2000-2009Prosthodontics 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Number Certified ByExamination Through 2000-2009Number of ActiveDiplomates 2000-091178 1472 1493 1511 1530 1555 1589 1616 1644 1693720 717 715 724 724 736 1068 1056 1085 1119Number of AcceptableApplications Received 2000- 88 97 157 133 136 157 182 186 208 25309ABP Board Certified (Diplomate). There has been incredible growth in board certifiedprosthodontists or Diplomates, reflecting an increase of 44% over the past ten years (Table 3).Actions leading to this increase included mandating that 100% of Program Directors are boardcertified, creation of board exam review courses and online resources, and enhancement of theABP Examination. These efforts were supported by both the ACP and the ACP EducationFoundation, to assist residents in attending these courses. The ABP continues to progressfollowing current educational testing methodologies, assuring the examination is more reliable,with improved validity, and less onerous. A new electronic written examination and new scenarioexamination, the latter in substitution for one of the clinical examinations, were implemented. Asof March 2010, there are 835 Active Diplomates [academic/administration=302, federalservices=112, private practice=411]. There are 316 Life Diplomates, with 1,151 total number ofActive and Life Diplomates. Relative to the total number of all educationally qualifiedprosthodontists approximately 33% (1151/3475) are ABP Diplomates.The percentage of Active Diplomates by vocation reveals that 50% are in private practice, 36%are in academia and 14% are in the Federal Services. While the percentage of those in theFederal Services is less than either private practice or academics, the Federal Services have thelargest percentage of Diplomates as a group. Based upon the last five years, it is projected that inthe next five years there will be an additional 237 new Active Diplomates and 20 new LifeDiplomates with a net result of 989 Active Diplomates and 320 Life Fellows for a total of 1,309diplomates in the year 2013.Figure 3.The trends in the number ofexaminations are expected toincrease significantly with thechanges in the ABP examinationprocess. In the past five years, a200% increase was noted (as foundin Question 4 data) in requests for thewritten and oral examinations. Withthis increase, there will be growth inthe number of Active Diplomates,conservatively estimated at 5% peryear, over the next five years (Figure3). Recent ABP examination changesare expected to further increase theoverall number of Diplomates.Prosthodontics - 72010 CDEL Re-recognition of the Specialty Report 7 of 279

The American College of Prosthodontists4. In collaboration with the recognized certifying board, provide overview comments on theboard eligibility requirements from the CDEL’s Annual Reports of the ADA-Recognized DentalSpecialty Certifying Boards, 2000-2009. Please note or any changes and the impact on thespecialty. If an eligibility pathway for internationally trained specialists is available, explain theprocess. (suggested response – up to two pages)Table 4. BOARD ELIGIBILITY REQUIREMENTS - ProsthodonticsProfessional 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009ADA or NDA Membership No No No No No No No No No NoSpecialty Society Membership No No No No No No No No No NoEducationYears of Advanced Education inAddition to DDS or DMD Degree3 3 3 3 3 3 3 3 3 3ExperienceTotal Years of SpecialtyExperience Including AdvancedEducation4 4 3 3 3 3 3 3 3 3OtherCitizenship Any Any Any Any Any Any Any Any Any AnyState Licensure No No No No No No No No No NoAlternate Pathway toCertificationNoNo*Table 5. SPECIALTY LICENSE OR CERTIFICATE BY STATESpecialty exam ABP certificateStateSpecialty permitgivenacceptedAlaska License Yes NoArkansas Certificate Yes NoIdaho License Yes NoIllinois License Yes YesKansas Certificate Yes YesKentucky License Yes NoMichigan Certificate No YesMinnesota License No YesMississippi Certificate Yes NoMissouri License No YesNevada License No YesNew Mexico License Yes YesOklahoma License Yes YesOregon Certificate Yes NoS. Carolina License Yes NoTennessee Certificate Yes YesWest Virginia Certificate Yes NoProsthodontics - 82010 CDEL Re-recognition of the Specialty Report 8 of 279

The American College of ProsthodontistsStates that require ABP Certification. Currently, 13 states require a specialty examination,although 8 states of 13 do not accept ABP certification while 5 of 13 accept the ABP certificationin lieu of their state specialty examination (Table 5). This information suggests that 33 states donot require any state specialty examination or American Board of Prosthodontics certification.The limitation that some states do not accept ABP Certification in those states that requirespecialty certificate or licensure influences the decision of those who would challenge theexamination. There are approximately 67 ABP certified prosthodontists that reside outside of theU.S. internationally, with the greatest number of these prosthodontists residing in Canada.Growth Trends. In the last five years, the ABP has received a significant number of candidatesrequesting Board Eligibility, and a 200% increase in the total number of Section A (written) andSection B (oral) examinations requested. In 2008, the ABP added a Section C – a scenariobasedexamination that may be taken in place of one of the Section B - Parts 2, 3 or 4 oralexaminations. The option of challenging a scenario-based examination offers alternatives forthose challenging the ABP process and may help alleviate barriers for those in private practice.Figure 4.The above line graph shows the number of educationally qualified prosthodontists whohave taken Section A, B, C Examinations and the number of new Diplomates increasing steadily(Figure 4). Estimates to 2013 are based upon the 2004-2008 data. The trends suggest anincrease in Section A and C Examinations, while Section B Examinations appear to trendupwards but at a lesser rate. The new examination protocol Section C-Scenario basedexamination that began in 2008 has shown a marked rise since its inception and is a strongindication that the new test opportunity created a valued option for those desiring boardcertification. This will continue to positively impact the number of “new” Diplomates of the ABP.Re-certification is required of all Active Diplomates. Active Diplomates are required tocomplete (40) points of continuing education and completion of one self-assessment writtenexamination within an 8-year period of initial board certification, which is repeated at 8-yearintervals. Continued proficiency must be documented by Active Diplomates and is monitoredannually by the American Board of Prosthodontics. To date, 655 recertification examinationshave been distributed and evaluated.Prosthodontics - 92010 CDEL Re-recognition of the Specialty Report 9 of 279

The American College of Prosthodontists5. List areas of major research changes and major technology advances over the last 10years. Provide an overview comment on how these changes and advances have affected thepractice of the specialty. (suggested response – up to three pages)The major research and technologic advances over the last 10 years that affectprosthodontics include remarkable changes in 1) (bio) informatics, 2) materials science, 3)imaging technology and 4) digital technology.Prosthodontics is strengthened because of these changes with particular reinforcementof the specialty’s capacity to gather patient-specific information, make patient-specific healthcare decisions, better communicate this information within the biomedical community using newtechnologies, better account for and evaluate the effect of treatment on the individual and thepopulation. The specialty has further recognized the importance of risk assessment withparticular interest in both dental caries and oral cancer. Oral cancer is of critical concern toProsthodontists; new technologies for screening and for risk assessment have increased thegeneral awareness for screening and concurrent with this the ACP produced an educationalDVD that details the process of proper oral cancer screening of our patients. Today, oral cancerscreening is a specific CODA standard for Advanced Education Programs in Prosthodontics.The ACP, together with thought leaders in the field of dental caries has prepared state of the artcaries risk assessment information and processes for dissemination to the Specialty ofProsthodontics in 2010 and 2011.The specialty of Prosthodontics has relevance to emerging technologies related todiagnostics and informatics that reinforces Prosthodontics historical role as a contributing leaderto diagnosis and treatment planning of oral health care. The past decade has seen theevolution of tooth replacement therapy. This evolution is occurring at two levels. One is the levelof diagnosis and treatment planning. The other is therapeutics and technology.When considering the evolution of diagnostics and treatment planning for toothreplacement therapy, digital technology and imaging technology has rapidly advanced and beensuccessfully translated in the past decade. Cone Beam Computed Tomography (CBCT) ofosseous structures, video-based imaging of soft tissues, and visible wavelength (and x-ray)based scanning technologies together permit the integrated three dimensional imaging ofpatients and related study casts. The ACP membership contributed to another CODAeducational standard that will assure future prosthodontists will receive education that embracesthese technologies for improved patient care.The information gathered from volumetric or three dimensional imaging can betransferred from the diagnostic realm to the therapeutic realm. The storm of new digitalmanufacture technologies remains to be fully evaluated, but indeed, digital manufacture offerssome important advantages to clinical therapy. The ability to perform guided surgery usingstereolithographic surgical guides made from CBCT images is one example of technologies thathave the opportunity to improve tooth replacement therapies. Prosthodontics has fullyembraced this technology in innovating the process of imaging technologies (throughdevelopment of radiopaque imaging templates) and by adopting the CODA standard foradvanced education in prosthodontics that prosthodontists participate in all aspects of implanttherapy including surgery.Another prominent example of new technology is the digital manufacture of crowns,bridges, and implant abutments. The computer aided design (CAD) of these components forindividual patients offers select advantages over hand modeling. The computer aidedmanufacture by direct methods (e.g. milling of ceramics and metals) or indirect methods (e.g.milling or printing of plastic/wax patterns) is rapidly displacing traditional dental laboratorytechnologies. The specialty of prosthodontics is home to many of the research leaders,educators and opinion leaders in this evolving field of dental therapeutics. The AmericanCollege of Prosthodontics continues to support these individuals and their interests inimprovement of patient care through technology development and translation.Prosthodontics - 102010 CDEL Re-recognition of the Specialty Report 10 of 279

The American College of ProsthodontistsDental implants were introduced several decades ago and in fact, when first introduce inNorth America, their use as promoted by industry was restricted to Oral Surgeons andProsthodontists. Thus, implants as a technology for tooth replacement therapy have been partof the specialty of prosthodontics since the early 1980’s and well before. In the last 10 years,several important innovations in dental implant therapy have advanced the specialty ofprosthodontics.As mentioned above, the role of CBCT imaging and the inherent need for imagingprostheses (stents/guides) involves prosthodontics and prosthodontists at the inception and endof this diagnostic procedure for dental implant placement and restoration. One further pointabout this technological change is that present advances not yet in the market place includepre-surgical planning of abutments and final prostheses. This is made available by the mergingof scanning information from the dental laboratory and the clinic and there joining in threedimensional models. The simplest way to perform this is through double scanning technologiesdeveloped for tooth replacement using implants for immediate loading protocols popularized as“teeth in a day” protocols. Prosthodontists have refined these technologies that enable thebetter implant therapy and patient care.Among the procedures in implant dentistry there has been increasing interest in early andimmediate loading of implants. Immediate loading is the process of placing an implant and animplant supported restoration at one time. There must be an integrated plan as well asintegrated thinking about the biology of implant wound healing of bone and mucosa, occlusionand esthetics. Advances in all aspect of knowledge have been achieved in this decade withwide participation of prosthodontists. The commitment of prosthodontists to Evidenced BasedDentistry is demonstrated in this field as several prospective comparative clinical trials havebeen published in support of immediate loading for specific conditions and other clinical trialsare ongoing and have been reported at national and international meetings. Systematic reviewof the literature (Jokstad 2007) supported the concept of immediate loading of implants placedin the anterior mandible but was unable to identify scientific support for immediate loading inother anatomic areas. Irrespective of the data set, immediate loading is part of the practice ofimplant dentistry. Its proper deployment as one strategy requires ongoing investigation, carefulplanning and education of the broader community of dentists. The American College ofProsthodontists is committed to support of all of these activities related to this mode of treatmentand other emerging therapies in dentistry.The spectrum of care provided for using dental implants is changing. This decade hasseen a strong push by the prosthodontic community to improve care of the edentulous patient.In the summer of 2008, the ACP with support of industry presented to the internationalcommunity at the FDI meeting in Stockholm, the current concepts and challenges in treatmentof edentulism. This information was also published in the Journal of Prosthodontics in 2009.The community of interest has developed enthusiasm for treatment of edentulism using minimalnumbers of implants for overdentures. An international consensus conference has identified themandibular implant supported overdenture as the standard of care for management of theedentulous mandible (Feine IJP 2002). Prosthodontists are now educated in thecomprehensive management of edentulism that includes the surgical placement of implants.Materials science related to Prosthodontics has been focused on ceramics. The use ofpressed and milled materials is driven by the public focus on esthetics. Diverse materials havebeen studied and among them zirconia has drawn greatest attention. Zirconia offers thepossibility for multiunit prosthesis (fixed dental prosthesis) where other materials haveinsufficient strength for broad based application. Related to the evolution of ceramics, thebonding of these different materials continues to be explored. Adhesive bonding to enamel andto a lesser degree to dentin has been reconsidered in the context of zirconia, lithium disilicateand leucite reinforced ceramic materials. Organized prosthodontics is part of this evolutionthrough its support of basic research, clinical research and dissemination of current information.For example, the ACP sponsored in April 2010 a conference entitled “The Art and Science ofModern Dental Ceramics 2010” where 20 expert clinicians offered scientific fact and expertopinion regarding these matters.Prosthodontics - 112010 CDEL Re-recognition of the Specialty Report 11 of 279

The American College of ProsthodontistsThe research environment in prosthodontics is strong. Despite the economic climatethat has reduced some opportunities in the past two or three years, other factors over the pastdecade have improved opportunities for research in prosthodontics (both the specialty and thewider discipline it serves). These opportunities touch all aspects of patient care, from diagnosticprocedures, to new therapies, to new materials, and ending in concerns for long term care of theindividual and the population in general (bioinformatics). The American College ofProsthodontists has paid particular attention to this environment, has contributed to the changein this environment, and monitors the role of technological advancement through research andinnovation in practice.Prosthodontists direct immersion in the changing research environment may beexemplified by the College’s convening of two different symposia focused on research andtechnology. The leadership of the ACP concern for the rapidly changing research climate wasaddressed in a conference of research faculty and investigators held in 2008 at the University ofNorth Carolina. With support of the American College of Prosthodontists Education Foundation,at two day conference addressing the spectrum of research activities in Prosthodonticsconcluded with a breakout discussion of needs and opportunities for innovation and research inProsthodontics. Specific actions were adopted by the ACP Board of Directors.The actions include:I. support for enhancing the CODA educational standards for advanced education inprosthodontics including a commitment to the research standard, inclusion of EvidenceBased Dentistry and evidence of adopting new technologies,II. promote research in advanced education programs by continued funding of researchopportunities,III. promote interest in innovation within the private practice community by engagingpractitioners in Clinical Evaluators Networks, andIV. advance basic research by Prosthodontists in US dental schools by creating the ACP’sYoung Prosthodontist Innovator Awards beginning in 2010In 2008, a second conference was held to focus more directly on the advancement ofDigital Technology. At this symposium, invited prosthodontists were exposed to emergingtechnologies presented by industry leaders. The outcome of this discussion was designated toinform the specialty in 2009 of the changing technological basis of the practice of prosthodonticsand to set the stage for future discussions of the prosthodontist’s role as early adopters andinnovators in clinical dentistry. The second Digital Dentistry Symposium is bookmarked for andbudgeted for early 2011. Since the 2006 ACP Annual Session has included the TechnologyForum, this has been an innovative and successful interactive session.The shared responsibility of teaching advanced and undergraduate dental educators thefundamental steps in conducting evidence based research evaluations of clinical scenarios. InApril 2010, the Academy of Prosthodontics financially supported and conducted an intensiveone day course for Prosthodontic educators. Eighty four individuals from across the USparticipated with 10 expert facilitators.Alternative approaches to research in small controlled (academic) environments are alsoimportant. Exploring efficiency and efficacy issues is relevant to the practice of prosthodontics.Practice-based research is ongoing in the US and the NIDCR has funded practice-basednetworks that evaluate patient outcomes of therapies. Published reports of practice-basedoutcomes are appearing in the field of dental implants (Stanford et al 2010) and dental ceramiccrowns (Blatz et al, 2009). In one example, hundreds of clinicians provided thousands ofimplants to evaluate the efficacy of a new implant surface technology. Within three years ofpatient treatment, a large data set was available to support the use of this available technology.Our commitment to change is reflected strongly in how prosthodontists communicate.Since 2006, the American College of Prosthodontics has expended great financial andorganization resources to the invigoration of its website as a place for communication and aninformational resource. The Prosthopedia ® is a living document with the intent of beingcontinuously updated and fully shared among viewers and participants. The importance ofProsthodontics - 122010 CDEL Re-recognition of the Specialty Report 12 of 279

The American College of Prosthodontistscommunication in this decade of change cannot be understated and looking forward, cannot beunderestimated. The Prosthodontic community is well prepared for change along with theevaluation of technologies for prudent adaptation in clinical practice.In summary, there are ongoing changes in the manner of tooth replacement using bothteeth and dental implants. Prosthodontics – the specialty and the discipline - is central to thecare of approximately 175 million individuals who are missing one or more teeth (NHANES III).The specialty has participated in the evolution of therapy using defined principles of scientificdiscovery and clinical translation. The evolution in diagnosis (imaging), manufacture(CAD/CAM), materials (ceramics), and cementation (bonding) has improved the management oftooth replacement and restoration. Prosthodontics is stronger (evidenced by a growingenrollment in education programs) and is more relevant today than in the previous decade. Thenext decade will require a redoubling of prosthodontics effort to meet the challenges of an agingpopulation, an economically diverse population and a population with growing therapeuticdemands.Prosthodontics - 132010 CDEL Re-recognition of the Specialty Report 13 of 279

The American College of Prosthodontists6. Review the summary data collected from the ADA Survey Center’s Survey of AdvancedDental Education Annual Reports over the past ten years regarding the number of programs andprogram enrollments. Provide overview comments on past or future trends regarding thisinformation. (suggested response - one page)Table 6. NUMBER OF PROSTHODONTIC PROGRAMS AND ENROLLMENTProsthodontics Number of Programs Total Enrollment2000-01 48 3782001-02 48 3772002-03 48 3922003-04 47 3982004-05 46 4012005-06 46 4072006-07 45 4252007-08 46 4312008-09 46 449Over the past ten years, there has been a 19% increase in enrollment in AdvancedEducation Programs in Prosthodontics (Table 6). There has been an increase in the number ofapplicants to advanced education programs in prosthodontics, suggesting there are also morehighly-qualified candidates. The ADA 2007-08 Survey of Advanced Dental Education (ADASurvey Center, January 2009) reports that for years 2003-2008 the number of applications toprosthodontic programs has increased from 894 to 1,162. During this same time frame the firstyear enrollment remained steady. This data represents a significant increase in the ratio of 6:1 in2003 to 9:1 in 2007 for the number of applications received for the number of positions availableindicating a greater demand for prosthodontic training.Figure 7.When reviewing the PASSdata table (Figure 7), thenumber of applicants toProsthodontic programs hasincreased by 2.5 times, asignificant increase over thepast ten years. There are 21of 46 Prosthodontic programsthat participate in PASS andbased on this data, there areapproximately 8.4 studentapplicants for each program.Knowing that the remaining 25 non-PASS programs are experiencing increased numbers ofapplicants, the ratio of applicants to programs is likely higher since one example of a school thatdid not participate in PASS was University of Texas Health Science Center San Antonio whichhad 53 student applicants for three positions, a ratio of 17.7:1. This observation is a verypositive, upward trend reflecting the interest in Prosthodontics specialty training and all programdirectors express high satisfaction with the number and quality of applicants. Concurrently withincreased numbers of applicants, there are multiple dental schools who have expressed aninterest in opening new programs including University of Pennsylvania-Penn Dental Medicine,Stonybrook University School of Dental Medicine, University of Detroit Mercy, University ofOklahoma, University of Missouri Kansas City and a possible re-opening of a program inUniversity of Louisville.There are 9 dental schools that have either opened or committed to open since 2000 andcurrently, there are 8 new possible dental schools being considered by systems such asUniversity of New Mexico, University of Arkansas and Texas Tech University (Valachovic, 2009).These new schools present great opportunities for creating new programs in Prosthodontics.The ACP created “A Guide for Creating an Accredited Advanced Education Program inProsthodontics” and maintains a list of individuals who self-identified their interest in becoming aProgram Director. These observations bode well for the future of prosthodontic programs!Prosthodontics - 142010 CDEL Re-recognition of the Specialty Report 14 of 279

The American College of Prosthodontists7. Review the summary data collected from the ADA Survey Center’s Survey of AdvancedDental Education Annual Reports over the past ten years regarding the number of full-time andboard certified program directors. Provide overview comments on past or future trendsregarding this information. (suggested response - one page)Table 8. PROSTHODONTIC DIRECTOR FULL PART-TIME OR CERTIFIEDProsthodontics Director is Full-Time Director is Board CertifiedYes No Yes % Certified2000-01 43 4 42 892001-02 44 4 43 902002-03 45 2 43 912003-04 47 1 42 882004-05 44 2 38 832005-06 43 3 41 892006-07 40 5 44 982007-08 43 3 45 982008-09 43 3 46 100Currently, 100% of program directors are board-certified. This is an incredibleincrease over the low of 83% just five years ago. This represents unanimous support for thevalue of board certification among educators and is encouraged by the ACP and ACP EducationFoundation that financially underwrites the meeting of these postdoctoral educators,independently two times per year. This allows a venue to address issues ranging from financialmanagement to revision of accreditation standards, to curricular matters of interest or any issuethat is pertinent for a program director.In some years, the Spring venue for programs includes predoctoral dental educators andthe networking that occurs in workshops, also provides opportunities for educators to becomeinvolved since many may well be the next generation of program directors. A digital resourcelibrary, known as Prosthopedia® (http://prosthopedia.prosthodontics.org/), has been created toprovide member access to a variety of resources. This modality allows program directors and allprosthodontist educators the ability to create and submit their teaching documents to includewritten information as well as digital images, video clips, etc., to a centralized, indexed resourceand allow sharing of the resources across all programs and dental schools. The ACP websitehosts the Prosthopedia® for all ACP members and offers a 30-day preview option fornonmembers.The program directors, through the ACP Education and Advancement Committeestructure, manage, create, conduct, and assess the Board Preparation Mock WrittenExamination on an annual basis. The Mock Board serves as a tool for assessment and can beused as a learning tool at the program director’s discretion. The program directors stronglyencourage residents’ participation in the annual Board Preparation Course that is conductedannually at the ACP Annual Session. Importantly, the ACP Education Foundation has supportedgraduate student registrations to the annual sessions to help defray costs for participation andattendance.The overall support for program directors and coordination among the programs hasgrown through assistance from the ACP and the ACP Education Foundation. With the supportmechanisms healthy and continuing to evolve based on initiatives directed by the programdirectors, the interest in these positions is high. With the potential for creating new programs, theprosthodontists who have self-identified as interested in open program director positions isupdated and the list of names is maintained in the ACP Central Office.Prosthodontics - 152010 CDEL Re-recognition of the Specialty Report 15 of 279

The American College of Prosthodontists8. Review the summary information attached as Appendix 1 and 2. This information has beenprovided by the Commission on Dental Accreditation regarding general changes in the languagecommon to all advanced specialty education standards and changes in the specialty’sdiscipline-specific accreditation standards. Please provide an overview comment on futuretrends regarding this information. (Suggested response - up to one page)The ACP is committed to build on the accomplishments achieved over the past tenyears. The specialty of prosthodontics exists because of its strong definition and related CODAeducational standards. The changes in CODA standards reflect the organized effort, whichcontinues to date, to establish a reoccurring agenda through which the predoctoral educatorsand the postdoctoral-advanced program educators meet formally in support of prosthodonticseducational programs. Those committed have assumed a significant responsibility andownership for reviewing CODA accreditation standards and suggesting revisions and updatinginformation for model content and best practices in support of educational activities. These twogroups of educators have committed to monitor the specialty, practice education and treatmentmodalities that relate to our diagnostically focused definition – clinical conditions associatedwith missing or deficient teeth and/or maxillofacial tissues using biocompatible substitutes – inorder to maintain the relevance of our educational programs and accreditation standards.The momentum began as a result of the 2000 Strategic Planning Process in which theofficial definition of Prosthodontics to become a diagnostic-focused definition was approved byCDEL and the ADA House of Delegates in 2003. This definition mandated a careful review ofthe educational programs and accreditation standards and has evolved over the years.Changes made in July 2004-January 2005 were related to implant-supported patient care andassociated formal education in order to increase the level of knowledge and skills in all aspectsof implant-supported education as a core treatment modality for the treatment of partial andcomplete edentulism.The impetus resulted in the Reframing the Future of Prosthodontics Summit in 2005 andin conjunction with the CODA Validity and Reliability Study (2006) and surveys (2006-2007), thespecialty underwent a review of both the discipline predoctoral education and advancedspecialty education accreditation standards. Proposed comprehensive changes to theprosthodontics specialty standards were submitted in July 2007 to CODA and officially updatedin January 2009 (Appended Accreditation Standards, highlighted version). The new standardsmandate oral cancer screening and assessment, as well as include the application andknowledge related to emerging technologies in providing assessment and care for our patients,including evidence based decision making, risk assessment for oral diseases, wound healing aspart of the standards. The oral cancer screening and assessment has been promoted as achange in the predoctoral accreditation standards, likely to have final action at the Summer2010 CODA meeting. With the launch of the Prosthopedia®, the resources are available for allour educators – both predoctoral and advanced education program directors. This reflects thecurrent and projected future for the practice of prosthodontics.The specialty of prosthodontics has been supportive of the CODA “boilerplatechanges” that have occurred over the past ten years, to include changes in advancedstanding and policy on enrollment increases. There has been in-depth discussion on theproposals for changes in definitions related to the levels of knowledge and levels of skills withinthe accreditation standards for specialties since March 2009. In brief, the ACP advancededucation in prosthodontics program directors oppose the proposed changes. The ACPresponded to CODA with a cogent response directed to the CODA Task Force and emphasizedthe statements emphasized within the response. (Reference documents appended, F-CODAAccreditation Standards annotated, G - ACP Resolutions and Comments on CODA ProposedChanges in the Definitions).Prosthodontics - 162010 CDEL Re-recognition of the Specialty Report 16 of 279

Changes in Scope of PracticeThe American College of Prosthodontists9. Highlight recent epidemiological data or studies that establish the incidence and/orprevalence of major conditions routinely diagnosed and/or treated by practitioners in thespecialty. Please provide overview comments on how these changes have affected the practiceof the specialty and the future practice of the specialty. (suggested response - up to fivepages)The data presented will show there is greater need for prosthodontic services, includingcomplex prosthodontics over the next 25 years. The needs for these services will continue toincrease with the growth in the adult population which is the fastest growing segment of the U.S.population. With these factors, the demand for complex prosthodontic services to be providedat the specialty level will also grow dramatically.According to Oral Health–Healthy People 2010: Objectives for Improving Health, 26% ofthe US population between the ages of 65 and 74 are completely edentulous. Other data showsthe prevalence of persons who are edentulous increases with age from 0% of the 18 to 24 yearolds; to 12% of the 50 to 54 year olds; 24% of the 60 to 64 year olds; and 43.9% of those 75and older (Marcus, et al., 1994). The rate of edentulism is estimated at 30% for African-Americans, American Indian, or Alaska Native for this age group, 26% for Caucasians, and 24%for Hispanics. Low-income adults aged 65 and older had the highest rate of edentulism (48% in1993), and there were dramatic differences between similar populations in the fifty states (13%in Hawaii to 47% in Kentucky are edentulous). Low education levels have been found to havethe highest and most consistent correlation with tooth loss. Early loss of teeth has shown to be asignificant factor leading to complete edentulism, with 7.4% of dentate Americans experiencingearly tooth loss becoming edentulous within the next decade. And, while reports indicate a 6%reduction in total edentulism between 1988 and 2002, significant growth in the US populationalong with possible declining access to dental care, shows a tendency for growth of edentulismin one or more dental arches over the next two decades. Based on the multiple factors,edentulous patients will need or demand an increase of approximately 230,000 units ofcomplete dentures per year.When considering complex prosthodontics in a partially dentate or dentate patient, acomplicating factor is the condition of the remaining dentition. The percent of treated anduntreated root caries increases markedly with age (Miller, et al., 1987). Approximately 7% ofdentate adults age 18 to 19 had at least one decayed or filled root surface, whereas, 54.4% of60 to 64 year olds had at least one decayed or filled root surface. Among seniors, 62.6% had atleast one decayed or filled root surface with 38% of these due to untreated decay (White, et al.,1995). Overall, 22.5% of dentate persons had root caries in 1988 -91. Mean root caries scoresincreased with age in every demographic group (Winn, et al., 1996).The data related to tooth loss and tooth retention will have a significant impact on thespecialty of prosthodontics. Based on the data related to edentulism, tooth loss and thecondition of remaining teeth, as well as other factors such as abrasion, attrition, erosion, and theneed for esthetic improvement (Douglass, 1992) coupled with the increase in the adultpopulation, there is an increased need for complex prosthodontics services.On review of three basic demographic trends occurring in the U.S.:(1) the population is getting larger,(2) the population is getting older,(3) the population is becoming more culturally diverse,The combination of these three trends, has a positive impact on the need for prosthodonticservices. Within 20 years the U.S. population is expected to exceed 325 million people. Thetotal U.S. population will therefore increase by 30% from 240 million in 1989 to more than 325million in 2020. Although there will be the same number of young people under age 20 years old(approximately 2 million at each level), they will represent a smaller proportion of the populationbecause of the increased number of older and senior adults. By the year 2020, it is projectedthat approximately 14% of the population will be less than 9 years old, 13% will be 10 to 19Prosthodontics - 172010 CDEL Re-recognition of the Specialty Report 17 of 279

The American College of Prosthodontistsyears old, 27% will be 29 to 39 years old, 30% will be 40 to 64 years old and 16% will be 65 andolder. There were approximately 28 million people over 65 in 1992, 39 million in 2000 and therewill be an estimated 64 million people over 65 in 2020 (Douglass, 1992). The number ofpersons older than 60 will increase 116%, doubling from 35 million to 77 million, and there willbe a near doubling of adults aged 74 - 90 years old from 5 million to 9 million by 2020(Douglass, 1990). The adults and older adults will have projected needs that cannot be metwith the existing work force (Douglass, 2002).There has been a major change in the number of retained teeth per person for every agecategory during the period from 1962 – 1991, as the number of missing teeth has declined. Thelargest increases have occurred in older adults, where the number of retained teeth hasincreased from 11 to 17 in the 55 to 64 age group, and from 4.1 to 16.8 for the 75 to 79 agegroup. Therefore, instead of 5 million teeth in adults aged 75+, there will be 69 million teeth inpersons 75+ by the year 2020 (Douglass, 1990). Increased tooth retention coupled withincreased numbers of older adults means that the actual number of teeth at risk to dentaldisease will increase sharply (Joshi, et al., 1996). The dramatic increase in the number of teethat risk for dental disease is estimated to reach 5 billion teeth by the year 2020, an 80% increasefrom 1980 (Reinhardt and Douglass, 1989). It has been shown that subjects who retainedhigher numbers of teeth have more periodontal disease and dental caries experience and havea higher demand for dental services (Joshi, et al., 1996; Douglass, et al., 2002).About 40.5% of the total National Health and Nutrition Examination Survey (NHANES) IIIsample, representing 61.5 million dentate adults has at least one tooth or tooth space that maybenefit from treatment. The percentage of individuals with at least one tooth or tooth space thatmay benefit from treatment, as well as the mean number of teeth or tooth spaces that maybenefit from treatment increases with age.Although dental caries incidence is down in children and young adults, there is evidencethat the incidence of dental caries has not declined and may be rising in the older population. Inlooking at dental caries, the total of decayed, missing and filled (DMF) teeth for adults in theU.S. has not declined over the past 25 years. The decline in the number of missing teeth isalmost equal to the increase in the number of filled teeth. With fewer missing teeth and morefilled teeth (and with no change in the remaining decayed teeth), the total DMF teeth is nearlyidentical for adults aged 45 to 64 over the 25 year period from 1960-85. The teeth in these olderadults appear to have been saved not by primary prevention, i.e., fluorides, but by restorativedental care (Douglass, 1992). NHANES III data also indicates that 20% of adults between theages of 18 and 74, representing 35.7 million civilian, non-institutionalized Americans, wearsome type of removable prosthesis. Selected indicators on denture use among persons 18 to 74years reveal no differences in patterns of denture use between 1981 and 1991. Maxillarycomplete and removable partial dentures were more common than mandibular prostheses.Therefore, NHANES III data indicate that despite increasing trends in tooth retention,dependence on removable prostheses is still a reality of life for many millions of Americans. Inaddition, a substantial number of these individuals may benefit from implant prosthodontics,which previously may not have been offered as a treatment option.In 1985, Weintraub and Burt predicted that edentulism would continue to decline despitethe aging of the population. However, the need for complete dentures would decline moreslowly than the rate of edentulism due to the replacement needs for existing edentulouspersons. The number of patients who are partially edentulous will increase significantly.Therefore, the need for more complex fixed prostheses, implant prostheses and removablepartial dentures will increase. Replacement of lost teeth is unlikely to disappear as a neededprosthodontic care service. In 1986, 90% of 65 to 69 year olds, 74% of 55 to 64 year olds, 68%of 45 to 54 year olds and 50% of 35 to 44 year olds had indications for either fixed, removableor implant prosthodontics. Therefore, most of the entire population over the age of 35 haspatterns of missing teeth that are clinically consistent with the need for prosthodontic services.The patterns of missing teeth tend to display a clinical appearance consistent with the need forfixed, removable and implant prosthodontics for the foreseeable future. These conservativeProsthodontics - 182010 CDEL Re-recognition of the Specialty Report 18 of 279

The American College of Prosthodontistsprosthodontic estimates suggest a 38% increase in the need for prosthodontic services over thenext two to three decades (Douglass, 1990).According to the World Health Organization, optimal health and optimal oral health is theresult of the preservation or replacement of 20 teeth. States of partial or complete edentulismpatients could render an individual disabled, due to his/her inability to eat and speak effectively,two of the essential tasks of life and related to overall health when considering theconsequences of tooth loss.Having a functional masticatory system is critical for the individual to replace the body’snutrients and maintain optimal diet, nutrition, and overall health. Studies have demonstrated thatedentulous patients have a poorer diet than their dentate counterparts. In this NHANES IIIstudy, 3,794 individuals were studied, of which 36% were completely edentulous. In a follow-upstudy of 6,985 patients, the authors found that patients with less than a full complement of teethhad reduced intake of carrots, salads, and dietary fiber than did fully dentate patients, withreductions in serum levels of beta carotene, folate and vitamin C. In another investigation,denture wearers were found to be at a nutritional disadvantage, and consumed statisticallyfewer carrots and tossed salads than the fully dentate. In addition, these authors demonstratedsignificantly reduced intake of dietary fiber and foods with adequate levels of beta-carotene,folate, and vitamin C when than did dentate patients. Other studies have indicated thatedentulous patients have more difficulty chewing foods, with resultant reduced intakes ofVitamin B 6 and carbohydrates than do dentate patients.Partial edentulism, whether from caries, periodontal or pulpal disease, may alsocontribute to complications in overall patient health. Hung and colleagues (2003) examined therelationship between tooth loss and changes in consumption of various food groups, along withnutrients that are critical to overall health among 31,000 health care professionals. They foundthat subjects who lost five or more teeth had greater reductions in intake of polyunsaturated fatsand vitamin E, smaller reductions in intake of dietary cholesterol and vitamin B12 and smallerincreases in intake of dietary fiber and whole fruits than did those who were completely dentate.Such a diet change may result in a reduced likelihood of meeting the recommended dietaryallowance of important vitamins and nutrients, and thereby adversely impacting bodycomposition and nutritional status, both of which are related to overall systemic health. In adifferent study by the same research group, the authors examined the dental records of 41,407men and 58,974 women who were initially free of any cardiovascular disease. After controllingfor cardiovascular risk factors (smoking, alcohol consumption, age, body mass index, etc), theauthors found that men and women with zero to ten teeth had a statistically significant increasedrisk of coronary heart disease compared to men and women with 25-32 teeth. Interestingly, therelationship between the number of teeth and the incidence of coronary heart disease wassimilar for subjects with and without periodontal disease. The paper concludes by providingsome insight into the possible causes of the inverse relationship between number of teeth andthe risk of coronary heart disease suggesting it may be due to some combination of antecedentperiodontal disease, antecedent endodontic inflammation, dietary changes following tooth loss,and other unknown mechanisms.In a study of nutritional status of patients with and without opposing pairs of posteriorteeth or those wearing dentures, those with fewer than four pairs of opposing posterior teethwere statistically at risk for poor nutrition. A study by Slade (1996) investigated dentate andedentulous patients’ chewing capacity. He found that 58.6% of edentulous patients reporteddifficulty in chewing various food groups, compared to 6.1% of patients with fewer than ninemissing teeth; higher rates of complete edentulism were found in older, female, less-educatedAustralian-born individuals. Finally, a study of body mass index (BMI) in Great Britain suggests astrong correlation with the number of remaining teeth and the maintenance of a normal BMI,defined as

The American College of Prosthodontistscare burden that requires immediate attention in both developed and developing countries.Therefore, there is a body of evidence indicating that while edentulism can be considereddisabling and perhaps, even a handicap, partial edentulism resulting in 20 teeth or less can alsodetrimentally affect overall health. These data suggest that replacement of missing teeth to reestablishan occlusion with 21 teeth or more is highly desirable.Dovetailing well with the World Health Organization’s statement is the growing scientificliterature regarding benefits of the shortened dental arch (SDA). The SDA concept is basedupon the premise that the most important parts of the dentition to preserve are the anterior andpremolar regions. Although, restoration of molars restores full function and oral health, the SDAdoes appear to satisfy many patients’ needs pertaining to masticatory function, occlusal stability,temporomandibular joint health, patient comfort and esthetic/psychosocial goals. Following on,since molars are more difficult to access given their posterior location and have contours androot configurations that predispose the patient to a higher risk of periodontitis and dental caries.Adhering to the SDA concept also minimizes the risk of experiencing these disease conditionsand the sequelae thereof.Tooth retention and tooth loss affect patients’ perception of satisfaction and quality of lifemeasures. Tooth loss associated with periodontal disease and caries has an apparent impacton an individual’s quality of life, and has been associated with lower levels of satisfaction withlife and a lower morale. In a 10-year prospective cohort study of 1,992 rural Americans, (Klein,et al.) reported that 68% of the sample was missing some teeth, and an additional 15.3% werecompletely edentulous. Of the sample population, 10.7% reported they could not enjoy somefoods due to problems associated with their teeth. Those with missing teeth were more likely tohave poorer self-related health issues than those with teeth.In summary, the cited series of analyses suggests that the need for complexprosthodontics will increase substantially in the adult population. As the population continues togrow, the need for prosthodontic services will also grow, at least for the next 25 years. Thatportion of the population with potentially the greatest need for prosthodontic services anddemand for complex prosthodontic services completed most effectively and predictably,provided at the specialty level will grow dramatically.Prosthodontics - 202010 CDEL Re-recognition of the Specialty Report 20 of 279

The American College of Prosthodontists11. Identify the principal health services provided to the public by individuals in this area ofpractice and whether this has changed in the past ten years. If this has changed, what has beenthe impact on profession and public?Prosthodontists replace missing teeth and the structures that support them.Prosthodontists are further responsible for prevention and early diagnosis of infectious diseasesof teeth (caries and periodontitis), oral cancer and traumatic loss of teeth and orofacialstructures. Prosthodontists are expert diagnosticians and based upon data collected by history,examination, radiographs and medical consultation, prosthodontists offer fixed or removableprostheses to meet treatment goals. The scope of care involves tooth replacement, estheticenhancement and functional management. This ranges from single tooth to full mouth tomaxillofacial rehabilitation. Prosthodontists are particularly expert in the treatment ofedentulism. It is important to note that the basis of therapy on diagnostic criteria has beenaffirmed by the ACP support of the Prosthodontic Diagnostic Indices for Complete and PartialEdentulous and Dentate patients.The scope of services provided by prosthodontists has remained similar during the pastten years but the frequency of certain services has shifted during that timeframe. Based onreports by Nash and Pfeifer (Nash and Pfeifer, 2006, 2007), of surveys of prosthodontists in theUS, the six procedures requiring the largest percentage of prosthodontist time (89% in 2001 and91% in 2004) include fixed prosthodontics, implant services, complete dentures, operative care,diagnosis, and partial dentures, Figure 9. Increased patient demand for cosmetic services andfor implant services is reflected in greater education and exposure to these procedures inprosthodontic practices and training programs. The increased demand for referral basedservices in the area of maxillofacial prosthodontics, temporomandibular disorders and sleepapnea have also impacted prosthodontic practices.Figure 9.Prosthodontics - 222010 CDEL Re-recognition of the Specialty Report 22 of 279

The American College of ProsthodontistsThe survey was also used to determine how prosthodontists spend their treatment time inproviding various dental and prosthodontic services. Figure 9 contains results comparing thepercentage of time rendering selected prosthodontics services in 2001, 2004, and 2007. Thesurvey revealed that the largest percentage of a prosthodontist’s treatment time is spentrendering procedures in fixed prosthodontics. Prosthodontist respondents reported they spendabout a quarter (24.1%) of their time rendering fixed prosthodontics services, followed byimplant restoration (18%), complete dentures (13%) (not including removable partial dentures),operative services (11%), and diagnostic services (11%). The average percentage of timerendering fixed prosthodontics (excluding implants) has declined slightly over the 6-year period,from 29.2% of time in 2001 to 24.1% in 2007. Of significant interest is the increasing trend forboth implant restoration and implant placement over the 6-year period from 2001 to 2007. Thepercentage of time in operative care was the only other procedure showing a decreasing trendover the same period. Overall, these trends suggest that the specialty of Prosthodontics isfurther distinguishing itself from general restorative dentistry.According to the surveys of Stade and Dickey (Stade & Dickey 1990; Dickey 1994; Dickey1999), about half (53.3% in 1990, 46.4% in 1994, and 49% in 1999) of private practitionerprosthodontists perform some maxillofacial prosthetic services in their practices. Themembership database of the American College of Prosthodontists lists 864 or 42% of membersin all categories of practice who perform maxillofacial services for their patients (not includingstudent or life members).Prosthodontics - 232010 CDEL Re-recognition of the Specialty Report 23 of 279

The American College of Prosthodontists12. Identify the setting(s) in which these services are customarily provided and whether thishas changed in the past ten years. If this has changed, what has been the impact on professionand public?The primary setting for prosthodontic services over the past 25 years has predominately been inprivate practice and continues to show strong trends in that sector. In 1986 it was noted that49.6% of prosthodontists were in private practice (Laney, et al, 1986) followed by 25.2% in theFederal services, 21.4% in academia and 3.8% listed hospital as their primary setting wheremaxillofacial prosthetic services were provided. Furthermore, with the combined (implant, fixedand removable prosthodontics) advanced education prosthodontics training programs haveencouraged a consolidation of treatment modalities whereby these services can be offered inthe private practice without necessarily involve a university or hospital setting when the patient’smedical health is not compromised. This observation is also true for maxillofacial prostheticprocedures but to a lesser degree as the need for team approach to care involving othermedical specialties is paramount. Recent advances in microvascular flaps and craniofacialimplants have changed the scope of care for the maxillofacial prosthodontist eliminating someconventional maxillofacial prosthetic procedures but creating other more advanced proceduresin their place.In 2000, the American College of Prosthodontists (ACP) database (corrected to exclude studentand retired members) lists 1464 (62%) members in private practice, 364 (15.3%) in education,289 (12%) Federal Services, 121 (5%) hospital, and 99 (4%) in administrative/public health.This data shows a shift toward the private practice sector with a lessening of the FederalServices and academia settings at that time. The current (2009) ACP membership database(corrected to exclude student, alliance, international and retired life members) further indicatesthe emphasis on private practice with 75.4% of the members reporting private practice as theirprimary activity, 15.7% education and 8.9% Federals Services.The increase from roughly half (49.6%) to three quarters (75.4%) of prosthodontists engaged inprivate practice is a significant shift in emphasis that has occurred over the past twenty years. Itis likely that a trend of this magnitude reflects increased demand for prosthodontic servicesamong that portion of the population seeking dental services (Douglass, 1990, 2002; Nash andPfeifer 2007). The increasing number of older adults retaining teeth for a longer span of timeoften results in more complex treatment needs requiring additional time and more advancedskills to maintain (Dickey, 1999; Nash and Pfeifer, 2006, 2007).The ACP holds growth as one of its strategic concerns and there is evidence that the efforts oforganized Prosthodontics is succeeding in expanding the numbers of prosthodontists availableto meet the need of the expanding patient base who require specialist care involvingprosthodontics. To align the understanding of the need by professions, the specialty is alsoengaged in a long term effort to educate both the public and medical and dental colleaguesregarding the value of prosthodontic specialty-level of care. Together, the expansion of needand the development of awareness have provided strong footing for the growth of the specialtyto better serve the public need.Prosthodontics - 242010 CDEL Re-recognition of the Specialty Report 24 of 279

The American College of Prosthodontists13. Provide any other information that the specialty believes may be relevant to the study ofthe specialty area of practice. (suggested response - one page)The specialty has organized itself to nimbly address change in the community ofmedicine and dentistry. The specialty has noted increased demand for services because ofinnovative technology, shifting demographics, changing epidemiology and emerging diseases.Examples of each include a) the evidence based merit of implants for all edentulous patients, b)the aging population who are partly dentate and likely to lose more if not all teeth, c) increasingprevalence of root caries, erosive disorders affecting enamel, and the static level of oral cancersin the US, and d) polypharma-induced xerostomia, sleep apnea and bisphosphonateosteonecrosis of the jaws. These changes reflect matters that may be best managed byspecialists for diagnosis and treatment, as well as life-long care and prevention.The specialty of prosthodontics is well prepared to meet these challenges. A primary reason isthe 20-year history of its commitment to evidence-based decision making. The process isintegral to our education process and is represented in the CODA standards. The ACPEducation Foundation and other corporate sponsors recognize the importance of evidencebasedpractice and have hosted educational workshops to train researchers, educators andpractitioners in scientific scrutiny. The data is well accepted by our members and the focus ofcontinued evaluation at national meetings and is represented in the official journal of theAmerican College of Prosthodontist, the Journal of Prosthodontics.Submission to the Journal of Prosthodontics continues to demonstrate significant growth and ahigh rejection rate (approaching 75%) demonstrates an increased awareness of publishingquality manuscripts in a recognized peer-reviewed forum; also, the rejection rate reflects effortsto publish only the finest manuscripts that meet scientific criteria. Over the past ten years, thenumber of submissions has grown from 50 manuscripts in 2000, to 341 manuscripts in 2009.The increased demand has resulted in published content that has more than doubled from 4 to8 issues annually, with 20 additional pages per issue. The annual citations of the Journal ofProsthodontics articles has increased by 91% annually, from 236 manuscripts in 2005, to 452manuscripts in 2009 indicating elevated value of Prosthodontic research to the dental researchcommunity at large.The development of new data is integral to our professional culture. Advances inresearch within advanced education programs to encourage residents toward scholarship anddiscovery, has resulted in a growing number of dual-trained specialists, as well as dentalscientist programs at the Ph.D. level of education. This advancement of prosthodontics hasbeen earmarked by our ability to conduct, and report, state-of-the-art clinical and basic sciencesprosthodontics research to our members. Research award competitions and financial supportto attend AADR and IADR meetings has allowed young prosthodontic scientists to expand his orher skill sets. The outcome of these programs has resulted in improved research beingperformed, an increase in the number of publications with greater penetration of appliedknowledge in clinical practice for the benefit of the patient.Incorporation of new technology and procedures into the practice of prosthodontics isoccurring at an ever-increasing rate. Prosthodontists have selected early adoption of evidencedbased therapies as a cornerstone of growth in the medical community. This is most noted forimplant therapy involving novel loading and provisionalization protocols, as well as thedeployment of computerized diagnostic and surgical control. A secondary benefit is theemerging outcomes of patient-based data that influences clinical decision making. Biomaterialscontinually change and the current evolution in ceramics for crowns and larger prostheses,being lead by prosthodontists and allied scientists. The future of dental oral rehabilitation isbright and the growing specialty of prosthodontics is poised to serve the community of dentistsand the patients they treat.Prosthodontics - 252010 CDEL Re-recognition of the Specialty Report 25 of 279

ReferencesThe American College of ProsthodontistsAmerican College of Prosthodontists: 2005 Survey of Prosthodontists: Results of a Survey.Chicago, IL, ACP 2006.American College of Prosthodontists: 2008 Survey of Prosthodontists: Results of a Survey.Chicago, IL, ACP 2008.American Dental Association: Distribution of Dentists in the United States by Region and State.Chicago, IL, ADA 2006.American Dental Association 2007-2008 Survey of Advanced Dental Education, ADA SurveyCenter, Surveys of Advanced Dental Education, January 2009Balshi SF, Wolfinger GJ, Balshi TJ: A retrospective analysis of 110 zygomatic implants in asingle-stage immediate loading protocol.Blatz MB, Bergler M, Holst S, Block MS: Zirconia abutments for single-tooth implants – rationaleand clinical guidelines. J Oral Maxillofac Surg 2009;67(11Suppl):74-81.Binon PP: Evaluation of machining accuracy and consistency of selected implants, standardabutments, and laboratory analogs.Cameron HU, Pilliar RM, MacNab I: The effect of movement on the bonding of porous metal tobone. Journal of Biomedical Materials Research 1973;7(4):301-311.Dickey KW: A Survey of Private Prosthodontic Practice, J Prosthodont 1994;3:167-171.Dickey KW: A Survey of Private Prosthodontic Practice, J Prosthodont 1999;8:119-125.Douglass KW, Furino A.: Balancing dental service requirements and supplies: epidemiologicand demographic evidence. J Am Dent Assoc 1990;121(5):587-92.Douglass CW: Future needs for dental restorative materials. Adv Dent Res 1992;6:4-6.Douglass CW, Shih A, Ostry L: Will there be a need for complete dentures in the United Statesin 2020? J Prosthet Dent 2002;87:5-8.Douglass CW, Watson AJ: Future needs for fixed and removable partial dentures in the UnitedStates. 2002;87(1):9-14.Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGillConsensus Statement on Overdentures. Montreal, Quebec, Canada. May 24-25, 2002.Int Jour Prosthod 2002;15(4):413-4.Healthy People 2010, Volume II, Section 21, Oral Health. Available atwww.healthypeople.gov/Publications; pp 21-18 to 21-19, accessed November 25, 2008.Hung HC, Willett WC, Merchant A, et al: Oral health and perpheral arterial disease. Circulation2003:107:1152-1157.Jokstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed or removableprosthesis placed on implant(s)? Int Jour Oral Maxillofac Implants 2007;22(Suppl.):19-48.Prosthodontics - 262010 CDEL Re-recognition of the Specialty Report 26 of 279

The American College of ProsthodontistsJoshi A, Douglass CW, Feldman H, Mitchell P, Jette A: Consequences of success: Do moreteeth translate into more disease and utilization? J Public Health Dent 1996;56:190-197.Klein GL, Kita K, Fish J, Sinkus B, Jensen GL: Nutrition and health for older persons in ruralAmerica: A managed care model. Jour Am Diet Assoc 1997;97:885-888.Laney WR: Application for the continued recognition of prosthodontics. Prepared and submittedby the Federation of Prosthodontic Organizations to the American Dental Association,1986.Marcus SE, Kaste LM, Brown LJ: Prevalence and demographic correlates of tooth loss amongthe elderly in the United States. Spec Care Dentist 1994:5414:123-127.Marcus SE, Drury TF, Brown LJ, Zion GR: Tooth retention and tooth loss in the permanentdentition of adults: United States, 1988-1991. J Dent Res 1996;75 Spec No:684-695.Miller A, Brunelle J, Carlos J, Brown L, Loe H: Oral health of United States adults: The nationalsurvey of oral health in US employed adults and seniors: 1985-86. NIH Pub. No.87-2868. Bethesda, MD: National Institute of Dental Research, 1987.Nash KD, Pfeifer DL: Prosthodontists in private practice: current and future conditions ofpractice in the United States (Part I). J Prosthodont 2007;16:288-301.Nash KD, Pfeifer DL: The private practice of prosthodontists: current and future conditions ofpractice in the United States (Part 2). J Prosthodont. 2007;16(5):383-393.Nash KD, Pfeifer DL: Prosthodontics as a specialty private practice: net income of privatepractitioners. J Prosthodont 2006;15(1):37-46.Nash KD, Pfeifer DL, Sadowsky SJ, Carrier DD. Private practice of prosthodontists: currentconditions of practice in the United States. J Prosthodont 2010;19:1-12.Reinhardt J, Douglass C: The need for operative dentistry services: projecting effects ofchanging disease patterns. Oper Dent 1989;14:114-120.Sheiham A, Steele JG, Marcenes W, Finch S, Walls AW: The relationship between oral healthstatus and body mass index among older people: a national survey of older people inGreat Britain. Br Dent J 2002;192:703-706.Slade GD, Spencer AJ, Roberts-Thomson K: Tooth loss and chewing capacity among olderadults in Adelaide. Aust NZ J Public Health 1996;20:76-82.Stade EH, Dickey KW: Private prosthodontic practice: A status report, J Prosthet Dent.1990;64:716-722.Stanford CM, Wagner W, Y Baenna RR, Norton M, McGlumphy E, Schmidt J: Evaluation of theEffectiveness of Dental Implant Therapy in a Practice-Based Network (FOCUS). Int JOral Maxillofac Implants 2010:25(2):367-273.Tahmaseb A, De Clerck R, Wismeijer D: Computer-guided implant placement: 3D planningsoftware, fixed intraoral reference points, and CAD/CAM technology. A Case report. INtJ Oral Maxillofac Implants 2009: 24(3):541-546.Prosthodontics - 272010 CDEL Re-recognition of the Specialty Report 27 of 279

The American College of ProsthodontistsTheoharidou A, Petridis HP, Tzannas K, Garefis P: Abutment screw loosening in single-implantrestorations: a systematic review. Int J Oral Maxillofac Implants 2008:23(4):681-690.Valachovic RW: Opportunities abound for new dental schools. How will we seize them? ADEACharting Progress. August 2009Valente F, Schiroli G, Sbrenna A: Accuracy of computer-aided oral implant surgery: a clinicaland radiographic study. Int J Oral Maxillofac Implants 2009:24(2):234-242.Weintraub J, Burt B: Oral health status in the United States: Tooth loss and edentulism. J DentEduc 1985:49:368-378.White B, Caplan D, Weintraub J: A quarter century of changes in oral health in the UnitedStates. J Dent Educ 1995;59:19-57.Winn D, Brunelle J, Selwitz R, Kaste L, Oldakowski R, Kingman A, Brown L: Coronal and rootcaries in the dentition of adults in the United States, 1988-91. J Dent Res 1996:75(SpecIss):642-651.Wolfinger GJ, Balshi TJ, Rangert B: Immediate functional loading of Branemark system implantsin edentulous mandibles: clinical report of the results of developmental and simplifiedprotocols. International Journal of Oral & Maxillofacial Implants. 2003;18(2):250-257.Prosthodontics - 282010 CDEL Re-recognition of the Specialty Report 28 of 279

Appended DocumentsThe American College of ProsthodontistsPageA. American College of Prosthodontists Strategic Plan………………………………….….30B. Parameters of Care…………………………………………………………………………..40C. Prosthodontics Diagnostic Index (PDI)a. Edentulous Patients……………………………………………………………….145b. Partially Edentulous Patients……………………………………………………..159c. Dentate Patients……………………………………………………………………173D. ACP Oral Cancer Screening Program……………………………………………………184E. Continuing Prosthodontics Education Courses…………………………………………240F. CODA Accreditation Standards for Advanced Specialty EducationPrograms in Prosthodontics, annotated file with proposed deletionsand proposed additions reflecting the submission for revision in 2008………………243G. ACP Resolutions and Comments on CODA Proposed Changesin the Definitions, April 23, 2009………………………………………………………….272Prosthodontics - 292010 CDEL Re-recognition of the Specialty Report 29 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix AAmerican College ofProsthodontists Strategic Plan2010 CDEL Re-recognition of the Specialty Report 30 of 279

American College of ProsthodontistsSTRATEGIC PLANRevised and Approved ACP Board of Directors March 2009ORGANIZATION MISSION AND PURPOSEMission: The mission of the American College of Prosthodontists (ACP) is to:• promote the highest standard of patient care• advance the art and science of prosthodontics,• promote the specialty of prosthodontics to the public, other dentists, andhealth care professionals,• ensure the quality of prosthodontic education, and• Provide professional services to its membership.The ACP inspires its members to pursue professional advancement and personalfulfillment through education, lifelong learning, research, advocacy, leadership,communication, and service.Purpose: The ACP shall be a not-for-profit organization qualifying under section501(c)(6) of the Internal Revenue Code of 198, as amended (or the correspondingprovision of any future United States Internal Revenue Law) . The Corporationexists for the purposes of: providing members and others with opportunities fordialogue, education, advancement, and improvement of all aspects ofprosthodontics through meetings and educational courses, communications,publications, and other programs and activities2010 CDEL Re-recognition of the Specialty Report 31 of 279

ENVISIONED FUTURE~ 10-30 YEAR HORIZON ~Envisioned future conveys a concrete, but yet unrealized, vision. It consists of anoverall statement and a series of goals to which the ACP is committed to achieving.Vision of ACP (Internal Vision)The ACP, improving the quality of life through the advancement ofProsthodontics:• Visionary leaders in advancing patient care through advocacy, education,and research• Innovators in the scope of prosthodontics• The valued organization for all prosthodontists• Architects of effective partnerships for prosthodontics• A global prosthodontic resourceVision of What ACP Will Achieve (External Vision)Organized Prosthodontics will have a shared vision of the specialty andprosthodontic care. Prosthodontists will work together to promote and achievethe vision of prosthodontic care available to all who could benefit from that care.Awareness of Value50% of the U.S. population will know what a prosthodontist is. 85% of thepopulation over 55 will know what a prosthodontist is and will understand thevalue of prosthodontic care.Professional colleagues will recognize the value of Prosthodontics in oral andsystemic health. Public awareness will be affirmed via an interactive ACPWebsite expanding into the international electronic mediaAccess to Prosthodontic CareProsthodontic care will be available to all – complex diagnosis and care providedby Prosthodontists and less complex diagnosis and care by general practitionersand others.The availability of prosthodontic care will meet the changing needs of the public.The number of prosthodontists will increase significantly by 2014.Page 32010 CDEL Re-recognition of the Specialty Report 33 of 279

o Private practitioners – greatly increased demand for services,incorporation of molecular/genetic technologies.o Educators and researchers – greatly increased demand for services,involved in education of prosthodontists and general dentists.Innovative education and practice models (including utilizing dental staff) willbe in place to meet prosthodontic needs.The dental lab technology industry will be strengthened by further recognition ofcredentialing status and support of educational programsAccess to finding prosthodontic services and finding a Prosthodontistinternationally will be established by electronic media.The public will be able to access evidence-based information regardingprosthodontic treatment and post-treatment care.Creation of a nationally recognizable outreach program will be established forgeriatric patients and patients having special needs.Role of ProsthodontistsProsthodontics will be the specialty with the primary responsibility for repairand replacement of craniofacial, alveolar and dental tissues using biologic,biomimetic and alloplastic materials (transitioning Prosthodontics frombiomaterials to biologic therapy).Prosthodontists will provide leadership in comprehensive diagnosis and care andachieve the goal of access to prosthodontic care for all.Prosthodontists will fill a significant role in primary care, including diagnosisand treatment of:o edentulism by providing both the prosthetic and surgical phases ofimplant dentistry;o worn or mutilated dentitions;o acquired or congenital deformities;o dentofacial esthetic needs; ando geriatric and medically compromised patient needs.Craniofacial anomalies will be diagnosed, treated and/or planned by aprosthodontist.Implant care will increase from the current level of 1% to 20% of edentulouspatients. 50% of prosthodontists will provide surgical placement of implants.Page 42010 CDEL Re-recognition of the Specialty Report 34 of 279

Prosthodontists will provide prosthodontic education to other practitioners anddental staff in order to support them in providing less complex diagnosis andcare.Prosthodontists will facilitate treatment of all edentulous at all income and sociallevels.Diagnosis will be embraced as a key element of Prosthodontics.o Specific diagnostic skill sets will be contemporary and recognized asassets associated to the specialty of prosthodontics.Prosthodontic EducationThe specialty will attract, educate, and fund the highest caliber of students insufficient numbers to meet the projected needs of the public.Graduate training programs will be strengthened and expanded:o Every position fully funded.o Greatly increased well qualified applicant pool.o Expansion of graduate program positions.o Synergies achieved with medical profession, e.g. with plasticsurgery, ENT, oral surgery, preventive and geriatric care, etc.o More private practice prosthodontic faculty in pre- and postdoctoraleducation.o Create educational centers for the diagnosis and treatment ofcomplex dental needso Highly competitive recruitment outreach to entice and attract thebest potential applicants to the graduate programs.Prosthodontists will have an expanded skill set and quality continuingeducation.Prosthodontic education will be included in medical schools, nursing training,pharmacology training, and other relevant areas.Prosthodontists will have an expanded skill set and quality continuing educationavailable in innovative ways.The prosthodontic identity will be reaffirmed in dental education.Create financial resource base to accommodate the projected outcomes inprosthodontic educationPage 52010 CDEL Re-recognition of the Specialty Report 35 of 279

Role of ResearchThe specialty will play a vital role in tissue engineering, biomaterials, clinical,and behavioral research.All graduate programs will include basic science and clinical training.Prosthodontic departments will obtain 5% of the total NIDCR budget.Outreach clinical research programs to private practice facilitating the integrationof new technologies into the workforce of prosthodontic specialty care.Have in existence a minimum of five (5) internationally recognizedprosthodontic research centers.Established resources coordinated with private, government and organizationalsupport to ensure the proposed role of research.Page 62010 CDEL Re-recognition of the Specialty Report 36 of 279

GOALS AND OBJECTIVES~ 3-5 YEAR PLANNING HORIZON ~Goals describe the outcomes the organization will achieve for its stakeholders (members,customers, the association itself, etc.). Three to five-year time frame; reviewed every yearby the Board.Objectives describe what we want to have happen with an issue. What would constitutesuccess in observable or measurable terms? Indicates a direction - increase, expand,decrease, reduce, consolidate, abandon, etc.; reviewed every year by the Board.GOAL A: RECOGNITION OF THE VALUE OF PROSTHODONTIC CAREPatients, general practitioners, specialists, and others will understandthe value of and demand the best in prosthodontic care, and will haveaccess to evidence-based public information about prosthodontictreatment and post-treatment care.ObjectivesA1. Increase public awareness and understanding of the value ofprosthodontic treatment. (HIGH)A2. Increase recognition of the benefits of prosthodontic care provided byprosthodontists. (HIGH)A3. Achieve increased reimbursement by third parties. (MEDIUM)GOAL B:ObjectivesNATIONAL ADVOCATE FOR PROSTHODONTIC CAREProsthodontists will lead the specialties and educationalenvironment in restorative, implant, esthetic, and reconstructivedentistry.B1. Enhance the scope of the specialty of prosthodontics through innovationin organization, education, and practice. (HIGH)B2. Position prosthodontists as the creators and purveyors of theprosthodontic knowledge base for patient care. (HIGH)B3. Increase ACP’s effectiveness with the American Dental Association andother dental organizations. (HIGH)B4. Increase ACP’s role in state and national health care issues andgovernment advocacy. (MEDIUM)B5. Leverage relationships with patient advocacy and health care groups.(HIGH)Page 72010 CDEL Re-recognition of the Specialty Report 37 of 279

GOAL C:STRONG SCIENCE, TECHNOLGY, AND RESEARCHProsthodontists will improve the quality of life by innovationthrough research and technology. Prosthodontists will supportadvances in basic science, clinical and educational technologies andcontribute to the formulation of new knowledgeObjectivesC1. Deploy new technologies for educational advances. (HIGH)C2. Integrate new science and technologies into the UG and PG dentalschool curricula. (HIGH)C3. Increase dental research that systematically assesses clinically relevantscientific evidence in the field of prosthodontics, including tissueengineering, biomaterials, clinical, and behavioral research (HIGH).C4. Actively support science and technology as inventors, beta testers,and early adopters. (HIGH)GOAL D: PROSTHODONTIC WORKFORCE GROWTHThe ACP will lead a multi-pronged initiative to grow the field ofprosthodontics within the next 10 years to meet the projecteddemand for prosthodontic services.ObjectivesD1: Increase the membership of ACP to 90% of trained prosthodontists.(HIGH)D2: Increase the number of trained prosthodontists. (HIGH)GOAL E:STRONG DENTAL EDUCATIONThe ACP will be a strong partner in prosthodontic undergraduate,postgraduate, and continuing dental education.ObjectivesE1. Develop and host a comprehensive prosthodontic indexed digital ACPresource library, Prosthopedia (HIGH).E2. Increase the role of prosthodontists as leaders and innovators in theeducational environment. (HIGH)E3. Increase the quality and number of applicants to prosthodonticresidency programs. (HIGH)Page 82010 CDEL Re-recognition of the Specialty Report 38 of 279

E4. Create effective linkages to fundamental and applied sciences – e.g.,biomat, bioinformatics, high tech industry, CAD-CAM, and genomics.(HIGH)E5. Lead curriculum reform to achieve a flexible and contemporarycurriculum that addresses and anticipates the needs of dental studentsand prosthodontic patients. (HIGH)GOAL F:ACP ORGANIZATIONAL HEALTHDevelop the needed resources to advance the ACP’s mission andvision and to assure a healthy future for the organization.ObjectivesF1. Ensure that knowledge based governance prevails. (HIGH)F2 Utilize best practices of multi-year planning, organizational design, andmanagement to optimize activities and assure financial integrity(HIGH).F3. Enable BOD leadership and oversight in growing the ACP. (HIGH)GOAL G: STRONG LABORATORY PARTNERSThe ACP will become an effective partner with the dental laboratoryindustry to improve prosthodontic care.ObjectivesG1. Increase the presence of the laboratory industry within ACP to enhanceinteraction with and advocacy for the laboratory industry. (MEDIUM)G2. Promote dental laboratory technician careers through participation indesign and implementation of education and continuing educationprograms. (HIGH)Page 92010 CDEL Re-recognition of the Specialty Report 39 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix BParameters of Care2010 CDEL Re-recognition of the Specialty Report 40 of 279

Journal of ProsthodonticsImplant, Esthetic, and Reconstructive DentistryOfficial Journal of The American College of ProsthodontistsVolume 14 Number 4 December 2005 SupplementPREAMBLEWHEN THE PARAMETERS of Care Document, Version 1, was published in March, 1996, itrepresented the commitment of the American College of Prosthodontists (ACP) to fulfill itsresponsibilities as the voice of the specialty of prosthodontics. The document enabled the ACP toanswer many calls for guidance from members, other dental specialists, general dentists, allied healthprofessionals, dental organizations, dental educators, third-party payors and managed care groups,governmental bodies, and most importantly, the patients whom prosthodontists serve. The Parametersof Care Document provided a foundation for increased professional and public awareness of the mostpredictable and favorable prosthodontic treatments available, both at the time of publication and in thefuture.The original document was developed with the direction and support of ACP Officers and membersof the Board of Directors. An outstanding group of members committed itself to organizingand writing the drafts of the document, which were refined, reviewed, and evaluated by the Educators/Mentorsconference, the House of Delegates, the Board of Directors, and a wide range ofmembers and communities of interest. When the House of Delegates accepted the document, theBoard of Directors directed the publication of the document in the Journal of Prosthodontics. That issueof March 1996, was a landmark document and represented a major milestone for the specialty ofprosthodontics.Since its publication, the Parameters of Care document has withstood the test of time. In addition,since then, the College has developed Classifications of Complete Edentulism, Partial Edentulism, andCompletely Dentate patients. The nomenclature now used is the Prosthodontic Diagnostic Index (PDI).Prosthodontics is a specialty of diagnosis and treatment planning, not of single tooth surface restoration.With these advancements, it was time for the document to be revised, updated, and rewritten, passingthe same process of review before being suitable for publication.Therefore, Version 2 of the Parameters of Care document is another defining moment for ourspecialty. The Parameters now include the (PDI) classification systems and the standards they entail. TheParameters also include Diagnostic Insurance Codes and Treatment Insurance Codes for the differentlevels of difficulty of prosthodontic patients. It is therefore a working document for clinical practice,educational settings, and patient presentations. It more thoroughly answers the call for guidance from allinterested parties. This document also includes checklists and worksheets for everyday use. In summary,this document is the College’s definition of the specialty of prosthodontics for its members, the profession,and the patients we serve.Robert G. Tupac, DDSChair, Parameters of Care CommitteeAmerican College of ProsthodontistsJournal of Prosthodontics, Vol 14, No 4 (December, Suppl.), 2005: pp 1-103 12010 CDEL Re-recognition of the Specialty Report 41 of 279

2 Parameters of Care Tupac et alPARAMETERS OF CARE FOR THE SPECIALTYOF PROSTHODONTICSBackground StatementThe consolidation of the governance of the specialty of prosthodontics has conveyed many responsibilitiesto the American College of Prosthodontists. One of these responsibilities is the development anddissemination of the Parameters of Care Document for the Specialty of Prosthodontics. This documentis written to help identify, define, and quantify many of the aspects of the delivery of prosthodonticspecialty services to the public.This Parameters of Care Document is intended to help clinicians in providing the highest-qualitylevel of clinical care, establish a consensus of professional opinion, and serve to constantly enhanceclinical performance. In addition, parameters of care may be of help in risk management, educationand testing, and third-party relations–appropriateness of care. The document provides a framework forquality assessment in prosthodontic specialty training programs. Thus, parameters of care are developedto improve patient care by providing clinicians first with a foundation and then with a broad frameworkor environment in which they can operate with predictable and favorable treatment outcomes. TheInstitute of Medicine defines “parameters’’ as systematically developed statements to assist practitionerand patient decisions about appropriate health care for specific clinical circumstances. The reasons fordeveloping parameters of care are as follows:1. Assessing and assuring the quality of care;2. Assisting in patient and clinician decision making;3. Educating individuals and groups;4. Reducing the risk of legal liability for negligent care;5. Guiding the allocation of health resources; and6. Identifying clinical situations that are most appropriately treated by specialty-trained clinicians.Practice parameters vary in the scope of the clinical problems they address and the specificitywith which they can be applied. Through the process of developing such parameters several criticalcharacteristics of credible practice parameters have been identified. Among these characteristics arethe following, which are most applicable to the ACP parameters:1. Prepared in an objective manner;2. Based on existing science;3. Representative of professional consensus; and4. Formulated to provide structured flexibility.The Process of Reaching a ConsensusThe quality of care is best defined in objective terms and by a process that minimizes subjective,unsubstantiated opinion. The American College of Prosthodontists Parameters of Care Documentwas developed with this in mind. The subcommittees responsible for the various sections reviewedand discussed the literature concerning the associated clinical and laboratory sciences. They reached aconsensus that was shared with all other subcommittee members. When consensus was reached amongthe parameter committee as a whole, the document was distributed to the membership, which providedwritten comments and participated in an open forum held at the 1994 ACP Annual Session. The originaldocument, and this subsequent revision, represent a consensus reflecting not only the deliberations ofthe expert subcommittee, but also a broad segment of the membership.Clinical practice involves the management of patients who present with considerable biologicalvariability. Parameters that do not take this into account and are too rigidly structured are not clinicallyappropriate. The structured flexibility inherent in the ACP parameters refers to a structure that defines2010 CDEL Re-recognition of the Specialty Report 42 of 279

December 2005, Supplement, Volume 14, Number 4 3the relevant dimensions of the care provided by prosthodontists. Such flexibility does not imply thatthese parameters are diluted, but rather that they incorporate the realities of the broad basis of clinicalpractice. It is important to recognize that practice parameters are designed to represent an objectiveinterpretation of clinical practice and its associated science. Although the parameters for each of theclinical sections may vary in their specificity because of the variability of their science base, they doprovide clear, focused guidance concerning patient management. Parameters also help identify gaps inscientific and clinical knowledge that warrant research and investigation.The Scope of the ParametersThe range of the clinical conditions treated by prosthodontists is as varied as any of the specialties.Thus, the development of parameters was a major undertaking. This revised and updated edition ofthe document is a continuation of the process of critical review and assessment of clinical practice. It isimportant to note that historically and traditionally the specialty of prosthodontics has considered itselfby a listing and description of clinical techniques; i.e., fixed prosthodontics, removable prosthodontics,maxillofacial prosthodontics, and implant prosthodontics. This type of consideration is restrictive in theconstantly evolving specialty of prosthodontics. Prosthodontics is defined by the diseases and conditionspresented by our patients, and the specialty is responsible for the diagnosis and treatment of complete andpartial edentulism. These parameters begin the critical process of delineating those clinical conditionsand diagnoses that prosthodontists most appropriately treat because of their advanced education andtraining. The patient’s underlying clinical condition that defines the need for treatment is the firstcritical factor that identifies the scope of prosthodontic specialty care; the techniques used are thesecond factor. Thus, this Parameters of Care Document identifies and defines clinical conditions thatrequire prosthodontic care:1. Comprehensive Clinical Assessment Parameter2. Limited Clinical Assessment Parameter3. Completely Dentate Patient Parameter4. Partial Edentulism Parameter5. Complete Edentulism Parameter6. Implant Placement and Restoration Parameter7. Tooth Preparation and Modification Parameter8. Esthetics Parameter9. Temporomandibular Disorders Parameter10. Upper Airway Sleep Disorders (UASDs) Parameter11. Maxillofacial Prosthetic Parameter12. Local Anesthesia Parameter13. Adjunctive Therapies ParameterBy defining the clinical conditions to be addressed by each parameter, the clinician and patient areable to select an appropriate treatment sequence. It is important to emphasize that the final judgmentregarding care for any given patient rests with the treating prosthodontist. All members of the Collegemust realize that a parameter of care has direct influence on the practice of prosthodontics and thatthey must familiarize themselves with all aspects of this document.This revised and updated document also represents the union of the Parameters of Care and theProsthodontic Diagnostic Index (PDI). Therefore, the Classifications (Completely Dentate, PartiallyEdentulous, and Completely Edentulous) have been incorporated into each appropriate section. Thus,the document indicates diagnosis and treatment planning as a function of the complexity of the patient’scondition.Introduction and OverviewThis document is an acknowledgement by the American College of Prosthodontists of the need tobe the leading force in the development and dissemination of a Parameters of Care Document for2010 CDEL Re-recognition of the Specialty Report 43 of 279

4 Parameters of Care Tupac et alprosthodontics. The ACP recognizes the current demand for a parameters document by other professionalspecialty societies, third-party payors, public interest groups, and the many levels of government.By assuming the responsibility for a prosthodontics Parameters of Care document, the membership ofthe ACP will prevent untoward influence of outside groups in the practice of prosthodontic care to thepublic. The ACP, consisting of fellows and members, is the most appropriately trained and educatedsociety to develop a parameters document. Solicitation of additional expertise was accomplished byinteraction with many prosthodontically oriented societies to ensure a balanced document that reflectsthe realities of the clinical environment.“Parameters of Care’’is a phrase used to describe an organized range of accepted patient managementstrategies, including guidelines, criteria, and standards. The establishment of parameters provides ameans to assess the appropriate nature and quality of a selected treatment modality for application toan identified clinical condition in patients requiring prosthodontic care. The initial document reflectedmany areas of prosthodontic care amenable to parameter formations. Although these parameters cover awide spectrum of prosthodontic practice, future development of additional parameters is foreseen. Theseparameters vary in their specificity and research base; thus, they represent an attempt to incorporate thebest available knowledge about the diagnosis and treatment of clinical conditions requiring prosthodonticcare.This document outlines areas of prosthodontic practice that reflect current clinical considerationsthat enhance the quality of care patients receive on a consistent basis. This document is developed foruse by the fellows and members of the ACP and other members of the dental profession to increase thequality and reliability of prosthodontic care; however, the ultimate judgment regarding appropriatenessof any specific procedure must be made by the prosthodontist in cooperation with the patient and inconsideration of the limitations presented by the patient. It must be understood that adherence tothe parameter does not guarantee a favorable outcome, nor does deviation from a parameter indicateless-than-acceptable care; however, when a prosthodontist, in consultation with a patient, does elect todeviate from a parameter, it is highly recommended that the reason for deviation be recorded in thepatient’s record.This document was developed to assist the educationally qualified prosthodontist of the ACP and othermembers of the dental profession to provide consistent, reliable, and predictable prosthodontic care tothe public. The intents are to raise the level of care to the public and to develop measurable criteria so thatoutcome assessment criteria can be developed in the future. Whereas many prosthodontic procedures areroutinely and appropriately performed by non-prosthodontists, it is incumbent for a dental practitionerproviding prosthodontic care to recognize those clinical conditions that require the additional trainingand expertise of prosthodontic specialists so that the patient will receive the most reliable and predictablecare.Summary StatementThe ACP Parameters of Care Document was developed with the goal of being as inclusive as scientificallypossible in recognizing variations in patients’ clinical conditions and current therapeutic techniques.However, certain clinical conditions and procedures are associated with considerable uncertainty andvariation in clinical outcome, especially in prosthodontic procedures in which patient cooperation andcompliance are integral to favorable outcomes. In some instances there is an inadequate amount ofvalid scientific information to thoroughly substantiate patient management procedures. However, whensuch situations were recognized, the parameters were developed using thorough and critical literaturereviews, appropriateness criteria, and available clinical outcome data. As new information is developed,each parameter will be reviewed and revised on a regular schedule. This parameters document is thecontinuation of critical reassessment of evidence-based clinical practice. The parameters document isa work in progress that requires timely nurturing and revision to maintain its credibility. The ACP iscommitted to continued attention to this document.Thus, achieving quality is not a finite end but rather a continuous process that is driven by the discoveryof new information and the changing expectations of practitioners, patients, and the public. The ACP2010 CDEL Re-recognition of the Specialty Report 44 of 279

December 2005, Supplement, Volume 14, Number 4 5is committed to the ongoing search for improved treatment procedures to enhance the prosthodontichealth of the public.AuthorsAs members of the Committee on Parameters of Care, it is important to recognize the dedication andhard work of these members as the authors of this landmark project. It must also be noted that valuablecontributions were made by many individuals who cannot be personally recognized; however, withouttheir assistance this document could not have been completed.Members of the original Committee on Parameters of Care include:Thomas J. McGarry, DDS, (Chair),Marion J. Edge, DDS, MS (Ed),Robert E. Gillis, Jr., DMD, MSD,Kenneth L. Hilsen, DDS,Richard E. Jones, DDS, MSD,Barry Shipman, DMD,Robert G. Tupac, DDS,Jonathan P. Wiens, DDS, MSD.Members of the Revision Committee of Parameters of Care include:Robert G. Tupac, DDS (Chair),Robert E. Gillis, Jr., DMD, MSD,Gregory N. Guichet, DDS,Richard E. Jones, DDS, MSD,Christopher Marchack, DDS,Thomas J. McGarry, DDS,Arthur Nimmo, DDS,Barry Shipman, DMD,Harel Simon, DMD,Christopher Smith, DDS.AcknowledgmentsThis document is a compilation of work by many groups and individuals both within and outside thefield of dentistry. It is most appropriate to recognize the American Association of Oral and MaxillofacialSurgeons. Their pioneering work in the parameters of care field has led the way for the rest of dentistry.AAOMS was especially helpful and generous in the formative stages of the ACP document.Two other organizations deserving special recognition are The American Academy of MaxillofacialProsthetics and The Academy of Prosthodontics.This project has endured with the support of four consecutive presidents of the ACP: Dr Ron Woody,Dr. Peter Johnson, Dr. Carl Schulter, and Dr. Ken Turner.The revised edition was accomplished under the presidencies of Dr. Nancy Arbree and Dr. PatrickLloyd.Application of Parameters of Care to Clinical PracticeThe ultimate utility of parameters of care in clinical practice is a key issue that must be considered inthe process of introducing and further developing the ACP Parameters of Care. To assist practitionersin the use of these parameters, the following approach to the document is suggested. This approach isdesigned to tailor the application of parameters to the procedures usually followed in the management ofa patient, regardless of the presenting condition. In addition, the procedures apply whether the patient’spresenting condition or the patient’s presenting concerns are the reason for the initial contact. Six issues2010 CDEL Re-recognition of the Specialty Report 45 of 279

6 Parameters of Care Tupac et alare considered in applying the parameters to each of the clinical conditions contained in the parametersdocument. Each of the clinical conditions within the 13 clinical areas is analyzed on the basis of thesesix issues, which are considered essential in determining the criteria for satisfactory clinical practice.Following is a definition of these issues:1. Indications for Care delineate the reasons for prosthodontic management, including the symptoms ofdescriptive characteristics of patients who would be candidates for this type of prosthodontic care.For each condition all or some of the indications may be applicable;2. Therapeutic Goals describe the purpose of each treatment in terms of results desired both by the patientand by the prosthodontist;3. Factors Affecting Risk are severity factors that increase risk and the potential for known complications.They are specific variables usually descriptive of the patient’s characteristics or condition (e.g.,age, factors in medical history, etc.) that may affect the outcome either favorably or unfavorably.These factors may present or impede achievement of the therapeutic goals, increase the potentialfor unfavorable outcomes, or may promote or facilitate favorable outcomes. For example, patientnoncompliance may compromise the success of treatment, whereas compliance will enhance it;4. Standards of Care outline the procedures followed in providing care that meets therapeutic goals,maximizes favorable outcomes, and minimizes risks and complications, based on the current state ofknowledge;5. Favorable Outcomes consist of the clinical observations or other evidence that the usually expectedresults of treatment have been achieved. From these outcomes, measurable elements can be derivedfor entry into a computer program and compilation into a national database so that success rates foreach procedure can be analyzed; and6. Known Risks and Complications are those conditions, circumstances, or outcomes that are known to beassociated with the management of patients. Whether or not they are avoidable, data as to theirfrequency of occurrence will be useful for identifying preferred prosthodontic methods and practicepatterns. These issues can be divided into three groups depending on when they occur in the continuumof patient care. The following is a tabulation of this grouping and a discussion of how these issues canbe applied to clinical conditions.AssessmentDuring the initial contact with the patient there is an assessment of the presenting condition(s) andacknowledgement of the patient’s concerns. This includes a determination of the indications for care andidentification of the therapeutic goals to be achieved if such care is provided. The factors affecting risk arethose severity factors that increase risks and the potential for known complications. These factors shouldbe identified for the condition(s) being treated and considered in the treatment planning process.TherapyOnce the presenting condition has been assessed by the prosthodontist, a plan of treatment is establishedand agreed upon. The standards of care are those therapeutic interventions that have been identifiedas appropriate for the respective clinical condition(s). The specific standard of care selected by theprosthodontist is determined on the basis of the information reviewed at the assessment interval.OutcomesThe final determination that is made in applying the parameters is the outcome of the therapy thatwas employed to treat the clinical condition with which the patient presented and address the patient’sconcerns. The specialty performance assessment indices (i.e., favorable outcomes and the known risks andcomplications) are intended to provide the basis for an objective evaluation of the patient’s conditionafter therapeutic intervention. Favorable outcomes and known risks and complications are indices used2010 CDEL Re-recognition of the Specialty Report 46 of 279

December 2005, Supplement, Volume 14, Number 4 7by the specialty to assess the appropriateness of the prosthodontic care provided. More than one outcomeindicator may be identified in the course of this evaluation.This analysis of prosthodontic practice by indications for care, therapeutic goals, risk factors, standardsof care, and performance assessment indices provides the foundation for broad-based performanceimprovements in the practice of the specialty.The selected references at the conclusion of each section acknowledge the sources of informationused by the revision committee in its work. They are not intended to be an exhaustive list of informationon the subject.NoteCurrent Procedural Terminology (CPT) is copyright 2005 American Medical Association. All rights reserved.No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumesno liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.CPT ® is a trademark of the American Medical Association.Current Procedural Terminology C○ 2005 American Medical Association. All rights reserved.Current Dental Terminology C○ 2002, 2004 American Dental Association. All rights reserved.1) Comprehensive Clinical Assessment ParameterPrefaceThe comprehensive clinical assessment is the critical step in achieving predictable and successfulprosthodontic therapy. The identification and collection of clinical assessment data is necessary toaccomplish the integration of that data into a diagnosis, treatment plan, and prognosis. The clinical datagathered form the foundation of the diagnostic process. With this diagnostic foundation, the treatmentplan can be developed to address clinical conditions and patient desires. Thus, a prognosis can be offeredto the patient based on the clinical assessment, the diagnosis, and the treatment plan. This sequence oftreatment will increase the predictability of prosthodontic care. A standardized diagnostic criterion willenable a prosthodontist to offer an accurate prognosis and will enable the collection of outcome data forthe treatment plan executed.Evaluation of the patient’s prosthodontic status requires obtaining and documenting relevant medicaland dental history information, conducting a thorough clinical assessment of extraoral and intraoralstructures, reviewing physical symptoms, and evaluating the patient’s psychosocial status.Examination CriteriaI. Chief ComplaintII. Identification of providersA. Identification of primary dental care provider(s)B. Identification of other adjunctive dental care providersC. Identification of health care providersIII. HistoryA. Medical1. Current medications2. Drug allergies/hypersensitivity3. Alterations in normal physiology4. Review of physical signs and symptoms5. Identification of medical conditions that affect dental careB. DentalC. Psychosocial factors2010 CDEL Re-recognition of the Specialty Report 47 of 279

8 Parameters of Care Tupac et alIV. Extraoral ExamA. TMD screeningB. Maxillofacial defectsC. Skeletal evaluationD. Soft tissueV. Intraoral ExamA. Periodontal screeningB. Maxillofacial defectsC. OcclusalD. DentalE. Soft tissueVI. RecordsA. RadiographsB. Diagnostic castsC. ImagingD. ChartingE. Hypertension screeningF. Consultations with other health care providersGeneral Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goals oftreatment, the known benefits and risks of the procedure(s), the factors that may affect the known risksand complications, the treatment options, the need for active maintenance by the patient, and the needfor future replacement/revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include the documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT ® ), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.2010 CDEL Re-recognition of the Specialty Report 48 of 279

December 2005, Supplement, Volume 14, Number 4 9Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Comprehensive Clinical AssessmentICD-9-CM306.8 Other specified psychophysiological malfunction: Bruxism, Teeth grinding520 Disorders of tooth development and eruption521 Diseases of hard tissues of teeth522 Diseases of pulp and periapical tissues523 Gingival and periodontal diseases524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structures526 Diseases of the jaws527 Diseases of the salivary glands528 Diseases of the oral soft tissues, excluding diseases specific for gingival and tongue529 Diseases and other conditions of the tongue873.6 Tooth (broken) uncomplicated873.7 Tooth (broken) complicatedA. Indications for care1. Clinical condition(s) requiring prosthodontic care as defined by Prosthodontic Diagnostic Index(PDI) [ACP Patient Classifications System] and other clinical conditions2. Professional referral [99201-99204 CPT-2005]3. Dental evaluation prior to medical treatment [99271-5 CPT-2005]4. Dental evaluation relating to side effects of medical treatment [99271-5 CPT-2005]5. Patient concerns [99201-99204 CPT-2005]B. Therapeutic goals1. Identify the factors that would influence diagnosis, treatment planning, and treatment completion2. Patient education3. Develop an accurate prognosis for treatment of diagnosed condition(s)4. Develop alternative treatment plans5. Address patient concernsC. Risk factors affecting clinical assessment1. Inability to record necessary data because of physical/psychological limitations2. Refusal of patient referral to additional health care providers3. Lack of patient understanding or unrealistic expectations4. Patient noncompliance5. Psychosocial factorsD. Standards of care1. Presentation of diagnostic findings [D0100-D0999, D9310 CDT-2005]2. Discussion of treatment alternatives and consequences of no treatmentE. Specialty performance assessment criteria1. Favorable outcome of clinical assessmenta) Noninvasive or minimally invasive procedures that rarely have irreversible consequencesb) Identify sufficient information to assist in the successful treatment of the patient’s clinicalconditionc) Identify factors that might compromise the treatment outcome2010 CDEL Re-recognition of the Specialty Report 49 of 279

10 Parameters of Care Tupac et al2. Known risks and complicationsa) Temporary pain from necessary clinical examinationb) Transient bleedingc) Dislodgment of existing restorationsd) Hyperactive gag reflexe) Increased anxiety levelsf) Extraction of mobile teeth during diagnostic impression makingg) Aggravation of preexisting or unknown disease conditionsh) Lack of patient understanding or unrealistic expectationsSelected References (Comprehensive Clinical Assessment Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Abbott FB: Psychological assessment of the prosthodontic patient before treatment. Dent Clin North Am 1984;28:361-367Burket LW, Lynch MA, Brightman VJ, et al: Burket’s Oral Medicine: Diagnosis and Treatment (ed 8). Philadelphia, Lippincott,1984Dawson PE: Evaluation, Diagnosis, and Treatment of Occlusal Problems (ed 2). St. Louis, Mosby, 1989Friedman JW: Development of criteria and standards for dental care. Dent Clin North Am 1985;29:465-475Friedman S: Diagnosis and treatment planning. Dent Clin North Am 1977;21:237-247Full-mouth reconstruction: fixed removable. Dent Clin North Am 1987;31:305-562Hall WB, Roberts WE, LaBarre EE: Decision Making in Dental Treatment Planning. St. Louis, Mosby, 1994Hoad-Reddick G, Grant AA: Prosthetic status: the formation of a schedule. J Prosthet Dent 1988;59:105-10Lackey AD: Examining your smile. Dent Clin North Am 1989;33:133-137McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for complete edentulism. The American College of Prosthodontics.J Prosthodont 1999;8:27-39McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for partial edentulism. J Prosthodont 2002;11:181-193McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for the completely dentate patient. J Prosthodont 2004;13:73-82McNeill C: Temporomandibular Disorders: Guidelines for Classification, Assessment, and Management (ed 2). Chicago,Quintessence, 1993Mitchell DF, Standish SM, Fast TB: Oral Diagnosis, Oral Medicine (ed 2). Philadelphia, Lea & Febiger, 1971Okeson JP: Management of Temporomandibular Disorders and Occlusion (ed 3). St. Louis, Mosby, 1993Pearson TA, Blair SN, Daniels SR, et al: AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atheroscleroticvascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002;106:388-391Roblee RD: Interdisciplinary Dentofacial Therapy: A Comprehensive Approach to Optimal Patient Care. Chicago, Quintessence,1994Rosenberg MM: Periodontal and Prosthetic Management for Advanced Cases. Chicago, Quintessence, 1988Rosenstiel SF, Land MF, Fujimoto J: Contemporary Fixed Prosthodontics (ed 3). St. Louis, Mosby, 2001Sonis ST, Fazio RC, Fang LST: Principles and Practice of Oral Medicine (ed 2). Philadelphia, Saunders, 1995Symposium on periodontal restorative interrelationships. Dent Clin North Am 1980;24:167-393Wood NK, Goaz PW: Differential Diagnosis of Oral Lesions (ed 4). St. Louis, Mosby, 1991Zambito RF, Sciubba JJ: Manual of Dental Therapeutics. St. Louis, Mosby, 1991Preface2) Limited Clinical Assessment ParameterMany patients evaluated by prosthodontists do not require a comprehensive clinical assessment. Thereare multiple types of limited assessments:1. Referral2. Emergency2010 CDEL Re-recognition of the Specialty Report 50 of 279

December 2005, Supplement, Volume 14, Number 4 113. Second opinions4. OtherThe dental history and clinical examination should focus on the limited problem or complaintidentified by a health care provider and/or presented by the patient. It should also include a generalsurvey of the oral cavity and related structures. The prosthodontist must use his or her discretion inidentifying which of the examination criteria need be evaluated to complete a limited assessment:1. Chief complaint2. Identification of primary care provider3. Identification of all other health care providers4. Identification of necessary examination criteria to achieve a diagnosisGeneral Criteria and StandardsInformed consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.2010 CDEL Re-recognition of the Specialty Report 51 of 279

12 Parameters of Care Tupac et alParameter Guidelines: Limited Clinical AssessmentICD-9-CM306.8 Other specified psychophysiological malfunction: Bruxism, Teeth grinding520 Disorders of tooth development and eruption521 Diseases of hard tissues of teeth522 Diseases of pulp and periapical tissues523 Gingival and periodontal diseases524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structures526 Diseases of the jaws527 Diseases of the salivary glands528 Diseases of the oral soft tissues, excluding diseases specific for gingival and tongue529 Diseases and other conditions of the tongue873.6 Tooth (broken) uncomplicated873.7 Tooth (broken) complicatedA. Indications for care1. Clinical condition(s) requiring prosthodontic care as defined by Prosthodontic Diagnostic Index(PDI) [ACP Patient Classifications System] and other clinical conditions2. Professional referral [99201-99204 CPT-2005]3. Dental evaluation prior to medical treatment [99271-5 CPT-2005]4. Dental evaluation relating to side effects of medical treatment [99271-5 CPT-2005]5. Patient concerns [99201-99204 CPT-2005]B. Therapeutic goals1. Identify the factors that would influence diagnosis, treatment planning, and treatment completion2. Patient education3. Develop an accurate prognosis for treatment of diagnosed condition(s)4. Develop alternative treatment plans5. Address patient concernsC. Risk factors affecting clinical assessment1. Inability to record necessary data because of physical/psychological limitations2. Refusal of patient referral to additional health care providers3. Problem-focused, limited examination4. Patient noncompliance5. Psychosocial factorsD. Standards of care1. Informed consent regarding consequences of no treatment and limited examination [D0100-D0999, D9310 CDT-2005]2. Patient education to include need for comprehensive assessment3. Inform patient of other observed pathology not part of the limited assessmentE. Specialty performance assessment criteria1. Favorable outcome of clinical assessmenta. Noninvasive or minimally invasive procedures that rarely have irreversible consequencesb. Identify sufficient information to assist in the successful treatment of the patient’s clinicalconditionc. Identify factors that would compromise the treatment outcome2. Known risks and complicationsa. Temporary pain from necessary clinical examinationb. Transient bleedingc. Dislodgment of existing restorationsd. Hyperactive gag reflex2010 CDEL Re-recognition of the Specialty Report 52 of 279

December 2005, Supplement, Volume 14, Number 4 13e. Increased anxiety levelsf . Extraction of mobile teeth during diagnostic impression makingg. Aggravation of preexisting or unknown disease conditionsh. Lack of patient understanding or unrealistic expectationsSelected References (Limited Clinical Assessment Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of informationAlling CC: Dental emergencies. Dent Clin North Am 1973;17:361-565Burket LW, Lynch MA, Brightman VJ, et al: Burket’s Oral Medicine: Diagnosis and Treatment (ed 8). Philadelphia, Lippincott,1984Dawson PE: Evaluation, Diagnosis, and Treatment of Occlusal Problems (ed 2). St. Louis, Mosby, 1989DeVore DT: Legal considerations for treatment following trauma to teeth. Dent Clin North Am 1995;39:203-219Full-mouth reconstruction: fixed removable. Dent Clin North Am 1987;31:305-562Hall WB, Roberts WE, LaBarre EE: Decision Making in Dental Treatment Planning. St. Louis, Mosby, 1994Josell SD: Evaluation, diagnosis and treatment of the traumatized patient. Dent Clin North Am 1995;39:15-24McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for complete edentulism. The American College of Prosthodontics.J Prosthodont 1999;8:27-39McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for partial edentulism. J Prosthodont 2002;11:181-193McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for the completely dentate patient. J Prosthodont 2004;13:73-82Okeson JP: Management of Temporomandibular Disorders and Occlusion (ed 3). St. Louis, Mosby, 1993Rosenberg MM: Periodontal and Prosthetic Management for Advanced Cases. Chicago, Quintessence, 1988Rosenstiel SF, Land MF, Fujimoto J: Contemporary Fixed Prosthodontics (ed 3). St. Louis, Mosby, 2001Symposium on periodontal restorative interrelationships. Dent Clin North Am 1980;24:167-393Wood NK: Treatment Planning: A Pragmatic Approach. St. Louis, Mosby, 1978Preface3) Completely Dentate Patient ParameterThe completely dentate patient is a patient with an intact continuous permanent dentition with nomissing teeth or roots, excluding the third molars. This parameter is structured to accommodateincreasing levels of diagnostic and restorative complexity. All the disciplines of dentistry may be includedin the classifications–surgical considerations, periodontal considerations, endodontic considerations, orthodonticconsiderations, oral pathology considerations, TMD considerations, operative considerations,and prosthodontic considerations.In the treatment of the completely dentate patient, the integration of all of the above considerationsis where the specialty of prosthodontics has the most to offer a patient. The management of the myriadvariables in the completely dentate patient is the essence of specialty-level prosthodontic therapy.Classifying diagnostic categories enables selection of appropriate treatment.The Prosthodontic Diagnostic Index (PDI) [ACP Patient Classifications System] for the completelydentate patient is delineated by two criteria. The classification is assigned based upon consideration andevaluation of the following criteria:1. Tooth condition2. Occlusal schemeBy use of the PDI, patients will have the opportunity to have the most appropriate therapy selectedto address their clinical conditions. The four classes of the completely dentate patient are:1. Class I – characterized by ideal or minimally compromised tooth condition and occlusal scheme. Allcriteria are favorable.2010 CDEL Re-recognition of the Specialty Report 53 of 279

14 Parameters of Care Tupac et al2. Class II – characterized by moderately compromised tooth condition and occlusal scheme. This classdisplays noted continuation of the physical degradation of one or both of the criteria.3. Class III – characterized by substantially compromised tooth condition requiring the reestablishmentof the occlusal scheme without a change in the occlusal vertical dimension, with or without substantiallocalized adjunctive therapy.4. Class IV – characterized by severely compromised tooth condition requiring the reestablishmentof the occlusal scheme with a change in the occlusal vertical dimension, with or without extensiveadjunctive therapy.This diagnostic system will help identify those conditions that require clinical techniques associatedwith advanced prosthodontic training. These diagnostic categories will help standardize treatmentregimens and will help provide outcome data for diagnosis/treatment combinations.Terminal dentition describes a condition in which there are insufficient teeth to maintain functionand the arch, as a whole, will transition to the edentulous state. The etiology might be periodontaldisease, caries, trauma, insufficient teeth to maintain function, prosthodontic discomfort, and/or patientdesires. Transition to total edentulism should only be considered when the patient is fully informed ofall variables (e.g., prognosis of teeth, chance of success measured against longevity of treatment) andconsequences that affect the value of treatment. Patient desires and expectations must be considered inconjunction with the professional knowledge and judgment of the prosthodontist.It must be noted that in the treatment of the completely dentate patient, patient attitude, cooperation,and compliance are of great importance in long-term success. Successful treatment for the completelydentate patient is a mutual effort between the prosthodontist and the patient. A refractory patient is onewho presents with chronic complaints following appropriate therapy. In those instances where patientexpectations exceed physical limitations, a mutually satisfactory result may not be possible through thecompletion of their treatment plan.General Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insurance2010 CDEL Re-recognition of the Specialty Report 54 of 279

December 2005, Supplement, Volume 14, Number 4 15providers have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Technology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Partial EdentulismICD-9-CM306.8 Other specified psychophysiological malfunction: Bruxism, Teeth grinding521 Diseases of hard tissues of teeth522 Diseases of pulp and periapical tissues523 Gingival and periodontal diseases524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structuresA. Indications for care1. Caries [521.0-521.09 ICD-9-CM]2. Attrition [521.10-521.15 ICD-9-CM]3. Erosion [521.30-521.35 ICD-9-CM]4. Abrasion [521.20-521.25 ICD-9-CM]5. Abfraction6. Fractures/microfractures/cracks [873.6-873.7 ICD-9-CM]7. Endodontic therapy8. Intra-arch and interarch integrity [524.0-524.2 ICD-9-CM]9. Tooth mobility10. Diastemas11. Tooth malposition12. Loss of occlusal vertical dimension [524.2 ICD-9-CM]13. Esthetics14. Pathogenic occlusion [524.4 ICD-9-CM]15. Failed existing restorations16. Correction of congenital abnormalities17. Lack of mastication18. Impaired speech19. Impaired swallowing20. Lack of TM joint and orofacial muscle support21. Psychosocial factors22. Airway restriction23. Lack of intra- and interarch integrity and stability24. Patient concernsB. Therapeutic goals1. Improved mastication2. Improved speech3. Improved esthetics4. Improved swallowing2010 CDEL Re-recognition of the Specialty Report 55 of 279

16 Parameters of Care Tupac et al5. Restoration of facial height6. TM joint and orofacial muscle support7. Positive psychosocial response8. Airway support9. Improved comfort10. Improved tooth form and function11. Tooth stabilization12. Restore intra-arch and interarch integrity and stability13. Improved periodontal health14. Address patient concernsC. Risk factors affecting quality of treatment1. Dyskinesia2. Existing systemic disease3. Hyperactive gag reflex4. Xerostomia5. Increased salivation6. Periodontal disease7. Endodontic complications8. Alveolar bone loss9. Occlusal factors10. Skeletal factors11. Inadequate tooth structure12. Parafunctional habits13. Caries susceptibility14. Psychosocial factorsD. Standards of care1. Patient education2. Informed consent3. Preprosthetic preparationa. Nonsurgicalb. Surgicalc. Endodonticd. Periodontale. Orthodonticf . TMDg. Other referral4. Class I completely dentate patient [D2000-D2999 CDT 2005]a. Treatment of etiologic factorsb. Intracoronal and extracoronal restorative proceduresc. Partial or complete arch impressiond. Articulation in maximum intercuspation on an articulatore. Insertion of prosthesisf . Post treatment follow-up5. Class II completely dentate patient [D2000-D2999 CDT 2005]a. Treatment of etiologic factorsb. Intracoronal and extracoronal restorative proceduresc. Partial or complete arch impressiond. Articulation in maximum intercuspation on an articulatore. Insertion of prosthesisf . Post treatment follow-up6. Class III completely dentate patient [D2000-D2999 CDT 2005]a. Treatment of etiologic factors2010 CDEL Re-recognition of the Specialty Report 56 of 279

December 2005, Supplement, Volume 14, Number 4 17b. Intracoronal and extracoronal restorative proceduresc. Complete arch impressiond. Maxillomandibular record at the existing occlusal vertical dimensione. Facebow record and articulation on a semi-adjustable articulatorf . Insertion of prosthesisg. Post treatment follow-up7. Class IV completely dentate patient [D2000-D2999 CDT 2005]a. Accommodation to systemic conditionsb. Treatment of etiologic factorsc. Establish therapeutic occlusal vertical dimensiond. Intracoronal and extracoronal restorative procedurese. Complete arch impressionf . Maxillomandibular record at the confirmed therapeutic occlusal vertical dimension and eccentricrecords as necessaryg. Facebow record and articulation on a semi- or fully adjustable articulatorh. Metal or porcelain try-in and assessmenti. Insertion of prosthesisj. Post treatment follow-upE. Specialty performance assessment criteria1. Favorable outcomesa. Reduction and/or elimination of etiologyb. Improved masticationc. Improved speechd. Improved estheticse. Improved swallowingf . Establishment of therapeutic occlusal vertical dimensiong. Restored TM joint and orofacial muscle supporth. Improved tooth stabilityi. Address patient concernsj. Positive psychosocial responsek. Improved airway supportl. Improved comfortm. Satisfactory patient adaptationn. Improved intra-arch and interarch integrity and stability.2. Known risks and complicationsa. Refractory patient responseb. Ulcerationsc. Speech alterationsd. Unacceptable estheticse. Unrealistic patient expectationsf . Materials failure/incompatibilityg. Functional limitationsh. Difficult mastication and swallowingi. TM joint and/or orofacial muscle dysfunctionj. Periodontal complicationsk. Endodontic complicationsl. Alterations in taste perceptionm. Allergic responsen. Unknown longevity of materialso. Increased caries susceptibilityp. Tooth sensitivityq. Tongue/cheek bitingr. Pain2010 CDEL Re-recognition of the Specialty Report 57 of 279

18 Parameters of Care Tupac et alSelected References (Completely Dentate Patient Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Binkley TK, Binkley CJ: A practical approach to full mouth rehabilitation. J Prosthet Dent 1987;57:261-266Braly BV: Occlusal analysis and treatment planning for restorative dentistry. J Prosthet Dent 1972;27:168-171Ganddini MR, Al-Mardini M, Graser GN, et al: Maxillary and mandibular overlay removable partial dentures for the restorationof worn teeth. J Prosthet Dent 2004;91:210-4McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for the completely dentate patient. J Prosthodont 2004;13:73-82McHorris WH: Occlusal adjustment via selective cutting of natural teeth. Part I. Int J Periodontics Restorative Dent 1985;5:8-25McHorris WH: Occlusal adjustment via selective cutting of natural teeth. Part II. Int J Periodontics Restorative Dent 1985;6:8-29Rivera-Morales WC, Mohl ND: Relationship of occlusal vertical dimension to the health of the masticatory system. J ProsthetDent 1991;65:547-553Rivera-Morales WC, Mohl ND: Variability of closest speaking space compared with interocclusal distance in dentulous subjects.J Prosthet Dent 1991;65:228-232Stockstill JW, Bowley JF, Attanasio R: Clinical decision analysis in fixed prosthodontics. Dent Clin North Am 1992;36:569-580Turner KA, Missirlian DM: Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-474Verrett RG: Analyzing the etiology of an extremely worn dentition. J Prosthodont 2001;10:224-233Preface4) Partial Edentulism ParameterThe assessment of partial edentulism encompasses everything from the loss of a single tooth to the lossof all teeth but one. All the disciplines of dentistry may be involved–surgical considerations, periodontalconsiderations, endodontic considerations, orthodontic considerations, oral pathology considerations,TMD considerations, operative considerations, and prosthodontic considerations.In the treatment of partial edentulism, the integration of all of the above considerations is where thespecialty of prosthodontics has the most to offer a patient. The management of the myriad variablesin partially edentulous conditions is the essence of specialty-level prosthodontic therapy. Classifyingdiagnostic categories enables selection of appropriate treatment.The Prosthodontic Diagnostic Index (PDI) [ACP Patient Classifications System] for Partial Edentulismis delineated by four criteria. The classification is assigned based upon consideration andevaluation of the following criteria:1. Location and extent of the edentulous area(s)2. Condition of abutments3. Occlusion4. Residual ridge characteristicsWith the use of the PDI, patients will have the opportunity to have the most appropriate therapyselected to address their clinical conditions. The four classes of partial edentulism are:1. Class I – characterized by ideal or minimally compromised teeth and supporting anatomic structures.All criteria are favorable.2. Class II – characterized by moderately compromised teeth and supporting anatomic structures. Thisclass displays noted continuation of the physical degradation of one or more of the four criteria.3. Class III – characterized by substantially compromised teeth and supporting anatomic structures.This class requires the reestablishment of the entire occlusal scheme without a change in the occlusalvertical dimension with or without substantial localized adjunctive therapy.4. Class IV – characterized by severely compromised teeth and supporting anatomic structures requiringa reestablishment of the entire occlusal scheme with a change in the occlusal vertical dimension.2010 CDEL Re-recognition of the Specialty Report 58 of 279

December 2005, Supplement, Volume 14, Number 4 19This diagnostic system will help identify those conditions that require clinical techniques associatedwith advanced prosthodontic training. These diagnostic categories will help standardize treatmentregimens and will help provide outcome data for diagnosis/treatment combinations.Terminal dentition describes a condition in which there are insufficient teeth to maintain functionand the arch, as a whole, will transition to the edentulous state. The etiology might be periodontaldisease, caries, trauma, insufficient teeth to maintain function, prosthodontic comfort, and/or patientdesires. Transition to total edentulism should only be considered when the patient is fully informed ofall variables (e.g. prognosis of teeth, chance of success measured against longevity of treatment) andconsequences that affect the value of treatment. Patient desires and expectations must be considered inconjunction with the professional knowledge and judgment of the prosthodontist.Dental implant therapy offers an alternative to maintenance of a failing dentition and its associatedsequelae. The significant transition to edentulism involves special treatment considerations. Immediatedentures are measured by different criteria than definitive prostheses. The initial goals are immediatereplacement of form and function and management during the healing phase. When an approximatestate of stability is achieved, the goals shift to restoration of long-term form and function.It must be noted that in the treatment of partial edentulism, patient attitude, cooperation, andcompliance are of great importance in long-term success. The successful treatment for partial edentulismis a mutual effort between the prosthodontist and the patient. A refractory patient is one who presentswith chronic complaints following appropriate therapy. In those instances where patient expectationsexceed physical limitations, a mutually satisfactory result may not be possible through the completionof their treatment plan.General Criteria and StandardsInformed consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of the2010 CDEL Re-recognition of the Specialty Report 59 of 279

20 Parameters of Care Tupac et alAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental Terminology C○2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Partial EdentulismICD-9-CMUse additional codes to identify causes of Partial Edentulism (525.10-525.19)525.50 Partial edentulism, unspecified525.51 Partial edentulism, Class I525.52 Partial edentulism, Class II525.53 Partial edentulism, Class III525.54 Partial edentulism, Class IVThe specific determinants of the PDI for Partial Edentulism can be found in the ICD-9-CM codes521-525, some examples are listed below:306.8 Other specified psychophysiological malfunction: Bruxism, Teeth grinding521 Diseases of hard tissues of teeth522 Diseases of pulp and periapical tissues523 Gingival and periodontal diseases524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structures873.6 Tooth [broken] uncomplicated873.7 Tooth [broken] complicatedA. Indications for care1. Lack of mastication2. Impaired speech3. Esthetics4. Impaired swallowing5. Reduction of facial height6. Lack of TM joint and orofacial muscle support7. Psychosocial factors8. Airway restriction9. Unsatisfactory existing prostheses10. Lack of intra- and interarch integrity and stability11. Patient concernsB. Therapeutic goals1. Mastication2. Improved speech3. Esthetics4. Improved swallowing5. Restoration of facial height6. TM joint and orofacial muscle support7. Positive psychosocial response8. Airway support9. Improved comfort2010 CDEL Re-recognition of the Specialty Report 60 of 279

December 2005, Supplement, Volume 14, Number 4 2110. Restoration of intra-arch and interarch integrity and stability by replacement of teeth andassociated structures.11. Address patient concernsC. Risk factors affecting the quality of treatment1. Dyskinesia2. Preexisting systemic conditions3. Hyperactive gag reflex4. Xerostomia5. Increased salivation6. Periodontal disease7. Endodontic complications8. Alveolar bone loss9. Occlusal factors10. Skeletal factors11. Inadequate tooth structure12. Parafunctional habits13. Caries susceptibility14. Psychosocial factorsD. Standards of care1. Preprosthetic preparationa. Nonsurgicalb. Surgicalc. Endodonticd. Periodontale. Orthodonticf . TMD2. Class I partially edentulous patient [525.51 ICD-9-CM]a. Removable partial denture [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Diagnostic survey and design3. Abutment preparation (i.e., rest preparations, guide planes, etc.)4. Complete arch impression technique5. Articulation in maximum intercuspation on an articulator6. Insertion of prosthesis7. Post-treatment follow-upb. Fixed partial denture [D6200-D6999 CDT-2005]1. Treatment of etiologic factors2. Abutment preparation3. Impression – partial or complete arch4. Articulation in maximum intercuspation on an articulator5. Insertion of prosthesis6. Post-treatment follow-upc. Implant supported/retained restoration (see Implant Placement & Restoration Parameter)[D6000-D6199 CDT-2005]3. Class II partially edentulous patient [525.52 ICD-9-CM]a. Removable partial denture [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Diagnostic survey and design3. Abutment preparation (i.e., intra- and extracoronal restorations, rest preparations, guideplanes, etc.)4. Complete arch impression technique5. Articulation in maximum intercuspation on an articulator2010 CDEL Re-recognition of the Specialty Report 61 of 279

22 Parameters of Care Tupac et al6. Insertion of prosthesis7. Post-treatment follow-upb. Fixed partial denture [D6200-D6999 CDT-2005]1. Treatment of etiologic factors2. Abutment preparation3. Complete arch impression4. Articulation in maximum intercuspation on an articulator5. Insertion of prosthesis6. Post-treatment follow-upc. Implant supported/retained restoration (see Implant Placement & Restoration Parameter)[D6000-D6199 CDT-2005]4. Class III partially edentulous patient [525.53 ICD-9-CM]a. Removable partial denture [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Diagnostic survey and design3. Abutment preparation (i.e., intra- and extracoronal restorations, rest preparations, guideplanes, intra- and extracoronal attachments, etc.)4. Dual stage impression technique5. Maxillomandibular record at the presenting occlusal vertical dimension6. Facebow record and articulation on a semi-adjustable articulator7. Framework try-in and assessment8. Trial placement9. Insertion of prosthesis10. Post-treatment follow-upb. Fixed partial denture [D6200-D6999 CDT-2005]1. Treatment of etiologic factors2. Abutment preparation3. Complete arch impression4. Maxillomandibular record at the presenting occlusal vertical dimension5. Facebow record and articulation on a semi-adjustable articulator6. Insertion of prosthesis7. Post-treatment follow-upc. Implant supported/retained restoration (see Implant Placement &109. Restoration Parameter)[D6000-D6199 CDT-2005]5. Class IV partially edentulous patient [525.54 ICD-9-CM]a. Removable partial denture [D5000-D5899 CDT-2005]1. Accommodation to systemic conditions2. Treatment of etiologic factors3. Diagnostic survey and design4. Establishment of therapeutic occlusal vertical dimension5. Abutment preparation (i.e., intra- and extracoronal restorations, rest preparations, guideplanes, intra- and extracoronal attachments, etc.)6. Dual or multi-stage impression technique7. Maxillomandibular record at the confirmed therapeutic occlusal vertical dimension andeccentric records as necessary8. Facebow record and articulation on a semi-adjustable articulator9. Framework try-in and assessment10. Trial placement11. Insertion of prosthesis12. Post-treatment follow-upb. Fixed partial denture [D6200-D6999 CDT-2005]1. Accommodation to systemic conditions2. Treatment of etiologic factors2010 CDEL Re-recognition of the Specialty Report 62 of 279

December 2005, Supplement, Volume 14, Number 4 233. Abutment preparation4. Complete arch impression5. Maxillomandibular record at the established occlusal vertical dimension and eccentricrecords as necessary6. Facebow record and articulation on a semi- or fully adjustable articulator7. Framework try-in and assessment8. Insertion of prosthesis9. Post-treatment follow-upc. Implant supported/retained restoration (see Implant Placement & Restoration Parameter)[D6000-D6199 CDT-2005]d. Treatment of terminal partial edentulism1. Documentation of existing conditions2. Informed consent3. Long-term provisional restoration4. Post-treatment follow-up5. Patient educationE. Specialty performance assessment criteria1. Favorable outcomesa. Improved masticationb. Improved speechc. Improved estheticsd. Improved swallowinge. Restoration of facial heightf . Restored TM joint and orofacial muscle supportg. Positive psychosocial responseh. Improved airway supporti. Improved comfortj. Satisfactory patient adaptationk. Improved intra-arch and interarch integrity and stability.2. Known risks and complicationsa. Refractory patient responseb. Ulcerationsc. Speech alterationsd. Unacceptable estheticse. Unrealistic patient expectationsf . Materials failure/incompatibilityg. Biomechanically induced implant complicationsh. Difficulty chewing and/or swallowingi. TM joint and/or orofacial muscle dysfunctionj. Alterations in taste perceptionk. Allergic responsel. Degradation of supporting structuresSelected References (Partial Edentulism Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.2010 CDEL Re-recognition of the Specialty Report 63 of 279

24 Parameters of Care Tupac et alGeneralAvant WE: Fulcrum and retention lines in planning removable partial dentures. J Prosthet Dent 1971;25:162-166Avant WE: Indirect retention in partial denture design. J Prosthet Dent 1966;16:1103-1110Becker CM, Bolender CL: Designing swinglock partial dentures. J Prosthet Dent 1981;46:126-132Berg T, Caputo AA: Comparison of load transfer by maxillary distal-extension removable partial dentures with a spring-loadedplunger attachment and I-bar retainer. J Prosthet Dent 1992;68:492-499Berg T, Caputo AA: Load transfer by a maxillary distal-extension removable partial denture with cap and ring extracoronalattachments. J Prosthet Dent 1992;68:784-789Bergman B, Hugoson A, Olsson CO: Caries, periodontal and prosthetic findings in patients with removable partial dentures: aten-year longitudinal study. J Prosthet Dent 1982;48:506-514Brudvik JS, Wormley JH: Construction techniques for wrought-wire retentive clasp arms as related to clasp flexibility. J ProsthetDent 1973;30:769-774Cecconi BT: Effect of rest design on transmission of forces to abutment teeth. J Prosthet Dent 1974;32:141-151Cecconi BT, Asgar K, Dootz E: The effect of partial denture clasp design on abutment tooth movement. J Prosthet Dent 1971;24:44-56DeVan MM: The nature of the partial denture foundation: Suggestions for its preservation. J Prosthet Dent 1952;2:210-218Eissman HF, Radke RA, Noble WH: Physiologic design criteria for fixed dental restorations. Dent Clin North Am 1971;15:543-568Fisher RL: Factors that influence the base stability of mandibular distal-extension removable partial dentures: a longitudinalstudy. J Prosthet Dent 1983;50:167-171Frank RP, Nicholls JI: An investigation of the effectiveness of indirect retainers. J Prosthet Dent 1977;38:494-506Frank RP, Brudvik JS, Noonan CJ, et al: Clinical outcome of the altered cast impression of the procedure compared with use of aone-piece cast. J. Prosthet Dent 2004;91:468-476Frantz WR: Variations in a removable maxillary partial denture design by dentists. J Prosthet Dent 1975;34:625-633Frechette AR: The influences of partial denture design on distribution of force to abutment teeth. J Prosthet Dent 1965;15:474-483Hindels GW: Load distribution in extension saddle partial dentures. J Prosthet Dent 1952;2:92-100Holmes JB: Influence of impression procedures and occlusal loading on partial denture movement. J Prosthet Dent 1965;15:474-483Jacobson TE: Rotational path partial denture design: A 10-year clinical follow-up. Part I. J Prosthet Dent 1994;71:271-277Jacobson TE: Rotational path partial denture design: A ten-year clinical follow-up - Part II. J Prosthet Dent 1994;71:278-282Johnson GK, Leary JM: Pontic design and localized ridge augmentation in fixed partial denture design. Dent Clin North Am1992;36:591-605Kaires AK: Partial denture design and its relation to force distribution and masticatory performance. J Prosthet Dent 1956;6:672-683Kapur KK, Deupree R, Dent RJ, et al: A randomized clinical trial of two basic removable partial denture designs. Part I: comparisonsof five-year success rates and periodontal health. J Prosthet Dent 1994;72:268-282Kelly E: Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent1972;27:140-150Kennedy E: Partial Denture Construction. Brooklyn, Dental Items of Interest, 1928King GE: Dual-path design for removable partial dentures. J Prosthet Dent 1978;39:392-395Kratochvil FJ: Influence of occlusal rest position and clasp design on movement of abutment teeth. J Prosthet Dent 1963;13:114-24Kratochvil FJ, Davidson PN, Guijt J: Five-year survey of treatment with removable partial dentures. Part I. J Prosthet Dent1966;16:708-720McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for partial edentulism. J Prosthodont 2002;11:181-193Nyman S, Ericsson I: The capacity of reduced periodontal tissues to support fixed bridgework. J Clin Periodontol 1982;9:409-414Roach FE: Principles and essentials of bar clasp partial dentures. J Am Dent Assoc 1930;17:124-138Reynolds JM: Abutment selection for fixed prosthodontics. J Prosthet Dent 1968;19:483-488Steffel VL: Fundamental principles involved in partial denture design. J Am Dent Assoc 1951;42:534-544Stein RS: Pontic-residual ridge relationship: a research report. J Prosthet Dent 1966;16:361-385Stone ER: Tripping action of bar clasps. J Am Dent Assoc 1936;23:596-617Tjan AH: Biologic pontic designs. Gen Dent 1983;31:40-44PonticsAnte JH: Construction of pontics. J Can Dent Assoc 1936:2:482-486Becker CM, Kaldahl WB: Current theories of crown contour, margin placement and pontic design. J Prosthet Dent 1981;45:268-277Boyd HR: Pontics in fixed partial dentures. J Prosthet Dent 1955;5:55-64Cavazos E Jr: Tissue response to fixed partial denture pontics. J Prosthet Dent 1968;20:143-153Clayton JA, Green E: Roughness of pontic materials and dental plaque. J Prosthet Dent 1970;23:407-411Crispin BJ: Tissue response to posterior denture base-type pontics. J Prosthet Dent 1979;42:257-261Eissman HF, Radke RA, Noble WJ: Physiologic design criteria for fixed dental restorations. Dent Clin North Am 1971;15:543-568Harmon CB: Pontic design. J Prosthet Dent 1958;8:496-5032010 CDEL Re-recognition of the Specialty Report 64 of 279

December 2005, Supplement, Volume 14, Number 4 25Henry PJ: Pontic form in fixed partial dentures. Aust Dent J 1971;16:1-7Hirshberg SM: The relationship of oral hygiene to embrasure and pontic design: a preliminary study. J Prosthet Dent 1972;27:26-38Hood JA: Stress and deflection of three different pontic designs. J Prosthet Dent 1975;33:54-59Klaffenbach AO: Biomechanical restoration and maintenance of the permanent first molar space. J Am Dent Assoc 1952;45:633-644Parkinson CF, Schaberg TV: Pontic design of posterior fixed partial prostheses: is it a microbial misadventure? J Prosthet Dent1984;51:51-54Perel ML: A modified sanitary pontic. J Prosthet Dent 1972;28:589-592Podshadley AG: Gingival response to pontics. J Prosthet Dent 1968;19:51-57Porter CB Jr: Anterior pontic design: a logical progression. J Prosthet Dent 1984;51: 774-776Reynolds JM: Abutment selection for fixed prosthodontics. J Prosthet Dent 1968;19:483-488Schweitzer JM, Schweitzer RD, Schweitzer J: Free-end pontics used on fixed partial dentures. J Prosthet Dent 1968;20:120-138Silness J, Gustavsen F, Mangernes K: The relationship between pontic hygiene and mucosal inflammation in fixed bridge recipients.J Periodontal Res 1982;17:434-439Smith DE, Potter HR: The pontic in fixed bridgework. D Digest 1937;43:16-20Stein RS: Pontic-residual ridge relationship: a research report. J Prosthet Dent 1966;16:251-285Tripodakis AP, Constandtinides A: Tissue response under hyperpressure from Convex pontics. Int J Periodontics Restorative Dent1990;10:408-414Tissue Response to Pontic DesignsClayton JA, Green E: Roughness of pontic materials and dental plaque. J Prosthet Dent 1970;23:407-411Parkinson CF, Schaberg TV: Pontic design of posterior fixed partial prostheses: is it a microbial misadventure? J Prosthet Dent1984;51:51-54Podshadley AG: Gingival response to pontics. J Prosthet Dent 1968;19:51-57Silness J, Gustavsen F, Mangernes K: The relationship between pontic hygiene and mucosal inflammation in fixed bridge recipients.J Periodontal Res 1982;17:434-439Types of PonticsBehrend DA: The design of multiple pontics. J Prosthet Dent 1981;46:634-638Perel ML: A modified sanitary pontic. J Prosthet Dent 1972;28:589-592Design CriteriaBecker CM, Kaldahl WB: Current theories of crown contour, margin placement and pontic design. J Prosthet Dent 1981;45:268-277Residual Ridge Contour in Pontic DesignGarber DA, Rosenberg ES: The edentulous ridge in fixed prosthodontics. Compend Contin Educ Dent 1981;2:212-224Hawkins CH, Sterrett JD, Murphy HJ, et al: Ridge contour related to esthetics and function. J Prosthet Dent 1991;66:165-168Lemmerman K: Rationale for stabilization. J Periodontol 1976;47:405-411Lindhe J, Nyman S: The role of occlusion in periodontal disease and the biological rationale for splinting treatment of periodontitis.Oral Sci Rev 1977;10:11-43(Note: Additional references addressing fixed restorative techniques are contained in the Tooth Morphology Preparation &Modification Parameter. References for implant restorations are included in the Implant Placement & Restoration Parameter.)Preface5) Complete Edentulism ParameterThe diagnosis of complete edentulism establishes that a total debilitation of the dental apparatus hasoccurred. The complete loss of dentition affects a myriad of normal and essential human functions:1. Inability to masticate2. Reduction in digestive process3. Reduction in mastication/enjoyment of food varieties and textures4. Speech aberrations5. Inability to incise2010 CDEL Re-recognition of the Specialty Report 65 of 279

26 Parameters of Care Tupac et al6. Absence and/or reduction in tooth display during smiling7. Reduction in emotional display – happiness/sadness8. Loss of self-esteem9. Sexual dysfunction and avoidance10. Increased effects of aging11. Loss of support for orofacial musculature12. Continual reduction in alveolar bone13. Decrease in airway maintenance14. Decrease in nutritional statusHistorically, all patients who are completely edentulous have been grouped into a single diagnosticcategory and, thus, have been assigned a single therapeutic technique. This incorrect assumption haslimited the treatment available to these patients. Classifying diagnostic categories enables selection ofappropriate treatment.The Prosthodontic Diagnostic Index (PDI) [ACP Patient Classifications System] for CompleteEdentulism delineates four levels. The classification is assigned based upon consideration and evaluationof the following criteria:1. Bone height – mandibular2. Maxillomandibular relationship3. Residual ridge morphology4. Muscle attachmentsBy integrating the PDI, patients will have the opportunity to have the most appropriate therapyselected to address their clinical conditions. The four classes of complete edentulism are:1. Class I – characterized by ideal or minimally compromised anatomic structures. All criteria arefavorable.2. Class II – characterized by moderately compromised supporting anatomic structures. This class isa continuation of the physical degradation of the denture-supporting structures and, in addition, ischaracterized by the early onset of systemic disease interactions, localized soft tissue factors, andpatient management/lifestyle considerations.3. Class III – characterized by substantially compromised supporting anatomic structures. This classdisplays the need for surgical revision of the denture-supporting structures to allow for adequateprosthodontic function. Additional factors now play a significant role in treatment outcomes.4. Class IV – characterized by severely compromised supporting anatomic structures. This class displaysthe most debilitated edentulous condition wherein surgical reconstruction is indicated, but cannotalways be accomplished due to the patient’s health, desires, and past dental history. When surgicalrevision is not selected, prosthodontic techniques of a specialized nature must be used to achieve anadequate treatment outcome.It must be noted that in the treatment of complete edentulism, patient attitude, cooperation,and compliance are of great importance in long-term success. The successful treatment for completeedentulism is a mutual effort between the prosthodontist and the patient. A refractory patient is onewho presents with chronic complaints following appropriate therapy. In those instances where patientexpectations exceed physical limitations, a mutually satisfactory result may not be possible through thecompletion of their treatment plan.Implant therapy must be considered for the treatment of the completely edentulous mandibulararch. Clinical evidence demonstrates that significant reduction in alveolar atrophy/resorption can beachieved with dental implant therapy. In addition, implant therapy enhances the patient’s ability to usethe prosthesis successfully.2010 CDEL Re-recognition of the Specialty Report 66 of 279

December 2005, Supplement, Volume 14, Number 4 27General Criteria and StandardsInformed consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Complete EdentulismICD-9-CMUse additional codes to identify cause of Complete Edentulism (525.10-525.26)525.40 Complete edentulism, unspecified525.41 Complete edentulism, Class I525.42 Complete edentulism, Class II525.43 Complete edentulism, Class III525.44 Complete edentulism, Class IVThe specific determinants of the PDI for Complete Edentulism can be found in the ICD-9-CM codes524-525, 528:524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structures528.7 Other disturbances of oral epithelium, including tongue528.9 Other and unspecified diseases of the oral soft tissues2010 CDEL Re-recognition of the Specialty Report 67 of 279

28 Parameters of Care Tupac et alA. Indications for care1. Lack of mastication2. Impaired speech3. Esthetics4. Impaired swallowing5. Reduction of facial height6. Lack of TM joint and orofacial muscle support7. Psychosocial factors8. Airway restriction9. Unsatisfactory existing prostheses10. Chronic pain11. Patient concernsB. Therapeutic goals1. Improved mastication2. Improved speech3. Improved esthetics4. Improved swallowing5. Restoration of facial height6. TM joint and orofacial muscle support7. Positive psychosocial response8. Improved airway support9. Improved comfort10. Address patient concernsC. Risk Factors affecting the quality of treatment1. Dyskinesia2. Preexisting conditions3. Hyperactive gag reflex4. Xerostomia5. Increased salivation6. Psychosocial factorsD. Standards of care1. Class I edentulous patient [525.41 ICD-9-CM]a. Complete dentures [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Single stage impression technique3. Maxillomandibular record in centric relation at the occlusal vertical dimension4. Articulation on a non-adjustable articulator5. Maximum intercuspation in centric relation6. Trial placement7. Insertion of prosthesis8. Post-treatment follow-upb. Implant-supported or -retained complete dentures – see criteria for Class III or IV completeedentulism. [D6000-D6199 CDT-2005]c. Maintenance of existing prosthesis [D5400-D5899 CDT-2005]d. Patient Education2. Class II edentulous patient [525.42 ICD-9-CM]a. Complete dentures [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Dual stage impression technique using a custom impression tray3. Maxillomandibular record in centric relation at the occlusal vertical dimension4. Facebow record and articulation on a semi-adjustable articulator5. Maximum intercuspation in centric relation2010 CDEL Re-recognition of the Specialty Report 68 of 279

December 2005, Supplement, Volume 14, Number 4 296. Trial placement7. Clinical remount to finalize planned occlusal scheme8. Insertion of prosthesis9. Post-treatment follow-upb. Implant-supported or -retained complete dentures – see criteria for Class III or IV completeedentulism [D6000-D6199 CDT-2005]c. Maintenance of existing prosthesis [D5400-D5899 CDT-2005]d. Patient Education3. Class III edentulous patient [525.43 ICD-9-CM]a. Conditions requiring preprosthetic preparation1. Nonsurgical2. Surgical3. Implantsb. Complete dentures [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Dual stage impression technique using a custom impression tray3. Maxillomandibular record in centric relation at the occlusal vertical dimension4. Facebow record and articulation on a semi-adjustable articulator5. Maximum intercuspation in centric relation6. Trial placement7. Clinical remount to finalize planned occlusal scheme8. Insertion of prosthesis9. Post-treatment follow-upc. Implant-supported/retained dentures (see Implant Placement & Restoration Parameter)[D6000-D6199 CDT-2005]d. Patient education4. Class IV edentulous patient [525.44 ICD-9-CM]a. Conditions requiring preprosthetic preparation1. Nonsurgical2. Surgical3. Implantsb. Complete dentures [D5000-D5899 CDT-2005]1. Treatment of etiologic factors2. Multi-stage impression technique using a modified custom impression tray, if needed3. Maxillomandibular record in centric relation at the occlusal vertical dimension4. Facebow record and articulation on a semi-adjustable articulator5. Maximum intercuspation in centric relation6. Trial placement7. Clinical remount to finalize planned occlusal scheme8. Insertion of prosthesis9. Post insertion modification (functional relines, processed soft liners, occlusal correctionprocedures, etc.)10. Extended post-treatment follow-upc. Implant-supported/retained dentures (see Implant Placement & Restoration Parameter)[D6000-D6199 CDT-2005]d. Patient educationE. Specialty performance assessment criteria1. Favorable outcomesa. Improved masticationb. Improved speechc. Improved estheticsd. Improved swallowing2010 CDEL Re-recognition of the Specialty Report 69 of 279

30 Parameters of Care Tupac et ale. Restoration of facial heightf. Restored TM joint and orofacial muscle supportg. Positive psychosocial responseh. Improved airway supporti. Improved comfortj. Satisfactory patient adaptation2. Known risks and complicationsa. Refractory patient responseb. Ulcerationsc. Speech alterationsd. Unacceptable estheticse. Unrealistic patient expectationsf. Materials failureg. Biomechanically induced implant complicationsh. Difficulty chewing and/or swallowingi. TM joint and/or orofacial muscle supportj. Alterations in taste perceptionsSelected References (Complete Edentulism Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Atwood DA: Some clinical factors related to rate of resorption of residual ridges. J Prosthet Dent 1962;12:441-450Atwood DA: A cephalometric study of the clinical rest position of the mandible. Part I: The variability of the clinical rest positionfollowing the removal of occlusal contacts. J Prosthet Dent 1956;6:504-509Beck HO: Occlusion as related to complete removable prosthodontics. J Prosthet Dent 1972;27:246-262Becker CM, Swoope CC, Guckes AD: Lingualized occlusion for removable prosthodontics. J Prosthet Dent 1977;38:601-608Boos RH: Intermaxillary relation established by biting power. J Am Dent Assoc 1940;27:1192-1199Brewer AA, Rebiel PR, Nassif NJ: Comparison of zero degree teeth and anatomic teeth on complete dentures. J Prosthet Dent1967;17:28-35DeVan MM: The concept of neutrocentric occlusion as related to denture stability. J Am Dent Assoc 1954;48:165-169Ettinger RL, Taylor TD, Scandrett FR: Treatment needs of overdenture patients in a longitudinal study: five-year results. JProsthet Dent 1984;52:532-537Fish EW: Using the muscles to stabilize the full lower denture. J Am Dent Assoc 1933;20:2163-2169Frush JP, Fisher RD: Introduction to dentogenic restorations. J Prosthet Dent 1955;5:586-595Hardy IR, Kapur KK: Posterior border seal - its rationale and importance. J Prosthet Dent 1958;8:386-397Hickey JC, Williams BH, Woelfel JB: Stability of mandibular rest position. J Prosthet Dent 1962;11:566-572Kolb HR: Variable denture-limiting structures of the edentulous mouth. Part I: Maxillary border areas. J Prosthet Dent1966;16:194-201Kolb HR: Variable denture-limiting structures of the edentulous mouth. Part II: Mandibular border areas. J Prosthet Dent1966;16:202-212Kurth LE: Physics of mandibular movement related to full denture construction. Ann Dent 1933;12:131-141Lytle RB: The management of abused oral tissues in complete denture construction. J Prosthet Dent 1957;7:27-42Martone A, Edwards L: The phenomenon of function in complete denture prosthodontics. Anatomy of the mouth and relatedstructures. Part I: The face. J Prosthet Dent 1961;11:1006-1018Martone A, Edwards L: The phenomenon of function in complete denture prosthodontics. Anatomy of the mouth and relatedstructures. Part II: Musculature of expression. J Prosthet Dent 1961;11:1006-1018McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for complete edentulism. The American College of Prosthodontics.J Prosthodont 1999;8:27-39Niswonger ME: The rest position of the mandible and the centric relation. J Am Dent Assoc 1934;21:1572-1582Pleasure MW: Anatomic versus nonanatomic teeth. J Prosthet Dent 1953;3:747-754Pound E: Let/S/ be your guide. J Prosthet Dent 1977;38:482-489Rudd KD, Morrow RM: Occlusion and the single denture. J Prosthet Dent 1973;30:4-10Sears VH: Thirty years of nonanatomic teeth. J Prosthet Dent 1953;3:596-6172010 CDEL Re-recognition of the Specialty Report 70 of 279

December 2005, Supplement, Volume 14, Number 4 31Silverman MM: Determination of vertical dimension by phonetics. J Prosthet Dent 1956;6:465-471Tallgren A: Changes in adult face height due to aging, wear and loss of teeth and prosthetic treatment. Acta Odontol Scand1957;15:1-122Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal studycovering 25 years. J Prosthet Dent 1972;27:120-123Thompson JR: The rest position of the mandible and its significance to dental science. J Am Dent Assoc 1946;33:151-180Trapozzano VR: Testing of occlusal patterns on the same denture base. J Prosthet Dent 1959;9:53-69Wright CR Muysens JH, Strong LH, et al: A study of the tongue and its relation to denture stability. J Am Dent Assoc 1949;39:269-275Preface6) Implant Placement and Restoration ParameterThe specialty of Prosthodontics is the specialty responsible for the diagnosis and treatment of completeand partial Edentulism. The prosthodontist is responsible for preparing a patient preprostheticallyfor subsequent prosthodontic procedures. Not only does a prosthodontist replace and repair teeth,but also prepares the patient to receive artificial tooth and tissue replacements. Prosthodontists areresponsible for managing all aspects of the treatment of complete and partial edentulism regardless ofthe complexity of any adjunctive preprosthetic procedures required. When a tooth is or teeth are lost,the well-documented sequelae of loss of adjacent alveolar structures and the concomitant decrease inprosthetic function can now be delayed along with an increase in function versus conventional tissueborneappliances. Dental implant therapy can be used to replace missing teeth and preserve alveolarbone.A dental implant is a prosthetic device of alloplastic material implanted into the oral tissues beneaththe mucosal and/or periosteal layer and on/or within the bone to provide retention and support of fixedor removable prostheses. The placement of a dental implant is part of a prosthodontic treatment planthat addresses the diagnosis of a missing tooth or teeth, and the treatment is the replacement of a tooth,multiple teeth, and/or contiguous structures surrounding the oral and facial region along with manyextra-oral applications. The diagnosis for the need of a dental implant is a prosthodontic diagnosis thatreflects all the usual criteria for tooth and contiguous structure replacement. Only after a prosthodonticneed has been established is the surgical diagnosis made to determine if the prosthodontic need canbe satisfied. The therapeutic purpose and value of a dental implant is to support and retain teeth andpreserve remaining bone.Thus, dental implant restoration is a prosthodontically driven procedure that requires extensivepresurgical consultations and treatment planning. The prosthodontist is responsible for the placementof the dental implant according to the prescription of the prosthodontist or referring dentist. Theprosthodontist is responsible for acquiring and/or conveying sufficient diagnostic information to ensurethe accurate placement of dental implant(s) to maximize prosthodontic function. Sufficient presurgicalconsultations should identify alternative implant sites so that surgical flexibility is maintained to deal withunforeseen anatomic limitations. With the rapid advancements in soft tissue and bone augmentation,the placement of implants outside the normal anatomic location to support prosthodontic replacement isbecoming less acceptable unless there has been informed consent by the patient for alternative implantlocation and angulation. Prosthodontists have the unique educational background and experience in bothplacement and restoration at the specialty level of education. By planning and creating the restoration,the prosthodontist has the advantage of placing the implant in the most favorable location to fulfill thepatient’s needs.Because prosthodontists are the recognized specialists in tooth and contiguous structure replacement,prosthodontists must strive to position the implants in the most advantageous location and angulationfor future prosthodontic procedures. The prosthodontist must evaluate the patient to determine thenumber, type, length, and location of the dental implants so that the prosthodontic restoration willremain healthy and functional. The prosthodontist, in cooperation with the patient, must remain flexiblein the final prosthodontic reconstruction to account for surgical variability and anatomic limitations. It2010 CDEL Re-recognition of the Specialty Report 71 of 279

32 Parameters of Care Tupac et alis the responsibility of the prosthodontist to be familiar with the different types of implants because eachsystem has its own intricacies and capabilities. The prosthodontist should be knowledgeable about anyimplant system recommended and/or used in patient treatment.Initially, prosthodontic restorations supported and/or retained by implants have had the greatestimpact on completely edentulous patients. In fact, the McGill Proclamation declares the two-implantmandibular overdenture as the first choice for the completely edentulous patient. Today implants canbe used in the partially edentulous patient for a variety of applications. Whether it is the conservation ofhealthy abutment teeth by using single or multiple implant replacements of teeth instead of conventionalfixed prosthodontics, or perhaps the reduction in prosthetically influenced alveolar resorption by implantsupported/retainedcomplete dentures, the impact of implant prosthodontics will continue to improvethe health and comfort of patients. Treatment of only the area of pathology without sacrificing orjeopardizing adjacent healthy tissues is now a reality.A refractory patient is one who presents with chronic complaints following appropriate therapy. Inthose instances where patient expectations exceed physical limitations, a mutually satisfactory resultmay not be possible through the completion of their treatment plan.General Criteria and StandardsInformed consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient-management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.2010 CDEL Re-recognition of the Specialty Report 72 of 279

December 2005, Supplement, Volume 14, Number 4 33Parameter Guidelines: Implant Placement and RestorationA. Indications for care1. Complete edentulism (see Complete Edentulism Parameter) [525.40-525.44 ICD-9-CM]2. Partial edentulism (see Partial Edentulism Parameter) [525.50-525.54 ICD-9-CM]3. Implant-specific indicatorsa. Adequate host bone [525.20-525.26 ICD-9-CM]b. Adequate soft tissue [528.71-528.72 ICD-9-CM]c. Prosthetic need [525.40-525.44, 525.50-525.54 ICD-9-CM]d. Maintenance of soft tissue architecturee. Alveolar bone preservationf. Improved functionB. Therapeutic goals1. Complete edentulism (see Complete Edentulism Parameter)2. Partial edentulism (see Partial Edentulism Parameter)3. Implant-specific goalsa. Bone preservationb. Soft tissue preservationc. Prosthetic support and retentiond. Improved form and functione. Improved estheticsf. Provision of adequate bone-borne occlusal support stopsg. Limited painh. Limited period of disabilityi. Achievement of uncomplicated healingj. Appropriate understanding and acceptance of diagnosis, treatment plan, and possible outcomesk. Minimally invasive surgery (no removal of non-regenerable tissues)C. Risk factors affecting quality of treatment1. Complete edentulism (see Complete Edentulism Parameter)2. Partial edentulism (see Partial Edentulism Parameter)3. Implant-specific risk factorsa. Bone factors (quantity and quality)b. Surgicalc. Implant characteristicsd. Anatomical considerationse. Presence of active periodontal diseasef. Number of implants relative to number of teeth to be replacedg. Interarch distanceh. Biomechanical loading factorsi. Presence of local or systemic conditions which affect healing (e.g., history of radiation therapy,diabetes, etc.)j. Peri-implant tissue quality and contourk. Proximity of implant site to adjacent structuresl. Existing and proposed occlusal factorsm. Tobacco usen. Current and past pharmacological therapiesD. Standards of care1. Completely edentulous patient [525.40-525.44 ICD-9-CM]a. Pretreatment procedures1. Radiographic evaluation2. Articulated diagnostic casts, when indicated2010 CDEL Re-recognition of the Specialty Report 73 of 279

34 Parameters of Care Tupac et alb. Conditions requiring preprosthetic preparation1. Nonsurgical [D5850-D5851, D5875, D5899 CDT-2005]2. Surgical [D4263-D4276 CDT-2005]c. Placement procedures [D6010, D6040, D6050 CDT-2005]1. Aseptic technique2. Appropriate surgical protocol3. Preoperative instructionsd. Removable complete denture [D6053, D6055 CDT-2005]1. Treatment of etiologic factors2. Dual-stage impression technique using a custom impression tray3. Abutment selection [D6056-D6057 CDT-2005]4. Maxillomandibular record in centric relation at the occlusal vertical dimension5. Facebow record and articulation on a semi-adjustable articulator6. Maximum intercuspation in centric relation7. Assessment of implant components and/or framework8. Trial denture evaluation9. Surgical template [D6190, D6199 CDT-2005]10. Clinical remount to finalize planned occlusal scheme11. Insertion of prosthesis12. Post-treatment follow-up13. Patient educatione. Fixed complete denture (metal-resin hybrid or metal-ceramic) [D6056-D6067 CDT-2005]1. Treatment of etiologic factors2. Impression3. Abutment selection4. Maxillomandibular record in centric relation at the occlusal vertical dimension5. Facebow record and articulation on a semi-adjustable articulator6. Maximum intercuspation in centric relation7. Surgical template [D6190, D6199 CDT-2005]8. Assessment of implant components and/or framework9. Prosthesis try-in and assessment10. Insertion of prosthesis11. Post-treatment follow-up12. Patient education2. Partially edentulous patient [525.50-525.54 ICD-9-CM]a. Pretreatment procedures1. Radiographic evaluation2. Articulated diagnostic casts3. Diagnostic wax-up4. Surgical template (see surgical standards) [D6190, D6199 CDT-2005]b. Conditions requiring preprosthetic preparation1. Nonsurgical [D5850-D5851, D5875, D5899 CDT-2005]2. Surgical [D4263-D4276 CDT-2005]c. Removable partial denture (implant RPD) [D6054 CDT-2005]1. Treatment of etiologic factors2. Diagnostic survey and design3. Tooth abutment preparation (i.e., intra- and extracoronal restorations, rest preparations,guide planes, intra- and extracoronal attachments, etc.)4. Implant abutment selection [D6055-D6067 CDT-2005]5. Dual or multi-stage impression technique6. Maxillomandibular record in centric relation7. Facebow record and articulation on a semi-adjustable articulator2010 CDEL Re-recognition of the Specialty Report 74 of 279

December 2005, Supplement, Volume 14, Number 4 358. Implant component try-in9. Framework try-in and assessment10. Trial placement11. Insertion of prosthesis12. Post-treatment follow-upd. Fixed partial denture [D6056-D6077,D6079 CDT-2005]1. Treatment of etiologic factors2. Abutment selection [D6056,D6057 CDT-2005]3. Complete arch impression4. Maxillomandibular record at the established occlusal vertical dimension and eccentricrecords as necessary5. Facebow record and articulation on a semi- or fully adjustable articulator6. Framework try-in and assessment7. Insertion of prosthesis8. Post-treatment follow-up9. Patient educatione. Single tooth restoration [D6058-D6067 CDT-2005]1. Treatment of etiologic factors2. Abutment selection [D6056, D6057 CDT-2005]3. Impression4. Maxillomandibular record5. Try-in and assessment6. Insertion of prosthesis7. Post-treatment follow-up8. Patient educationE. Specialty Performance Assessment1. Favorable outcomesa. Completely edentulous patient (see Complete Edentulism Parameter)b. Partially edentulous patient (see Partial Edentulism Parameter)c. Implant specific1. Long-term preservation of supporting bone2. Establish bone-borne support stops3. Soft tissue preservation4. Improved prosthetic support and retention5. Improved form and function6. Implant(s) capable of supporting a prosthesis for a minimum of five years7. Bone height loss of less than 0.2 mm annually following the first year of service8. No evidence of peri-implant radiolucency9. Ease of maintenance10. Improved esthetics2. Known risks and complicationsa. Completely edentulous patient (see Complete Edentulism Parameter)b. Partially edentulous patient (see Partial Edentulism Parameter)c. Implant specific1. Surgical2. Anesthesia, paresthesia, hyperesthesia, hypoesthesia3. Acute and/or chronic infection4. Unanticipated bony deficiency5. Dental injury during surgery6. Injury to adjacent teeth7. Nasal or sinus fistula8. Hemorrhage2010 CDEL Re-recognition of the Specialty Report 75 of 279

36 Parameters of Care Tupac et al9. Prolonged period of disability10. Unanticipated repeat oral surgery11. Loss of implant prior to restoration12. Loss of implant after restoration13. Loss of supporting bone14. New or increased pain15. Neuropathy and/or paresthesia16. Implant placement in an unfavorable prosthodontic location17. Materials failure18. Biomechanical implant overload19. Compromised phonetics20. Compromised esthetics21. Increased probing depths22. Reduction and/or loss of use of current prosthesis during entire healing phase23. Inability of patient to adapt to new implant supported/retained prosthesisSelected References (Implant Placement and Restoration Parameter)This list of selected references is intended only to acknowledge some of the sources of informationdrawn on in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Adell R, Lekholm U, Rockler B, et al: A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int JOral Surg 1981;10:387-416Adell R, Eriksson B, Lekholm U, et al: A long-term follow-up study of osseointegrated implants in the treatment of totallyedentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-359Albrektsson T, Zarb G, Worthington P, et al: The long-term efficacy of currently used dental implants: a review and proposedcriteria of success. Int J Oral Maxillofac Implants 1986;1:11-25Astrand P, Borg K, Gunne J, et al: Combination of natural teeth and osseointegrated implants as prosthesis abutments: a 2-yearlongitudinal study. Int J Oral Maxillofac Implants 1992;6:305-312Bosker H, Van Dijk L: The transmandibular implant: a 12-year follow-up study. J Oral Maxillofac Surg 1989;47:442-450Branemark PI: Osseointegration and its experimental background. J Prosthet Dent 1983;50:399-410Branemark PI, Zarb GA, Albrektsson T: Patient Selection and Preparation: Tissue-Integrated Prostheses: Osseointegration inClinical Dentistry. Chicago, Quintessence, 1985, pp 199-210Branemark PI, Zarb GA, Albrektsson T: Laboratory Procedures and Protocol: Tissue-Integrated Prostheses: Osseointegration inClinical Dentistry. Chicago, Quintessence, 1985, pp 293-316Branemark PI, Zarb GA, Albrektsson T: Prosthodontic Procedures: Tissue-Integrated Prostheses: Osseointegration in ClinicalDentistry. Chicago, Quintessence, 1985, pp 199-210Branemark PI, Zarb GA, Albrektsson T: Other Prosthodontic Applications: Tissue-Integrated Prostheses: Osseointegration inClinical Dentistry. Chicago, Quintessence, 1985, pp 283-292Buser D, Weber HP, Bragger U, et al: Tissue integration of one-stage ITI implants: 3-year results of a longitudinal study withHollow-Cylinder and Hollow-Screw implants. Int J Oral Maxillofac Implants 1991;6:405-412Chaushu G, Schwartz-Arad D: Full-arch restoration of the jaw with fixed ceramo-metal prosthesis: late implant placement. JPeriodontol 1999;70:90-94De Bruyn H, Collaert B, Linden U, et al: A comparative study of the clinical efficacy of Screw Vent implant versus Branemarkfixtures, installed in a periodontal clinic. Clin Oral Implants Res 1992;3:32-41Feine JS, Carlsson GE, Awad MA, et al: The McGill consensus statement on overdentures. Mandibular two-implant overdenturesas first choice standard of care for edentulow patients. Int J Oral Maxillotac Implants 2002;17:601-602Goldberg NI: Risk of subperiosteal implants. Dental Implants: Benefit and Risk. U.S. Department of Health and Human Services1980;89-95Goodacre CJ, Bernal G, Rungcharassaeng K, et al: Clinical complications with implants and implant prostheses. J Prosthet Dent2003;90:121-132Goodacre CJ, Kan JY, Rungcharassaeng K: Clinical complications of osseointegrated implants. J Prosthet Dent 1999;81:537-552Kent JN, Block MS, Finger IM, et al: Biointegrated hydroxylapatite-coated dental implants: 5-year clinical observations. J AmDent Assoc 1990;121:138-1442010 CDEL Re-recognition of the Specialty Report 76 of 279

December 2005, Supplement, Volume 14, Number 4 37Kan JY, Rungcharassaeng K, Bohsali K, et al: Clinical methods for evaluating implant framework fit. J Prosthet Dent 1999;81:7-13Kan JY, Rungcharassaeng K: Site development for anterior single implant esthetics: the dentulous site. Compend Contin EducDent. 2001;22:221-226,228,230-231Kirsch A, Ackermann KL: The IMZ osteointegrated implant system. Dent Clin North Am 1989;33:733-791Kois JC: Predictable single tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent 2001;22:199-206Kucey BK: Implant placement in prosthodontics practice: a five-year retrospective study. J Prosthet Dent 1997;77:171-176Laney WR, Tolman DE, Keller EE, et al: Dental Implants: tissue-integrated prosthesis utilizing the osseointegration concept.Mayo Clin Proc 1986;61:91-97Laney WR: Selecting edentulous patients for tissue-integrated prostheses. Int J Oral Maxillofac Implants 1986;1:129-138Lewis SG, Llamas D, Avera S: The UCLA abutment: a 4-year review. J Prosthet Dent 1992;67:509-515Lewis S: Treatment planning: teeth versus implants. Int J Periodontics Restorative Dent. 1996;16:366-377Naert I, Quirynen M, Theuniers G, et al: Prosthetic aspects of osseointegrated fixtures supporting overdentures: a 4-year report.J Prosthet Dent 1991;65:671-680Priest G: Single-tooth implants and their role in preserving remaining teeth: a 10-year survival study. Int J Oral MaxillofacImplants 1999;14:181-188Randow K, Ericsson I, Nilner K, et al: Immediate functional loading of Branemark dental implants. An 18-month clinical follow-upstudy. Clin Oral Implants Res 1999;10:8-15Sadowsky SJ: Mandibular implant-retained overdentures: a literature review. J Prosthet Dent. 2001;86:468-473Scharf DR, Tarnow DP: Success rates of osseointegration for implants placed under sterile versus clean conditions. J Periodontol1993;64:954-956Simon H: Treatment planning considerations: questionable teeth or implants? J Calif Dent Assoc 2003;31:326-327Simon H, Marchack CB: A simplified approach to implant-supported metal-ceramic reconstruction. J Prosthet Dent 2004;91:525-531Simon H, Yanase RT: Terminology for implant prostheses. Int J Oral Maxillofac Implants 2003;18:539-543Skalak R: Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent 1983;49:843-848Small IA: Benefit and risk of mandibular staple bone plates. Dental Implants: Benefit and Risk. U.S. Department of Health andHuman Services 1980;139-51Small PN, Tarnow DP: Gingival recession around implants: a 1-year longitudinal prospective study. Int J Oral Maxillofac Implants2000;15:527-532Smith RA, Berger R, Dodson TB: Risk factors associated with dental implants in healthy and medically compromised patients.Int J Oral Maxillofac Implants 1992;7:367-372Smithloff M, Fritz ME: The use of blade implants in a selected population of partially edentulous adults: a 15-year report. JPeriodontics 1987;58:589-593Spear F: When to restore, when to remove: the single debilitated tooth. Compend Contin Educ Dent. 1999;20:316-318,322-323,327-328Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal studycovering 25 years. J Prosthet Dent 1972;27:120-132Tarnow DP, Cho SC, Wallace SS: The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol2000;71:546-549Tarnow DP, Emtiaz S, Classi A: Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutivecase reports with 1- to 5-year data. Int J Oral Maxillofac Implants 1997;12:319-324Taylor RL, Bergman GF: Laboratory techniques for the Branemark system. Chicago, Quintessence, 1990, pp 22-77Tolman DE, Laney WR: Tissue-integrated prosthesis complications. Int J Oral Maxillofac Implants 1992;7:477-484Van Steenberghe D, Lekholm U, Bolender C, et al: Applicability of osseointegrated oral implants in the rehabilitation of partialedentulism: a prospective multicenter study on 558 fixtures. Int J Oral Maxillofac Implants 1990;5:272-281Worthington P, Branemark P-I (eds.): Advanced osseointegration surgery: applications in the maxillofacial regions. Chicago,Quintessence, 1992, pp 80-93Wyatt CC: The effect of prosthodontic treatment on alveolar bone loss: a review of the literature. J Prosthet Dent 1998;80:362-366Zarb GA, Schmitt A: The longitudinal clinical effectiveness of osseointegrated dental implants: The Toronto Study. Part II: Theprosthetic results. J Prosthet Dent 1990;64:53-61Zarb GA, Schmitt A: The longitudinal clinical effectiveness of osseointegrated dental implants: The Toronto Study. Part III:Problems and complications encountered. J Prosthet Dent 1990;64:185-94Zitzmann NU, Marinello CP: Clinical and technical aspects of implant-supported restorations in the edentulous maxilla: the fixedpartial denture design. Int J Prosthodont 1999;12:307-312Zitzmann NU, Marinello CP: Treatment plan for restoring the edentulous maxilla with implant-supported restorations: removableoverdenture versus fixed partial denture design. J Prosthet Dent 1999;82:188-196Zitzmann NU, Marinello CP: Implant-supported removable overdentures in the edentulous maxilla: clinical and technical aspects.Int J Prosthodont 1999;12:385-390Zitzmann NU, Marinello CP: Fixed or removable implant-supported restorations in the edentulous maxilla: literature review.Pract Periodontics Aesthet Dent 2000;12:599-6082010 CDEL Re-recognition of the Specialty Report 77 of 279

38 Parameters of Care Tupac et alPreface7) Tooth Preparation and Modification ParameterThe preparation and modification of teeth are an essential part of the specialty of prosthodontics. Teethare the foundation of many prosthodontic therapies; thus, the diagnosis and treatment of individualtooth structure must be accomplished within the scope of the overall prosthodontic therapy.General Criteria and Standards (See Introduction)Informed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient-management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Tooth Preparation and ModificationPlease refer to the appropriate parameter of completely dentate, partial edentulism, or completeedentulism for specific diagnostic and treatment codes.A. Indications for care1. Loss of tooth structure/integritya. Cariesb. Attrition2010 CDEL Re-recognition of the Specialty Report 78 of 279

December 2005, Supplement, Volume 14, Number 4 39c. Erosiond. Abrasione. Abfractionf. Fractures/microfractures/cracksg. Endodontic therapy2. Intra-arch and interarch integritya. Mobility/stabilizationb. Diastema/interproximal contact closuresc. Tooth malpositiond. Loss of vertical dimension of occlusione. Estheticsf. Pathogenic occlusiong. Fixed or removable partial denture and overdenture tooth abutmentsh. Failed preexisting restorationsi. Correction of congenital abnormalitiesj. Tooth morphology not acceptable for prosthodontic designk. Patient concernsB. Therapeutic goals1. Improved mastication2. Improved speech3. Improved esthetics4. Improved swallowing5. Restoration of facial height6. TM joint and orofacial muscle support7. Positive psychosocial response8. Airway support9. Improved comfort10. Improved tooth form and function11. Restore intra-arch and interarch integrity and stability12. Maintain or improve periodontal health13. Improved prosthetic retention, stability and support.C. Risk factors affecting quality of treatment1. Dyskinesia2. Preexisting systemic conditions3. Hyperactive gag reflex4. Xerostomia5. Increased salivation6. Periodontal disease7. Endodontic complications8. Occlusal factors9. Skeletal factors10. Inadequate tooth structure11. Parafunctional habits12. Caries susceptibility13. Psychosocial factors14. Preexisting tooth position and alignment15. Patient concernsD. Standards of care1. Preprosthetic preparationa. Nonsurgicalb. Surgicalc. Endodontic2010 CDEL Re-recognition of the Specialty Report 79 of 279

40 Parameters of Care Tupac et ald. Periodontale. Orthodonticf. TMD2. Treatment of etiologic factors3. Intracoronal and extracoronal restorative procedures4. Post-treatment follow-up5. Patient educationE. Specialty performance assessment criteria1. Favorable outcomesa. Improved masticationb. Improved speechc. Improved estheticsd. Improved swallowinge. Restoration of facial heightf. Restored TM joint and orofacial muscle supportg. Positive psychosocial responseh. Improved airway supporti. Improved comfortj. Satisfactory patient adaptationk. Improved intra-arch and interarch integrity and stabilityl. Improved tooth form and functionm. Improved periodontal healthn. Improved prosthetic support or retention2. Known risks and complicationsa. Refractory patient responseb. Speech alterationsc. Unacceptable estheticsd. Unrealistic patient expectationse. Materials failure/incompatibilityf. Difficulty chewing and/or swallowingg. TM joint and/or orofacial muscle dysfunctionh. Alterations in taste perceptioni. Allergic responsej. Endodontic complicationsk. Periodontal complicationsl. Increased caries susceptibilitym. Dentinal sensitivityn. Tongue/ cheek bitingo. PainSelected References for Tooth Modification Parameter (See Introduction)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Literature references for this parameter cover all areas ofdentistry and extend to techniques not solely associated with the specialty. Members are encouraged tobe conversant with the literature for each and every procedure attempted. The following reading listcovers those areas most often associated with prosthodontics. Citation of the reference material is notmeant to imply endorsement of any statement contained in the reference material, nor that the list isan exhaustive compilation of information on the topic. Readers should consult other sources to obtain acomplete bibliography.2010 CDEL Re-recognition of the Specialty Report 80 of 279

December 2005, Supplement, Volume 14, Number 4 41Principles of PreparationGoodacre CJ: Designing tooth preparations for optimal success. Dent Clin North Am 2004;48:359-385Goodacre CJ, Campagni WV, Aquilino SA: Tooth preparations for complete crowns: an art form based on scientific principles. JProsthet Dent 2001;85:363-376Shillingburg HT: Fundamentals of fixed prosthodontics (ed 3). Chicago, Quintessence, 1997Shillingburg HT, Jacobi R, Brackett SE: Fundamentals of tooth preparations for cast metal and porcelain restorations. Chicago,Quintessence, 1987Preservation of Tooth Structure: Biological Considerations – PulpalJackson CR, Skidmore AE, Rice RT: Pulpal evaluation of teeth restored with fixed prosthesis. J Prosthet Dent 1992;67:323-325Laforgia PD, Milano V, Morea C, et al: Temperature change in the pulp chamber during complete crown preparation. J ProsthetDent 1991;65:56-61Morrant GA: Dental instrumentation and pulpal injury. Part II: Clinical considerations. J Br Endod Soc 1977;10:55-63Seltzer S, Bender IB: The dental pulp: biologic considerations in dental procedures (ed 2). Philadelphia, Lippincott, 1975, pp 180Preservation of Tooth Structure: Biological Considerations – PeriodontalBader JD, Rozier RG, McFall WT Jr, et al: Effect of crown margins on periodontal conditions in regularly attending patient. JProsthet Dent 1991;65:75-79Becker CM, Kaldahl WB: Current theories of crown contour, margin placement and pontic design. J Prosthet Dent 1981;45:268-277Berman MH: The complete-coverage restoration and the gingival sulcus. J Prosthet Dent 1973;29:301-309Block PL: Restorative margins and periodontal health: a new look at an old perspective. J Prosthet Dent 1987;57:683-689Carnevale G, di Febo G, Fuzzi M: A retrospective analysis of the perio-prosthetic aspect of teeth re-prepared during periodontalsurgery. J Clin Periodontal 1990;17:313-316Crispin BJ, Watson JF: Margin placement of esthetic veneer crowns. Part I: Anterior tooth visibility. J Prosthet Dent 1981;45:278-282Dowling EA, Maze GI, Kaldahl WB: Post-surgical timing of restorative therapy: a review. J Prosthodont 1994;3:172-177Dragoo MR, Williams GB: Periodontal tissue reactions to restorative procedures. Int J Periodontics Restorative Dent 1981;1:8-23Eissman HF, Radke RA, Noble WJ: Physiologic design criteria for fixed dental restorations. Dent Clin North Am 1971;15:543-568Felton DA, Kanoy BE, Bayne SC, et al: Effect of in-vivo crown margin discrepancies on periodontal health. J Prosthet Dent1991;65:357-364Ferencz JL: Maintaining and enhancing gingival architecture in fixed prosthodontics. J Prosthet Dent 1991;65:650-657Freilich MA, Niekrash CE, Katz RV, et al: Periodontal effects of fixed partial denture retainer margins: configuration and location.J Prosthet Dent 1992;67:184-190Gardner FM: Margins of complete crowns - literature review. J Prosthet Dent 1982;48:396-400Goodacre CJ: Gingival esthetics. J Prosthet Dent 1990;64:1-12Ingber JS, Rose LF, Coslet JG: The “biologic width’’- a concept in periodontics and restorative dentistry. Alpha Omega 1922;70:62-65Jameson LM, Malone WF: Crown contours and gingival response. J Prosthet Dent 1982;47:620-624Koth DL: Full crown restorations and gingival inflammation in a controlled population. J Prosthet Dent 1982;48:681-685Marcum JS: The effect of crown marginal depth upon gingival tissue. J Prosthet Dent 1967;17:479-487Newcomb GM: The relationship between the location of subgingival crown margins and gingival inflammation. J Periodontol1974;45:151-154Newell DH: The role of prosthodontist in restoring root-resected molars: a study of 70 molar root resections. J Prosthet Dent1991;65:7-15Orkin DA, Reddy J, Bradshaw D: The relationship of the position of crown margins to gingival health. J Prosthet Dent 1987;57:421-424Palomo F, Kopczyk RA: Rationale and methods for crown lengthening. J Am Dent Assoc 1978;96:257-260Preston J: Rational approach to tooth preparation for ceramo-metal restorations. Dent Clin North Am 1977;21:683-98Reeves WG: Restorative margin placement and periodontal health. J Prosthet Dent 1991;66:733-736Richter WA, Ueno H: Relationship of crown margin placement to gingival inflammation. J Prosthet Dent 1973;30:156-161Ross SE, Garguilo A: The surgical management of the restorative alveolar interface. Int J Periodontics Restorative Dent 1982;2:8-31Silness J: Periodontal conditions in patients treated with dental bridges. 3. The relationship between the location of the crownmargin and the periodontal condition. J Periodontal Res 1970;5:225-229Stein RS, Clickman I: Prosthetic considerations essential for gingival health. Dent Clin North Am 1960;4:177-188Stetler KJ, Bissada NF: Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginalrestorations. J Periodontol 1987;58:696-700Tarnow D, Stahl SS, Magner A, et al: Human gingival attachment responses to subgingival crown placement: Marginal remodeling.J Clin Periodontol 1986;13:563-5692010 CDEL Re-recognition of the Specialty Report 81 of 279

42 Parameters of Care Tupac et alValderhaug J, Ellingsen JE, Jokstad A: Oral hygiene, periodontal conditions and carious lesions in patients treated with dentalbridge. A 15-year clinical and radiographic follow-up study. J Clin Periodontol 1993;20:482-89Waerhaug J: Histologic considerations which govern where the margins of restorations should be located in relation to the gingival.Dent Clin North Am 1960;4:161-176Wang HL, Burgett FG, Shyr Y: The relationship between restoration and furcation involvement on molar teeth. J Periodontol1993;64:302-305Wise MD: Stability of gingival crest after surgery and before anterior crown placement. J Prosthet Dent 1985;53:20-23Retention and Resistance: GeneralAnnerstedt A, Engström U, Hansson A, et al: Axial wall convergence of full veneer crown preparations. Documented for dentalstudents and general practitioners. Acta Odontol Scand 1996;54:109-112Ayad MF, Rosenstiel SF, Salama M: Influence of tooth surface roughness and type of cement on retention of complete cast crowns.J Prosthet Dent 1997;77:116-121Douglas RD, Przybylska M: Predicting porcelain thickness required for dental shade matches. J Prosthet Dent 1999;82:143-149el-Ebrashi MK, Craig RG, Peyton FA: Experimental stress analysis of dental restorations. IV. The concept of parallelism of axialwalls. J Prosthet Dent 1969;22:346-353Gilboe DB, Teteruck WR: Fundamentals of extracoronal tooth preparation. Part I. Retention and resistance form. J Prosthet Dent1974;32:651-656Hegdahl T, Silness J: Preparation areas resisting displacement of artificial crowns. J Oral Rehabil 1977;4:201-207Hovijitra S, Robinson F, Brehm T: The relationship between retention and convergence of full crowns when used as fixed partialdenture retainers. J Indiana Dent Assoc 1979;58:21-24Jorgensen KD: The relationship between retention and convergence angle in cemented veneer crowns. Acta Odontol Scand1955;13:35-40Kaufman EG, Coelho DH, Dolin L: Factors influencing the retention of cemented gold castings. J Prosthet Dent 1961;11:487-502Mack PJ: A theoretical and clinical investigation into the taper achieved on crown and inlay preparations. J Oral Rehabil 1980;7:255-65Maxwell AW, Blank LW, Pelleu GB Jr: Effect of crown preparation height on the retention and resistance of gold castings. GenDent 1990;38:200-202Nicholls JI: Crown retention. I. Stress analysis of symmetric restorations. J Prosthet Dent 1974;31:179-84Ohm E, Silness J: The convergence angle in teeth prepared for artificial crowns. J Oral Rehabil 1978;5:371-375Proussaefs P, Campagni W, Bernal G, et al: The effectiveness of auxiliary features on a tooth preparation with inadequateresistance form. J Prosthet Dent 2004;91:33-41Rosenstiel E: The retention of inlays and crowns as a function of geometrical form. Brit Dent J 1957;103:388-394Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Shillingburg HT, Fisher DW: A partial veneer restoration. Aust Dent J 1972;17:411-417Smith CT, Gary JJ, Conkin JE, et al: Effective taper criterion for the full veneer crown preparation in preclinical prosthodontics.J Prosthodont 1999;8:196-200Smyd ES: Advanced thought in indirect inlay and fixed bridge fabrication. J Am Dent Assoc 1944;34:759-768Trier AC, Parker MH, Cameron SM, et al: Evaluation of resistance form of dislodged crowns and retainers. J Prosthet Dent1998;80:405-409Tuntiprawon M: Effect of surface roughness on marginal seating and retention of complete metal crowns. J Prosthet Dent1999;81:142-147Ebel HE, Guyer SE, Lefkowitz W: Retention in the preparation of teeth for cast restorations. J Prosthet Dent 1976;35:526-531Wiskott HW, Nicholls JI, Belser UC: The relationship between abutment taper and resistance of cemented crowns to dynamicloading. Int J Prosthodont 1996;9:117-130Wiskott HW, Nicholls JI, Belser UC: The effect of tooth preparation height and diameter on the resistance of complete crowns tofatigue loading. Int J Prosthodont 1997;10:207-215Retention and Resistance: Intracoronal RestorationsGabel AB: Present-day concepts of cavity preparation. Dent Clin North Am 1957;1:3-17Howard WW, Moller RC: Atlas of Operative Dentistry (ed 2). Mosby, St. Louis, 1973, pp 73Kishimoto M, Shillingburg HT Jr, Duncanson MG: Influence of preparation features on retention and resistance. Part II: threequartercrowns. J Prosthet Dent 1983;49:188-192Retention and Resistance: Partial Veneer CrownsCowger GT: Retention, resistance and esthetics of the anterior three-quarter crown. J Am Dent Assoc 1961;62:167-171Guyer SE: Multiple preparations and fixed prosthodontics. J Prosthet Dent 1970;23:529-5532010 CDEL Re-recognition of the Specialty Report 82 of 279

December 2005, Supplement, Volume 14, Number 4 43Lorey RE, Myers GE: The retentive qualities of bridge retainers. J Am Dent Assoc 1968;76:568-572Moffa JP, Phillips RW: Retentive properties of parallel pin restorations. J Prosthet Dent 1967;17:387-400Potts RG, Shillingburg HT Jr, Duncanson MG Jr: Retention and resistance of preparations for cast restorations. J Prosthet Dent1980;43:303-308Reisbick MH, Shillingburg HT Jr: Effect of preparation geometry on retention and resistance of cast gold restorations. J CalifDent Assoc 1975;3:51-59Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Shillingburg HT, Fisher DW: The partial veneer restoration. Aust Dent J 1972;17:411-417Shooshan ED: A pinledge casting technique: Its application in periodontal splinting. Dent Clin North Am 1960;4:189-206Tjan AH, Miller GD: Biogeometric guide to groove placement on three-quarter crown preparations. J Prosthet Dent 1979;42:405-410Retention and Resistance: Full Veneer CrownsLorey RE, Myers GE: The retentive qualities of bridge retainers. J Am Dent Assoc 1968;76:568-572Potts RG, Shillingburg HT Jr, Duncanson MG Jr: Retention and resistance of preparations for cast restorations. J Prosthet Dent1980;43:303-308Reisbick MH, Shillingburg HT Jr: Effect of preparation geometry on retention and resistance of cast gold restorations. J CalifDent Assoc 1975;3:51-59Thom LW: Principles of cavity preparation in crown and bridge prosthesis; the full crown. J Am Dent Assoc 1950;41:284-289Weed RM, Baez RJ: A method for determining adequate resistance form of complete cast crown preparations. J Prosthet Dent1984;52:330-334Retention and Resistance: ContemporaryLeempoel PJ, Lemmens PL, Snoek PA, et al: The convergence angle of tooth preparations for complete crowns. J Prosthet Dent1987;58:414-416Noonan JE Jr, Goldfogel MH: Convergence of the axial walls of full veneer crown preparations in a dental school environment. JProsthet Dent 1991;66:706-708Nordlander J, Weir D, Stoffer W, et al: The taper of clinical preparations for fixed prosthodontics. J Prosthet Dent 1988;60:148-151Parker MH, Calverley MJ, Gardner FM, et al: New guidelines for preparation taper. J Prosthodont 1993;2:61-66Parker MH, Gunderson RB, Gardner FM, et al: Quantitative determination of taper adequate to provide resistance form: conceptof limiting taper. J Prosthet Dent 1988;59:281-288Parker MH, Malone KH 3rd, Trier AC, et al: Evaluation of resistance form for prepared tooth. J Prosthet Dent 1991;66:730-733Trier AC, Parker MH, Cameron SM, et al: Evaluation of resistance form of dislodged crowns and retainers. J Prosthet Dent1998;80:405-409Walton TR: An up to 15-year longitudinal study of 515 metal-ceramic FPDs: Part1. Outcome. Int J Prosthodont 2002;15:439-445Wilson AH Jr, Chan DCN: The relationship between preparation convergence and retention of extracoronal retainers. JProsthodont 1994;3:74-78Zuckerman GR: Resistance form for the complete veneer crown: principles of design and analysis. Int J Prosthodont 1988;1:302-307Resin-Bonded RetainersBarrack G: Recent advances in etched cast restorations. J Prosthet Dent 1984;52:619-626Burgess JO, McCartney JG: Anterior retainer design for resin-bonded acid-etched fixed partial dentures. J Prosthet Dent1989;61:433-436Eshleman JR, Janus CE, Jones CR: Tooth preparation designs for resin-bonded fixed partial dentures related to enamel thickness.J Prosthet Dent 1988;60:18-22Kern M, Schwarzbach W, Strub JR: Stability of all-porcelain, resin-bonded fixed restorations with different designs: an in-vitrostudy. Int J Prosthodont 1992;5:108-113Livaditis GJ: Cast metal resin-bonded retainers for posterior teeth. J Am Dent Assoc 1980;101:926-929Rammelsberg P, Pospiech P, Gernet W: Clinical factors affecting adhesive fixed partial dentures: a six year study. J Prosthet Dent1992;70:300-307Saad AA, Claffey N, Byrne D, et al: Effects of groove placement on retention/resistance of maxillary anterior resin-bonded retainers.J Prosthet Dent 1995;74:133-139Shillingburg HT: Fundamentals of fixed prosthodontics (ed 3). Chicago, Quintessence, 1997Simon JF, Gartrell RG, Grogono A: Improved retention of acid-etched fixed partial dentures: a longitudinal study. J Prosthet Dent1992;68:611-615Thompson V, Barrack G, Simonsen R: Posterior design principles in etched cast restoration. Quintessence Int 1983;14:311-3182010 CDEL Re-recognition of the Specialty Report 83 of 279

44 Parameters of Care Tupac et alMarginal Integrity: GeneralByrne G: Influence of finish-line form on crown cementation. Int J Prosthodont 1992;5:137-144Craig RG, el-Ebrashi MK, Peyton FA: Stress distribution in porcelain-fused-to-gold crowns and preparations constructed withphotoelastic plastics. J Dent Res 1971;50:1278-1283el-Ebrashi MK, Craig RG, Peyton FA: Experimental stress analysis of dental restorations. 3. The concept of geometry of proximalmargins. J Prosthet Dent 1969;22:233-245Faucher RR, Nicholls JI: Distortion related to margin design in porcelain-fused-to-metal restorations. J Prosthet Dent 1980;43:149-155Gardner FM: Margins of complete crowns - literature review. J Prosthet Dent 1982;48:396-400Guyer SE: Multiple preparations and fixed prosthodontics. J Prosthet Dent 1970;23:529-553Hunter AJ, Hunter AR: Gingival margins for crowns: a review and discussion. Part II: Discrepancies and configurations. J ProsthetDent 1990;64:636-642Pascoe DF: Analysis of the geometry of finishing lines for full crown restorations. J Prosthet Dent 1978;40:157-162Preston JD: Rational approach to tooth preparation for ceramo-metal restorations. Dent Clin North Am 1977;21:683-698Richter-Snapp K, Aquilino SA, Svare CW, et al: Change in marginal fit as related to margin design, alloy type, and porcelainproximity in porcelain-fused-to-metal restorations. J Prosthet Dent 1988;60:435-439Rosner D: Function, placement and reproduction of bevels for gold castings. J Prosthet Dent 1963;13:1160-1166Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Shillingburg HT, Jacobi R, Brackett SE: Fundamentals of Tooth Preparations for Cast Metal and Porcelain Restorations. Chicago,Quintessence, 1987Syu JZ, Byrne G, Laub LW, et al: Influence of finish-line geometry on the fit of crowns. Int J Prosthodont 1993;6:25-30Marginal Integrity: Intracoronal RestorationsBarnes IE. The production of inlay cavity bevels. Br Dent J 1974;137:379-390Farah JW, Dennison JB, Powers JM. Effects of design on stress distribution in intracoronal gold restorations. J Am Dent Assoc1977;94:1151-1154Fisher DW, Caputo AA, Shillingburg HT, Duncanson MG. Photoelastic analysis of inlay and only preparations. J Prosthet Dent1975;33:47-53Ingraham R. The application of sound biomechanical principles in the design of inlay amalgam and gold oil restorations. J AmDent Assoc 40:402-413Mahler DB, Terkla LG. Relationship of cavity design to restorative materials. Dent Clin North Am 1965;9:149-157McColum BB. Tooth preparation in its relation to oral physiology. J Am Dent Assoc 1940;27:701-707Marginal Integrity: Partial Veneer CrownsBaum L: New cast gold restorations for anterior teeth. J Am Dent Assoc 1960;61:1-8el-Ebrashi MK, Craig RG, Peyton FA: Experimental stress analysis of dental restorations. 3. The concept of geometry of proximalmargins. J Prosthet Dent 1969;22:233-245Farah JW, Craig RG: Finite element stress analysis of a restored axisymmetric first molar. J Dent Res 1974;53:859-866Gassiraro LD: Seven-step tooth preparation for a gold onlay. J Prosthet Dent 1994;71:119-123Johnson JF: The application and construction of the pinledge retainer. J Prosthet Dent 1953;3:559-567Kishimoto M, Shillingburg HT Jr, Duncanson MG: Influence of preparation features on retention and resistance. Part II: threequartercrowns. J Prosthet Dent 1983;49:188-192Racowsky LP, Wolinsky LE: Restoring the badly broken-down tooth with esthetic partial coverage restorations. Compend ContinEduc Dent 1981;2:322-335Rosenstiel E: The marginal fit of inlays and crowns. Br Dent J 1964;117:432-442Rosenstiel E: To bevel or not to bevel? Br Dent J 1975;138:389-392Shillingburg HT, Fisher DW: The partial veneer restoration. Aust Dent J 1972;17:411-417Smith GE, Grainger DA: Biomechanical design of extensive cavity preparations for cast gold. J Am Dent Assoc 1974;89:1152-1157Willey RE: The preparation of abutments for veneer retainers. J Am Dent Assoc 1956;53:141-154Marginal Integrity: Full Gold CrownsGavelis JR, Monrency JD, Riley ED, et al: The effect of various finish line preparations on the marginal seal and occlusal seat offull crown preparations. J Prosthet Dent 1981;45: 138-145Kishimoto M, Hobo S, Duncanson MG Jr, et al: Effectiveness of margin finishing techniques on cast gold restorations. Int JPeriodontics Restorative Dent 1981;1:20-29Pardo GI: A full cast restoration design offering superior marginal characteristics. J Prosthet Dent 1982;48:539-5432010 CDEL Re-recognition of the Specialty Report 84 of 279

December 2005, Supplement, Volume 14, Number 4 45Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Smith CD, Twiggs SW, Fairhurst CW, et al: Determining the marginal discrepancy of cast complete crowns. J Prosthet Dent1985;54:778-784Marginal Integrity: Porcelain-Fused-to-Metal CrownsBrecker SC: Porcelain baked to gold -anew medium in prosthodontics. J Prosthet Dent 1956;6:801-810Craig RG, el-Ebrashi MK, Peyton FA: Stress distribution in porcelain-fused-to-gold crowns and preparations constructed withphotoelastic plastics. J Dent Res 1971;50:1278-1283Crispin BJ, Watson JF: Margin placement of esthetic veneer crowns. Part I: Anterior tooth visibility. J Prosthet Dent 1981;45:278-282Donovan T, Prince J: An analysis of margin configurations for metal-ceramic crowns. J Prosthet Dent 1985;53:153-157Faucher RR, Nicholls JI: Distortion related to margin design in porcelain-fused-to-metal restorations. J Prosthet Dent 1980;43:149-155Johnston JF, Mumford G, Dykema RW: The porcelain veneered gold crown. Dent Clin North Am 1963;7:853-864Preston JD: Rational approach to tooth preparation for ceramo-metal restoration. Dent Clin North Am 1977;21:683-698Richter-Snapp K, Aquilino SA, Svare CW, et al: Change in marginal fit as related to margin design, alloy type, and porcelainproximity in porcelain-fused-to-metal restorations. J Prosthet Dent 1988;60:435-439Shelby DS: Practical considerations and design of porcelain-fused-to-metal. J Prosthet Dent 1962;12:542-548Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Shillingburg HT, Hobo S, Fisher DW: Preparation design and margin distortion in porcelain-fused-to-metal restorations. J ProsthetDent 1973;29:276-284Silver M, Howard MC, Klein G: Porcelain bonded to a cast metal understructure. J Prosthet Dent 1961;11:132-145Watson JF, Crispin BJ: Margin placement of esthetic veneer crowns. Part III: Attitudes of patients and dentists. J Prosthet Dent1981;45:499-501Marginal Integrity: All Ceramic CrownsBartels JC: Full porcelain veneer crowns. J Prosthet Dent 1957;7:533-540Bartels JC: Preparation of the anterior teeth for porcelain jacket crowns. J South Calif Dent Assoc 1962;30:199-205Bastain CC: The porcelain jacket crown. Dent Clin North Am 1959;3:133-146Fairley JM, Deubert LLW: Preparation of a maxillary central incisor for a porcelain jacket restoration. British Dent J 1958;104:208-212Nuttall EB: Factors influencing success of porcelain jacket restorations. J Prosthet Dent 1961;11:743-748Morris HF: Department of Veterans Affairs Cooperative Studies Project No. 242. Quantitative and qualitative evaluation of themarginal fit of cast ceramic, porcelain-shoulder, and cast metal full crown margins. Participants of CSP No. 147/242. J ProsthetDent 1992;67:198-204Pettrow JN: Practical factors in building and firing characteristics of dental porcelain. J Prosthet Dent 1961;11:334-344Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Structural Durability/Material RequirementsMagne P, Douglas WH: Rationalization of esthetic restorative dentistry based on biomimetics. J Esthet Dent 1999;11:5-15Preston JD: Rational approach to tooth preparation for ceramo-metal restoration. Dent Clin North Am 1977;21:683-698Shillingburg HT: Fundamentals of Fixed Prosthodontics (ed 3). Chicago, Quintessence, 1997Thom LW: Principles of cavity preparation in crown and bridge prosthesis; the full crown. J Am Dent Assoc 1950;41:284-289Willey RE: The preparation of abutments for veneer retainers. J Am Dent Assoc 1956;53:141-154.Contemporary Porcelain SystemsBergman B, Nilson H, Andersson M: A longitudinal clinical study of Procera ceramic-veneered titanium copings. Int J Prosthodont1999;12:135-139Lehner C, Studer S, Brodbeck U, et al: Short-term results of IPS-Empress full-porcelain crowns. J Prosthodont 1997;6:20-30Lin MT, Sy-Munoz J, Munoz CA, et al: The effect of tooth preparation form on the fit of Procera copings. Int J Prosthodont1998;11:580-590Magne P, Belser U: Esthetic improvements and in vitro testing of In-Ceram Alumina and Spinell ceramic. Int J Prosthodont1997;10:459-466McLaren EA, White SN: Survival of In-Ceram crowns in a private practice: a prospective clinical trial. J Prosthet Dent 2000;83:216-222McLean JW: Evolution of dental ceramics in the twentieth century. J Prosthet Dent 2001;85:61-662010 CDEL Re-recognition of the Specialty Report 85 of 279

46 Parameters of Care Tupac et alNathanson D: Etched porcelain restorations for improved esthetics. part II: Onlays. Compendium 1987;8:105-110Odman P, Andersson B: Procera AllCeram crowns followed for 5 to 10.5 years: a prospective clinical study. Int J Prosthodont2001;14:504-509Oh SC, Dong JK, Luthy H, et al: Strength and microstructure of IPS Empress 2 glass-ceramic after different treatments. Int JProsthodont 2000;13:468-472Oilo G, Tornquist A, Durling D, et al: All-ceramic crowns and preparation characteristics: a mathematic approach. Int J Prosthodont2003;16:301-306Pera P, Gilodi S, Bassi F, et al: In-vitro marginal adaptation of alumina porcelain ceramic crowns. J Prosthet Dent 1994;72:585-590Scotti R, Catapano S, D’Elia A: A clinical evaluation of In-Ceram crowns. Int J Prosthodont. 1995;8:320-323Sorensen JA, Choi C, Fanuscu MI, et al: IPS Empress crown system: three-year clinical trial results. J Calif Dent Assoc 1998;26:130-136Studer S, Lehner C, Brodbeck U, et al: Short-term results of IPS-Empress inlays and onlays. J Prosthodont 1996;5:277-287Suarez MJ, Gonzalez De Villaumbrosia P, Pradies G, et al: Comparison of the marginal fit of Procera AllCeram crowns with twofinish lines. Int J Prosthodont 2003;16:229-232Wagner WC, Chu TM: Biaxial flexural strength and indentation fracture toughness of three new dental core ceramics. J ProsthetDent 1996;76:140-144.Webber B, McDonald A, Knowles J: An in vitro study of the compressive load at fracture of Procera AllCeram crowns with varyingthickness of veneer porcelain. J Prosthet Dent 2003;89:154-160White SN, Caputo AA, Li ZC, et al: Modulus of rupture of the Procera All-Ceramic System. J Esthet Dent 1996;8:120-126.Emergence Profile/Crown ContourBecker CM, Kaldahl WB: Current theories of crown contour, margin placement and pontic design. J Prosthet Dent 1981;45:268-277Burch JG: Ten rules for developing crown contours in restorations. Dent Clin North Am 1971;15:611-618Croll BM: Emergence profiles in natural tooth contour. Part I: Photographic observations. J Prosthet Dent 1989;62:4-10Croll BM: Emergence profiles in natural tooth contour. Part II: Clinical considerations. J Prosthet Dent 1990;63:374-379Goodacre CJ: Gingival esthetics. J Prosthet Dent 1990;64:1-12Jameson LM, Malone WF: Crown contours and gingival response. J Prosthet Dent 1982;47:620-624Morris ML: Artificial crown contours and gingival health. J Prosthet Dent 1962;12:1146-1156Perel ML: Axial crown contours. J Prosthet Dent 1971;25:642-649Stein RS, Kuwata M: A dentist and a dental technologist analyze current ceramo-metal procedures. Dent Clin North Am1977;21:729-749Waller MI: The anatomy of the maxillary molar furcal plan crown preparation. J Am Dent Assoc 1979;99:978-982Youdelis RA, Weaver JD, Sapkos S: Facial and lingual contours of artificial complete crown restorations and their effects on theperiodontium. J Prosthet Dent 1973;29:61-66.Facial Butt MarginsGoodacre CJ, Van Roekel NB, Dykema RW, et al: The collarless metal-ceramic crown. J Prosthet Dent 1977;38:615-622Koidis PT, Schroeder K, Johnston W, et al: Color consistency, plaque accumulation, and external marginal surface characteristicsof the collarless metal-ceramic restoration. J Prosthet Dent 1991;65:391-400Lehner CR, Mannchen R, Scharer P: Variable reduced metal support for collarless metal ceramic crowns: a new model for strengthevaluation. Int J Prosthodont 1995;8:337-345Magne P, Magne M, Belser U: The esthetic width in fixed prosthodontics. J Prosthodont 1999;8:106-118Rhodes SK: The porcelain butt margin with hydrocolloid impression technique. J Prosthet Dent 1988;59:418-420Seymour K, Zou L, Samarawickrama DY, et al: Assessment of shoulder dimensions and angles of porcelain bonded to metal crownpreparations. J Prosthet Dent 1996;75:406-411Sozio RB, Riley DJ: A precision ceramic-metal restoration with a facial butted margin. J Prosthet Dent 1977;37:517-521Zena RB, Kahn Z, von Fraunhofer JA: Shoulder preparations for collarless metal ceramic crowns: hand-planing as opposed torotary instrumentation. J Prosthet Dent 1989;62:273-277Intracoronal PorcelainInokoshi S, Van Meerbeek B, Willems G, et al: Marginal accuracy of CAD/CAM inlays made with the original and the updatedsoftware. J Dent 1992;20:171-177Isenberg PB, Essig ME, Leinfelder KF: Three-year clinical evaluation of CAD/CAM restorations. J Esthet Dent 1992;4:173-176Isidor F, Brondum K: A clinical evaluation of porcelain inlays. J Prosthet Dent 1995;74:140-144Qualtrough AJ, Cramer A, Wilson NH, et al: An in vitro evaluation of the marginal integrity of a porcelain inlay system. Int JProsthodont 1991;4:517-523Siervo S, Pampalone A, Valenti G, et al: Porcelain CAD-CAM veneers. Some new uses explored. J Am Dent Assoc 1992;123:63-67Taleghani M, Leinfelder KF, Lane J: Posterior porcelain bonded inlays. Compendium 1987;8:410,412,414-4152010 CDEL Re-recognition of the Specialty Report 86 of 279

December 2005, Supplement, Volume 14, Number 4 47Facial Veneers/LaminatesHui KK, Williams B, Davis EH, et al: A comparative assessment of the strengths of porcelain veneers for incisor teeth dependenton their design characteristics. Br Den J 1991;171:51-55Magne P, Belser UC: Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent2004;16:7-18Peutzfeldt A, Asmussen E: Mechanical properties of three composite resins for the inlay/onlay technique. J Prosthet Dent1991;66:322-324Sheets CG, Taniguchi T: Advantages and limitations in the use of porcelain veneer restorations. J Prosthet Dent 1990;64:406-411TextbooksChiche GJ, Pinault A: Esthetics of Anterior Fixed Prosthodontics. Chicago, Quintessence, 1994Crispin BJ: Contemporary Esthetic Dentistry: Practice Fundamentals. Chicago, Quintessence, 1994Dykema RW, Goodacre CJ, Phillips R: Johnston’s Modern Practice in Fixed Prosthodontics (ed 4). Philadelphia, Saunders, 1986Garber DA, Goldstein RE: Porcelain & Composite Inlays & Onlays: Esthetic Posterior Restorations. Chicago, Quintessence, 1994Kratochvil FJ: Partial Removable Prosthodontics. Philadelphia, Saunders, 1988Krol AJ, Jacobson TE, Finzen FC: Removable Partial Denture Design: Outline Syllabus (ed 4). San Francisco, InDent, 1990McGivney GP, Carr AB, McCracken WL: McCracken’s removable partial Prosthodontics (ed 10). St. Louis, Mosby, 2000Rosenstiel SF, Land MF, Fujimoto Junhei: Contemporary Fixed Prosthodontics (ed 3). St. Louis, Mosby, 2001Shillingburg HT: Fundamentals of fixed prosthodontics (ed 3). Chicago, Quintessence, 1997Dowel CoreAbou-Rass M, Jann JM, Jobe D, et al: Preparation of space for posting: effect on thickness of canal walls and incidence of perforationin molars. J Am Dent Assoc 1982;104:834-837Barkhordar RA, Radke R, Abbasi J: Effect of metal collars on resistance of endodontically treated teet to root fracture. J ProsthetDent 1989;61:676-678Bergman B, Lundquist P, Sjogren U, et al: Restorative and endodontic results after treatment with cast posts and cores. J ProsthetDent 1989;61:10-15Bergenholtz G, Nyman S: Endodontic complications following periodontal and prosthetic treatment of patients with advancedperiodontal disease. J Periodontol 1984;55:63-68Bourgeois RS, Lemon RR: Dowel space preparation and apical leakage. J Endod 1981;7:66-69Camp LR, Todd MJ: The effect of dowel preparation on the apical seal of three common obturation techniques. J Prosthet Dent1983;50:664-666Goodacre CJ, Spolnik KJ: The prosthodontic management of endodontically treated teeth: a literature review. Part III. Toothpreparation considerations. J Prosthodont 1995;4:122-128Gutmann JL: The dentin-root complex: anatomic and biologic considerations in restoring endodontically treated teeth. J ProsthetDent 1992;67:458-467Guzy GE, Nicholls JI: In vitro comparison in intact endodontically treated teeth with and without endo-post reinforcement. JProsthet Dent 1979;42:39-44Hatzikyriakos AH, Reisis GI, Tsingos N: A 3-year postoperative clinical evaluation of posts and cores beneath existing crowns. JProsthet Dent 1992;67:454-458Hemmings KW, King PA, Setchell DJ: Resistance to torsional forces of various post and core designs. J Prosthet Dent 1991;66:325-329Hoag EP, Dwyer TG: A comparative evaluation of three post and core techniques. J Prosthet Dent 1982;47:177-181Hunter AJ, Feiglin B, Williams JF: Effects of post placement on endodontically treated teeth. J Prosthet Dent 1989;62:166-172Jackson CR, Skidmore AE, Rice RT: Pulpal evaluation of teeth restored with fixed prosthesis. J Prosthet Dent 1992;67:323-325Johnson JK, Sakumura JS: Dowel form and tensile force. J Prosthet Dent 1978;40:645-649Kakehashi Y, Luthy H, Naef R, et al: A new all-ceramic post and core system: clinical, technical, and in vitro results. Int JPeriodontics Restorative Dent 1998;18:586-593Karlsson S: A clinical evaluation of fixed bridges, 10 years following insertion. J Oral Rehabil 1986;13:423-432Krupp JD, Caputo AA, Trabert KC, et al: Dowel retention with glass-ionomer cement. J Prosthet Dent 1979;41:163-166Leary JM, Aquilino SA, Svare CW: An evaluation of post length within the elastic limits of dentin. J Prosthet Dent 1987;57:277-281Lovdahl PE, Nicholls JI: Pin-retained amalgam cores vs. cast-gold dowel cores. J Prosthet Dent 1977;38:507-514Magura ME, Kafrawy AH, Brown CE Jr: Human saliva coronal microleakage in obturated root canals: an in-vitro study. J Endod1991;17:324-331Milot P, Stein RS: Root fracture in endodontically treated teeth related to post selection and crown design. J Prosthet Dent1992;68:428-435Neagley RL: The effect of dowel preparation on the apical seal of endodontically treated teeth. Oral Surg Oral Med Oral Pathol1969;28:739-7452010 CDEL Re-recognition of the Specialty Report 87 of 279

48 Parameters of Care Tupac et alPortell FR, Bernier WE, Lorton L, et al: The effect of immediate versus delayed dowel space preparation on the integrity of theapical seal. J Endond 1982;8:154-160Randow K, Glantz PO, Zoger B: Technical failures and some related clinical complications in extensive fixed prosthodontics. Anepidemiological study of long-term clinical quality. Acta Odontol Scand 1986;44:241-255Reuter JE, Brose MO: Failures in full crown retained dental bridges. Br Dent J 1984;157:61-63Ross IF: Fracture susceptibility of endodontically treated teeth. J Endod 1980;6:560-565Ruemping DR, Lund MR, Schnell RJ: Retention of dowels subjected to tensile and torsional forces. J Prosthet Dent 1979;41:159-162Schwartz NL, Whitsett LD, Berry TG, et al: Unserviceable crowns and fixed partial dentures: life-span and causes for loss ofserviceability. J Am Dent Assoc 1970;81:1395-1401Shillingburg HT, Kessler JC, Wilson EL: Root dimensions and dowel size. CDA J 1992;10:43-49Sorensen JA, Engelman MJ: Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529-536Sorensen JA, Martinoff JT: Clinically significant factors in dowel design. J Prosthet Dent 1984;52:28-35Sorensen JA, Martinoff JT: Intracoronal reinforcement and coronal coverage: a study of endodontically treated teeth. J ProsthetDent 1984;51:780-784Sorensen JA, Martinoff JT: Endodontically treated teeth as abutments. J Prosthet Dent 1985;53:631-636Standlee JP, Caputo AA, Hanson EC: Retention of endodontic dowels: effects of cement, dowel length, diameter, and design. JProsthet Dent 1978;39:400-405Suchina JA, Ludington JR: Dowel space preparation and the apical seal. J Endod 1985;11:11-17Tilk MA, Lommel TJ, Gerstein H: A study of mandibular and maxillary root widths to determine dowel size. J Endod 1979;5:79-82Trabert KC, Caputo AA, Abou-Rass M: Tooth fracture-acomparison of endodontic and restorative treatments. J Endod 1978;4:341-345Turner CH: Post-retained crown failure: a survey. Dent Update 1982;9:221,224-226,228-229Turner CH: The utilization of roots to carry post-retained crowns. J Oral Rehabil 1982;9:193-202Walton JN, Gardner FM, Agar JR: A survey of crown and fixed partial denture failures: length of service and reasons for replacement.J Prosthet Dent 1986;56:416-421Weine FS, Wax AH, Wenckus CS: Retrospective study of tapered, smooth post systems in place for 10 years or more. J Endod1991;17:293-297Zillich RM, Corcoran JF: Average maximum post lengths in endodontically treated teeth. J Prosthet Dent 1984;52:489-491Zmener O: Effect of dowel preparation on the apical seal of endodontically treated teeth. J Endod 1980;6:687-690Preface8) Esthetics ParameterEsthetic dentistry encompasses those procedures designed to enhance and improve form and functionin addition to the cosmetic appearance of the maxillofacial region. Esthetic dentistry procedures areperformed on both hard and soft tissue to either subjectively or objectively address patient concerns.Although prosthodontists feel that all treatment is to be rendered in an esthetic manner, there aretimes when treatment is performed solely to enhance and produce esthetic goals. As in all prosthodonticprocedures, a thorough history and examination must be completed. Esthetic treatment is predicatedupon case selection, treatment, and patient expectations.Perceptions of esthetic needs may be highly subjective. Therefore, this parameter suggests that formand appearance may be subjectively or objectively assessed in a qualitative or quantitative manner.The irreversibility of many esthetic procedures requires that the patient be fully aware of futureadditional and/or alternative treatments if their initial esthetic goals are not met. However, it remainsthe prosthodontist’s responsibility and obligation not to exceed normal physiologic limits of the patient inpursuit of an elective goal. The proper selection of treatment occurs through a comprehensive dialoguebetween the prosthodontist and the patient in which both subjective and objective evaluations are usedto determine appropriateness of treatment and thus enable the assumption of a reasonable risk/benefitratio.The elective nature of esthetic procedures requires that the patient be thoroughly educated aboutpossible risks and adverse consequences along with the need for dedicated maintenance procedures. Manyapproaches are possible in the prosthodontic management of esthetic problems; thus, the prosthodontistshould make appropriate referrals to other health care providers for both consultation and treatmentwhen indicated. The purpose of this parameter is to help with the identification of factors affecting risksand standards of care, indications of favorable outcomes, and known risks and complications for themajority of prosthodontic esthetic procedures.2010 CDEL Re-recognition of the Specialty Report 88 of 279

December 2005, Supplement, Volume 14, Number 4 49General Criteria and StandardsInformed consent: All elective irreversible esthetic procedures should be preceded by the patient’s consent.Informed consent is obtained after the patient has been informed of the indications for the procedure(s),the goals of treatment, the known benefits and risks of the procedure(s), the factors that may affect theknown risks and complications, the treatment options, the need for active maintenance by the patient,the need for future replacement/revisions, and the favorable outcome.Documentation: Parameters of care for the prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental Terminology C○2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: EstheticsPlease refer to the appropriate parameter of completely dentate, partial edentulism, or completeedentulism for specific diagnostic and treatment codes.A. Indications for care1. Patient concerns2. Unacceptable tooth morphologya. Wearb. Congenital abnormalitiesc. Surface texture3. Color4. Diastema/interproximal contacts/closures5. Tooth malposition6. Inadequate crown length due to passive eruption7. Unesthetic restorations8. Unacceptable gingival architecture2010 CDEL Re-recognition of the Specialty Report 89 of 279

50 Parameters of Care Tupac et alB. Therapeutic goals1. Address patient concerns2. Improve esthetics3. Positive psychosocial response4. Improve tooth form5. Maintain functionC. Risk factors affecting quality of treatment1. Unrealistic patient expectations2. Lack of clear communication3. Existing systemic disease4. Periodontal disease5. Endodontic complications6. Occlusal factors7. Tooth position and alignment8. Skeletal factors9. Inadequate tooth structure10. Soft/hard tissue architecture11. Lip and cheek anatomy12. Orofacial muscular complications13. Psychosocial factors14. Parafunctional habitsD. Standards of care1. Patient education2. Informed consent3. Preprosthetic preparationa. Nonsurgicalb. Surgicalc. Endodonticd. Periodontale. Orthodonticf. TMDg. Plastic surgicalh. Other referral4. Intracoronal and extracoronal restorative procedures5. Fixed, removable, and implant prosthodontic procedures6. Post-treatment follow-up careE. Specialty performance assessment criteria1. Favorable outcomesa. Patient concerns addressedb. Improved estheticsc. Positive psychosocial responsed. Satisfactory patient adaptatione. Improved tooth formf. Maintained function2. Known risks and complicationsa. Unrealistic patient expectationsb. Refractory patient responsec. Speech alterationsd. Unacceptable estheticse. Materials failure/incompatibilityf. Functional limitationsg. TM joint and/or orofacial muscle dysfunction2010 CDEL Re-recognition of the Specialty Report 90 of 279

December 2005, Supplement, Volume 14, Number 4 51h. Allergic responsei. Endodontic complicationsj. Periodontal complicationsk. Irreversibility of proceduresl. Unknown longevity of materialsm. Lack of regular professional maintenancen. Increased incidence of retreatmento. Increased caries riskp. Tooth sensitivitySelected References (Esthetics Parameter)This list of selected references is intended only to acknowledge some of the sources of informationdrawn on in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Adolfi D: Natural Esthetics. Chicago, Quintessence, 2002Beckett HA, Evans RD: Changing the appearance of anterior teeth with porcelain veneers: a case report. Eur J Prosthodont RestorDent 1994;2:113-115Campbell SD: Esthetic modification of cast dental-ceramic restorations. Int J Prosthodont 1990;3:123-129Chiche GJ, Aoshima H: Smile Design: A Guide for Clinician, Ceramist, and Patient. Chicago, Quintessence, 2004Chiche GJ, Pinault A: Esthetics of Anterior Fixed Prosthodontics. Chicago, Quintessence, 1994Christensen GJ, Christensen RP: Clinical observations of porcelain veneers: a three-year report. J Esthet Dent 1991;3:174-179Crispin BJ: Contemporary Esthetic Dentistry: Practice Fundamentals. Chicago, Quintessence, 1994Cutbirth ST: Restoration of maxillary anterior teeth using porcelain jacket crowns and porcelain veneers. J Esthet Dent 1992;4:1-5Denissen HW, Gardner FB, Wijnhoff GF, et al: All porcelain anterior veneer bridges. J Esthet Dent 1990;2:22-27De Rouffignac M, De Cooman J: Aesthetic all-porcelain anterior restorations. Pract Periodontics Aesthet Dent 1992;4:9-13Dietschi D, Spreafico R: Adhesive Metal-Free Restorations: Current Concepts for the Esthetic Treatment of Posterior Teeth.Chicago, Quintessence, 1997Donovan TE, Chee WW: Conservative indirect restorations for posterior teeth. Cast versus bonded ceramic. Dent Clin North Am1993;37:433-443Feinman RA, Goldstein RE, Garber DA: Bleaching Teeth. Chicago, Quintessence, 1987Friedman MJ: Augmenting restorative dentistry with porcelain veneers. J Am Dent Assoc 1991;122:29-34Friedman MJ: The enamel ceramic alternative: porcelain veneers vs metal ceramic crowns. J Calif Dent Assoc 1992;20:27-33Garber DA, Goldstein RE, Feinman RA: Porcelain Laminate Veneers. Chicago, Quintessence, 1988Garber DA, Goldstein RE: Porcelain & Composite Inlays & Onlays: Esthetic Posterior Restorations. Chicago, Quintessence, 1994Goldstein RE: Esthetics in Dentistry (ed 2). Hamilton, Ont, B.C. Decker, 1998Goldstein RE, Belinfante L, Nahai F: Change Your Smile (ed 3). Chicago, Quintessence, 1997Hobo S: Porcelain laminate veneers with three-dimensional shade reproduction. Int Dent J 1992;42:189-198Ibsen RL, Ouellet DF: Restoring the worn dentition. J Esthet Dent 1992;4:96-101Lang SA, Starr CB: Castable glass ceramics for veneer restorations. J Prosthet Dent 1992;67:590-594Magne P, Belser U: Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Chicago, Quintessence,2002Magne P, Belser UC: Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent2004;16:7-18Magne P, Douglas WH: Rationalization of esthetic restorative dentistry based on biomimetics. J Esthet Dent 1999;11:5-15Magne P, Magne M, Belser U: The esthetic width in fixed prosthodontics. J Prosthodont 1999;8:106-118Miller MB: Aesthetic anterior reconstruction using a combined periodontal/restorative approach. Pract Periodontics Aesthet Dent1993;5:33-40Parmeijer CH: Porcelain laminate veneers. J Calif Dent Assoc 1991;19:59-62Plasmans PJ, Reukers EA: Esthetic veneering of amalgam restorations with composite resin - combining the best of both worlds?Oper Dent 1993;18:66-71Preston JD, Bergen SF: Color Science and Dental Art. St. Louis, Mosby, 1980Putter H: Bleaching and/or porcelain veneers: case reports. J Esthet Dent 1992;4:67-70Robbins JW: Color characterization of porcelain veneers. Quintessense Int 1991;22:853-856Rufenacht CR: Principles of Esthetic Integration. Chicago, Quintessence, 20002010 CDEL Re-recognition of the Specialty Report 91 of 279

52 Parameters of Care Tupac et alRufenacht CR. Fundamentals of Esthetics. Chicago, Quintessence, 1990Sheets CG, Taniguchi T: Advantages and limitations in the use of porcelain veneer restorations. J Prosthet Dent 1990;64:406-411Simon H, Raigrodski AJ: Gingiva-colored ceramics for enhanced esthetics. Quint Dent Technol 2002;25:155-172Tarnow DP, Magner AW, Fletcher P: The effect of the distance from the contact point to the crest of bone on the presence orabsence of the interproximal dental papilla. J Periodontol 1992;63:995-996Thanos C, Friedman MH, Sorensen J, et al: 1990 USC esthetic dentistry symposium. J Calif Dent Assoc 1990;18:13-17Tjan AH, Miller GD, The JG: Some esthetic factors in a smile. J Prosthet Dent. 1984;51:24-28Touati B, Miara P, Nathanson D: Esthetic Dentistry and Ceramic Restorations. London, Martin Dunitz, 1999Weinstein AR: Bleaching, bonding, and veneering: a rationale for material and technique choice. Pract Periodontics Aesthet Dent1991;3:34-41Weinstein AR: Esthetic applications of restorative materials and techniques in the anterior dentition. Dent Clin North Am1993;37:391-409Williamson RT: Techniques for aesthetic enhancement of porcelain laminate veneer restorations: a case report. Pract PeriodonticsAesthet Dent 1994;6:73-78Yamada K: Porcelain laminate veneers for discolored teeth using complimentary colors. Int J Prosthodont 1993;6:242-247Preface9) Temporomandibular Disorders Parameter“Temporomandibular disorders’’ (TMD) is the most universal term being used today to represent ahost of problems associated with the temporomandibular joint, the surrounding masticatory and relatedmusculature, and other contiguous tissue components. Patients with these problems are appropriatelytreated by prosthodontists.General Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are accepted2010 CDEL Re-recognition of the Specialty Report 92 of 279

December 2005, Supplement, Volume 14, Number 4 53by dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Temporomandibular DisordersICD-9-Codes306.8 Other specified psychophysiological malfunction: bruxism, teeth grinding524.2 Anomalies of dental arch relationship524.3 Unspecified anomaly of tooth position524.5 Dental facial functional abnormalities524.6 Temporomandibular joint disorder524.76 Dentoalveolar anomalies (occlusal plane anomalies)729.1 Myalgia and myostis, unspecified830 Dislocation of jaw848.1 Other and ill-defined strains and sprains of jawPlease refer to the appropriate parameter of completely dentate, partial edentulism, and completeedentulism for specific diagnostic and treatment codes.A. Indicators for care1. Orofacial pain2. TM joint pain3. Myofacial pain4. Diminished function5. Limitation in range of motion6. Inability to masticate7. Change in skeletal and/or dental relationships8. Traumatic injuries9. Stress, mental and physical10. Perceived hearing loss11. Patient concernsB. Therapeutic goals1. Reduction/management of pain2. Improved function range of motion3. Provide intra-arch and interarch stability and support4. Provide TM joint and orofacial support5. Address patient concerns6. Patient educationC. Risk factors affecting quality of treatment1. Recalcitrant acute pain2. Pain unresponsive to treatment3. Ongoing, limited, or decreasing function4. Instability of stomatognathic systema. Temporomandibular jointb. Neuromuscular systemc. Dentitiond. Maxillomandibular relatione. Heightened occlusal awareness2010 CDEL Re-recognition of the Specialty Report 93 of 279

54 Parameters of Care Tupac et al5. Preexisting systemic conditions6. Patient noncompliance with prescribed treatment7. Chronic pain behavior8. Psychosocial considerations9. Esthetic considerations10. Periodontal considerations11. Parafunctional habits12. Previous treatment13. Swallowing habits14. Tongue positionD. Standards of care1. Comprehensive clinical prosthodontic assessment [D0150, D0160, D0470, D0999 CDT-2005]2. Acute TMD Disorder [D0140, D7820, D7830, D7880, D7899, D7630, D9610 CDT 2005]3. Evaluation of previous treatment [D0170 CDT 2005]4. Appropriate diagnostic imaging [D0321, D0322, D0330, D0340, D0350 CDT 2005]5. Appropriate consultations/referrals6. Monitoring of adjunctive therapy [D0170 CDT 2005]7. Occlusal therapy, which may include: [(D2710-D2799, D7780, D8210, D8220, D9920, D9930,D9940, D9950-D9952, D9999 CDT 2005]a. Orthotic devicesb. Occlusal equilibrationc. Provisional restorationsd. Final restorations8. Maintenance [D0170 CDT 2005]9. Patient education10. Informed consent11. Pharmacological therapy [D9610, D9630 CDT 2005]12. Physical therapy [97014, 97032, 97001, 97002, 97110, 97014, 97504, 97010, 97039, 97112, 97520CPT 2005]13. Post-treatment follow-up careE. Specialty performance assessment criteria1. Favorable outcomes:a. Reduction/management of painb. Improved functionc. Improved intra-arch and interarch stability and supportd. Improved TM joint and orofacial muscle supporte. Acceptable patient compliance2. Known risks and complicationsa. Persistent or increased painb. Decreased stomatognathic functionc. Unanticipated motor or sensory nerve abnormalityd. Prolonged period of disabilitye. Psychological sequelaef. Recurrence of symptomsg. Postural limitationsh. Need for continued orthotic therapyi. Unfulfilled patient expectationsSelected References (Temporomandibular Disorders Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to imply2010 CDEL Re-recognition of the Specialty Report 94 of 279

December 2005, Supplement, Volume 14, Number 4 55endorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Attanasio R, Cinotti WR, Grieder A: Craniomandibular disorders: exam and data collection. Clin Prev Dent 1988;10:26-30Baragona PM, Cohen HV: Long-term orthopedic appliance therapy. Dent Clin North Am 1991;35:109-121Bell WE: Orofacial Pains – Classification, Diagnosis, Management, (ed 4). Chicago, Year Book Medical Publishers, 1989Bell WE: Temporomandibular Disorders: Classification, Diagnosis, Management, (ed 3). Chicago, Year Book Medical Publishers,1990Clark GT, Seligman DA, Solberg WK, et al: Guidelines for the examination and diagnosis of temporomandibular disorders. JCraniomandib Disord 1980;3:7-14Dawson PE: Evaluation, Diagnosis and Treatment of Occlusal Problems, (ed 2). St. Louis, Mosby-Year Book, 1989Dobbs D: The medical/legal aspects of TMD. Cranio 1994;12:65-70Hilsen KL, Attanasio R, DeSteno C, et al: TMD prosthodontics: Treatment and management goals. J Prosthod 1995;4:58-64Kaplan AS, Assael LA: Temporomandibular Disorders: Diagnosis and Treatment. St. Louis, Saunders, 1994Kinderknecht KE, Hilsen KL: Informed consent for the prosthodontic patient with temporomandibular disorders. J Prosthod1995;4:205-209McNeill C: Temporomandibular Disorders: Guideline for Classification, Assessment and Management. The American Academyof Orofacial Pain. Chicago, Quintessence, 1990McNeill C: Temporomandibular disorders: Guidelines for diagnosis and management. CDA J 1991;19:1526Mohl ND, Zarb GA, Carlsson GE, et al: A Textbook of Occlusion. Chicago, Quintessence, 1988Nassif NJ, Hilsen KL: Screening for temporomandibular disorders: history and clinical examination. American Dental Association.J Prosthod 1992;1:42-46Okeson JP: Management of Temporomandibular Disorders and Occlusion. St. Louis, Mosby-Year Book, 1993Parker MW: A dynamic model of etiology in temporomandibular disorders. J Am Dent Assoc 1990;120:283-290Pullinger AG, Monteiro AA: Functional impairment in TMJ patient and nonpatient groups according to a disability index andsymptom profile. Cranio 1988;6:156-164Pullinger AG, Selgiman DA, Solberg WK: Temporomandibular disorders. Part I: Functional status, dentomorphologic features,and sex differences in a nonpatient population. J Prosthet Dent 1988;59:228-235Pullinger AG, Selgiman DA, Solberg WK: Temporomandibular disorders. Part II: Occlusal factors associated with temporomandibularjoint tenderness and dysfunction. J Prosthet Dent 1988;59:363-367Talley RL, Murphy GJ, Smith SD, et al: Standards for the history, examination, diagnosis, and treatment of temporomandibulardisorders (TMD): a position paper. Cranio 1990;8:60-77Preface10) Upper Airway Sleep Disorders (UASDs) ParameterThe treatment of UASDs (severe snoring – Upper Airway Resistance Syndrome [UARS], and ObstructiveSleep Apnea [OSA]) falls into three main categories: oral devices, constant positive airway pressure(CPAP), and surgery. The prosthodontist is qualified to design and fabricate various types of oraldevices and use them in the treatment and management of these disorders. These devices mechanicallyreposition the anatomy to maintain airway potency by holding the tongue or mandible in a forwardposition or stabilize the soft palate. Because these disorders can be serious health risks, they mustbe diagnosed, documented, and evaluated by qualified physicians and their progress monitored. Thisteamwork approach is mandatory. These disorders affect 50–100 million people and secondarily affecttheir bed partners.General Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.2010 CDEL Re-recognition of the Specialty Report 95 of 279

56 Parameters of Care Tupac et alCoding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Sleep DisordersICD-9-CM780.50 Sleep disturbances, unspecifiedA. Indications for care1. Severe snoring (upper airway resistance syndrome [UARS]) without Hypoxia or Apnea2. UASDs3. Airway restriction during sleep4. Psychosocial factors5. Anatomical abnormalities (obesity, tumors, polyps)B. Therapeutic goals1. Improve sleep quality and quantity2. Maintain airway potency during sleep3. Positive psychosocial response4. Reduction/management of UARS and OSAC. Risk factors affecting quality of treatment1. Restricted opening2. Instability of the stomatognathic systema. Temporomandibular jointb. Neuromuscularc. Dentition3. Periodontal disease4. Preexisting systemic diseases5. Patient noncompliance with prescribed treatment6. Parafunctional habits2010 CDEL Re-recognition of the Specialty Report 96 of 279

December 2005, Supplement, Volume 14, Number 4 577. Psychosocial factors8. Inadequate supporting structuresa. Tooth formb. Number of teethc. Residual ridge9. Hyperactive gag reflex10. Skeletal factors11. Anatomical abnormalities (polyps, tumors, hypertrophy)D. Standards of care[D9999 CDT 2005] Unspecified adjunctive procedure by report1. Coordination with sleep physiciana. Physician prescription (must be prescribed by physician since this is a medical problem beingtreated appropriately by a dentist)2. Comprehensive clinical assessment3. Trial proceduresa. Trial devicesb. Adjustment procedures4. Tongue retaining devices5. Mandibular advancement devices6. Soft palate lifting devices7. Oral orthotic device [CPT E1399]8. Patient education9. Post-treatment follow-up careE. Specialty performance assessment criteria1. Favorable outcomesa. Improved sleep quality and quantityb. Reduction in daytime sleepinessc. Acceptable patient complianced. Positive psychosocial responsee. Improved airway support during sleep2. Known risks and complicationsa. Ineffectiveness of treatmentb. TMD – joint or muscle dysfunctionc. Tooth pain or mobilityd. Increased salivatione. Noncompliancef. Material failureg. Allergic responseh. Alterations in arch-to-arch relationi. Soft-tissue irritabilitySelected References [Upper Airway Sleep Disorders (UASDs) Parameter]This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Cartwright R, Ristanovic R, Diaz F, et al: A comarative study of treatments for positional sleep apnea. Sleep 1991;14:546-552Chen NH, Li KK, Li SY, et al: Airway assessment by volumetric computed tomography in snorers and subjects with obstructivesleep apnea in a Far-East Asian population. Laryngoscope 2002;112:721-7262010 CDEL Re-recognition of the Specialty Report 97 of 279

58 Parameters of Care Tupac et alClark GT: Sleep apnea. OSA and dental appliances. CDA J 1988;16:26-33Clark GT, Arand D, Chung E, et al: Effect of anterior mandibular positioning on obstructive sleep apnea. Am Rev Respir Dis1993;147:624-629Clark GT, Nakano M: Dental appliances for the treatment of obstructive sleep apnea. J Am Dent Assoc 1989;118:611-615, 617-619Emamian SA, Dubovsky EC, Vezina LG, et al: CT scout films: don’t forget to look! Pediatr Radiol 2003;33:535-539Ferguson KA, Ono T, Lowe AA, et al: A randomized crossover study of an oral appliance vs nasal-continuous positive airwaypressure in the treatment of mild-moderate obstructive sleep apnea. Chest 1996;109:1269-1275Fleetham JA: Upper airway imaging in relation to obstructive sleep apnea. Clin Chest Med 1992;13:399-416George PT: A modified functional appliance for treatment of obstructive sleep apnea. J Clin Orthod 1987;21:171-175Hendler BH, Costello BJ, Silverstein K, et al: A. A protocol for uvulopalatopharyngoplasty, mortised genioplasty, and maxillomandibularadvancement in patients with obstructive sleep apnea; an analysis of 40 cases. J Oral Maxillofac Surg 2001;59:892-897Koopmann CF Jr, Moran WB Jr: Surgical management of obstructive sleep apnea. Otolaryngol Clin North Am 1990;23:787-808Knudson RC, Meyer JB Jr, Montalvo R: Sleep apnea prosthesis for dentate patients. J Prosthet Dent 1992;68:109-111Kryger MH: Management of obstructive sleep apnea. Clin Chest Med 1992;13:481-492Langevin B, Sukkar F, Leger P, et al: Sleep apnea syndromes (SAS) of specific etiology: review and incidence from a sleep laboratory.Sleep 1992;15:S25-S32Meyer JB Jr, Knudson RC: Fabrication of a prosthesis to prevent sleep apnea in edentulous patients. J Prosthet Dent 1990;63:448-451Meyer JB Jr, Knudson RC: The sleep apnea syndrome. Part II: Treatment. J Prosthet Dent 1990;63:320-324Nasser S, Rees PJ: Sleep apnoea: causes, consequences and treatment. Br J Clin Pract 1992;46:39-43Palomaki H, Partinen M, Erkinjuntti T, et al: Snoring, sleep apnea syndrome and stroke. Neurology 1992;42:75-82Partinen M, Telakivi T: Epidemiology of obstructive sleep apnea syndrome. Sleep 1992;15:S1-S4Paskow H, Paskow S: Dentistry’s role in treating sleep apnea and snoring. NJMed 1991;88:815-817Peh WC, Ip MS, Chu FS, et al: Computed tomographic cephalometric analysis of Chinese patients with obstructive sleep apnea.Australas Radiol 2000;44:417-423Pepin JL, Levy P, Veale D, et al: Evaluation of the upper airway in sleep apnea syndrome. Sleep 1992;15:S50-S55Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airwayreconstruction. Oral Maxillofac Surg 1993;51:742-747Robertson CJ: The effect of long-term mandibular advancement on the hyoid bone and pharynx as it relates to the treatment ofobstructive sleep apnoea. Aust Orthod J 2000;16:157-166Schmidt-Nowara WW, Meade TE, Hays MB: Treatment of snoring and obstructive sleep apnea with a dental orthosis. Chest1991;99:1378-1385Skinner MA, Kingshott RN, Jones DR, et al: Lack of efficacy for a cervicomandibular support collar in the management ofobstructive sleep apnea. Chest 2004;125:118-126Skinner MA, Robertson CJ, Kingshott RN, et al: The efficacy of a mandibular advancement splint in reaction to cephalometricvariables. Sleep Breath 2002;6:115-124Tangugsorn V, Krogstad O, Espeland L, et al: Obstructive sleep apnea: multiple comparisons of cephalometric variables of obeseand non-obese patients. J Craniomaxillofac Surg 2000;28:204-212Triplett WW, Lund BA, Westbrook PR, et al: Obstructive sleep apnea syndrome in patients with class II malocclusion. Mayo ClinProc 1989;64:644-652Tsuchiya M, Lowe AA, Pae EK, et al: Obstructive sleep apnea subtypes by cluster analysis. Am J Orthod Dentofacial Orthop1992;101:533-542Wittels EH, Thompson S: Obstructive sleep apnea and obesity. Otolaryngol Clin North Am 1990;23:751-760Yildirim MN, Fitzpatrick MF, Whyte KF, et al: The effect of posture on upper airway dimensions in normal subjects and in patientswith the sleep apnea/hypopnea syndrome. Am Rev Respir Dis 1991;144:845-847Preface11) Maxillofacial Prosthetic ParameterMaxillofacial prosthetics typically involves the prosthodontic treatment of acquired defects, congenitaldefects, and developmental defects. Many maxillofacial prosthetic procedures follow surgical resectionsrequiring the replacement of anatomical structures with prostheses. Whereas maxillofacial prostheticinstruction is inherent in the training of educationally qualified prosthodontists, it is important to notethat certain prosthodontists have taken additional formalized and accredited education and trainingin the field of maxillofacial prosthetics. Often, the special skills acquired by these prosthodontists arerequired to achieve optimum patient care.Treatment of these patients requires substantial adjunctive therapy using a multidisciplinary approachand interaction with the medical community. The reading lists do not encompass all of this2010 CDEL Re-recognition of the Specialty Report 98 of 279

December 2005, Supplement, Volume 14, Number 4 59complexity. Interested parties are encouraged to cross-reference literature cited in this document aswell as other sources.This parameter is divided into specific areas detailing the guidelines for each segment. The evaluationand treatment of intraoral defects (Parameters A – F) utilize the Comprehensive Clinical Assessment,the Completely Dentate, the Partial Edentulism, and the Complete Edentulism Parameters whereappropriate. The majority of maxillofacial prosthetic patients will be classified Class IV using the PDI(Prosthodontic Diagnostic Index) Classification system. Treatment of these patients requires experienceat or beyond the competence level in maxillofacial prosthetics.These subparameters cover:A. Maxillary defect1. Acquired2. Congenital or developmentalB. Mandibular defect1. Acquired2. Congenital or developmentalC. Palatopharyngeal incompetence and insufficiencyD. Soft palate defect1. Acquired2. Congenital or developmentalE. Composite resection defectF. Traumatic injuryG. Auricular defect1. Acquired2. Congenital or developmentalH. Orbital defects – evisceration, enucleation, exenterationI. Nasal defect—acquiredJ. Pre- and post-radiation therapy careK. Pre- and post-chemotherapy careL. Implant retained extraoral prosthesisGeneral Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensure2010 CDEL Re-recognition of the Specialty Report 99 of 279

60 Parameters of Care Tupac et alaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.11A) Maxillary Defect1. Acquired2. Congenital and DevelopmentalThe maxilla functions as a partition between the nasal and oral cavities. Surgical resection of tumors,the tumors themselves, or other treatment may cause communication between these two cavities. Varioustypes of obturator prostheses can function to re-establish this partition. The educationally qualifiedprosthodontist is best trained to evaluate the patient for prosthetic restoration of the defect (potentialor actual). Secondary surgical reconstruction procedures after primary tumor ablation can improvepostsurgical anatomy and enhance prosthesis stability and success. A prosthesis can often restore thepatient to normal function.Areas of consideration and reference include but are not limited to:Obturator Prosthesis, Interim [D5936 CDT-2005, 21079 CPT-2005]Obturator Prosthesis, Definitive [D5932 CDT-2005, 21080 CPT-2005]Obturator Prosthesis, Surgical [D5931 CDT-2005, 21076 CPT-2005]Maxillary Resection, Reconstruction ProsthesisMaxillofacial Stabilizing Prosthesis [21089 CPT-2005]Palatal Lift Prosthesis [D5955 CDT-2005, 21083 CPT-2005]Resection ProsthesisSpeech Aid, Modification [21084 CPT-2005]Speech Aid, Pediatric [D5953 CDT-2005, 21084 CPT-2005]Speech Aid, Adult [D5952 CDT-2005, 21084 CPT-2005]Surgical splint [D5988 CDT-2005, 21085 CPT-2005]Surgical stent [D5982 CDT-2005]Trismus Device [D5937 CDT-2005]Parameter Guidelines: Maxillary DefectICD-9 Codes – Acquired117.0–117.9140.0–140.9160.0–160.9170.0171.0210.0–210.92010 CDEL Re-recognition of the Specialty Report 100 of 279

December 2005, Supplement, Volume 14, Number 4 61237.70–237.72237.9446.3446.4526.0–526.9744.81–744.89784.49787.2802.2–802.9ICD-9 Codes – Congenital Developmental356.0356.9357.0–357.9358.0358.9359.0359.1359.2744.81–744.89744.9749.0–749.04749.10–749.14749.20–749.25750.10–750.9784.49A. Indications for care1. Altered and unintelligible speech2. Loss of/or difficulty with mastication3. Loss of/or difficulty with deglutition4. Oronasal or oropharyngeal communication5. Airway management6. Loss of dental-alveolar and associated structures7. Loss of patient’s self-esteem and quality of lifeB. Therapeutic goals1. Intelligible speech2. Improved mastication3. Improved deglutition4. Separation of oro-nasal-pharyngeal regions5. Improved health of oral and nasal structures6. Modify and/or substitute for dento-alveolar structures7. Improved patient’s self-esteem and quality of life8. Improved postsurgical facial formC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Presence of disease2. Size and location of defect and presence or lack of structure within the defect3. Inadequate remaining supporting structures—inadequate alveolus or tooth form/numbers, strategicposition (or lack) of teeth4. Radiation therapy-xerostomia, altered hard and soft tissues5. Chemotherapy2010 CDEL Re-recognition of the Specialty Report 101 of 279

62 Parameters of Care Tupac et al6. Limitation of opening—scar contracture or trismus7. Compromised or missing opposing dentition8. Hyperactive gag reflex9. Psychosocial factors10. Caries susceptibility11. Occlusal factors, to include altered mandibular envelope of motion, and/or altered and restrictedmandibular movement12. Preexisting systemic conditions13. Parafunctional habits14. Skeletal factors15. Neurological alterations to include changes in sensory input and neuromuscular function16. Periodontal/endodontic complications17. Saliva and salivary gland alterationsD. Standards of care1. Comprehensive clinical assessment2. Preprosthetic preparationa. Appropriate review of medical historyb. Appropriate consultation with physician/surgeonc. Appropriate oral surgical evaluationd. Appropriate endodontic evaluatione. Appropriate periodontic evaluationf. Appropriate dental specialty reviewg. Implant evaluation3. Placement of obturator prosthesesa. Surgical obturatorb. Interim obturatorc. Definitive obturator4. Adjunctive dental care to support or retain prosthesis5. Surgical revision or reconstruction6. Preprosthetic preparationa. Nonsurgicalb. Surgicalc. Endodonticd. Periodontale. Orthodontic7. Direct or perform intracoronal and extracoronal restorative procedures8. Education in proper prosthesis maintenance9. Post-treatment follow-upE. Specialty performance assessment1. Favorable outcomesa. Improved speechb. Improved masticationc. Improved deglutitiond. Improved estheticse. Improved self-imagef. Restoration of facial height and supportg. Airway supporth. Improved control of saliva and mucousi. Support to TM joint and orofacial musclesj. Satisfactory patient adaptation2. Known risks and complicationsa. Recurrence or progression of the diseaseb. Difficulties with speech, mastication, deglutition2010 CDEL Re-recognition of the Specialty Report 102 of 279

December 2005, Supplement, Volume 14, Number 4 63c. Unstable/unretained prosthesisd. Tissue changes requiring modification/refabrication of prosthesise. Degradation of supporting dental or loss of anatomical structuresf. Fluid egress around obturatorg. Unrealistic expectationsh. Lack of patient compliance or understandingi. Ulcerationsj. Alterations in taste perceptionk. Endodontic/periodontal complicationsl. Material failure/incompatibilitym. Continued negative self-imagen. Nasal regurgitationo. Compromise of facial supportp. Loss of integration of implants secondary to adjunctive radiation therapy11B) Mandibular Defect1. Acquired2. Congenital and DevelopmentalResection or loss of a portion of the mandible can result in a variety of functional deficits thatare dependent on the extent of the defect (surgery, radiation, trauma), the concomitant therapy, andthe timing of rehabilitative efforts. The educationally qualified prosthodontist is best trained to evaluatethe defect and to coordinate and manage the design and fabrication of prostheses to compensate for theresulting functional loss. Prostheses may be fabricated for either a maxillary, mandibular, or combinationdefect. Secondary surgical reconstruction procedures to include osseointegration reconstruction aftertumor removal can improve post-surgical anatomy and thus enhance prosthesis stability and success.The prostheses can guide mandibular movement and assist in restoring the functions of mastication,deglutition, and speech, as well as restoring more normal facial form.Areas of consideration and reference include but are not limited to:Mandibular Reconstruction Prosthesis [21081CPT-2005]Mandibular Resection Prosthesis (w/guide) [D5934 CDT-2005, 21081 CPT-2005]Mandibular Resection Prosthesis (w/o guide) [D5935 CDT-2005, 21081 CPT-2005]Maxillofacial Stabilizing Prosthesis [21089 CPT-2005]Palatal Augmentation Prosthesis [D5954 CDT-2005, 21082 CPT-2005]Surgical SplintParameter Guidelines: Mandibular DefectICD-9 Codes – Acquired140.0–149.9160.0–160.9170.1195.0210.0210.9237.70–237.72237.9446.3446.4526.0–526.9787.2787.42010 CDEL Re-recognition of the Specialty Report 103 of 279

64 Parameters of Care Tupac et alICD-9 Codes – Congenital Development520.4520.5520.6755.59756.0A. Indications for care1. Loss of all or part of mandible2. Deviation of mandible due to partial resection3. Neuromuscular or neural malfunction of primary or secondary cause4. Loss of function from 1, 2, or 3; i.e., difficulty with deglutition and/or fluid control, speech, andmastication5. Poor self-esteem and quality of life6. Psychosocial factors7. Professional referral8. Occlusal instabilityB. Therapeutic goals1. Guide mandibular movement2. Retrain use of remaining neuromuscular complex3. Improve deglutition4. Improve mastication5. Improve speech6. Substitute for dento-alveolar anatomy7. Improve facial support/cosmetics8. Improve lip support9. Improve salivary controlC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Sequelae from surgery2. Concomitant therapies (i.e., radiation, chemotherapy)3. Deviation of the mandible or altered/restricted mandibular movements4. Presence/absence of physical therapy post-surgery5. Extent of scarring6. Loss of muscular function7. Loss of sensory function8. Loss of surrounding tissues, tongue, lips, buccal mucosa9. Presence/absence of neck dissection10. Presence/absence of teeth11. Edentulisma. Same archb. Opposing arch12. Periodontal disease13. Endodontic complications14. Psychosocial factors15. Poor residual bone quality16. CariesD. Standards of care1. Comprehensive clinical assessment2. Preprosthetic preparationa. Appropriate review of medical historyb. Appropriate consultation with physician/surgeon2010 CDEL Re-recognition of the Specialty Report 104 of 279

December 2005, Supplement, Volume 14, Number 4 65c. Appropriate surgical evaluationd. Appropriate endodontic evaluatione. Appropriate periodontic evaluationf. Implant evaluationg. Evaluation for surgical revision or reconstructionh. Graft evaluation3. Adjunctive care to support or retain prostheses4. Prosthesis placement5. Maintenance/alteration of prostheses6. Patient education7. Post-treatment careE. Specialty performance assessment1. Favorable outcomesa. Improved mandibular movementb. Improved occlusionc. Improved masticationd. Improved deglutitione. Improved speechf. Improved quality of lifeg. Improved facial supporth. Positive psychosocial responsei. Satisfactory patient adaptationj. Airway supportk. Improved control of fluids2. Known risks and complicationsa. Progression or recurrence of the diseaseb. Continued difficulty with mastication, speech, deglutitionc. Unstable prosthesisd. Lack of patient compliance or understandinge. Tissue changes requiring modifications or remaking of prosthesisf. Degradation of teeth and supporting tissuesg. Progression of the patient’s diseaseh. Material failure/incompatibilityi. Allergic responsej. Soft-tissue irritationk. Airway compromisel. Tissue breakdown/bone exposurem. Loss of integration of implantsn. Fracture of hardwareo. Unrealistic patient expectations11C) Palatopharyngeal Incompetence or InsufficiencyPalatopharyngeal insufficiency refers to the condition that results when the soft palate is of insufficientlength (as seen in congenital or acquired deformities) to achieve palatopharyngeal closure during thedynamic activities of speech, phonation, and deglutition. Palatopharyngeal incompetence refers to thecondition that results when the soft palate is of sufficient length but is compromised neuromuscularly,thus making palatopharyngeal closure impossible. The treatment of these disorders falls intotwo categories. This includes surgery and oral/dental prosthetic devices. The educationally qualifiedprosthodontist is most trained to design and fabricate prostheses to treat and manage these disorders.These prostheses mechanically alter the anatomy of the palatopharyngeal mechanism, minimizing theloss of air and fluids resulting in improved speech and deglutition. These can be either a speech-aid2010 CDEL Re-recognition of the Specialty Report 105 of 279

66 Parameters of Care Tupac et alprosthesis in the case of insufficiency, a palatal lift prosthesis for incompetence, or a combination ofthese two prostheses.Areas of consideration and reference include but are not limited to:Maxillofacial Stabilizing ProsthesisPalatal Augmentation ProsthesisPalatal Lift Prosthesis, ModificationPalatal Lift Prosthesis, DefinitivePalatal Lift Prosthesis, InterimSpeech Aid, AdultSpeech Aid, ModificationSpeech Aid, PediatricParameter Guidelines: Palatopharyngeal IncompetenceICD-9 Codes145.0–147.9237.70–237.72377.9434.91744.81–744.89744.9749.00–749.04749.10–749.14749.20–749.25750.10–750.9A. Indications for care1. Unintelligible or socially unacceptable speech2. Loss of deglutition (regurgitation of food and/or fluid into nasal cavities and sinuses)3. Exposure of nasopharyngeal space (palatopharyngeal insufficiency)4. Poor patient self-esteem and quality of life5. Psychosocial factors6. Professional referralB. Therapeutic goals1. Speech improvement2. Improved deglutition3. Positive psychosocial response4. Improvement in patient self-esteem and quality of life5. Replace dento-alveolar anatomy6. Improved occlusion7. Improved masticationC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Neuromuscular disease2. Long-term prognosis3. Size and location of palatopharyngeal deformity4. Inadequate supporting structure – poor arch form and/or inadequate tooth numbers or form toinclude strategic position of teeth in the dental arch5. Edentulism (maxillary arch)6. Discordant maxillo-mandibular relations and occlusion7. Hyperactive gag reflex2010 CDEL Re-recognition of the Specialty Report 106 of 279

December 2005, Supplement, Volume 14, Number 4 678. Periodontal disease9. Endodontic complications10. Parafunctional habits11. Psychosocial factorsD. Standards of care1. Comprehensive clinical assessment2. Preprosthetic preparationa. Appropriate review of medical historyb. Appropriate consultation with attending physician/surgeon/therapistc. Appropriate nonsurgical evaulationd. Appropriate surgical evaluatione. Appropriate endodontic evaluationf. Appripirate periodontal evaluationg. Implant placement evaluation3. Adjunctive dental care to support or retain prosthesis4. Placement of prosthesis:a. Palatopharyngeal speech aidi. Diagnostic (pediatric and adult)ii. Definitive (pediatric and adult)b. Palatal liftc. Palatal augmentation prosthesis5. Surgical revision and/or reconstruction6. Intracoronal and extracoronal restorative procedures7. Maintenance of prosthesis8. Patient education9. Post-treatment careE. Specialty performance assessment1. Favorable outcomesa. Improved speechb. Improved masticationc. Improved deglutitiond. Improved self-esteem and quality of lifee. Positive psychosocial responsef. Satisfactory patient adaptation2. Known risks and complicationsa. No improvement in speechb. No improvement in deglutitionc. Unstable prosthesisd. Hyponasal speeche. Airway compromisef. Unrealistic patient expectationsg. Lack of patient compliance or understandingh. Tissue changes requiring modifications or remaking of prosthesisi. Degradation of teeth and supporting structuresj. Progression of the patient’s diseasek. Material failure/incompatibilityl. Allergic responsem. Soft-tissue irritationn. Gaggingo. Aspiration2010 CDEL Re-recognition of the Specialty Report 107 of 279

68 Parameters of Care Tupac et al11D) Soft Palate Defect1. Acquired2. Congenital and DevelopmentalTreatment of diseases of the soft palate can create defects that are a challenge to restore. Thesetissues are dynamic in function and not easily replaced or duplicated. Pretreatment planning can beinvaluable and is strongly encouraged. The educationally qualified prosthodontist is best trained totreat and manage these disorders. These prostheses attempt to restore the dynamic function of thepalato-pharyngeal complex to control and direct the flow of air, fluid, and food in a normal physiologicalmanner.Areas of consideration and reference include but are not limited to:Palatal Lift Prosthesis, Definitive [D5955 CDT-2005, 21083 CPT-2005]Palatal Lift Prosthesis, Interim [D5958 CDT-2005]Palatal Lift Prosthesis, Modification [D5959 CDT-2005]Speech Aid, Modification [D5960 CDT-2005, 21084 CPT-2005]Speech Aid, Adult [D5953 CDT-2005, 21084 CPT-2005]Speech Aid, Pediatric [D5953 CDT-2005, 21084 CPT-2005]Surgical Obturator [D5931 CDT-2005, 21076 CPT-2005]Definitive Obturator [D5932 CDT-2005, 21080 CPT-2005]Parameter Guidelines: Soft Palate DefectICD-9 CodesSee Palatopharyngeal Incompetence or Insufficiency.A. Indications for care1. Unintelligible speech (or loss of intelligibility)2. Difficulty with deglutition (nasal regurgitation)3. Oro-nasal or oro-pharyngeal communication4. Loss of patient’s self-esteem and quality of life5. Professional referral6. Nasal refluxB. Therapeutic goals1. Intelligible speech2. Improve deglutition (reduce nasal reflux)3. Improved psychosocial response4. Improve self-esteem and quality of lifeC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Size and location of the defect2. Function of remaining velopharyngeal mechanism3. Presence or absence of dento-alveolar support4. Opposing dentition5. Periodontal disease6. Endodontic complications7. Psychosocial factors8. Concomitant therapies9. Change in neuromuscular reflexD. Standards of care1. Preprosthetic preparationa. Review of medical historyb. Evaluation with physician/surgeon/speech pathologist2010 CDEL Re-recognition of the Specialty Report 108 of 279

December 2005, Supplement, Volume 14, Number 4 69c. Oral surgery evaluationd. Endodontic evaluatione. Periodontal evaluationf. Implant evaluation, if appropriate2. Adjunctive care to retain support prosthesis, i.e., implants, fixed prosthesis3. Prosthesis fabrication and placement4. Maintenance/modification of prosthesis5. Patient education and post-treatment carea. Dentalb. Concomitant therapy, i.e., speechE. Specialty performance assessment:1. Favorable outcomesa. Improved speechb. Improved deglutitionc. Improved quality of lifed. Improved self-imagee. Improved psychosocial responsef. Improved palato-pharyngeal competence2. Known risk and complicationsa. No improvement in speechb. No improvement in deglutitionc. Continued nasal refluxd. Patient unable/unwilling to wear prosthesise. Lack of patient compliance or understandingf. Tissue changes requiring remake or modification of prosthesisg. Degradation of teeth and supporting tissuesh. Progression of patient’s diseasei. Material failure/incompatibilityj. Soft-tissue irritationk. Airway compromisel. Aspiration11E) Composite Resection DefectComposite defects by definition involve multiple facial structures, compromise multiple sensory systems,and frequently require multiple integrated prostheses that support, contact, and/or function together.Multiple defects have multiple sensory loss and loss of control of body fluids. The loss of tissues oftenleaves the patient with a severe facial deformity, which may result in:a. Behavior maladjustmentb. Prejudice regarding employmentc. Difficulties in interpersonal relationshipsd. Unintelligible speeche. Frustrationf. Loss of self-esteem andg. Sexual dysfunctionThe educationally qualified prosthodontist is best trained to evaluate the patient for restoration ofthe defect.Areas of consideration and reference include but are not limited to:Facial Augmentation Implants [21089 CPT-2005]Facial Moulage [D5912 CDT-2005]2010 CDEL Re-recognition of the Specialty Report 109 of 279

70 Parameters of Care Tupac et alFacial Moulage, Sectional [D5911 CDT-2005]Facial Prosthesis, ReplacementMandibular Resection/Reconstruction Prosthesis [21081 CPT-2005]Maxillofacial Stabilization Prosthesis [21089 CPT-2005]Nasal Prosthesis [21087 CPT-2005]Obturator Prosthesis, Definitive [21080 CPT-2005]Obturator Prosthesis, Interim [21079 CPT-2005]Obturator Prosthesis, Surgical [21076 CPT-2005]Maxillary resection, reconstruction prosthesisOrbital Prosthesis [21077 CPT-2005]Intraoral prosthesis [21081 CPT-2005]Parameter Guidelines: Composite Resection DefectICD-9 CodesRefer to subparameters 11A, 11B, 11C, 11E, 11G, 11H.A. Indications for care1. Facial soft-tissue deformity resulting from skin, muscle, and connective tissue loss2. Facial hard-tissue deformity from loss of bone, teeth, and cartilage3. Loss of sensory organ (eye) resulting in blindness4. Loss of sensory organ (nose) resulting in loss of smell5. Oral tissue loss (hard and soft tissues), resulting in reduced oral competency, decreased mastication,disrupted speech, dysphasia, and facial reflux during eating and swallowing6. Exposure of nasal, sphenoid, and frontal sinuses7. Compromised speech resonance with increased nasality8. Communication of oral-nasal-facial cavities9. Loss of patient’s self-esteem10. Professional referralsB. Therapeutic goals1. Restoration of facial form2. Restoration of ocular form3. Restoration of oral competence with reduction of oral and facial reflux4. Substitution for dento-alveolar structures and facial structures5. Improvement of nasal-oral-facial cavity separation6. Improvement in self-esteem and quality of life7. Improvement in deglutition and mastication8. Restoration of speech, improved resonance, and reduced nasality9. Restoration of sinus partition to improve normal humidity10. Reduction of mucous crusting and control of normal discharge of bodily fluidsC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Status of existing disease: contiguous, local, or systemic2. Size and location of defect3. Number of sensory structures normally found within defect4. Inability to speak and communicate5. Complications from alterations in normal anatomical soft-tissue form and bony support6. Local wound changes, friable tissues, scar tissue, hemorrhage7. Compromise from functional rehabilitation to form rehabilitation8. Maintenance of nasal and oral airway9. Incomplete surgical reconstruction10. Preexisting systemic conditions11. Psychosocial factors12. Scarring2010 CDEL Re-recognition of the Specialty Report 110 of 279

December 2005, Supplement, Volume 14, Number 4 7113. Loss of function of remaining structure secondary to treatment14. Postirradiation and chemotherapeutic tissue changes and sequelae15. Motor skills of the patient/ lack of motion16. Unrealistic expectationsD. Standards of care1. Comprehensive clinical assessment2. Pretreatment evaluationa. Appropriate review of medical historyb. Appropriate maxillofacial examinationc. Appropriate dental examinationd. Appropriate implant evaluatione. Consider consultations to include physician/surgeon3. Adjunctive pretreatment surgical revisions to defect site4. Adjunctive dental care to support or retain prosthesis if defect is contiguous with oral cavitya. Implantb. Surgical revisionsc. Dental care and maintenance5. Selection or fabrication of ocular element6. Placement of composite prosthesis7. Patient education and instruction in use8. Maintenance of prosthesis: composite and intraoral9. Pretreatment follow-up10. Accurate impression11. Prosthesis design12. Post-treatment follow-up careE. Specialty performance assessment1. Favorable outcomesa. Improved facial/ocular aestheticsb. Maintenance of humidification in defectc. Reduction in airborne pollutants to defects membranes and tissuesd. Improved speech, deglutitione. Reduction of nasal or oral regurgitation and salivary flowf. Airway supportg. Improved patient self-esteem and quality of lifeh. Acceptable patient adaptation and use of prosthesisi. Minimal tissue irritation2. Known risks and complicationsa. Difficulty in maintaining prosthesis position (unstable)b. Difficulty in prosthesis maintenancec. Tissue changes (color and anatomical) requiring modificationd. Difficulty in reducing refluxe. Unrealistic patient expectationsf. Irritation or ulceration from prosthesisg. No improvement in speech, deglutitionh. No improvement in control of fluidsi. Continued poor self-esteemj. Recurrence of diseasek. Lack of patient cooperation/motivationl. Loss of retentioni. Adhesive allergy or ineffectivenessii. Implants: Loss in integrationiii. Implants: Fracture of framework or implant retained devicem. Loss of prosthesis/damage to prosthesis2010 CDEL Re-recognition of the Specialty Report 111 of 279

72 Parameters of Care Tupac et al11F) Traumatic InjuryTraumatic injury often causes unique tissue problems. The educationally qualified prosthodontist is besttrained to evaluate the defect and coordinate, manage, and design prostheses to deal with the resultantdefect(s). The prosthesis can restore form and function and reestablish partitions between contiguouscavities. The treatment of these problems, especially the more complex ones, often involves multiplesurgeries to attempt reconstruction, necessitating multiple prostheses used over time.Areas of consideration and reference include but are not limited to:Auricular Prosthesis [D5914 CDT-2005, 21086 CPT-2005]Commissure Splint [D5987 CDT-2005]Cranial Implants [62140 CPT-2005]Facial Augmentation Implants [62141 CPT-2005]Facial Moulage [D5912 CDT-2005]Facial Moulage, Sectional [D5911 CDT-2005]Facial Prosthesis [D5919 CDT-2005, 21088 CPT-2005]Facial Prosthesis, Replacement [D5929 CDT-2005]Nasal Prosthesis [D5913 CDT-2005, 21087 CPT-2005]Nasal Septal Prosthesis [D5922 CDT-2005]Obturator Prosthesis, Definitive [D5932 CDT-2005, 21080 CPT-2005]Obturator Prosthesis, Interim [D5936 CDT-2005, 21079 CPT-2005]Ocular Prosthesis [D5916 CDT-2005]Ocular Prosthesis, Interim [D5932 CDT-2005]Surgical Splint [D5988 CDT-2005]Surgical Stent [D5982 CDT-2005]Trismus Device [D5937 CDT-2005]Dental ProsthesesParameter Guidelines: Traumatic InjuryICD-9 Codes801–804.9870–873.9910–910.9A. Indications for care1. Loss of soft or hard tissue in the head or neck area2. Assess location of fragments of teeth, bone, restorations, or foreign objects after trauma3. Professional/patient referral/request4. Poor patient self-esteem and quality of life5. Surgical techniques do not adequately restore missing tissuesB. Therapeutic goals1. Coordinate appropriate care with other health professionals2. Improve function and appearance (ideal)3. Improve partition between various head and neck spaces4. Control fluids5. Assist airflow6. Improve speech7. Improve deglutition8. Treat dento-alveolar structures9. Improve patient’s self-esteem and quality of life2010 CDEL Re-recognition of the Specialty Report 112 of 279

December 2005, Supplement, Volume 14, Number 4 73C. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Increased scarring2. Loss of hard and soft tissues3. Decreased oral opening may restrict access4. Collapse or loss of arch integrity5. Loss of dento-alveolar structures6. Premorbid prosthetic experience7. Other disease processes or medications that may compromise results8. Altered neurological condition and/or response9. Treatment delayed because of other more urgent or life-threatening care10. Inability to properly maintain restoration because of additional injuries (i.e., quadriplegia)11. Psychosocial12. Patient’s expectations13. Lack of patient motivation and/or complianceD. Standards of care1. Comprehensive clinical assessment2. Appropriate consultation and referral for alternative treatment modalities3. Prosthesis to include surgical stents, splints, intraoral and extraoral prostheses (if applicable)4. Adjunctive dental care to support or retain prosthesis5. Prosthetic preparationa. Review of medical historyb. Maxillofacial examinationc. Dental examinationd. Implante. Medical6. Educate in proper prosthesis maintenance7. Post-treatment follow-upE. Specialty performance assessment1. Favorable outcomesa. Improved speechb. Improved masticationc. Improved deglutitiond. Improved estheticse. Improved self-imagef. Improved facial height and supportg. Airway supporth. Support to muscles and jointsi. Patient adaptationj. Improved control of fluids2. Known risks and complicationsa. Difficulties with speech, mastication, deglutitionb. Unstable/unretained prosthesisc. Tissue changes requiring new prosthesis/modificationd. Additional surgical procedures requiring new prosthesis/modificatione. Unrestored tissue deficit (especially neurologic)f. Degradation of support structures including dento-alveolar complexg. Fluid incompetencyh. Unrealistic expectationsi. Ulceration of tissuesj. Alterations in sensory perception (taste, smell)k. Delayed dento-alveolar complications2010 CDEL Re-recognition of the Specialty Report 113 of 279

74 Parameters of Care Tupac et all. Material failure/incompatibilitym. Continued psychosocial problemsn. Lack of patient compliance or understanding11G) Auricular Defect1. Acquired2. Congenital and DevelopmentalAuricular acquired and congenital defects may be partial or total; various types of grafted tissue orimplants may be present. An auricular prosthesis is intended to potentially restore both the anatomicaspects of the auricle as well as provide the function of sound guidance and support other devices suchas eyeglasses or hearing aids.The educationally qualified prosthodontist is best trained to evaluate and treat the patient forrestoration of the defect.Areas of consideration and reference include but are not limited to:Auricular ProsthesisFacial Augmentation ImplantsFacial MoulageFacial Moulage, SectionalFacial ProsthesisFacial Prosthesis, ReplacementImplant RetentionParameter Guidelines: Auricular DefectICD-9 Codes161.1171.1172.2173.2212.0216.2237.70–237.72744.0–744.09744.1744.21–744.29744.3A. Indications for care1. Restoration of facial form2. Psychosocial implications3. Patient request for treatment4. Professional referral5. Efficacy of treatment compared with surgical alternatives6. Unsatisfactory surgical result7. Improve directional hearingB. Therapeutic goals1. Restore facial form2. Potential to restore directional hearing3. Restore esthetics4. Improved patient self-esteem and quality of life2010 CDEL Re-recognition of the Specialty Report 114 of 279

December 2005, Supplement, Volume 14, Number 4 755. Allow patient to wear jewelry6. Support use of eyeglasses7. Improve less-than-ideal surgical resultsC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Size and location of defect2. Presence and location of remaining auricular appendages3. Postradiation sequelae4. Psychosocial factors5. Patient’s age6. Unrealistic patient expectation7. Lack of patient compliance8. Environmental factors causing prosthesis instability9. Tissue irritation from reaction to materials10. Patient motor skills in proper prosthesis placement11. Inadequate retention/compromised retentionD. Standards of care1. Comprehensive clinical assessment2. Review medical history3. Surgical elimination of unacceptable tissue remnants4. Appropriate consultation and referrals for alternative treatment modalities5. Prosthesis compatibility with soft tissues6. Accurate impression, prosthesis design, and coloration7. Maintenance of prosthesis8. Patient education9. Evaluate for possible alternative means of retention, i.e., implants10. Post-treatment follow-up careE. Specialty performance assessment1. Favorable outcomesa. Improved psychosocial attitude and self-esteemb. Improved facial symmetryc. Improved estheticsd. Improved directional hearinge. Allow use of jewelryf. Improved wearing of eyeglasses2. Known risks and complicationsa. Unrealistic patient expectationsb. Loss of prosthesis/damage to prosthesisc. Change in color and appearance of prosthesis with timed. Tissue irritation from materials and/or allergic responsee. Lack of patient compliancef. Tissue changes requiring modification or refabrication of prosthesisg. Changing seasons resulting in changing skin colorh. Ulcerations, bruisesi. Recurrence of diseasej. Loss of retention11H) Orbital Defects: Evisceration, Enucleation, ExenterationOrbital evisceration, enucleation, exenteration, and/or degeneration establishes that at least one globehas been removed or involved. The surgical parameters determining evisceration versus exenteration, forthe most part, impact very little on the ocular prosthesis. Orbital exenteration due to tumors, however,2010 CDEL Re-recognition of the Specialty Report 115 of 279

76 Parameters of Care Tupac et almay also involve partial or total removal of soft tissues and the bony zygoma, maxilla, and frontal bonesand may communicate with nasal and/or oral cavities. The loss of tissues that are involved with tumorsfrequently leaves the patient with severe facial deformity that may result in:1. Behavior maladjustment2. Prejudice regarding employment3. Difficulties in interpersonal relationships4. Altered voice quality5. Loss of self-esteem6. Sexual dysfunctionThe educationally qualified prosthodontist is most trained to design and fabricate prostheses to treatand manage these disorders.Areas of consideration and reference include but are not limited to:Facial Augmentation Implants [D5925 CDT-2005]Facial Moulage [D5912 CDT-2005]Facial Moulage, Sectional [D5911 CDT-2005]Facial Prosthesis [D5919 CDT-2005, 21088 CPT-2005]Facial Prosthesis, Replacement [D5929 CDT-2005]Ocular Prosthesis, Interim [D5923 CDT-2005]Ocular Prosthesis [D5916 CDT-2005]Orbital Prosthesis [D5915 CDT-2005, 21077 CPT-2005]ImplantParameter Guidelines: Orbital DefectICD-9 Codes170.0171.1173.1173.2173.3190.0–190.9216.1237.70–237.72446.4743.00–743.06743.10–743.12A. Indications for care1. Loss of sensory organ (eye) resulting in blindness2. Facial soft tissue deformity, resulting from skin, muscle, and connective tissue loss3. Facial hard tissue deformity, resulting from loss of bone and cartilage4. Exposure of nasal, frontal, and sphenoid sinuses5. Degenerated orbit (sclera shell)6. Loss of self-esteem7. Professional referralsB. Therapeutic goals1. Mobility coordination with contralateral side (ocular)2. Color stable and correct (ocular/orbital)3. Size conformity with contralateral side (ocular/orbital)4. Improve facial, ocular, and orbital form5. Improve voice quality2010 CDEL Re-recognition of the Specialty Report 116 of 279

December 2005, Supplement, Volume 14, Number 4 776. Restore sinus partition to improve normal humidity reduction7. Separate oro-nasal pharyngeal areas8. Reduction of mucous crusting by recreating a humid environmentC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Ptosis2. Implant selection and placement3. Patient cooperation/compliance4. Dryness5. Muscle contracture, scar formation6. Amount of soft tissue loss7. Amount of bone loss8. Migrated implant9. Distorted lid borders10. Shallow lid borders11. Contracted socket12. Sequelae of adjunctive treatment13. Sequelae of wound healing, contracture, scar formation14. Size, location, and contour of defect15. Variation in skin coloration16. Postradiation sequelae17. Psychosocial factor18. Patient’s age19. Unrealistic patient expectations20. Tissue reaction to materials21. Motor skills to place prosthesis22. Lack of patient motivation and/or compliance23. Exposure to environmental factorsD. Standards of care1. Review medical history2. Surgical consultation/alternation to reduce risk factors or supplement retention including implantutilization3. Prosthetic preparationa. Facial moulageb. Photographs4. Patient education5. Conformer, trial conformer, and pressure conformer (when appropriate)6. Implant retention to include multipart elastic retention (if appropriate)7. Maintenance of prosthesis and post-treatment follow-upE. Specialty performance assessment1. Favorable outcomesa. Improved postsurgical facial form/cosmeticsb. Improved airflowc. Improved quality of lifed. Acceptable patient adaptation and use of prosthesise. Adequate retention with minimal tissue irradiationf. Positive psychosocial adaptationg. Improved quality of speech2. Known risks and complicationsa. Poor retention, difficulty in maintaining position of prosthesisb. Unachievable esthetic expectationsc. Unrealistic patient expectations2010 CDEL Re-recognition of the Specialty Report 117 of 279

78 Parameters of Care Tupac et ald. Tissue irritationse. Tissue changes, requiring prosthesis modificationf. Recurrence of diseaseg. Lack of patient complianceh. Change in color and appearance of prostheses with timei. Loss of retention1. Adhesive allergy or ineffectiveness2. Implants: Loss of integration3. Implant fractures of framework or implant retentive devicej. Loss of prosthesis/damage to prosthesisk. Changing season resulting in changing skin color11I) Nasal Defect1. AcquiredA nasal prosthesis provides more than just an esthetic replacement device. A stable nasal prosthesisimproves the patient’s self-esteem and ability to interact with society; it directs airflow and helps tomaintain humidity and protect nasal mucous membranes. The educationally qualified prosthodontisthas the scientific knowledge to work closely with surgical colleagues to achieve optimum care. Secondarysurgical reconstructive procedures, skin grafting, and the use of osseointegration reconstruction aftertumor removal can enhance prosthesis stability and success.Areas of consideration and reference include but are not limited to:Facial Augmentation Implants Prosthesis [D5925 CDT-2005]Facial Moulage [D5912 CDT-2005]Facial Moulage, Sectional [D5911 CDT-2005]Facial Prosthesis [D5919 CDT-2005, 21088 CPT-2005]Facial Prosthesis, Replacement [D5929 CDT-2005]Nasal Prosthesis [D5913 CDT-2005, 21087 CPT-2005]Parameter Guidelines: Nasal DefectICD-9 Codes160.0170.0172.3173.3195.0237.70–237.72446.3446.4744.81–744.89744.9A. Indications for care1. Restoration of facial form2. Psychosocial implicationa. Self-esteemb. Unwillingness to be seen in society3. Patient request for treatment4. Efficacy of treatment compared with surgical alternatives5. Unsatisfactory surgical result6. Professional referrals2010 CDEL Re-recognition of the Specialty Report 118 of 279

December 2005, Supplement, Volume 14, Number 4 79B. Therapeutic goals1. Improve facial form2. Potential to protect nasal mucous membranes3. Improved esthetics4. Improved patient self-esteem and quality of life5. Improved air flow6. Improved speechC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Size and location of defect2. Quality of tissues3. Preradiation sequelae4. Psychosocial factors5. Patient’s age6. Patient’s expectation and motivation7. Patient’s compliance8. Tissue irritation from reaction to materials9. Adjunctive treatment sequelaeD. Standards of care1. Pretreatment evaluationa. Review medical historyb. Maxillofacial examc. Dental examination2. Consider adjunctive pretreatment surgical revision of site to include consideration for implants3. Consider appropriate consultation and referrals for alternative treatment modalities (skin graftimplants)4. Appropriate material selection and coloration5. Accurate impression, prosthesis design, and alternative retention modalities6. Maintenance of prosthesis7. Patient education8. Post-treatment follow-up careE. Specialty performance assessment1. Favorable outcomesa. Improved psychosocial attitude and self-esteemb. Improved facial symmetryc. Improved estheticsd. Improved air flowe. Protect nasal mucous membranes2. Known risks and complicationsa. Unrealistic patient expectationsb. Loss and/or damage to prosthesisc. Change in color and appearance of prosthesis with timed. Tissue irritation from materials and allergic response, inflammation, or ulceratione. Lack of patient compliancef. Tissue changes requiring modification or refabrication of prosthesisg. Recurrence of diseaseh. Loss of retentioni. Adhesive allergyii. Implants: Loss of integrationiii. Implants: Fracture of framework or implant-retained devisei. Loss of prosthesis/damage to prosthesisj. Changing seasons resulting in changing skin color2010 CDEL Re-recognition of the Specialty Report 119 of 279

80 Parameters of Care Tupac et al11J) Pre- and Postradiation Therapy CareHigh-dose modern radiation therapy has increased the chance of cure of head and neck malignancy bothwhen used alone and when in conjunction with surgery and/or chemotherapy. This treatment causessignificant short-term and long-term sequelae. Pretreatment evaluation to include preventive measuresand long-term treatment planning are essential. The therapeutic use of radiation therapy continues toevolve. The use of different particle application, combination therapies using chemotherapeutic agentsto sensitize tumor cells and IMRT application continues to challenge the clinician to improve therapeuticand preventative treatments including continuing educational activities. The use of therapeutic agentssuch as topical fluoride application is highly valuable. The educationally qualified prosthodontist is besttrained to design and fabricate prostheses and to treat and manage these disorders.Areas of consideration and reference include but are not limited to:Fluoride Carrier [D5986 CDT-2005, 21089 CPT-2005]Radiation Carrier [D5983 CDT-2005]Radiation Shield Positioner [D5984 CDT-2005]Radiation Source ProsthesisTrismus DeviceManagement and maintenance of hard and soft tissue complicationsParameter Guidelines: Pre- and Postradiation Therapy CareICD-9 CodesDiagnosis codes are directly related to the disease process being treated by the radiation.A. Indications for care1. Head and neck cancer, which may be treated with radiation2. Postoperative sites where radiation is indicated3. Postradiation patient:a. Treatment of hard tissuesb. Treatment of soft tissuesc. Need for prosthetic care4. Professional referralsB. Therapeutic goals1. Reduce soft tissue reactions2. Reduce radiation exposure to noninvolved tissues3. Reduce or prevent xerostomia, ageusia, and anosmia4. Reduce long-term complications of soft and hard tissues5. Prevent radiation decay6. Reduce radiation-induced periodontal disease7. Reduce incidence of osteoradionecrosis8. Long-term treatment planning, pre- and postradiation therapy9. Maintain normal range of mandibular movementC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complication)1. Perivascular fibrosis2. Salivary changesa. Viscosityb. pHc. Volume3. Radiation exposurea. Graysb. Field volume2010 CDEL Re-recognition of the Specialty Report 120 of 279

December 2005, Supplement, Volume 14, Number 4 81c. Particle typed. Energy source4. Age and physical condition5. Weight loss during radiation6. Smoking and/or use of alcohol7. Patient compliance8. Individual tissue reactionD. Standards of care1. Comprehensive clinical assessment (Parameter 1)2. Pretreatment dental care to avoid or reduce complications and/or side effects of radiation therapy3. Primary factors:a. Incidence of radiation cariesb. Incidence of radiation-induced periodontal diseasec. Incidence of osteoradionecrosis4. Patient support in dealing with xerostomia, ageusia, and anosmia5. Management and maintenance of hard and soft tissue complicationsE. Specialty performance assessment1. Complete oral evaluation before initiation of radiation treatment if possible2. Education of patient regarding dental hygiene and oral care3. Modification of dental treatment planning after radiation to include long-term treatment planning11K) Pre- and Post-Chemotherapy CareNonsurgical treatment of disease processes, although not usually removing tissue en masse, has bothshort-term and long-term sequelae of treatment. Side effects can be significant and debilitating, requiringintervention, treatment, and education of the patient to prevent complications. The educationallyqualified prosthodontist or other dentists trained in oncology are best qualified to evaluate these patientsand provide appropriate care.Systemic chemotherapy produces an increase of serious risk of infection and hemorrhage, as well asother morbidities such as mucositis, oral ulceration, and impaired healing. Patients receiving systemicchemotherapy should have arrangements made by their medical oncologist for an oral/dental evaluationbefore chemotherapy to eliminate potential dental sources of infection; disease-based exception andmedical treatment decisions may supersede this. Continued dental observation is also necessary toprevent delays or interruption of medical treatment due to acute dental or oral disease.Areas of consideration and reference include but are not limited to:1. Fluoride Carrier2. Maintenance and management of hard and soft tissue complicationsParameters Guidelines: Pre- and Post-Chemotherapy CareICD-9 CodesDiagnosis codes are directly related to the disease process being treated by the radiation.A. Indications of care1. Primary or metastatic cancer to be treated with systemic chemotherapyB. Therapeutic goals1. Reduce potential for oral, dental infection2. Reduce soft tissue reaction to chemotherapy3. Maintain nutrition4. Reduce xerostomia, ageusia, anosmia5. Avoid invasive dental procedures during chemotherapy6. Prechemotherapy oral dental treatment as indicated7. Prevent delays or interruptions in chemotherapy due to dental infection2010 CDEL Re-recognition of the Specialty Report 121 of 279

82 Parameters of Care Tupac et alC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Reduced hemopoietic functions2. Mucositis3. Candidiasis and other fungal infectious agents4. Weight loss5. Viral and bacterial-induced mucosal infection6. Poor oral hygieneD. Standards of care1. Appropriate clinical assessment2. Minimize xerostomia, ageusia, and anosmia3. Reduced periodontal risks4. Minimal mucositis5. Maintain adequate nutrition-body weight stability6. Continually monitor oral hygiene status7. Provide necessary noninvasive dental care8. Appropriate follow-up and treatment planning9. Management and maintenance of hard and soft tissue complicationsE. Specialty performance assessment1. Evaluate dental status before chemotherapy to eliminate potential oral, dental infection2. Monitor extraction sites for healing before the initiation of chemotherapy3. Educate patient regarding oral cancer and good dental hygiene during chemotherapy4. Monitor and treat mucositis11L) Implant Retained Extraoral ProsthesisCranial-based osseointegrated implants are capable of providing retention for a variety of extraoralprostheses needed for reconstruction of facial deformities. Eliminating the need for adhesives improvesthe convenience and longevity of the prosthetic device while eliminating much of the insecurity associatedwith patient apprehension and self-consciousness. Surgical and maxillofacial prosthetic pretreatmentplanning is critical to the successful application of these techniques. Thus, the educationally qualifiedprosthodontist is the most appropriately trained practitioner to create these prostheses.Areas of consideration and reference include but are not limited to:Facial Prosthesis [D5919 CDT-2005, 21088 CPT-2005]Cranial Based Osseointegrated ImplantsFacial Moulage [D5912 CDT-2005]Facial Moulage, Sectioned [D5911 CDT-2005]Facial Prosthesis [D5919 CDT-2005, 21088 CPT-2005]Facial Prosthesis Replacement [D5929 CDT-2005]Parameter Guidelines: Implant-Retained Extraoral ProsthesisICD-9 CodesRefer to subparameters 11F, 11G, 11H.A. Indications for care1. Restoration of facial form2. Psychosocial implication3. Patient request for treatment4. Efficiency of treatment compared with surgical referral5. Patient referral6. Unsatisfactory existing adhesive retained prosthesis2010 CDEL Re-recognition of the Specialty Report 122 of 279

December 2005, Supplement, Volume 14, Number 4 837. Physically impaired prosthesis placement skills8. Unsatisfactory existing soft tissue retention caseB. Therapeutic goals1. Restored facial form2. Protect exposed mucous membranes3. Restored esthetics4. Improved patient self-esteem5. Improved patient confidence in retention of prosthesis6. Improved quality of life7. Improved compromised surgical resultC. Risk factors affecting quality of treatment (severity factors that increase risk and the potential forknown complications)1. Size and location of the defect2. Possible surgical tissue contours3. Possible radiation sequela4. Psychosocial factors5. Patient’s age6. Patient’s expectations and motivation7. Patient’s compliance8. Tissue reaction to penetrating materials9. Soft-tissue depth and movement at penetration side10. Bone availability, quality, and depth at receptor sites11. Previous radiation therapy and bone residual vascularity12. Superstructure design and ease of maintenance13. Dexterity, visual acuity, and motor skills in placement of prosthesis14. Soft-tissue reaction at penetration site over timeD. Standards of care1. Review medical history (includes radiation ports, type, amount, etc.)2. Surgical removal of impending tissue remnants3. Appropriate consultation and referrals for alternative treatment modalities4. Prosthesis compatibility with existing tissues5. Accurate impression, superstructure design with correct prosthesis construction, retention modalities,and coloration6. Post-treatment maintenance of prosthesis7. Education of patient8. Knowledge of osseointegration theory, principles, and techniques9. Referral of adjunctive care as indicated (HBO)E. Specialty performance assessment1. Favorable outcomesa. Improved psychosocial attitude, self-esteem, and confidenceb. Improved facial symmetryc. Improved estheticsd. Improved organ function (i.e., airflow, directional hearing, etc.)e. Protection of exposed mucous membranes2. Known risk and complicationsa. Unrealistic patient expectationsb. Loss of prosthesis usec. Change in color and appearance of prosthesisd. Loss of prosthesis marginal integrity with usee. Tissue irritation at implant penetration sitef. Tissue changes requiring modification or refabrication of prosthesisg. Loss of mechanical retention2010 CDEL Re-recognition of the Specialty Report 123 of 279

84 Parameters of Care Tupac et alh. Loss of superstructure integrityi. Loss of implant(s)j. Lack of patient complianceSelected References (Maxillofacial Prosthetic Parameter)This list of selected references is intended only to acknowledge some of the source of informationdrawn upon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.Auricular ProsthesisAndres CJ, Haug SP: Facial prosthesis fabrication: technical aspects, in Taylor TD (ed): Clinical Maxillofacial Prosthetics. Chicago,Quintessence, 2000, pp 233-244Beumer J, Ma T, Marunick MT, et al: Restoration of facial defects: Etiology, disability, and rehabilitation, in Beumer J, Curtis TA,Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku EuroamericaInc., 1996, pp 377-454Brown KE: Fabrication of ear prosthesis. J Prosthet Dent 1969;21:670-676Bulbulian AH: Congenital and postoperative loss of the ear: Reconstruction by prosthetic method. J Am Dent Assoc 1942;29:1161-1168Chalian VA, Drane JB, Standish SM: Maxillofacial Prosthetics; Multidisciplinary Practice. Baltimore, Williams and Wilkins, 1971Rahn AO, Boucher LJ: Maxillofacial Prosthetics Principles and Concepts. Philadelphia, Saunders, 1970Seelaus R, Troppmann RJ: Facial prosthesis fabrication: coloration techniques, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 245-264Tjellstrom A, Lindstrom J, Nylen O, et al: The bone-anchored auricular episthesis. Laryngoscope 1981;91:811-815Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296.Commissure SplintCheuk SL, Kirkland JL: Splint for burns to lip commisures. J Prosthet Dent 1984;52:563Czerepak CS: Oral splint therapy to manage electrical burns of the mouth in children. Clin Plast Surg 1984;11:685-692Khan Z, Banis JC Jr: Oral commissure expansion prosthesis. J Prosthet Dent 1992;67:383-385Sela M, Tubiana I: A mouth splint or severe burns of the head and neck. J Prosthet Dent 1989;62:679-681Toljanic JA, Paik CY, Edmonds DC, et al: Splint appliance for the management of posttrauma lip deformities: technical note andcase reports. J Trauma 1992;32:252-255.Cranial ImplantsBeumer J 3 rd , Firtell DN, Curtis TA: Current concepts in cranioplasty. J Prosthet Dent 1979;42:67-77Chalian VA, Drane JB, Standish SM: Maxillofacial Prosthetics: Multi-Disciplinary Practice. Baltimore, Williams & Wilkins,Baltimore, 1971Courtemanche AD, Thompson GB: Silastic cranioplasty following cranio-facial injuries. Plast Reconstr Surg 1968;41:165-170Firtell DN, Grisius RJ: Cranioplasty of the difficult frontal region. J Prosthet Dent 1981;46:425-429Grant FC, Norcross NC: Repair of cranial defects by cranioplasty. Ann Plast Surg 1939;110:488-512Hamada MO, Lee R, Moy PK, et al: Craniofacial implants in maxillofacial rehabilitation. J Calif Dent Assoc 1989;17:25-28Jacob RF, Collard SM: The effect of steam autoclave sterilization on methyl methacrylate cranial implant materials. Int JProsthodont 1991;345-352Lecene P: Cranioplasty and cranial prosthesis. Plast Reconstr Surg 1986;78:530-535Maniscalo JE, Garcia-Bengochea F: Cranioplasty: A method of prefabricating alloplastic plates. Surg Neurol 1974;2:339-241Mankovich NJ, Curtis DA, Kagawa T, et al: Comparison of computer-based fabrication of alloplastic cranial implants withconventional techniques. J Prosthet Dent 1986;155:606-609Rahn AO, Boucer LJ: Maxillofacial Prosthetics Principles and Concepts. Philadelphia, Saunders, 1970Reuben JR, Cleminshaw H: Cranioplasty prosthesis: a preliminary report of a method aiming at accurate preoperative construction.S Afr Med J 1964;38:111-112Ross PJ, Jelsma F: Experiences with acrylic plastic for cranioplasties. Am Surg 1960;26:519-524Schupper N: Cranioplasty prostheses for replacement of cranial bone. J Prosthet Dent 1968;19:594-957Segall BW: The construction and implantation of a silicone rubber cranial prosthesis. J Prosthet Dent 1974;31:194-197Shaw RC, Thering HR: Reconstruction of cranial defects. Clin Plast Surg 1975;2:539-5492010 CDEL Re-recognition of the Specialty Report 124 of 279

December 2005, Supplement, Volume 14, Number 4 85Small TM, Graham MP: Acrylic resin for the closure of skull defects. Br J Surg 1945;33:106-113Spence WT: Form-fitting plastic cranioplasty. J Neurosurg 1945;11:219-225van Putten MC Jr., Yamada S: Alloplastic cranial implants made from computed topographic scan-generated casts. J ProsthetDent 1992;68:103-108Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: Prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Endosseous Implants for Maxillofacial ProsthesesAugust M, Bast B, Jackson M, et al: Use of the fixed mandibular implant in oral cancer patients: a retrospective study. J OralMaxillofac Surg 1998;56:297-301Eckert SE, Desjardins RP: The Impact of endosseous implants on maxillofacial prosthetics, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 145-153Gurlek A, Miller MJ, Jacob RF, et al: Functional results of dental restoration with osseointegrated implants after mandiblereconstruction. Plast Reconstr Surg 1998;101:650-659Jisander S, Grenthe B, Alberius P: Dental implant survival in the irradiated jaw: a preliminary report. Int J Oral MaxillofacImplants 1997;12:643-648Kovacs AF: Influence of chemotherapy on endosteal implant survival and success in oral cancer patients. Int J Oral MaxillofacSurg 2001;30:144-147Marx RE, Morales MJ: The use of implants in the reconstruction of oral cancer patients. Dent Clin North Am 1998;42:177-202Rieger JM, Wolfaardt JF, Jha N, et al: Maxillary obturators: the relationship between patient satisfaction and speech outcome.Head Neck. 2003;25:895-903Visch LL, van Waas MA, Schmitz PI, et al: A clinical evaluation of implants in irradiated oral cancer patients. J Dent Res2002;81:856-859Weischer T, Mohr C: Ten-year experience in oral implant rehabilitation of cancer patients: treatment concept and proposedcriteria for success. Int J Oral Maxillofac Implants 1999;14:521-528Werkmeister R, Szulczewski D, Walteros-Benz P, et al: Rehabilitation with dental implants of oral cancer patients. CraniomaxillofacSurg 1991;27:38-41Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: Prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Facial Augmentation ImplantsBelinfante LS, Mitchell DL: Use of alloplastic material in the canine fossa-zygomatic area to improve facial esthetics. J Oral Surg1977;35:121-125Craig RD, Simpson W, Stanley W: The correction of facial contour defects by precision-made silastic implants. Br J Plast Surg1975;28:67-70Epstein LI: Clinical experience with Proplast as an implant. Plast Reconstr Surg 1979;63:219-223Hamada MO, Lee R, Moy PK, et al: Craniofacial implants in maxillofacial rehabilitation. J Calif Dent Assoc 1989;17:25-28McCollough EG, Weil C: Augmentation of facial defects using Mersilene mesh implants. Otolaryngol Head Neck Surg 1979;87:515-521Parr GR, Goldman BM, Rahn AO: Maxillofacial prosthetic principles in the surgical planning for facial defects. J Prosthet Dent1981;46:323-329Raval P, Schaaf NG: Custom fabricated silicone rubber implants for issue augmentation—a review. J Prosthet Dent 1981;45:432-434Wolfaardt JF, Cleaton-Jones P, Lownie J, et al: Biocompatibility testing of a silicone maxillofacial prosthetic elastomer: soft tissuestudy in primates. J Prosthet Dent 1992;68:331-338Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: Prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Facial MoulageBulbulian AG: A professional look at plaster casts. FBI Law Enforcement Bull 1965;34:2-7Chalian VA, Drane JB, Standish SM: Maxillofacial prosthetics multi-disciplinary practice. Baltimore, Williams and Wilkins, 1971Clarke CD: Moulage prosthesis. Am J Ortho Oral Surg 1941;27:214-225McKinstry RE: Fundamentals of Facial Prosthetics. Clearwater, FL, ABI Professional Publications, 1995Moergeli JR: A technique for making a facial moulage. J Prosthet Dent 1987;57:253Thomas KF: Prosthetic Rehabilitation. London, Quintessence, 19842010 CDEL Re-recognition of the Specialty Report 125 of 279

86 Parameters of Care Tupac et alFacial Moulage, SectionalAquilino SA, White J, Taylor TD, et al: Thermoplastic custom trays for making regional facial impressions. J Prosthet Dent1985;53:686-688Clarke CD: Moulage prostheses. Am J Ortho Oral Surg 1941;27:214-225Beumer J, Zlotolow I: Restoration of facial defects—etiology, disability and rehabilitation, in Beumer J, Curtis TA, Firtell DN(eds): Maxillofacial Rehabilitation (ed 1). St. Louis, Mosby-Year Book, 1979, pp 311-371Levy M, Schortz RH, Blumenfeld I, et al: A flexible moulage for the fabrication of an orbital prosthesis. J Prosthet Dent 1980;43:436-438McKinstry RE: Fundamentals of Facial Prostheses. Clearwater, FL, ABI Professional Publications, 1995Facial ProsthesisBeumer J, Ma T, Marunick MT, et al: Restoration of facial defects: etiology, disability, and rehabilitation, in Beumer J, Curtis TA,Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku EuroamericaInc., 1996, pp 377-454Bululian AG: Facial Prosthetics. Springfield, Charles C. Thomas Co., 1973Chalian VA, Drane JB, Standish SM: Maxillofacial Prosthetics Multi-Disciplinary Practice. Baltimore, Williams and Wilkins, 1971Fonseca EP: The importance of form, characterization, and retention in facial prostheses. J Prosthet Dent 1966;16:338-343McClelland RC: Facial prosthesis following radical maxillofacial surgery. J Prosthet Dent 1977;38:327-330McKinstry RE: Fundamentals of Facial Prosthetics. Clearwater, FL, ABI Professional Publications, 1995Rahn AO, Boucher LJ: Maxillofacial Prosthetics Principles and Concepts. Philadelphia, Saunders, 1970Rhodes RD 3 rd : Restoration of facial defects with individually prefabricated silicone prostheses. Plast Reconstr Surg 1969;43:201-204Thomas KF: Prosthetic Rehabilitation. London, Quintessence, 1984Wang R, Collard SM, Lemon J: Adhesion of silicone to polyurethane in maxillofacial prostheses. Int J Prosthodont 1994;7:43-49Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Facial Prosthesis, ReplacementMcClelland RC: Facial prostheses following radical maxillofacial surgery. J Prosthet Dent 1977;38:327-330McKinstry RE: Fundamentals of Facial Prosthetics. Clearwater, FL, ABI Professional Publications, 1995Schaaf NG: Color characterizing silicone rubber facial prostheses. J Prosthet Dent 1970;24:198-202Thomas KF: Prosthetic Rehabilitation. London, Quintessence, 1994Fluoride CarrierADA Oral Health Care Guidelines, Patients receiving cancer chemotherapyBeumer J, Curtis TA, Nishimura R: Radiation therapy of head and neck tumors: oral effects, dental manifestations anddental treatment, in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and SurgicalConsiderations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 43-112Daly TR, Drane JB: Prevention and management of dental problems in irradiated patients. J Am Soc Prev Dent 1976;6:21-25Dreizen S, Bodey GP, Rodriguez V: Oral complications of cancer chemotherapy. Postgrad Med 1975;58:75-82Greenberg MS, Cohen SG, McKitrick JC, et al: The oral flora as a source of septicemia in patients with acute leukemia. Oral Surg1982;53:32-36Hickey AJ, Toth BB, Lindquist SB: Effect of intravenous hyperalimentation and oral care on the development of oral stomatitisduring cancer chemotherapy. J Prosthet Dent 1982;47:188-193King GE, Martin JW: Prosthodontic care of patients receiving chemotherapy and irradiation to the head and neck. Curr ProblCancer 1983;7:43-50Lindquist SF, Hickey AJ, Drane JB: Effect of oral hygiene on stomatitis in patients receiving cancer chemotherapy. J ProsthetDent 1978;40:312-314Masella RP, Cupps RE, Laney WR: Dental management of the irradiated patient. Northwest Dent 1972;51:269-275NIH Consensus Development Conference Statement. Oral complications of cancer therapies: diagnosis, prevention andtreatment. April, 17–19, 1989Overholser CD, Peterson DE, Williams LT, et al: Periodontal infection in patients with acute nonlymphocyte leukemia. Prevalenceof acute exacerbations. Arch Intern Med 1982;142:551-554Peterson DE, Minah GE, Overholser CD, et al: Microbiology of acute periodontal infection in myelosuppressed cancer patients. JClin Oncol 1987;5:1461-14682010 CDEL Re-recognition of the Specialty Report 126 of 279

December 2005, Supplement, Volume 14, Number 4 87Peterson DE, Overholser CD: Increased morbidity associated with oral infection in patients with acute nonlymphocytic leukemia.Oral Surg oral Med Oral Pathol 1981;51:390-393Peterson DE, Overholser CD, Schimpff SC, et al: Relationship of intensive oral hygiene to systemic complications in acute nonlymphocyticleukemia patients. Clin Research 1981;29:440ASonis ST, Peterson DE: Oral complications of chemotherapy and their management, in Shklar G: Oral Cancer. Philadelphia,Saunders, 1984, pp 186-201Toth BB, Frame RT: Dental Oncology: the management of disease and treatment-related oral/dental complications associatedwith chemotherapy. Curr Prob Cancer 1983;7:7-35Mandibular Resection Prosthesis (with Guide)Beumer J, Curtis TA: Acquired defects of the mandible: etiology, treatment and rehabilitation, in Beumer J, Curtis TA, FirtellDN (eds): Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. St. Louis, Mosby-Year Book, 1979Beumer J, Marunick MT, Curtis TA, et al: Acquired defects of the mandible: etiology, treatment and rehabilitation, in Beumer J,Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, IshiyakuEuroamerica Inc., 1996, pp 113-224Cantor R, Curtis TA: Prosthetic management of edentulous mandibulectomy patients. II. Clinical procedures. J Prosthet Dent1971;25:546-555Jacob RF: Prosthodontic rehabilitation of the mandibulectomy patient, in Taylor TD (ed): Clinical Maxillofacial Prosthetics.Chicago, Quintessence, 2000, pp 171-188Kelly EK: Partial denture design applicable to the maxillofacial patient. J Prosthet Dent 1965;15:168-173Laney WR: Prosthetic management of acquired mandibular defects. Proceeding of the 1st international symposium. Verlog,Stuttgart, 1970;2:330-333Martin JW, Shupe RJ, Jacob RF, et al: Mandibular positioning prosthesis for the partially resected mandibulectomy patient. JProsthet Dent 1985;53:678-680Moore DJ, Mitchell DL: Rehabilitating dentulous hemimandibulectomy patients. J Prosthet Dent 1976;26:202-206Rubenstein JE: Implant rehabilitation of the mandible compromised of radiotherapy, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 189-203Schaaf NG: Oral reconstruction for edentulous patients after partial mandibulectomies. J Prosthet Dent 1976;36:292-297Taylor TD: Diagnostic considerations for prosthodontic rehabilitation of the mandibulectomy patient, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 155-170Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Zaki HS: Prosthodontic rehabilitation following total and partial glossectomy, in Taylor TD (ed): Clinical Maxillofacial Prosthetics.Chicago, Quintessence, 2000, pp 205-213Mandibular Resection Prosthesis (Without Guide)Adisman IK, Birnbach S: Surgical prosthesis for reconstructive mandibular surgery. J Prosthet Dent 1966;16:988-991Beumer J, Marunick MT, Curtis TA, et al: Acquired defects of the mandible: etiology, treatment and rehabilitation, in Beumer J,Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, IshiyakuEuroamerica Inc., 1996, pp 113-224Jacob RF: Prosthodontic rehabilitation of the mandibulectomy patient, in Taylor TD (ed): Clinical Maxillofacial Prosthetics.Chicago, Quintessence, 2000, pp 171-188Laney WR: Prosthetic management of acquired mandibular defects. Proceeding of the 1st international symposium, Verlog,Stuttgart, 1970;2:330-33Robinson JE, Rubright WC: Use of a guide plane or maintaining the residual fragment in partial or hemimandibulectomy. JProsthet Dent 1964;14:992-999Rubenstein JE: Implant rehabilitation of the mandible compromised of radiotherapy, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 189-203Schaaf NG: Oral reconstruction for edentulous patients after partial mandibulectomies. J Prosthet Dent 1976;36:292-297Swoope CC: Prosthetic management of resected edentulous mandibles. J Prosthet Dent 1969;21:197-202Taylor TD: Diagnostic considerations for prosthodontic rehabilitation of the mandibulectomy patient, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 155-170Zaki HS: Prosthodontic rehabilitation following total and partial glossectomy, in Taylor TD (ed): Clinical Maxillofacial Prosthetics.Chicago, Quintessence, 2000, pp 205-213Maxillary ResectionArcure MR, Taylor TD: Clinical management of the dentate maxillectomy patient, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 103-1212010 CDEL Re-recognition of the Specialty Report 127 of 279

88 Parameters of Care Tupac et alCurtis TA, Beumer J: Restoration of acquired hard palate defects: Etiology, disability and rehabilitation, in Beumer J, Curtis TA,Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku EuroamericaInc., 1996, pp 225-284Curtis TA, Beumer J: Speech velopharyngeal function, and restoration of soft palate defects, in Beumer J, Curtis TA, MarunickMT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996,pp 285-330Genden EM, Okay D, Stepp MT, et al: Comparison of functional quality of life outcomes in patients with and withoutpalatomaxillary reconstruction: a preliminary report. Arch Otolaryngol Head Neck Surg 2003;129:775-780Jacob R: Clinical management of the edentulous maxillectomy patient, in Taylor TD (ed): Clinical Maxillofacial ProstheticsClinical Maxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 85-102Mahanna GK, Beukelman DR, Marshall JA, et al: Obturator prostheses after cancer surgery: an approach to speech outcomeassessment. J Prosthet Dent. 1998;79:310-316Sullivan M, Gaebler C, Beukelman D, et al: Impact of palatal prosthodontic intervention on communication performance ofpatients’ maxillectomy defects: a multilevel outcome study. Head Neck 2002;24:530-538Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: Prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Nasal ProsthesisAndres CJ, Haug SP: Facial prosthesis fabrication: Technical aspects, in Taylor TD (ed): Clinical Maxillofacial Prosthetics.Chicago, Quintessence, 2000, pp 233-244Beumer J, Ma T, Marunick MT, et al: Restoration of facial defects: Etiology, disability, and rehabilitation, in Beumer J, Curtis TA,Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku EuroamericaInc., 1996, pp 377-454Brown KE: Fabrication of a nose prosthesis. J Prosthet Dent 1971;26:543-554Bulbulian AH: Facial Prosthetics. Springfield, Charles C. Thomas Co., 1973Chalian VA, Drane JB, Standish SM: Maxillofacial Prosthetics Multi-Disciplinary Practice. Baltimore, Williams and Wilkins, 1971McKinstry RE: Fundamentals of Facial Prosthetics. Clearwater, FL, ABI Professional Publications, 1995Parr GR, Goldman BM, Rahn AO: Maxillofacial prosthetic principles in the surgical planning for facial defects. J Prosthet Dent1981;46:323-329Rahn AO, Boucher LJ: Maxillofacial Prosthetics Principles and Concepts. Philadelphia, Saunders, 1970Seelaus R, Troppmann RJ: Facial prosthesis fabrication: coloration techniques, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 245-264Thomas KF: Prosthetic Rehabilitation. London, Quintessence, 1994Wolfaardt JF, Wilkes GH, Anderson JD: Craniofacial osseointegration: prosthodontic treatment, in Taylor TD (ed): ClinicalMaxillofacial Prosthetics. Chicago, Quintessence, 2000, pp 277-296Nasal Septal ProsthesisBeekhuis GJ, Eisenstein B: Repair of nasal septal perforation with a silicone button. Laryngoscope 1977;84:635-637Bozzetti A, Collini M, Ravasini G, et al: Temporary intranasal prosthesis for a surgical defect of septum and columella. J ProsthetDent 1985;54:824-826Davenport JC, Hunt AT: The construction of nasal septal obturators. Quintessence Dent Technol 1985;9:233-238Facer GW, Kern EB: Nasal septal perforations: use of Silastic button in 108 patients. Rhinology 1979;17:115-120Pallanch JF, Facer GW, Kern EB, et al: Prosthetic closure of nasal septal perforations. Otolaryngol Head Neck Surg 1982;90:448-452Van Dishoeck EA, Lashely FO: Closure of a septal perforation by means of an obturator. Rhinology 1975;13:33-37Zaki HS: A new approach in construction of nasal septal obturators. J Prosthet Dent 1980;43:439-444Zarb GA: The maxillary resection and its prosthetic replacement. J Prosthet Dent 1967;18:268-281.Obturator Prosthesis, DefinitiveAramany MA: Basic principles of obturator design for partially edentulous patients. Part II: design principles. J Prosthet Dent1978;40:656-662Birnbach S, Barnhard B: Direct conversion of a solid obturator to a hollow obturator prosthesis. J Prosthet Dent 1989;62:58-60Boucher LJ, Heupel EM: Prosthetic restoration of a maxilla and associated structures. J Prosthet Dent 1966;16:154-168Curtis TA, Beumer J: Restoration of acquired hard palate defects: Etiology, disability and rehabilitation, in Beumer J, Curtis TA,Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku EuroamericaInc., 1996, pp 225-2842010 CDEL Re-recognition of the Specialty Report 128 of 279

December 2005, Supplement, Volume 14, Number 4 89DaBreo EL, Chalian VA, Lingeman R, et al: Prosthetic and surgical management of osteogenic sarcoma of the maxilla. J ProsthetDent 1990;63:316-320Desjardins RP: Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent 1978;39:424-435Devlin H, Barker GR: Prosthetic rehabilitation of the edentulous patient requiring a partial maxillectomy. J Prosthet Dent1992;67:223-227Gardner LK, Parr GR, Rahn AO: Simplified technique for the fabrication of a hollow obturator prosthesis using vinyl polysiloxane.J Prosthet Dent 1991;66:60-62Gary JJ, Donovan M, Garner FT, et al: Rehabilitation with calvarial bone grafts and osseointegrated implants after partial maxillaryresection: a clinical report. J Prosthet Dent 1992;67:743-746Geissler PR, McKinlay KM: A two-part obturator prosthesis for use following maxillectomy in edentulous patients. Clin OtolaryngolAllied Sci 1977;2:149-152Guerra ON: Obturator prosthesis for edentulous patients. 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90 Parameters of Care Tupac et alObturator Prosthesis, SurgicalBlack WB: Surgical obturation using a gated prosthesis. J Prosthet Dent 1992;68:339-342Carl W: Preoperative and immediate postoperative obturators. J Prosthet Dent 1976;36:298-305DaBreso EL, Chalian VA, Lingemann R, et al: Prosthetic and surgical management of osteogenic sarcoma of the maxilla. J ProsthetDent 1990;63:316-320Desjardins RP: Early rehabilitative management of the maxillectomy patient. J Prosthet Dent 1977;38:311-318Didier M, Laccoureye O, Brasnu D, et al: New surgical obturator prosthesis for hemimaxillectomy patients. J Prosthet Dent1993;69:520-523Huryn JM, Piro JD: The maxillary immediate surgical obturator prosthesis. J Prosthet Dent 1989;61:343-347Lang BR, Bruce RA: Presurgical maxillectomy prosthesis. J Prosthet Dent 1967;17:613-619La Velle W, Arcuri M, Panje W, et al: Transmolar pin and magnetic carrier for midfacial reconstruction: a clinical report. JProsthet Dent 1989;70:204-206Minsley GE, Warren DW, Hinton V: Physiologic responses to maxillary resection and subsequent obturation. J Prosthet Dent1989;57:338-344Wolfaardt JF: Modifying a surgical obturator prosthesis into an interim obturator prosthesis: A clinical report. J Prosthet Dent1989;62:619-621Zarb GA: The maxillary resection and its prosthetic replacement. J Prosthet Dent 1967;18:268-281Ocular ProsthesisBartlett SO, Moore DJ: Ocular prosthesis: a physiologic system. J Prosthet Dent 1973;29:450-459Bulbulian AH: Facial Prosthetics. Springfield, Charles C. Thomas Co., 1973Chalian VA, Drane JB, Standish SM: Maxillofacial Prosthetics, Multi-Disciplinary Practice. Baltimore, Williams and Wilkins, 1971Cortes AL, Smith CR, Seals RR Jr: Light-cured dimethacrylate ocular prosthesis. Trends Tech Contemp Dent Lab 1993;10:41-44Haug SP, Andres CJ: Fabrication of custom ocular prosthesis, in Taylor TD (ed): Clinical Maxillofacial Prosthetics. Chicago,Quintessence, 2000, pp 265-276McKinstry RE: Fundamentals of Facial Prosthetics. Clearwater, FL, ABI Professional Publications, 1995Parr GR, Goldman BM, Rahn AO: Surgical considerations in the prosthetic treatment of ocular and orbital defects. J ProsthetDent 1983;49:379-385Rahn AO, Boucher LJ: Maxillofacial Prosthetics Principles and Concepts. Philadelphia, Saunders, 1970Ocular Prosthesis, InterimGould HL: Evisceration and the cosmetic cover shell, in Guibor P, Smith B (eds): Contemporary Oculoplastic Surgery. New York,Stratton, WW, 1974, pp. 168 A5104cParr GR, Goldman BM, Rahn AO: Surgical considerations in the prosthetic treatment of ocular and orbital defects. J ProsthetDent 1983;49:379-385Price E, Simon JW, Calhoun JH: Prosthetic treatment of severe microphthalmos in infancy. J Pediatr Ophthalmol Strabismus1986;23:22-24Orbital ProsthesisAndres CJ, Haug SP: Facial prosthesis fabrication: technical aspects, in Taylor TD (ed): Clinical Maxillofacial Prosthetics. Chicago,Quintessence, 2000, pp 233-244Barron JB, Rubenstein JE, Archibald D, et al: Two-piece orbital prosthesis. J Prosthet Dent 1983;49:386-388Beumer J, Ma T, Marunick MT, et al: Restoration of facial defects: Etiology, disability, and rehabilitation, in Beumer J, Curtis TA,Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku EuroamericaInc., 1996, pp 377-454Brown KE: Fabrication of orbital prosthesis. J Prosthet Dent 1969;22:592-607Bulbulian AH: Facial prosthetics. Springfield, Charles C. Thomas Co., 1973Chalian VA, Drane JB, Standish SM: Maxillofacial Prosthetics, Multi-Disciplinary Practice. Baltimore, Williams and Wilkins, 1971McKinstry RE: Fundamentals of Facial Prosthetics. Clearwater, FL, ABI Professional Publications, 1995Rahn AO, Boucher LJ: Maxillofacial Prosthetics Principles and Concepts. Philadelphia, Saunders, 1970Seelaus R, Troppmann RJ: Facial prosthesis fabrication: coloration techniques, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 245-264Shifman A, Levin AC, Levy M, et al: Prosthetic restoration of orbital defects. J Prosthet Dent 1979;42:543-546Thomas KF: Prosthetic Rehabilitation. London, Quintessence, 19942010 CDEL Re-recognition of the Specialty Report 130 of 279

December 2005, Supplement, Volume 14, Number 4 91Palatal Augmentation ProsthesisAramany MA, Downs JA, Beer QC, et al: Prosthodontic rehabilitations for glossectomy patients. J Prosthet Dent 1982;48:78-81Cantor R, Curtis TA, Shipp T, Beumer J 3 rd ,etal: Maxillary speech prostheses for mandibular surgical defects. J Prosthet Dent1969;22:253-260Christensen JM, Hutton JE, Hasegawa A, et al: Evaluation of the effects of palatal augmentation on partial glossectomy speech.J Prosthet Dent 1983;50:539-543Davis JW, Lazarus C, Logemann J, et al: Effect of a maxillary glossectomy prosthesis on articulation and swallowing. J ProsthetDent 1987;57:715-719De Souza LJ, Martins OJ: Swallowing and speech after radical total glossectomy with tongue prosthesis. Oral Surg Oral Med OralPathol 1975;39:356-360Eckert SE, Desjardins RP, Taylor TD: Clinical management of the soft palate defect, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 121-132Gillis RE, Leonard RJ: Prosthetic treatment for speech and swallowing in patients with total glossectomy. J Prosthet Dent1983;50:808-814Godoy AJ, Perez DG, Lemon JC, et al: Rehabilitation of a patient with limited oral opening following glossectomy. Int J Prosthodont1991;4:70-74Golden GL: A hollow palatal drop maxillary denture and a mandibular obturator prosthesis: a case report. J Ga Dent Assoc1979;52:17-20Greven AJ, Meijer MF, Tiwari RM: Articulation after total glossectomy: a clinical study of speech in six patients. Eur J DisordCommun 1994;29:85-93Groetsema WR: An overview of the maxillofacial prosthesis as a speech rehabilitation aid. J Prosthet Dent 1987;57:204-208Izdebski K, Ross JC, Roberts WL, et al: An interim prosthesis for the glossectomy patient. J Prosthet Dent 1987;57:608-611Kaplan P: Immediate rehabilitation after total glossectomy: a clinical report. J Prosthet Dent 1993;69:462-463Knowles JC, Chalian VA, Shanks JC: A functional speech impression used to fabricate a maxillary speech prosthesis for a partialglossectomy patient. J Prosthet Dent 1984;51:232-237LaBlance GR, Kraus K, Steckol KF: Rehabilitation of swallowing and communication following glossectomy. Rehabil Nurs1991;16:266-270Lemon JC, Godoy AJ, Perez DG, et al: Rehabilitation of a patient with limited oral opening following glossectomy. Int J Prosthodont1991;4:70-74Leonard RJ, Gillis R: Differential effects of speech prostheses in glossectomized patients. J Prosthet Dent 1990;64:701-708McKinstry RE, Aramany MA, Beery QC, et al: Speech considerations in prosthodontic rehabilitation of the glossectomy patient.J Prosthet Dent 1985;53:384-387Meyer JB Jr, Knudson RC, Meyers KM: Light-cured interim palatal augmentation prosthesis: A clinical report. J Prosthet Dent1990;63:1-2Robbins KT, Bowman JB, Jacob RF: Postglossectomy deglutitory and articulatory rehabilitation with palatal augmentationprostheses. Arch Otolaryngol Head and Neck Surg 1987;113:1214-1218Sharma AB, Curtis TA: Clift lip and palate in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation,Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 331-376Taicher S, Tubiana I, Sela M: Prosthetic rehabilitation of mandibulectomy and glossectomy patients. Isr J Dent Sci 1989;2:167-169Weber RS, Ohlms L, Bowman J, et al: Functional results after total or near total glossectomy with laryngeal preservation. ArchOtolaryngol Head Neck Surg 1991;117:512-515Wheeler RL, Logemann JA, Rosen MS: Maxillary reshaping prostheses: effectiveness in improving speech and swallowing ofpostsurgical oral cancer patients. J Prosthet Dent 1980;43:313-319.Palatal Lift Prosthesis, InterimBlakeley RW: The rational for a temporary speech prosthesis in palatal insufficiency. Br J Disord Commun 1969;4:134-139Curtis TA, Beumer J: Speech velopharyngeal function, and restoration of soft palate defects, in Beumer J, Curtis TA, MarunickMT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996,pp 285-330Gibbons P, Bloomer HH: The palatal lift: a supportive-type speech aid. J Prosthet Dent 1958;8:362-369Gonazalez JB, Aronson AE: Palatal lift prosthesis for treatment of anatomic and neurologic palatopharyngeal insufficiency. CleftPalate J 1970;7:91-104Lang BR, Kipfmueller LJ: Treating velopharyngeal inadequacy with the palatal lift concept. Plast Reconstr Surg 1969;43:467-477Mazaheri M, Mazaheri EH: Prosthodontic aspects of palatal elevation and palatopharyngeal stimulation. J Prosthet Dent1976;35:319-326Schaefer KS, Taylor TD: Clinical application of the palatal lift, in Taylor TD (ed): Clinical Maxillofacial Prosthetics. Chicago,Quintessence, 2000, pp 133-143.2010 CDEL Re-recognition of the Specialty Report 131 of 279

92 Parameters of Care Tupac et alPalatal Lift Prosthesis, DefinitiveAlpine KD, Stone CR, Badr SE: Combined obturator and palatal lift prosthesis: a case report. Quintessence Int 1990;21:893-896Curtis TA, Beumer J: Speech velopharyngeal function, and restoration of soft palate defects, in Beumer J, Curtis TA, MarunickMT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996,pp 285-330Esposito SJ, Mitsumoto H, Shanks M: Use of palatal lift and palatal augmentation prostheses to improve dysarthria in patientswith amyotrophic lateral sclerosis: a case series. J Prosthet Dent 2000;83:90-98Gibbons P, Bloomer HH: The palatal lift: a supported-type prosthetic speech aid. J Prosthet Dent 1958;8:362-369Gonzalez JB, Aronson AE: Palatal lift prosthesis for treatment of anatomic and neurologic palatopharyngeal insufficiency. CleftPalate J 1970;7:91-104Hall PK, Hardy JC, LaVelle WE: A child with signs of developmental apraxia of speech with whom a palatal lift prosthesis wasused to manage palatal dysfunction. J Speech Hear Disord 1990;55:454-460Holley LR, Hamby GR, Taylor PP: Palatal lift for velopharyngeal incompetence: report of case. ASDC J Dent Child 1973;40:467-470Kerman PC, Singer LS, Davidoff A: Palatal lift and speech therapy for velopharyngeal incompetence. Arch Phys Med Rehabil1973;54:271-276Kipfmueller LJ, Lang BR: Treating velopharyngeal inadequacies with a palatal lift prosthesis. J Prosthet Dent 1972;27:63-72Lang BR, Kipfmueller LJ: Treating velopharyngeal inadequacy with the palatal lift concept. Plast Reconstr Surg 1969;43:467-477La Velle WE, Hardy JC: Palatal lift prosthesis for treatment of palatopharyngeal incompetence. J Prosthet Dent 1979;42:308-315Marshall RC, Jones RN: Effects of a palatal lift prosthesis upon the speech intelligibility of a dysarthric patient. J Prosthet Dent1971;25:327-333Matsui Y, Ohno K, Michi K, et al: Application of hydroxyapatite-coated implants as support for palatal lift prosthesis edentulouspatients with cleft palate: a clinical report. Int J Oral Maxillofac Implants 1993;8:316-322Mazaheri M, Mazaheri EH: Prosthodontic aspects of palatal elevation and palatopharyngeal stimulation. J Prosthet Dent1976;35:319-326McHenry M, Wilson R: The challenge of unintelligible speech following traumatic brain injury. Brain Inj 1994;8:363-375Ramsey WO, Elias SA, Kreutzer L: Alternative approaches to retention of palatal lift prostheses. Int J Periodontics RestorativeDent 1984;4:50-59Sato Y, Sato M, Yoshida K, et al: Palatal lift prostheses for edentulous patients. J Prosthet Dent 1987;58:206-210Schaefer KS, Taylor TD: Clinical application of the palatal lift, in Taylor TD (ed): Clinical Maxillofacial Prosthetics. Chicago,Quintessence, 2000, pp 133-143Spratley MH, Chenerey HJ, Murdock BE: A different design of palatal lift appliance: review and case reports. Aust Dent J1988;33:491-495Turner GE, Williams WN: Fluoroscopy and nasoendoscopy in designing palatal lift prostheses. J Prosthet Dent 1991;66:63-71Walter JD: Palatopharyngeal activity in cleft palate subjects. J Prosthet Dent 1990;63:187-192Wedin S: Rehabilitation of speech in cases of palato-pharyngeal paresis with the aid of an obturator prosthesis. Br J DisordCommun 1972;7:117-130Wolfaardt JF, Wilson FB, Rochet A, et al: An appliance based approach to the management of palatopharyngeal incompetency: aclinical pilot project. J Prosthet Dent 1993;69:186-195Palatal Lift Prosthesis, ModificationLang BR: Modification of the palatal lift speech aid. J Prosthet Dent 1967;17:620-626Mazaheri M, Mazaheri EH: Prosthodontic aspects of palatal elevation and palatopharyngeal stimulation. J Prosthet Dent1976;35:319-326Schaefer KS, Taylor TD: Clinical application of the palatal lift, in Taylor TD (ed): Clinical Maxillofacial Prosthetics. Chicago,Quintessence, 2000, pp 133-143Radiation & ChemotherapyBeumer J, Curtis TA, Nishimura R: Radiation therapy of head and neck tumors: Oral effects, dental manifestations anddental treatment, in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and SurgicalConsiderations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 43-112Klokkevold PR: Cancer chemotherapy: Oral manifestations, complications, and management, in Beumer J, Curtis TA, MarunickMT (eds): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996,pp 25-42Kramer DC: The Radiation therapy patient: Treatment planning and post treatment care, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 37-522010 CDEL Re-recognition of the Specialty Report 132 of 279

December 2005, Supplement, Volume 14, Number 4 93Radiation CarrierArksornnukit M, McKinstry RE, Cwyner RB: Silicone nasal radiation carriers. J Prosthet Dent 1992;67:516-518Beumer J, Curtis TA, Nishimura R: Radiation therapy of head and neck tumors: Oral effects, dental manifestations anddental treatment, in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and SurgicalConsiderations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 43-112Cheng VS, Oral K, Aramany MA: The use of acrylic resin oral prosthesis in radiation therapy of oral cavity and paranasal sinuscancer. Int J Radiat Oncol Biol Phys 1982;8:1245-1250Delclos L: Radiotherapy for head and neck cancer. Teamwork: problems common to physician and dentist. J Prosthet Dent1965;15:157-167Hudson FR, Crawley MT, Samarasekera M: Radiotherapy treatment planning for patients fitted with prostheses. Br J Radiol1984;57:603-608Meyer JB Jr., Knudson RC, Butler EB: Intranasal stent for stabilization and fixation of interstitial radioactive isotopes. J ProsthetDent 1991;65:813-815Rosenstein HE, DeMasi V, Fine L, et al: Radiation carrier for treatment of nasopharyngeal carcinomas. J Prosthet Dent1987;58:617-619Rudd KD: Maxillary appliance for controlled radium needle placement. J Prosthet Dent 1966;16:782-787Radiation ShieldBeumer J, Curtis TA, Nishimura R: Radiation therapy of head and neck tumors: Oral effects, dental manifestations anddental treatment, in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation, Prosthodontics and SurgicalConsiderations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 43-112Farahani M, Eichmiller FC, McLaughlin WL: Metal-polysiloxane shields for radiation therapy of maxillo-facial tumors. Med Phys1991;18:273-278Fleming TJ, Rambach SC: A tongue-shielding radiation stent. J Prosthet Dent 1983;49:389-392Fujita M, Hirokawa Y, Tamamoto M, et al: Dose-reducing effect of Lipowitz metal-embedded spacers in interstitial brachytherapyfor carcinoma of the mobile tongue. Oral Surg Oral Med Oral Pathol 1994;77:589-593Klein HM, Stargardt A: Efficiency of a lead-containing tie for radiation protection of the thyroid gland. Br J Radiol 1992;65:1003-1006Marrs JE, Hounsell AR, Wilkinson JM: The efficacy of lead shielding in megavoltage radiotherapy. Br J Radiol 1993;66:140-144Speech Aid, AdultArcuri MR, Lavelle WE, Higuchi KW, et al: Implant-supported prostheses for treatment of adults with cleft palate. J ProsthetDent 1994;71:375-378Aram A, Subteiny JD: Velopharyngeal function and cleft palate prostheses. J Prosthet Dent 1959;9:149-158Baden E: Fundamental principles of orofacial prosthetic therapy in congenital cleft palate. Part II. Prosthetic treatment. J ProsthetDent 1954;4:568-579Curtis TA, Beumer J: Speech velopharyngeal function, and restoration of soft palate defects, in Beumer J, Curtis TA, MarunickMT (ed): Maxillofacial Rehabilitation, Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996,pp 285-330Desjardins RP: Prosthodontic management of the cleft-palate patient. J Prosthet Dent 1975;33:655-665Eckert SE, Desjardins RP, Taylor TD: Clinical management of the soft palate defect, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 121-132Harkins CS: Role of the prosthodontist in the rehabilitation of cleft palate patients. J Am Dent Assoc 1951;43:29-33Lloyd RS, Pruzansky S, Subteiny JD: Prosthetic rehabilitation of a cleft palate patient subsequent to multiple surgical and prostheticfailures. J Prosthet Dent 1957;7:216-230Malson TS: Nonobstructing prosthetic speech aid during growth and orthodontic treatment. J Prosthet Dent 1957;7:403-415Mazaheri M: Indications and contraindications for prosthetic speech appliances in cleft palate. Plast Reconstr Surg 1962;30:663-669Sharma AB, Curtis TA: Clift lip and palate, in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation,Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 331-376Shelton RL, McCauley RJ: Use of a hinge-type speech prosthesis. Cleft Palate J 1986;23:312-317Speech Aid, ModificationDorf DS, Reisberg DJ, Gold HO: Early prosthetic management of cleft palate. Articulation development prosthesis: a preliminaryreport. J Prosthet Dent 1985;53:222-226Eckert SE, Desjardins RP, Taylor TD: Clinical management of the soft palate defect, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, 2000, pp 121-1322010 CDEL Re-recognition of the Specialty Report 133 of 279

94 Parameters of Care Tupac et alPosnick WR: Prosthetic management of palatopharyngeal incompetency for the pediatric patient. ASDC J Dent Child 1976;43:46-48Speech Aid, PediatricAram A, Subteiny JD: Velopharyngeal function and cleft palate prosthesis. J Prosthet Dent 1959;9:149-158Baden R: Fundamental principles of orofacial prosthetic therapy in congenital cleft palate. Part II. Prosthetic treatment. J ProsthetDent 1954;4:568-579Eckert SE, Desjardins RP, Taylor TD: Clinical management of the soft palate defect, in Taylor TD (ed): Clinical MaxillofacialProsthetics. Chicago, Quintessence, pp 121-132Harkins CS: Role of the prosthodontist in the rehabilitation of cleft palate patients. J Am Dent Assoc 1951;43:29-33Lloyd RS, Pruzansky S, Subteiny JD: Prosthetic rehabilitation of a cleft palate patient subsequent to multiple surgical and prostheticfailures. J Prosthet Dent 1957;7:216-230Malson TS: Nonobstruction prosthetic speech aid during growth and orthodontic treatment. J Prosthet Dent 1957;7:403-415Mazaheri M: Indications and contraindications for prosthetic speech appliances in cleft palate. Plast Reconstr Surg, 1962;30:663-669Sharma AB, Curtis TA: Clift lip and palate, in Beumer J, Curtis TA, Marunick MT (eds): Maxillofacial Rehabilitation,Prosthodontics and Surgical Considerations. St. Louis, Ishiyaku Euroamerica Inc., 1996, pp 331-376Surgical SplintAramany MA: New trends in construction of splints. J Prosthet Dent 1970;23:88-95Bolouri A, Williams CE: Using the existing complete denture as a surgical template. J Prosthet Dent 1984;51:129-131Chow TK, Bok WS: New surgical splint for segmental maxillary osteotomies. J Oral Maxillofac Surg 1993;51:97-98Fraser-Moodie W: Mr. Gunning and his splint. Brit J Oral Surg 1969;7:112-115Goss AN, Brown RO: An improved Gunning splint. J Prosthet Dent 1975;33:562-566Jerbi FC: Prostheses, Stents and Splints for the Oral Cancer patient. In: Oral care for oral cancer patient. Public Health ServicePub N, 11-12, 1958Kurihara Y, Wakatsuki T, Harada Y, et al: Mandibular alveolar ridge extension method using a surgical splint with poroushydroxyapatite (HAP) particles. Bull Tokyo Dent Coll 1991;32:71-79Lambert PM: A two-piece surgical splint to facilitate hydroxylapatite augmentation of the mandibular alveoloar ridge. J OralMaxillofac Surg 1986;44:329-331Laney WR, Gibilisco JA: Diagnosis and Treatment in Prosthodontics. Philadelphia, Lea and Febiger, 1983Maxymiw WG, Wood RE, Anderson JD: The immediate role of the dentist in the maxillectomy patient. J Otolaryngol 1989;18:303-305Sabin H, Saltzman E: Intraoral splints for surgical fractures of the mandible. J Prosthet Dent 1970;23:320-326Scuba JR, McLaughlin JP: Simplified splint construction with light-cured resin. J Oral Maxillofac Surg 1990;48:1341-1343Turvey T, Hall DJ, Fish LC, et al: Surgical-orthodontic treatment planning for simultaneous mobilization of the maxilla andmandible in the correction of dentofacial deformities. Oral Surg Oral Med Oral Pathol 1982;54:491-498Ward GE, Williamson RJ, Robben JO: The use of removable acrylic prostheses to retain mandibular fragments and adjacent softtissues in normal position after surgical resection. Plast Reconstr Surg 1949;4:537Surgical StentFirtell DN, Oatis GW, Curtis, et al: A stent for a split-thickness skin graft vestibuloplasty. J Prosthet Dent 1976;36:204-210Golden DP, Schaberg SJ: Comparison of fibrin adhesive and alveolar stent for skin graft fixation in mandibular vestibuloplasty. JCraniomaxillofac Surg 1987;15:261-264Jerbi FC: Prostheses, stents and splints for the oral cancer patient, in: Oral care for the oral cancer patient. Public Health ServicePub N 11–12, 1958King GE, Martin JW, Munson TJ: Functional mandibular surgical stents: Use in primary reconstruction of the cancer patient. JProsthet Dent 1983;49:217-219Laney WR, Gibilisco JA: Diagnosis and Treatment in Prosthodontics. Philadelphia, Lea and Febiger, 1983Weiner LJ, Moberg AW: An ideal stent for reliable and efficient skin graft application. Ann Plast Surg 1984;13:24-28Yard RA, Latta GH: Fabrication of a sectional surgical stent for hydroxyapatite augmentation for the edentulous residual ridge.J Prosthet Dent 1987;57:482-484Trismus Device (Not for TMD Treatment)Jeckel N, Rakosi T, Joos U: The neuromuscular reaction to continuous dynamic jaw extension in cases with restricted mouthopening. J Craniomaxillofac Surg 1987;15:94-982010 CDEL Re-recognition of the Specialty Report 134 of 279

December 2005, Supplement, Volume 14, Number 4 95Preface12) Local Anesthesia ParameterCriteria and standards in this section refer specifically and exclusively to methods used by prosthodontiststo control the pain and anxiety of patients treated in outpatient facilities (e.g., dental schools, hospitaloutpatient treatment facilities, prosthodontists’ offices, and other facilities where prosthodontics isaccomplished.)Anxiety, fear, and pain are of concern because each is inherent in the patient’s reaction to the type ofprosthodontic procedure being performed. All three must be controlled satisfactorily during therapy topermit safe and effective completion of the procedures. These anesthesia criteria have been developedto maximize safety and minimize risk in the population of patients being treated. The practitioner’sselection of a particular technique for controlling pain and anxiety during a specific procedure has to beindividually determined for each patient, considering the risks and benefits in each case.Techniques seldom used or applicable to very few patients are not included in this document.This category included hypnosis, acupuncture, transcutaneous electrical nerve stimulation (TENS),and specific medications and techniques for controlling acute or chronic pain. Behavior modificationtechniques (biofeedback) and psychiatric management also have been excluded.Although nitrous oxide–oxygen analgesia and nitrous oxide–oxygen sedation do fit within thedefinition of conscious sedation, we have chosen to exclude them from the techniques of conscioussedation presented here because the risk associated with their use is limited. The standards of careand specialty performance assessment indices (i.e., favorable outcomes, known risks, and complications)are the same as for local anesthesia. Conscious sedation has been shown to be extremely safe. Theminimally depressed state of consciousness-effected, even with the concurrent administration of otherdrugs, causes few physiological changes. However, physiological monitoring of the patient is essential,and the prosthodontist and assistants all should be trained in basic cardiac life support (BCLS) or itsequivalent.In the future, new indications or new anesthetic agents and techniques may lead to changes inequipment. As new pieces of equipment and the techniques for using them are evaluated and acceptedfor use, their inclusion in this document will be considered.When administering anesthetic and/or sedative procedures to a patient, the prosthodontist isencouraged to be familiar with the rules and regulations of his/her individual state dental board and tofollow the guidelines advocated by the American Dental Association.General Criteria and StandardsInformed Consent: The administration of anesthesia must be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the anesthetic procedure,the goals of treatment, the known benefits and risks of the anesthetic procedure, the factors thatmay affect the known risks and complications, the anesthetic management options, and the favorableoutcomes.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.2010 CDEL Re-recognition of the Specialty Report 135 of 279

96 Parameters of Care Tupac et alThe diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Local AnesthesiaA. Indications for care1. Need to provide a prosthodontic procedure, which may create sensations, especially pain, thatcould interfere with treatmentB. Therapeutic goals1. Profound anesthesia in the operative area2. Return of normal sensation within a prescribed period of timeC. Risk factors affecting quality of treatment1. Presence of coexisting major systemic disease2. Adequacy of preoperative clinical preparationa. Clinical preparation of patient (i.e., history and physical evaluation; laboratory and otherdiagnostic studies complete)b. Status of informed consent (e.g., completed, lacking)3. Presence of infection4. History of drug allergy5. History of allergy or sensitivity to local anesthetic agents or additive agents6. Psychological aversion to injections7. Presence of uncontrolled systemic conditions that may interfere with the normal healing processand subsequent tissue homeostasis (e.g., diabetes mellitus, bleeding dyscrasia, steroid therapy,immunosuppression, malnutrition)8. Presence of behavioral, psychological, or psychiatric disorders, including habits (e.g., alcohol,tobacco, or drug abuse) that may affect anesthetic management9. Existing drug or alcohol intoxication10. Degrees of patient cooperation and/or compliance11. Method of administration (block, infiltration, intraligamentary, and interosseous)D. Standards of care [D9200-D9299 CDT-2005]1. Completion of a medical history questionnaire, signed and dated by the patient or a responsibleparty2. Review of medical history form by the prosthodontist with all significant responses evaluated andnoted on the form (dialogue history)3. Pretreatment physical evaluation and vital signs recorded in the chart2010 CDEL Re-recognition of the Specialty Report 136 of 279

December 2005, Supplement, Volume 14, Number 4 974. Completion of medical consultation or additional laboratory testing, if indicated, before initiationof treatment (except in extreme emergency)5. Continual observation and supervision of patient through the treatment6. Explanation of postoperative instructions to the patient and/or responsible adult at the time ofdischarge7. Determination that vital signs are stable before discharge8. Determination that patient is appropriately responsive before dischargeE. Specialty performance assessment indices1. Favorable outcomesBy definition, the application or administration of local anesthetic agents is a totally reversibleprocedure. Except for the physiological and/or psychological trauma resulting from the procedureand except in rare cases of idiosyncratic reaction or allergy to the drugs involved, the patientshould have returned to his or her preanesthetic physiological and/or psychological state within12 hours after cessation of the administration of drug.2. Known risks and complicationsa. Events related to local anesthesia carei. Cardiac arrestii. Clinically apparent acute myocardial infarctioniii. Clinically apparent symptoms of acute cerebrovascular accidentiv. Respiratory arrestv. Fulminating pulmonary edemavi. Aspiration of gastric contents followed by radiographic findings of aspiration pneumonitisvii. Foreign body displaced into the airway or bronchiviii. Development of peripheral or central neurologic deficitix. Infectionx. Dental injuriesxi. Ocular injuriesxii. Organ damage (i.e., kidney, liver)b. Unplanned hospital admission shortly after outpatient procedure performed under localanesthesiac. Unplanned admission to an intensive care unit shortly after the administration of localanesthesiad. Imaging or clinical evidence of a broken needlee. Persistent trismusf. Evidence of intra-arterial or intravenous injection of the local anesthetic agentsSelected References (Local Anesthesia Parameter)This list of selected references is intended only to acknowledge some of the sources of information drawnupon in the preparation of this document. Citation of the reference material is not meant to implyendorsement of any statement contained in the reference material, or that the list is an exhaustivecompilation of information on the topic. Readers should consult other sources to obtain a completebibliography.American Dental Association, 1987. Guidelines for teaching the comprehensive control of pain and anxiety for intraoperativemonitoring of dental patients undergoing conscious sedation, drug sedation and general anesthesia. Am Dental Soc ofAnesthesiology Newsletter 1988;10:2-3American Heart Association: Textbook of Advanced Cardiac Life Support. Dallas, American Heart Association, 1988Eichhorn JH, Cooper JB, Cullen DJ, et al: Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA1986;256:22-29Longnecker DE, Murphy FL: Introduction to Anesthesia (ed 8). Philadelphia, Saunders, 1992Malamed SF, Quinn C: Sedation: A guide to Patient Management (ed 3). St. Louis, Mosby-Year Book, 1995Malamed SF: Handbook of Local Anesthesia (ed 4). St. Louis, Mosby, 1997Standards for cardiopulmonary resuscitation and emergency cardiac care. J Am Med Assoc 1974;227:182010 CDEL Re-recognition of the Specialty Report 137 of 279

98 Parameters of Care Tupac et alPreface13) Adjunctive Therapies ParameterThe integrated therapy of many prosthodontic treatment plans includes components of all aspectsof dentistry. Although the referral of a patient to appropriate specialists for treatment outside ofprosthodontics is the norm, there are situations and considerations in which the patient’s best interest isprotected by the prosthodontist performing limited procedures adjunctive to prosthodontic therapiesoutside the normal scope of the specialty. These procedures should be of a limited nature and bedeemed appropriate when referral would not be in the patient’s best interest. These treatments shouldbe preceded by a discussion with the patient concerning the risk/benefit ratio and a subsequent informedconsent. The prosthodontist should have demonstrated competence in any procedure performed and beaware that the standard of care for the procedure is determined by that group of dentists who mostappropriately perform that procedure.General Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient and theneed for future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient-management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current recognized ICD-9-CM code source andsubstantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT Manual is published. Current Dental TerminologyC○ 2002, 2004 American Dental Association. All rights reserved.2010 CDEL Re-recognition of the Specialty Report 138 of 279

December 2005, Supplement, Volume 14, Number 4 99Parameter Guidelines: Adjunctive TherapiesICD-9-CM521 Diseases of hard tissues of teeth522 Diseases of pulp and periapical tissues523 Gingival and periodontal diseases524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structures526 Diseases of the jaws527 Diseases of the salivary glands528 Diseases of the oral soft tissues, excluding diseases specific for gingival and tongue529 Diseases and other conditions of the tongueA. Indicators for care1. Limited clinical conditions outside of prosthodontics directly associated with a current treatmentplan2. Patient request/anxiety3. Patient care/comfort4. Professional referral5. Cost containmentB. Therapeutic goals1. Eliminate or manage clinical condition diagnosed2. Minimize operative procedures to patient3. Reduce anesthetic exposure4. Reduce patient discomfort/pain5. Eliminate or prevent an emergency conditionC. Risk factors affecting quality of treatment1. Severity of condition treated2. Preexisting systemic disease3. Patient noncompliance with postoperative instructions4. Known risks to therapy providedD. Standards of care1. Informed consent procedure2. Endodontic procedures3. Periodontal procedures4. Orthodontic procedures5. Oral & maxillofacial surgical procedures6. Demonstrated competence in the procedure performed7. Referral to an appropriate specialist for treatment of complications/failure to achieve therapeuticgoals8. Patient educationE. Specialty performance assessment criteria1. Favorable outcomesa. Elimination of emergency conditionb. Successful elimination or management of clinical conditionc. Minimal anesthetic exposured. Minimize operative exposuree. Minimize pain/recovery periodsf. Minimize patient anxiety2. Known risks and complicationsa. Exacerbation of condition2010 CDEL Re-recognition of the Specialty Report 139 of 279

100 Parameters of Care Tupac et alb. Failure to manage or eliminate clinical conditionc. Need for further specialty referralSelected ReferencesLiterature references for the Adjunctive Therapies Parameter cover all areas of dentistry and would betoo extensive to list. Members are encouraged to be conversant with the literature for each and everyprocedure attempted.Preface14) Terminal Dentition ParameterTerminal dentition describes a condition in which the teeth are insufficient to maintain function, andthe arch, as a whole, will transition to the edentulous state. The etiology might be periodontal disease,caries, trauma, inadequate number of remaining teeth to maintain function, prosthodontic comfort,and/or patient desires. Transition to complete edentulism should only be considered when the patientis fully informed of all variables (e.g., prognosis of teeth, chance of success measured against longevityof treatment) and consequences, which affect the value of treatment. Patient desires and expectationsmust be considered in conjunction with the professional knowledge and judgment of the prosthodontist.The decision to remove one or more teeth has a multi-factorial rationale ranging from patientpreferences, cost, prosthetic need, tissue preservation, reduction of infection/disease, medical necessity,and inadequate restorative prognosis. Since removal of a tooth/teeth is an irreversible, permanent act,the decision process must include a rigorous review of the myriad results of such treatment both inthe short term and the long term. Patient expectations must be balanced with the realities of toothremoval including the ongoing costs of long-term prosthodontic rehabilitation and maintenance, as wellas reduction in overall function depending on the prosthodontic treatment anticipated. Proper imagingrecords are critical in establishing an accurate prognosis based on the presenting anatomic factors andpatient expectations since all information will be lost after extraction unless previously recorded.General Criteria and StandardsInformed Consent: All prosthodontic procedures should be preceded by the patient’s consent. Informedconsent is obtained after the patient has been informed of the indications for the procedure(s), goalsof treatment, the known benefits and risks of the procedure(s), the factor(s) that may affect the knownrisks and complications, the treatment options, the need for active maintenance by the patient, the needfor future replacements and revisions, and the favorable outcome.Documentation: Parameters of care for prosthodontic procedures include documentation of objectivefindings, diagnosis, and patient management intervention.Coding and NomenclatureDiagnostic and procedural codes have been included in the ACP Parameters of Care only for generalguidance. The codes listed may not be all-inclusive or represent the most current or specific choices. Theinclusion of codes is not meant to supplant the use of current coding books or to relieve practitionersof their obligation to remain current in diagnostic and procedural coding. The ACP Committee onParameters of Care and Committee on Nomenclature do not endorse the use of this document as acoding manual.The diagnostic and procedural codes listed throughout this section may not be all-inclusive and shouldserve only as practice guidelines. ICD-9-CM (International Classification of Diseases, Ninth Revision, ClinicalModification) diagnostic codes may change yearly and must be reviewed and updated annually to ensureaccuracy. Specific diagnoses must be obtained from a current, recognized ICD-9-CM code source and2010 CDEL Re-recognition of the Specialty Report 140 of 279

December 2005, Supplement, Volume 14, Number 4 101substantiated by documentation in the dental record. Procedural codes listed throughout this sectionserve as a guide, which may be applicable to the treatment performed or management modality chosen.These may not be the most recent, applicable, or acceptable codes. Some dental/medical insuranceproviders have billing conventions unique to their organizations. It is the provider’s responsibility to beaware of these unique situations.Current Procedural Terminology (CPT), the recognized codes for dental/medical billing, are revisedyearly and must be reviewed and updated annually to ensure accuracy. The recent codes are acceptedby dental/medical insurance providers and should be obtained from the current year’s version of theAmerican Medical Association (AMA) CPT Manual. Current Procedural Terminology C○ 2005 American MedicalAssociation. All rights reserved.Current Dental Terminology (CDT) codes, the recognized codes for dental/medical billing, are revisedevery 3 years (previously every 5 years) and should be reviewed and updated whenever the most recentversion of the American Dental Association (ADA) CDT manual is published. Current Dental Terminology C○2002, 2004 American Dental Association. All rights reserved.Parameter Guidelines: Terminal DentitionICD-9-CMUse additional codes to identify cause of Partial Edentulism (525.10–525.19).1. 525.50 Partial edentulism, unspecified2. 525.51 Partial edentulism, Class I3. 525.52 Partial edentulism, Class II4. 525.53 Partial edentulism, Class III5. 525.54 Partial edentulism, Class IV6. 52x.xx Completely Dentate (codes under submission)The specific determinants of the PDI for Partial Edentulism can be found in the ICD-9-CM codes521–525; some examples are listed below:306.8 Other specified psychophysiological malfunction: Bruxism, Teeth grinding521 Diseases of hard tissues of teeth522 Diseases of pulp and periapical tissues523 Gingival and periodontal diseases524 Dentofacial anomalies, including malocclusion525 Other diseases and conditions of the teeth and supporting structures873.6 Tooth [broken] uncomplicated873.7 Tooth [broken] complicatedA. Indications for care1. Inadequate mastication2. Pain/discomfort3. Inadequate esthetics4. Inadequate support of TM joint and orofacial muscles5. Psychosocial factors6. Unsatisfactory existing prostheses7. Lack of intra-arch and interarch integrity and stability8. Questionable prognosisa. Loss of tooth structure/integrityb. Periodontally compromisedc. Endodontically compromised9. Significance of tooth position2010 CDEL Re-recognition of the Specialty Report 141 of 279

102 Parameters of Care Tupac et alB. Therapeutic goals1. Improved mastication2. Reduction of pain/discomfort3. Esthetics4. Occlusal rehabilitation5. Improved support of TM joint and orofacial muscles6. Positive psychosocial response7. Restore intra-arch and interarch integrity and stability by replacement of teeth and associatedstructures.8. Improved tooth form and function9. Improved treatment prognosis10. Improved prosthetic support or retention11. Transitional restorationC. Risk factors affecting the quality of treatment1. Dyskinesia2. Preexisting systemic conditions3. Hyperactive gag reflex4. Xerostomia5. Increased salivation6. Periodontal disease7. Endodontic complications8. Occlusal factors9. Skeletal factors10. Inadequate tooth structure11. Parafunctional habits12. Caries susceptibility13. Psychosocial factors14. Preexisting tooth position and alignment15. Inadequate hard and/or soft tissue16. Unrealistic patient expectationsD. Standards of care1. Preprosthetic preparationa. Appropriate nonsurgical evaluationb. Appropriate surgical evaluationc. Appropriate endodontic evaluationd. Appropriate periodontal evaluatione. Appropriate orthodontic evaluation2. Transitional fixed partial denture prostheses [D6253, D6793 CDT 2005]3. Transitional removable partial denture prostheses [D5211, D5212, D5820, D5821 CDT 2005]4. Transitional complete denture [D5130, D5140, D5810, D5811 CDT 2005]5. Transitional implants and associated prostheses [D6000-D6199 CDT 2005]6. Implant supported or retained prostheses [D6000-D6199 CDT 2005]7. Maintenance of existing prostheses [D5410-D5899 CDT 2005]8. Pretreatment follow-up [D5410-D5899 CDT 2005]9. Patient education10. Informed consentE. Specialty performance assessment criteria1. Favorable outcomesa. Improved masticationb. Improved speechc. Improved estheticsd. Improved swallowing2010 CDEL Re-recognition of the Specialty Report 142 of 279

December 2005, Supplement, Volume 14, Number 4 103e. Restored TM joint and orofacial muscle supportf. Positive psychosocial responseg. Improved comforth. Satisfactory patient adaptationi. Improved intra-arch and interarch integrity and stability.2. Known risks and complicationsa. Refractory patient responseb. Speech alterationsc. Unacceptable estheticsd. Unrealistic patient expectationse. Materials failure/incompatibilityf. Biomechanically induced implant complicationsg. Difficulty in chewing and/or swallowingh. TM joint and/or orofacial muscle dysfunctioni. Alterations in taste perceptionj. Allergic responsek. Degradation of supporting structuresPostscriptThe Parameters of Care are presented by the American College of Prosthodontists for a wide range ofuses. They are accepted by the American Board of Prosthodontics and as such are a necessary teachingtool in prosthodontic training programs and dental school curricula. They are meant to emphasize theimportance of the Prosthodontic Diagnostic Index in teaching, in diagnosis, and treatment planning forthe prosthodontist and general practitioner, and are to be used in patient presentations and lectures.They also provide guidelines for daily use in communication with dental insurance companies and inthe evaluation of the procedural requirements of the standard of care. This document provides thefoundation of the concept that prosthodontics is a specialty based on diagnosis of degree of difficultyinstead of individual tooth technique. It is a document designed to be used as a resource.Extra copies of this document can be ordered through Blackwell Publishing. Information is availableat the Journal of Prosthodontics’ web site at http://www.blackwellpublishing.com/jopr. Electronic copies arealso available to download. Electronic copies are free for subscribers, and available at a small fee tonon-subscribers.2010 CDEL Re-recognition of the Specialty Report 143 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix CProsthodontics Diagnostic Index(PDI)a. Edentulous Patientsb. Partially Edentulous Patientsc. Dentate Patients2010 CDEL Re-recognition of the Specialty Report 144 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix C. a.Prosthodontics Diagnostic Index(PDI)a. Edentulous Patients2010 CDEL Re-recognition of the Specialty Report 145 of 279

TOPICS OF INTERESTClassification System forComplete EdentulismThomas J. McGamy, DDS51hthurNimmo, DDS: James F. Skiba, DDS?Robert H. Ahlstrom, DDS, Christopher R. Smith, DDS,'and Jack H. Koumjian, DDS, MSD'The American College of Prosthodontists has developed a classification system for completeedentulism based on diagnostic findings. These guidelines may help practitioners determineappropriate treatments for their patients. Four categories are defined, ranging from Class I to ClassIV, with Class I representing an uncomplicated clinical situation and a Class IV patient representingthe most complex and higher-risk situation. Each class is differentiated by specific diagnosticcriteria. This system is designed for use by dental professionals who are involved in the diagnosis ofpatients requiring treatment for complete edentulism. Potential benefits of the system include: 1)better patient care, 2) improved professional communication, 3) more appropriate insurancereimbursement, 4) a better screening tool to assist dental school admission clinics, and 5)standardized criteria for outcomes assessment.J Prosthod 1999;8:27-39. Copyright 0 7999 by The American College of Prosthodontists.INDEX WORDS: complete dentures, diagnosis, treatment planning, prosthodontics, dentaleducation, graduate dental education, outcomes assessment, quality assurance, treatment outcomesOMPLETELY EDE,WLOUS PATIEhTS ex-C hibit a broad range of physical variations andhealth concerns. Classifying all edentulous patientsas a single diagnostic group is insensitive to themultiple levels of physical variation and the differingtreatment procedures required to restore functionand comfort. A graduated classification of completeedentulism has been developed that descri bPsvarying levels of loss of denture-supporting structures.This article defines complete edentulism as follows:the physical state of the jaw(s) following removal'Private pactice, Oklahoma Ciy, OK.2Projsjor and firedor ofrmplant Dentistly, Department oJRaloratilieDentistv, UniL'ewip ofDetrait Mery School of Lkntistv, Iletmit, ~2.11j'Pnvate practim, hfontontclair, iVJ4Priaatepractice, Reno, AT?-"-Pnvatepl-actice, San Antonio, TX.6Clinical Projtsw, Department $Restorative DentijQ, UCSF SchoolojDentisty andPricate Practice, Palo Alto, CA.ilzwptedJanuay 21,1999.Presented at the Annual Session ofthe Adcan Coliege of Prosthodoiitistsin Orlando, FL, Navember5,1997.Fun& lg The h i a n Colleze oJPmsthhodontis~.CnrresfnmdPnce to: Thomas J. McGaq DDS, 4320 McAulq Boubvard,Oklahoma Cab, OK 73120.Co&yright 0 1999 b The American Coliege ojPmsthodontists10.59-94 lX~~9i~80~-~OO5$5.00/0of all erupted teeth and the condition ofthe supportingstructures available for reconstructive or replacementtherapies. The condition of edentulism, for thepurpose of this article, is divided into four levelsaccording to specific diagnostic criteria.The absence of organized diagnostic criteria forcomplete edentulism has been a long-standing impedimentto effective care for patients. Recognitionof the diverse nature, scope, and degree of completeedentulism, although thoroughly described in thedental literature, has not been organized to efficientlyguide dental educators, general dentists,prosthodontists, and third-party payers in providingthe appropriate treatment for each patient. A systemfor facilitating patient identification is needed toimprove patient treatment outcomes.The American College of Prosthodontists (ACP)recognized its responsibility to the public and theprofession to correct this dilemma. The Subcommitteeon Prosthodontic Classification was formedin 1995 and charged with developing classificationsystems for prosthodontic patients. Timelyimplementation of this system will benefit patients,clinicians, and educators. The classification systemfor complete edentulism is presented in the followingsections.Journal ofProsthodontics, Vol8, No 1 (Marcti)> 1999:H 27-39 272010 CDEL Re-recognition of the Specialty Report 146 of 279

28 Cllas$caizon of Complete Edentulism McCany et a1Development of theClassification SystemA classification system has been successfully used toassess periodontal status for more than 20 years.'Recently, the American Association of Endodontistsdevised an evaluation system for determining endodonticrisk factors.2 These factors serve as guidelinesto determine when patients with advancedtreatment needs should be referred for consultationwith a specialist. The classification system for completeedentulism will establish separate diagnosticentities fur four levels of edentulism, ranked accordingto degree of dificulty of treatment.A review of the prosthodontic literature was usedto identify the many variables associated with completeedentulism. A questionnaire was then constructedto categorize the 89 variables identified.The questionnaire that was circulated within thesubcommittee asked for comments and literaturecitations to support inclusion of a variable into adiagnostic system. The data collected via this questionnairewere formatted into a new survey instrumentthat differentiated variables into four subclasses:I. Physical findmgs;2. Prosthetic history;3. Pharmaceutical history;4. Systemic disease evaluation.The variables in these four subclasses of variableswere further evaluated to determine their importancein relation to:Educational requirement: What additional clinicalskill or knowledge is necessary to manage thisvariable?Clinical responsibility: Is ths variable most significantto the patient, practitioner, or the dentallaboratory technician?Clinical technique modification: ?$'ill this variablerequire a change in conventional five-step technique,and could this variable have a significanteffect on patient satisfaction?Clinical and labomtory time requirement: Willthis variable require additional time by the practitioner,clinical staff, and/or the dental laboratorytechnician?Overall clinical significance: Will this variablerequire advanced education to manage?The subcommittee established a ranking of individualvariables. Subsequently, a classification systemwas developed based on the most objective variables.The survey was sent to a cross-sectional sample of10% of the ACP fellows and mernbqrs and to representativesof prosthodontic organizations. A five-stepscoring grid was included that asked if the classificationwould be one of the followlng: very helpful,helpful, not helpful and had minor flaws, or hadmajor flaws. Of the 250 drafts sent out, 56 werereturned. When the results were tallied, 73.4% ofresponses expressed the view that the classificationwould be very helpful or helpful. Nine percent saidthe system would not be helpful. Minor flaws wereidentified by 15.6% of the respondents, and 1.7%stated that the system had major flaws; however, noconsistent flaws were identified in the comments.The additional information gained from this surveyand initial draft comments was incorporated into adefinitive document.System ApplicationsThis system, when combined with the appropriateParameter of Care,3 will establish a basis for diagnosisand treatment procedures. In addition, patientswill be provided with treatment justifications forthird-part): payers to ensure that the patient is ableto receive appropriate prosthodonric care, shouldreferral to a spccialist be necessaryThe classification system will be of value to dentalfaculty responsible for screening new edentulouspatients. Dental educators will need to determinewhich classes of complete edentulism can be treatedwithin their predoctoral clinical program." Patientsdiagnosed at more advanced levels should be referredto graduate prosthodontics programs or to a practicingprosthodontist.Data gathered and organized using this systemwill enable the dental educator, general dentist, orprosthodontist to review clinical outcomes on evidence-baseddiagnostic criteria. By identifying thcadvanced patient before treatment and making thcappropriate referral, when indicated, the incidence ofretreatment should decrease.The classification system will be subject to monitoringand revision as new diagnostic and treatmentinformation becomes available in the literature. Theexperiences gained in its application in practice willenable the provider to determine which treatment2010 CDEL Re-recognition of the Specialty Report 147 of 279

Table 1. Checklist for Classification of Coniulete Edentulisni2010 CDEL Re-recognition of the Specialty Report 148 of 279

30 Clmsjfication ofCom&e Edentulirm a iMcGa? et a1Figure 1. Radiograph with residual bonc height of 2 1 mmor greater measured at the least vertical height of themandible (Type I).procedures would be most appropriate for a patientwith a specific diagnosis.With the premise that complete edentulism hasdiffering degrees of severity, the committee sought toidentify and group the most significant diagnosticcriteria. The following criteria should help in applyingthe guidelines in a consistent manner.A Systematic Review of DiagnosticCriteria for the Edentulous PatientThe diagnostic criteria are organized by their objectivenature and not in their rank of significance.Because of variations in adaptive responses, certaincriteria are more significant than others5 However,objective criteria will allow for the most accurateapplication of the classification system and nieasurementof its efficacy. Objectivity also will providereliable outcome data and mechanisms for review bythird-party payers and peer-review panels. The diagnosticcriteria used in the classification system arelisted in the worksheet (Table 1).Figure 3. Radiograph with residual bone height of 11 to15 mm mcasured at the least vertical height of themandible (Type HI).Bone Height: Mandible onlyThe identification and measurement of residualbone height is the most easily quantified objectivecriterion for the mandibular edentulous ridge.6-g Inaddition, it represents a measurement of the chronicdebilitation associated with complete edcntulism inthe mandible. Despite the lack of a known etiology, ithas been establishcd that the loss of denturesupportingstructures does occur.6.8 Atwood‘s descriptionin 1971 of alveolar bone loss is still applicabletoday: “Chronic progressive, irreversible and disablingprocess probably of multifactoral origin. At thepresent time, the importance of various cofactors isunknown.” The continued decrease in bone volumeaffects: 1) denture-bearing area; 2) tissues remainingfor reconstruction; 3) facial muscle support/attachment;4) total facial heightg; and 5) ridge morphol-ogy.The results of a radiographic survey of residualbone height measurement are affected by the variationin the radiographic techniques and magnificationof panoramic machines of different manufacturers.To minimize variability in radiographictechniques, the measurement should be made on theradiograph at that portion of the mandible of the leastFigure 2. Radiograph with residual bone height of 16 to20 mm measured at the least vertical height of themandible (Type n).Figure 4. Radiograph with residual bone height of 10 mmor less measured at the least vertical height of the mandible(Type IV).2010 CDEL Re-recognition of the Specialty Report 149 of 279

March 1999, Volume 8, Number 1 31Figure 5. Type A maxillary residual ridge.vertical height. The values assigned to each of thefour types listed below are averages that historicallyhave been used in relation to preprosthetic surgicalprocedures. A measurement is made and the patientis classified as follows:Type I (most favorable): residual bone height of 21mm or greater measured at the least verticalheight of the mandible (Fig 1);Type II: residual bone height of 16 to 20 mmmeasured at the least vertical height of the mandible(Fig 2);Type III: residual alveolar bone height of 11 to 15mm measured at the least vertical height of themandible (Fig 3);Type N: residual vertical bone height of 10 mm orless measured at the least vertical height of themandible (Fig 4).Residual Ridge Morphology: Maxilla OnlyResidual ridge morpholou is the most objective criterionfor the maxilla, because measurement of theFigure 7. Type C maxillary residual ridge.maxillary residual bone height by radiography is notreliable." The classification system continues on alogical progression, describing the effects of residualridge morphology and the influence of musculatureon a maxillary denture."Type A (most favorable) (Fig 5)Anterior labial and posterior buccal vestibulardepth that resists vertical and horizontal movementof the denture base.0 Palatal morpholog resists vertical and horizontalmovement of the denture base.Sufficient tuberosity definition to resist verticaland horizontal movement of the denture base.0 Hamular notch is well defined to establish theposterior extension of the denture base.Absence of tori or exostoses.Type B (Fig 6)Loss of posterior buccal vestibule.0 Palatal vault morphology resists vertical and horizontalmovement ofthe denture base.Tuberosity and hamular notch are poorly defined,compromising delineation of the posterior extensionof the denture base.Figure 6. Type B maxillary residual ridge.Figure 8. Type D maxillaryresidual ridge.2010 CDEL Re-recognition of the Specialty Report 150 of 279

32 Clarszjicatwn ofcomplete Edeiitulism McGar??; et a10 Maxillary palatal tori and/or lateral exostoses arerounded and do not affect the posterior extensionof the denture base.Type C (Fig 7)0 Loss of anterior labial vestibule.Palatal vault morpholog~7 offers minimal rcsistanceto vertical and horizontal movement of thedenture base.0 Maxillary palatal tori and/or lateral exostoses withbony undercuts that do not affect the posteriorextension of the denture base.Hyperplastic, mobile anterior ridgc offcrs minimumsupport and stabilit).-ofthe denture base.13,140 Reduction of the post malar space by the coronoidprocess during mandibular opening and/or excursivemovemcnts.Type D (Fig 8)0 Loss of anterior labial and posterior buccal vestibules.0 Palatal vault morpholoa does not resist vertical orhorizontal movement of the denture base.Maxillary palatal tori and/or lateral exostoses"(rounded or undercut) that intcrferc with theposterior border of the denture.Hyperplastic, redundant anterior ridge.Prominent anterior nasal spine.Muscle Attachments: Mandible onlyThe effects of muscle attachment and location aremost important to the function of a mandibulardent~re.~~'"'~ These characteristics are difficult toquantify. The classification system follows a logicalFigure 10. T\pe B mandibular muscle attarhmrnts. Lossof anterior labial vestibule.progression to describe the effects of muscular influenceon a mandibular denture. The clinician examinesthe patient and selects the category that is mostdescriptive of the mandibular muscle attachments.Type A (most favorable) (Fig 9)Attached mucosal base without undue muscularimpingement during normal function in all regions.Type B (Fig 10)Attached niucosal base in all regions exccpt labialvestibule .Mentalis muscle attachment near crest of alveolarridgc.Type C (Fig 11)Attached mucosal base in all regions except antcriorbuccal and lingual vestibules-canine to canine.Figure 9. Type A mandibular muscle attachments. Allvestibules are adequate.Figure 11. Type C mandibular muscle attachments. Lossof anterior labial and lingual vestibulcs.2010 CDEL Re-recognition of the Specialty Report 151 of 279

March 1.999, Volume 8, iVumber I 33dentition. Examine the patient and assign a class asfollows:Figure 12. Type D mandibular muscle attachments. Onlythe posterior lingual vestibule remains.0 Class I (most favorable): Maxillomandibular relationallows tooth position that has normal articulationwith the teeth supported by the rcsidualridge.Class II: Maxillomandibular relation requires toothposition outside the normal ridge relation to attainesthetics, phonetics, and articulation (eg, anterioror posterior tooth position is not supported by theresidual ridge; anterior vertical and/or horizontaloverlap exceeds the principles of fully balancedarticulation).0 Class III: LIaxillomandibular relation requirestooth position outside the normal ridge relationto attain esthetics, phonetics, and articulation(ie crossbitc-anterior or posterior toothposition is not supported by the residual ridge).Figure 13. Type E mandibular muscle attachmeiits. Nodiscernible vestibular anatomy remains.0 Genioglossus and meritalis muscle attachmentsnear crest of alveolar ridge.15Type D (Fig 12)0 Attached mucosal basc only in the posterior lingualregion.0 Mucosal base in all other regions is detached.Type E (Fig 13)No attached mumsa in any region.Maxilhadiibular RelationshipThe classification of the maxillomandibular relationshipcharacterizes the position of the artificial teethin relation to the residual ridge and/or to opposingIntegration of Diagnostic FindingsThe previous four subclassifications are importantdeterminants in the overall diagnosticclassification of complete edentulism. In addition,variables that can be expected to contribute toincreased treatment difficulty are distributedacross all classifications according to their significance.Classification Systemfor Complete EdentulismClass I (Fig 14 A-H)This classification level characterizes the stage ofederitulism that is most apt to be successfully treatedwith complete dentures using conventional prosthodontictechniques.6 All four of the diagnostic criteriaare favorable.Residual bone height of 21 mm or greater measuredat the least vertical height of the mandibleon a panoramic radiograph.Residual ridge morphology resists horizontal andvertical movement of the denture base; Type Amaxilla.Location of muscle attachments that arc conducivetu denture base stability and retention; TypeA or B mandible.Class I maxillomandibular relationship.2010 CDEL Re-recognition of the Specialty Report 152 of 279

Figure 14. Class Ipatient. (A) Panoramic radiograph. (B) Facial view at the approximate occlusal vcrtical dimension. (C)Otclusal view: maxillary arch. (0) Occlusal view: mandibular arch. (Ej Facial view: tongue in resting position. (4 Facialview: tongue elevated. (G) Lateral view of mandible: patient right. (23) Lateral view of mandible: patient left.2010 CDEL Re-recognition of the Specialty Report 153 of 279

Figure 15. Class II patient. (A) Panoramic radiograph. (B) Facial view a1 the approximate occlusal vertical dimension.(C) Occlusal view: maxillary arch. (0) Occlusalvicw: mandibular arch. (E) Facial view: tongue in resting position. (F) Facialview: tongue elevated. (G) Lateral view of mandible: paticnt right. (If) Lateralview of mandible patient left.2010 CDEL Re-recognition of the Specialty Report 154 of 279

Figure 16. Class KU patient. (A) Panoramic radiograph. (B) Facial view at the approximate occlusal vertical dimension.(C) Occlusal view: maxillary arch. (0) Occlusal view: mandibular arch. (E) Facial view: tongue in resting position. (F) Facialvkw: tongue elevated. (G) Lateral view of mandible: patient right. (H) Lateral view of mandible: patient left.2010 CDEL Re-recognition of the Specialty Report 155 of 279

Figure 17. Class IV patient. (4) Panoramic radiograph. (B) Facial tiew at the approximate occlusal vertical dimension.(C) Occlusal view: maxillary arch. (0) Occlusal view: mandibular arch. (E) Facial view: tongue in resting position. (F) Facialview: tongue elevated. (G) Lateral view of mandible: patient right. (H) Larcral view of mandible: patient left.2010 CDEL Re-recognition of the Specialty Report 156 of 279

38 Clm$cation of Cumllete EdClass 11 (Fig 15 A-H)This classification level distinguishes itself by thecontinued physical degradation of the denturesupportinganatomy, and, in addition, is characterizedby the early onset of systemic disease interactions,patient management, and/or lifestyleconsiderations.0 Residual bone height of 16 to 20 mrn measured atthe least vertical height of the mandible on apanoramic radiograph.0 Residual ridge morphology that resists horizontaland vertical movement of the denture base; TypeA or B maxilla.Location of muscle attachments with limited influenceon denture base stability and retention; TypeA or B mandible.Class I maxillomandibular relationship.Minor modifiers, psychosocial considerations,mild systemic disease with oral manifestation#Class 111 (Fig 16 A-N)This classification level is characterized by the needfor surgical revision of supporting structures to allowfor adequate prosthodontic function. Additional factorsnow play a significant role in treatment outcomes.Residual alveolar bone height of 11 to 15 mmmeasured at the least vertical height of the mandibleon a panoramic radiograph.Residual ridge morphology has minimum influenceto resist horizontal or vertical movement ofthe denture base; Type C maxilla.Location of muscle attachments with moderateinfluence on denture base stability and retention;Type C mandible.Class I, II, or III maxillomandibular relationship.0 Conditions requiring preprosthetic surgery'3:1) minor soft tissue procedures;2) minor hard tissue procedures including alveoloplastyI8;3) simple implant placement, no augmentationrequired;4) multiple extractions leading to complete edentulismfor immediate denture placement.Limited interarch space (18-20 mm).Moderate psychosocial consideration^'^^^^ andormoderatc oral manifestations of systemic diseasesor conditions such as xerostomia?l0 TMD symptoms present.140 Large tongue (occludes interdental space)** withor without hyperactivity.0 Hyperactive gagClass N (Fig 17)This classification level depicts the most debilitatededentulous condition. Surgical reconstruction is almostalways indicated but cannot always be accomplishedbecause of the patient's health, preferences,dental history, and financial considerations. Whensurgical revision is not an option, prosthodontictechniques of a specialized nature must be used toachieve an adequate treatment outcome.0 Kesidual vertical bone height of 10 mm or lessmeasured at the least vertical height of the mandibleon a panoramic radiograph.0 Residual ridge offers no resistance to horizontal orvertical movement; Type D maxilla.Muscle attachment location that can be expectedto have significant influence on denture basestability and retention; Type D or E mandible.0 Class I, 11, or 111 maxillomandibular relationships.0 Major conditions requiring preprosthetic surgery:I) complex implant placement,25 augmentationrequired;2) surgical correction of dentofacial deformities;3) hard tissue augmentation required;4) major soft tissue revision required, ie, vestibularextensions with or without soft tissue grafting.0 History of paresthesia or dysesthesia.Insufficient interarch space with surgical correc-tion required.Acquired or congenital maxillofacial defects.Severe oral manifestation of systemic disease orconditions such as sequelae from oncological treatment.Maxillo-mandibular ataxia (incoordination).Hyperactivity of tongue that can be associatedwith a retracted tongue position and/or its associatedmorphology.Hyperactive gag reflex managed with medication.Refractory patient (a patient who presents withchronic complaints following appropriate therapy).These patients may continue to have difficultyachieving their treatment expectations despite thethoroughness or frequency of the treatments provided.0 Psychosocial conditions warranting professionalintervention2010 CDEL Re-recognition of the Specialty Report 157 of 279

Murch 1999, Volume 8, Number I 39Guidelines for Use of the CompleteEdentulism Classification SystemIn those instances when a patient’s diagnostic crileriaare mixed between two or more classes, any singlecriterion of a more compt?ex clm places the patient intothe mnre complex class. The analysis of diagnosticfactors is facilitated with the use of a worksheet(Table 1).Use of this system is indicated for pretreatmentevaluation and classification of patients. Reevaluationof classification status should be consideredfollowing prcprosthetic surgery. Retrospective analysison a posttreatment basis may alter a patient’sclassification.Closing StatementThe classification system for complete edentulism isbased on the most objective criteria available tofacilitate uniform utilization of the system. Withsuch standardization, communication will be improvedamong dental professionals and third parties.This classification system will help to identify thosepatients most likely to require treatment by a spccialistor by a practitioner with additional training andexperience in advanced techniques. This systemshould also be valuable to research protocols asdifferent treatment proccdures are evaluated.AcknowledgmentThe authors thank Dr. Nancy Arbree and Ms. BrttyFreeman for their assistance in the preparation of thismanuscript. The authors also wish to recognize Dr. KentCohenour, Oral and Maxillofacial Surgeon, for his contributionto the original concept of a classification for completeedentulism.ReferencesGenco RJ: Classification and Clinical Radiographic Featuresof Periodontal Disease, in Robert J. Cenco, Henry M. Goldman,D. Walter Cohen (eds): Contemporary Periodontics(ed 6). St. Louis, MO, CliMosby, 1990, p 65American Association of Endodontists. Evaluating endcdontictreatment risk factors. Spring/Summer 1997. AAE, Chicago,ILParameters of Care for The American College of Prosthodontists.J Prosthod 1996;5:3-71Nimmo A, Wwlsey GD, Arbree NS, et al: Defining predoctoralprosthodontic curriculum: A workshop sponsnrcd by TheAmmican College of Prosthodontists and the ProsthodonticForum. J Prosthod 1998;7:30-345. Zarb GA Biomechanics of the edentulous state, in Zarb GA,Bolender CL, Carlsson GE (eds): Prosthodontic Treatmentfor Edentulous Patients (ed 11). St. Louis, MO, Mosby-YearBook, 1997,p 156. Atwood DA Some clinical factors related to rate of resorptionofresidual ridges. J Prosthet Dent 1962;12:4417. Ortman HR: Factors of bone resorption of the residual ridge.JProsthet Dent 1962;12:429408. Tallgren A The continuing reduction of the residual alveolarridges in complete denture wearers: h mixed-longitudinalstudy covering 25 years. J Prosthet Dent 1972;27:120-1329. Davis DM Developing an analoguehbstitute for the mandibulardenture-bearing area. in Zarb, Bolender, Carlsson (eds).Prosthodontic Treatment for Edentulous Patients (ed 11).St. Louis, MO. h4osby-Year Book, Inc, 1997, pp 162-17310. Zarb GA: Biomechanics of the edentulous state, in Zarb,Bolender, Carlsson (eds): Prosthodontic Treatment for EdentulousPatients (ed 11). St. Louis, MO, Mosby-Year Book,1997, pp 23-2411. Davis DhC Developing an analoguehbstitute for the maxillarydenture-bearing area, in Zarb, Bolender, Carlsson (eds).Prosthodontic Treatment for Edentulous Patients, 11 th edition,St. Louis,MO, Mosby-Year Book, 1997, pp 141-14912. Kolb Hk Variable denture-limiting structures of the edentulousmouth. Part I. hIaxillary border arras. J Prosthet Dent1966; 16: 194-20113. Hillerup S: Preprosthetic surgery in the elderly. J ProsthetDent 1994;72:.551-55814. Carlsson GE: Clinical morbidity and sequelae of treatmentwith complete dentures. J Prosthet Dent 1998;79:2015. Kazanjian VH: Surgery as an aid to more efficient service withprosthetic dentures. JAm Dent Assoc 1935;22:566-58116. DeVan h&k Basic principles in impression making. J ProsthetDent 1952;2:26-3517. Tilton GE: The denture periphery. JProsthet Dent 1952;2:290-30618. Kolb HR Variable denture-limiting structures of the edeutubusmouth. Part 11. Mandibular border areas. J Prosthet Dent1966;ifi:2n2-21219. van Waas MA: The influence ofpsychologic factors on patientsatisfaction with complete dentures. J Prosthet Dent 1990;63:545-54820. Vervoorn Jhl, Duinkerke ASH, Luteijn F, et al: Relativeimportance of psychologic factors in denture satisfaction.Commun Dent Oral Epidemiol 1991;1945-4721. Pendleton EC: The anatomy of the maxilla from the point ofview of full denture prosthesis.J Am Dent Assoc 1932;19:543-57222. Kinaldi P, Sharry J: Tongue force and fatigue in adults.J Prosthet Dent 1963;13:85723. Borkin UW Impression technique for patients that gag.JProsthet Dent 1958;9386-38724. Krol AJ: A new approach to the gagging problem. J ProsthetDent 1963;13:611-61625. Carlson B, CarlssonGE: Prosthodontic complications inosseointegrateddental implant treatment. Int J Oral MaxillofacImplants 1994;9:90-9426. .Jamb R Mixillofacid prosthodontics for the edentulouspatient. in Zarb, Bolender, Carlsson (eds). ProsthodonticTreatment for Edentulous Patients (ed 11). St. Louis, MO,Mohy-Year Book, 1997, pp 469-4902010 CDEL Re-recognition of the Specialty Report 158 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix C.b.Prosthodontics Diagnostic Index(PDI)b. Partially Edentulous Patients2010 CDEL Re-recognition of the Specialty Report 159 of 279

TOPICS OF INTEREST Classification System for Partial EdentulismThomas j. McGarry) DDS/ Arthur Nimmo, DDS/James F. Skiba) DDS/Robert H Ahlstrom) DDS) MS) 4 Christopher R. Smith) DDS) 5Jack H Koumjian) DDS) MSD)6 and Nancy S. Arbree, DDS) MS7The American College of Prosthodontists (ACP) has developed a classification system for partialedentulism based on diagnostic findings. This classification system is similar to the classificationsystem for complete edentulism previously developed by the ACP. These guidelines are intended tohelp practitioners determine appropriate treatments for their patients. Four categories of partialedentulism are defined, Class I to Class IV, with Class I representing an uncomplicated clinicalsituation and class IV representing a complex clinical situation. Each class is differentiated byspecific diagnostic criteria. This system is designed for use by dental professionals involved in thediagnosis and treatment of partially edentulous patients. Potential benefits of the system include (1)improved intraoperator consistency, (2) improved professional communication, (3) insurance reimbursementcommensurate with complexity of care, (4) improved screening tool for dental schooladmission clinics, (5) standardized criteria for outcomes assessment and research, (6) enhanceddiagnostic consistency, and (7) simplified aid in the decision to refer a patient.] Prosthodont 2002;11:181·193. Copyright © 2002 by The American College of Prosthodontists.INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education, outcomesassessment, quality assurance, treatment outcomes, patient risk profilesPARTIALLY EDENTULOUS patients exhibit a widerange of phys ical va riations and h ealth conditions. The a bse nce of organized diagnosticcriteri a for partia l ede ntulism has been a longstandi ng impedime nt to effective recogni tionJPrivate Practice, Oklahoma Cil)', OK.2Profe·Hor and Chainnan, Department o/Prosthodontics, Univmil)' 'IIFlorida College'll Dtnh'''J', Cainsville, FL.>Private Practice, Ill/onldalr, JIIJ.1Private Practice, Reno, NV, aild Associate Clini"al Professor, Department'II Restorative Denlifto" Univmity 'II the Pacific, Stockton, CA.5Associate Projessar, Department'll Clinical Su~ger)' , Universi t)' 'IIChica.~o, Chicago, IL."Clinical Associate Professor, Deparlment 'II Restorative Dentisto"Universil)' 'if California-San Francisco School 'II Dentist')', SanFrancsico, CA, and Private Practice, Palo A lto, CA.?Pr,!/imor and As.wciate Dean 'llAcademic AIJairs, Tufts UnivmirySchool'll Den tal Medicine and Private Practice, Boston, j\1A .Accepled April 8, 2002.Thil" project wasfu II ded b)! the A me1ican Colle,~e '!/ ProstilOdonlisls.Presented at Ihe Annual Sessions'll Ihe American Dental EducationAssociation, Washin,glon, DC, April 2, 2000, and the Ameri"a" Coliegl! 'IIProsthodol1tists, Hawaii, November 15, 2000.Cormpondence to: Thomas]. McCarl)', DDS, 4320 McAulq Blvd.,Oklahoma Cil)', OK 73120.Copyright © 2002 by The American Coliege ofProsthodontists1059-941X/02/1103-0006535 00/0doi. 10 1053/Jpro.2002. 126094of risk factors tha t may a ffect treatm e nt ou t­comes . Although described thoroughly in thedental li te rature,l.o the dive rse nat ure of pa r­tia l ede ntulism has no t been organize d in sucha way to g uid e de nta l profession als in the treatment planning process . T o address this problem,the American Coll ege of Prosthodontists(AC P) Subcommittee on Pros thodont ic Class i­ficat ion was form ed a nd ch arged with developinga class ific ation sys te m for partial ed entulismconsistent with the exis ting class ific a tionsys tem for complete edentulism. 2 A summaryof the ACP edentul ous class ification sys te m 1Sgive n in T abl e I.T he purpose of this class ification system is toprovid e a framework for the organization of clinicalobservations. Clinical variables that establish different leve ls of partial edentulism are organized ina simplified, sequential progression designed to facilitateconsis te nt and predictabl e treatment planningdecisions. T his framework is designed to indicateincre asing levels of diagnostic and treatmentcompl exity presented by patients with varying degreesof partial ede ntuJism. This may suggestpoints at which referral to other specialists is appropriate.The framework is structured to supportJ ournal of Prosthodonlics, Vol I I, No 3 (Sep lember), 2002: jJfJ 181-193 1812010 CDEL Re-recognition of the Specialty Report 160 of 279

182 Classification System for Partial Edentulism • M cGarry et alTABLE 1. ACP Class ification System of Complete EdentulismClass IThis class characterizes the stage of edentulism that is most apt to be successfully treated with complete denturesusing conventional prosthodontic techniques. All 4 of the diagnostic criteria are favorable.• Residual bone height of :2:21 mm measured at the least vertical height of the mandible on a panoramic radiograph.• Residual ridge morphology resistant to horizontal and vertical movement of the denture base; type A maxilla.• Location of muscle attachments conducive to denture base stability and retention; type A or B mandible• Class I maxilloma ndibular relationshipClass IIThis class is distingui shed by the continuEd physical degradation of the denture-supporting anatomy. It is alsocharacterized by the early onset of systemic disease interactions and by specific patient management a nd lifestyleconsiderations.• Residual bone height of ]6 to 20 mm measured at the least vertica l height of the mandible on a panoramicradiograph• Residual ridge morphology resistant to horizontal and vertical movement of the denture base; type A or B maxilla• Location of muscle attachments with limited influence on denture base stability and re tention; type A or Bmandible• Class I maxilloma ndibular relationship• Minor modifiers, psyc hosocial considerations, mild systemic disease with oral manifestationsClass IIIThis class is cha racterized by the need for surgical revision of supporting structures to a llow for adequateprosthodontic function. Additional factors now play a significant role in treatment outcomes.• Res idual al veol ar bone height of II to 15 mm measured at the least vertical height of the mandible on apanoramic radiograph• Residual ridge morphology with minimum influ ence to resist horizontal or vertical movement of the denturebase; type C maxilla• Location of muscle attachments with moderate influence on denture base stability and retention; type C mandible• Class I, II, or III maxillomandibular relationship• Conditions requiring preprosthetic surgery• Minor soft tiSSUE procedures• Minor hard tissue procedures including alveoloplasty• Simple implant placement; no augmentation required• Multiple extractions le ading to complete eclentulism for immediate denture placement• Limited interarch space (18 to 20 mm)• Moderate psychosocial considerations and/or moderate oral manifestations of systemic diseases or conditionssuch as xerostomia• Twill symptoms• Large tongue (occludes interdental space) with or without hyperactivity• H yperactive gag refl exClass IVThis class represents the most debilitated edentulolls condition. Surgical reconstruction is almost always indicatedbut cannot always be acco mplished because of the pati ent's health, preferences, past dental histo ry, and financialconsiderations. When surgical revision is not an option, prosthodontic techniques of a specialized nature must beused to achieve an adequate outcome.• Residual vertical bone height of:510 mm measured at the least vertical height of the mandible 01) a panoramicradiograph• Class I , II, or III maxillomandibular relationships• Res idual ridge ofTering no resistance to horizontal or vertical movement; type D maxilla• Muscle attachment location that can be expected to have significant influence on denture baSE stability andretention; type D or E mandible• Major conditions requiring preprosthetic surgery• Complex implant placement, augmentation requi red• Surgical correction of dentofacial deformities required• Hard tissue augmen tation required• jYIajor soft tissue revision required, that is, vestibular extensions with or witbout soft tissue grafting• History of paresthesia or dysesthesia• Insufficient interarch space necess itating surgical correction• Acquired or congenital maxillofacial defects• Seve re oral. manifesta tion of systemic disease or conditions such as sequelae from oncologic treatment• Maxillomandibular ataxia (incoordination)• H yperactivity of tong ue possi bl y associated with a retracted tongue position and/or its associated morphology• H ype ractive gag reflex managed "rith medication• Refractory patient (a patient wbo prese nts with chronic complaints foll owing appropriate therapy), who maycontinue to have difficulty achi eving their treatment expectations despite the thoroughness or frequency of thetreatments provided.• Psychosocial conditions warranting professional intervention2010 CDEL Re-recognition of the Specialty Report 161 of 279

September 2002, Volume I I, Number 3183diagnostically driven treatment plan options andwill also be useful in an educational environmentfor triaging the patient upon entry into an institutionalsetting.Partial edentulism is defined as the absenceof some bu t not all of the natu ral tee th in adental arch. In a partially edentulous patient,the loss and continuing degradation of the alveolarbone, adjacent teeth, and supportingstructures influence the leve l of difficulty inachieving adequate prosthetic restoration.The quality of the supporting structures contributesto the overall condition and is considered in the diagnostic levels of the classificationsystem.Only the most significant diagnostic criteriahave been id entified. Selection ofappropriate treatment will be developed subsequently in a Parametersof Care document 3 It is anticipated that boththe edentulous and partially edentulous classificationsys tems will be incorporated into existing electronicdiagnostic and procedural databases (SNO­DENT, lCD, CPT, and CDT).The classification system is intended to offer thefollowing benefits:1. Improved intraoperator consis tency2. Improved professional communication3. Insurance reimbursement commensurate withcomplexity of care4. An objective method for patient screening indental education5. Standardized criteria far outcomes assessmentand research6. Improved diagnostic consistency7. A simplified, organized aid in the decision-makingprocess relating to referral.ApplicationsDiagnos is must be determined before treatment recommendations can be made. Whilethis classification sys tem is not a predictor ofsuccess of the pros thodon ti c trea tmen t, clinicalou tcomes will be evaluated in terms of evidence-based criteria.When combined with the Parameters of Caredocument, this cl ass ification sys tem will provide abasis for diagnos is and treatment procedures. Theexperiences gained \"ill enable updating of the Parametersof Care. The classification system will besu bject to revision based upon inpu t from clinicians,as well as when new diagnostic and treatment informationbecomes available.Review of the Diagnostic CriteriaThis section describes four broad diagnostic categoriesrelevant to classification of partially edentulouspatients:1. Location and exten t of the edentulous area(s)2. Condition of abutments3. O cclusion4. Residual ridge characteristics.The criteria descriptions begin with the leas tcomplicated and progress to the most complicated.The diagnostic criteria are as follows.Criteria 1.- Location and Extent of theEdentulous Area(s)A. Ideal or minimally compromised edentulous areaThe edentulous span is confined to a single archand I of the following:• Any anterior maxillary edentulous area that doesnot exceed 2 incisors• Any anterior mandibular edentulous area thatdoes not exceed 4 incisors• Any posterior maxillary or mandibular edentulousarea that does not exceed 2 premolars, or Ipremolar and 1 molar.B. Moderately compromised edentulous areaEdentulous areas in both arches and in I of thefollowing:• Any anterior maxillary edentulous area that doesnot exceed 2 incisors• Any anterior mandibular edentulous area thatdoes not exceed 4 incisors• Any posterior maxillary or mandibular edentulousarea that does not exceed 2 premolars, or 1premolar and I molar• A missing m axill ary or mandibular canin e.C. Substantially compromised edentulous area• Any posterior m axillary or mandibular edentulousarea greate r than 3 teeth or 2 molars• Any edentulous areas including anterior and posteriorareas of 3 or more teeth.2010 CDEL Re-recognition of the Specialty Report 162 of 279

184 Classification System Jor Partial Edentulism • McGarry et alFigure 1. Class I patient. This patient I is categorized in Class I due to a n ideal or minimally compromised edentulousarea, abutment condition, and occl usion. There is a single edentulous area in I sextant. The residua l ridge is consideredtype A. (A) Fron tal vi ew, m aximum intercuspation. (B) Right lateral view, maxi mum intercuspation. (C) Lert lateral view,maximum intercuspation. (D) Occlusal \~ew, ma..'{illary arch. (.6') Occlusal view, mandibular arch. (F) Frontal view,protrusive relationship.D. Severely compromised edentulous area B. M oderateb' compromised abutment conditionAny edentulous area or combination of edentulousareas requiring a high level of patient compliance. • Abutments in I or 2 sextants* have insufficienttooth structure to retain or support intracoronalCriteria 2: Abutment Conditionsor extracoronal restorations.• Abutments in I or 2 sextants require localizedA Ideal or minimally compromised abutment conditio/l.J adjunctive therapy (ie, periodontal, endodon tic,No preprosthetic therapy is indicated.or orthodontic procedures).2010 CDEL Re-recognition of the Specialty Report 163 of 279

September 2002, Volume 11, Number 3185Figure 1. (Cont'd) (G) Right lateral view, right wo rking move ment. (J-I) Left lateral view, left working movement. (/)Full mouth radiographi c series.C. SubstantiaLly compromised abutment condition• Abutments in 3 sextants have insufficient toothstructure to retain or support intracoronal orextracoronal res torations.• Abutments in 3 sextants require more substantiallocalized adjunctive therapy (ie, periodontal,endodontic, or orthodontic procedures).D. Severely compromised abutment condition• Abutments in 4 or more sextants have insufficienttooth structure to retain or support intracoronalor ex tracoronal restorations.*J\ se.xtanl is a , ubdivisioll or the de nt al arch. Themaxillary and mandibular dental arches Inay be subdivided into 6 are", or sextants. In the maxilla, the ri g'htposlerior sex lant extends ['rom 1001h I to {ooth 5, Lilt' leftpos l. (- rior sex tant extends from tooth 12 to tooth 16, andthe ant" rior sexta nt ""'lends from toolh 6 to toolh II. InIh e mandible, the rig-hi posterior sex tanl extends fromtooth 2H to tooth 3 ~, the le rt posterior sextant ('xtl-odsrrom looth 17 10 tooth 21, and the anterior sexlanteXleods from w"lh 22 to looth 27.• Abutments in 4 or more sextants require extensiveadjunctive therapy (ie, periodontal, endodontic,or orthodontic procedures).• Abutments have guarded prognoses.Criteria 3: OcclusionA. IdeaL or minimally compromised occlusaL charactensIlcs• No preprosthetic therapy is required• Class I molar and j aw relationships are seen.B. Moderately compromised occlusal characteristics• O cclusion requires localized adjunctive therapy(eg, enameloplasty on premature occlusal contacts).• Class I molar and j aw relationships are seen.C. SubstantiaLLy compromised occlusaL characteristics• Entire occlusion must be reestablished, but withoutany change in the occlusal vertical dimension.• Class II molar and jaw relationships are seen.2010 CDEL Re-recognition of the Specialty Report 164 of 279

186 Classification Systemfor Partial Edentulism • McGarry et alFigure 2. Class II patient. This patient is Class II because he has edentulous areas in 2 sextants in different arches.IA) Frontal vi ew, maximum intercuspation. (B) Right lateral view, maximum intercuspation. (C) Left lateral view,maximum intercuspation. (D) Occlusal vi ew, maxillary arch. (E) Occlusal view, mandibular arch. (F) frontal vi ew,protrusive relationship. (G) Right lateral view, right working movement. (H) Left lateral view, left working movement.2010 CDEL Re-recognition of the Specialty Report 165 of 279

September 2002, Volume II, Number 3187Figure 2. (Cont'd) (1) Full moulh radiographic series.D. Severely compromised occlusal characteristics• Entire occlusion must be reestablished, includingchanges in the occlusal vertical dimension.• Class II division 2 and Class TIl molar and jawrelationships are seen.Criteria 4: Residual Ridge CharacteristicsThe criteria published for the Classification Systemfor Complete Edentulism are used to categorizeany edentulous span present in the partially edentulouspatient (see Table I).Classification System for Partial Edentulism The 4 criteria and their subclassifications are organizedinto an overall classification system for partialedentulism.Class I (Fig lA-I)This class is characterized by ideal or minimalcompromise in the location and extent of edentulousarea (which is confined to a single arch), abutmentconditions, occlusal characteristics, and residualridge conditions. All 4 of the diagnostic criteriaare favorable.1. The location and extent of the edentulous areaare ideal or minimally compromised:• The edentulous area is confined to a single arch.• The edentulous area does not compromise thephysiologic support of the abutments.• The edentulous area may include any anteriormaxillary span that does not exceed 2 incisors,any anterior mandibular span that does not exceed4 missing incisors, or any posterior spanthat does not exceed 2 premolars or I premolarand I molar.2. The abu tment condition is ideal or minimallycompromised, with no need for preprosthetictherapy.3. The occlusion is ideal or minimally compromised,with no need for preprosthetic therapy;maxillomandibular relationship: Class I molarand jaw relationships.4. Residual ridge morphology conforms to theClass I complete edentulism description.Class II (Fig 2)This class is characterized by moderately compromisedlocation and extent of edentulous areas inboth arches, abutment conditions requiring localizedadj unctive therapy, occlusal characteristics requiringlocalized adjunctive therapy, and residualridge conditions.1. The location and extent of the edentulous areaare moderately compromised:• Edentulous areas may exist in I or both arches.2010 CDEL Re-recognition of the Specialty Report 166 of 279

188 Classification System jor Partial Edentu lism • McGarr), et alFigure 3. C lass III pati ent. This pa ti ent is Class III because the edentulous area(s) are located in both arches andmultiple locations within each arch. The abutment condition is substantially compromised due to the need forextracoronal restorations. There are teeth that are extruded and malpositioned. The occlusion is substantia llycompromised because reestablishment of the occlusal scheme is required without a change in the occlusal ve rticaldimension. (Jl) Frontal view, maximum intercuspation. (B) Right lateral vi ew, maximum intercuspati on. (C) Left lateralview, ma,imum intercuspation. (D) Occlusal view, maxill ary arch. (E) Occlusal view, mandibular arch. (F) Frontal vi ew,protrusive relati onship. (G) Right lateral view, right working movem ent. (H) Left lateral view, left working movement.2010 CDEL Re-recognition of the Specialty Report 167 of 279

September 2002, Volume 11, Number 3189Figure 3. (Cont'd) (/) Full moulh radiographic seri es.• The edentulous areas do not co mpromise thephysiologic support of the abutments.• Edentulous areas may include any anterior maxillalYspan that does not exceed 2 incisors, anyanterior mandibular span that does not exceed 4incis ors, any posterior span (maxillary or mandibular)that does not exceed 2 premolars, or Ipremolar and I molar or any mlssmg canine(ma.;"illary or mandibular).2. Condition of the abutments is moderately compromised:• Abutments in I or 2 sextants have insufficienttooth structure to retain or support intracoronalor extracoronal restora tions.• Abutments in I or 2 sextants require localizedadjunctive therapy.3. O cclusion is moderately compromised:• O cclusal correction requires loca lized adjunctivetherapy.• Maxillomandibular relationship: Class I molarand jaw relationships.4. Residual ridge morphology conforms to theClass II complete edentulism description.Class III (Fig 3)This class is characterized by substantially compromisedlocation and extent of edentulous areas inboth arches, abutment condition requiring substantiallocalized adjunctive therapy, occlusal characteristicsrequiring re es tablishment of the entire occlusionwithout a change in the occlusal ve rticaldimension, and residual ridge condition.1. The loca tion and extent of the edentulous areasare substantially compromised:• Edentulous areas may be present 111 I or botharches.• Edentulous areas compromise the phys iologicsupport of the abutments.• Edentulous areas may include any posterior maxillaryor mandibular edentulous area greaterthan 3 teeth or 2 molars, or anterior and posterioredentulous areas of 3 or more teeth.2. The condition of the abutments is mod eratelycompromised:• Abutments in 3 sextants have insufficient toothstructure to re tain or support intracorona l orextracoronal restorations.• Abutments in 3 sextants require more substantiallocalizedadjunctive therapy (ie, periodontal,endodontic or orthodontic procedures).• Abu tments have a fair prognosis.3. O cclusion is substantially compromised:• Requires reestablishment of the entire occlusalscheme without an accompanying change in theocclusal vertical dimension.• rvIaxillomandibular relationship: Class II molarand jaw relationships.4. Res idual ridge morphology conforms to theClass III complete edentulism d escription.Class IV (Fig 4)This class is characterized by severely compromisedlocation and ex tent of edentulous areas with2010 CDEL Re-recognition of the Specialty Report 168 of 279

Figure 4. Class IV palienl. Edenlulous areas are found in bOlh arches, and the physiologic abutmenl SuppOrl iscompromised. Abulmenl condilion is severely compromised due lo advanced atlrition and failing restoralions,necessitating extracoronal restorations and adjunctive lherapy. The occlusion is seve rely compromised, necessilatingreeslablishmenl of occlusal vertical dimension and a proper occl usal sche me. (A) Frontal view, maximum inlercuspation.(B) Right lateral view, maximum intercuspalion. (C) Lerl lateral view, maximum inlercuspation. (D) Occlusal \~ew,maxillary arch. (E) Occlusal view, mandibular arch. (F) Frontal view, protrusive relationship. (G) Right lateral view, rightworking movemenl. (H) Lerl lateral view, left working movemenl.2010 CDEL Re-recognition of the Specialty Report 169 of 279

September 2002, Volume II, Number 3191Figure 4. (Cont'd) (1) Full moulh radiographic series.guarded prognosis, abutments requiring extensivetherapy, occlusion characteristics requiring reestablishmentof the occlusion with a change in theocclusal vertical dimension, and residual ridge conditions.1. The location and extent of the edentulous areasresults in severe occlusal compromise:• Edentulous areas may be extensive and mayoccur in both arches.• Edentulous areas compromise the physiologicsupport of the abutment teeth to create aguarded prognosis.• Edentulous areas include acquired or congenitalmaxillofacial defects.• At least 1 edentulous area has a guarded prognosis.2. Abu tments are severely compromised:• Abutments in 4 or more sextants have insufficienttooth structure to retain or support intracoronalor extracoronal restorations.• Abutments in 4 or more sextants require extensivelocalized adjunctive therapy.• Abutments have a guarded prognosis.3. Occlusion is severely compromised:• Reestablishment of the entire occlusal scheme,including changes in the occlusal vertical dimen­SIOn, IS necessary.• Maxillomandibular relationship: class II division2 or Class III molar and jaw relationships.4. Residual ridge morphology conforms to the classIV complete edentulism description.Other characteristics include severe manifestationsof local or systemic dis ease, including sequelaefrom oncologic treatment, maxillomandibular dyskinesiaand/or ataxia, and refractory patient (apatient who presents with chronic complaints followingappropriate therapy).Guidelines for the Use of Classification System for Partial Edentulism The analysis of diagnostic factors is facilitated wlththe use of a worksheet (Table 2) . Each cri terion isevaluated and a check mark placed in the appropriatebox. In those instances in which a patient'sdiagnostic criteria overlap 2 or more classes, thepatient is placed in the more complex class.The following additional guidelines should befollowed to ensure consistent application of theclassification system:1. Consideration of future treatment proceduresmust not influence the choice of diagnostic level.2. Initial preprosthetic treatment and/or adjunctivetherapy can change the initial classificationlevel. Classification may need to be reassessedafter existing prostheses are removed.3. Esthetic concerns or challenges raise the classificationby 1 level in Class I and II patients.2010 CDEL Re-recognition of the Specialty Report 170 of 279

I192 Classification Sy stemfor Partial Edentulism • McGarry et al4. The presence of TNID symptoms raises the classificationby I or more levels in Class I and IIpatients.5. In a patient presenting with an edentulous maxillaopposing a partiaUy edentulous mandible,each arch is diagnosed according to the appropriateclassification system; that is, the maxilla isclassified according to the complete edentulismclassification system, and the mandible is classifiedaccording to the partial edentulism classificationsys tem. The sole exception to this ruleoccurs when the patient presents with an edentulousmandible opposed by a partially edentulousor dentate maxilla. This clinical situationprese nts significant complexity and potentiallong-term morbidity and as such, should be diagnosedas a Class IV in either sys tem.6. Periodontal health is intimately related to thediagnosis and prognosis for partially edentulouspatients. For the purpose of this system, it isassumed that patients will receive therapy toachieve and maintain periodontal health so thatappropriate prosthodon tic care can be accomplished.Closing StatementThe classifica tion system for partial edentulism isbased on the most objective criteria available tofacilitate uniform use of the system. Such standardizationmay lead to improved communicationsamong dental professionals and third parties. Thisclassification system will serve to identify thosepatients most likely to require treatment by a specialistor by a practitioner with additional trainingand experience in advanced techniques. This systemshould also be valuable to research protocols asdifferent treatment procedures are evaluated. Withthe increasing complexity of patient treatment, thispartial edentulism classification system, coupled\·\~th the complete ed entulism classification system,will help dental school faculty assess entering pa-TABLE 2. Worksheet Used to Determine ClassificationClass J Class JI Class 1JI Class IVLocation & Extent of Edentulous AreasIdeal or minimally compromised-single archIVIoderately compromised-both archesSubstantially compromised­ > 3 tee thSeverely compromised-guarded prognosisC ongenital or acquired maxillofacial defectAbutment ConditionIdeal or minimally compromisedMod era tely compromised-I-2 sextantsSubstantially compromised-3 sextantsSeve rely compromised--4 o r m ore sextantsOcclusionIdeal or minimally compromisedMode rately compromised-local adjunctive txSubstantially co mpromised-occlusal sch em eSeverely compromised--

September 2002, Volume ii, Number 3193tients for the most appropriate patient assignmentfor better care. Based on use and observations bypractitioners, educators, and researchers, this systemwill be modified as needed.AcknowledgementThe authors thank Dr. David Cagna and Dr. Rodney D.Phoenix, Department of Prosthodontics, University ofTexas Health Science C enter, San Antonio for theirassistance in providing the classification illustrations.ReferencesI. DeVan IvIM: The nature of the partial denture foundation:Suggestions for its preservation.] Prosthet Dent 1951 ;2:210·21 82. Applegate OC: An evaluation of the support for the re movablepartial denture..l Prosthet Dent 1960;10: 1123. ReYl1 olds]M: Abutment sel ection for r,xed prosthodontics.]Prosthe t Dent 1968; 19:483-4884. i'v1ehta]D,]oglekar AP: Vertical jaw rela tions as a factor inpartial dentures. ] Prosthet Dent 1969;21:618-6255. Willarson KL: R emovable partia l denture prosthesis[o r the periodontal patient. Th e curre nt status-anoption. Dent Clin North Am 1969;13:263-2796. Kelly E: Changes caused by a ma ndibular removable pa rtialdenture opposing a maxillary complete denture.] ProsthetDent 19 72;27:1 40-1507. Laney \VR, Desjardins RP: Surgical preparation of th e partiallyedentulous patient. Dent Clin North Am 1973;17:611-6308. Turner CH, Ritchie GM: The problems of maxillary completedentures opposed by re tained mandibular incisor andcanine teeth (I). Quintess ence lnt 1978;9:29-349. Culpepper WD, Moulton PS: Considerations in fix ed prosthodontics. Dent Clin North Am 1979;23:21-3510. Saunders TR, Gillis R.E ]r, Desjardins RP: The maxillarycomplele denlure opposing th e mandibular bilateral di stalextensionpa rtial d enture: Treatment considerations.] ProslhetDent 1979;41:124-128II Dibai N, Mechanic E: Prosthodontic treatment for the complex mandibular Class I partially edentulous patient.] De ntQue 1980; I7:63-6512. Za rb GA, MacKay HF: The panially edentulous patient. I.The biologic price of prosthodontic intervention. Aust De ntJ 1980;2563-6813. Pekkarinen V, Yli-Urpo A: Dysfunction of th e masticatorysystem and the mutilated dental arch: Anamnestic index,dysfunctio n index and occlusal ind ex before restora tive andprosthetic trea tment. Proc Finn Dent Soc 1984;80:73-7914. Misch CE, Judy KW: Classification of partially edentulousa rches for implant dentislly. IntJ Oral lmplantol 1987;4:7- 1315. Arlin Mi.: Dental implants and the partially edentulouspatient. Diagnosis and treatment planning. Oral Health1989;79: 19-2116. Devlin H: Replacem ent of miss ing molar leeth-A prosth.odontic dilemma. Br Dent J 1994; 176:3 1-3317. Goldberg PV: Retention of teeth and placement of implantsinthe partially edentulous maxilla: the decision-makingprocess. Dent Implantol Upda te 1995;6:9-1318. Ben-Ur Z, Shifman BZ, Aviv 1: Further aspects of design fordistal extension removable partial dentmes based on theKennedy classification . .1 Oral Rehabil 1999;26: 165- I6919 Ihde SK: Fixed prosthodontics in skeleta l Class III patie ntswith partially edentulous jaws and age-related prognathism:The basal osseointegration procedure. Implant Dent 1999;8:241-24620. Sabri R: Management of missing maxillary lateral incisors..1 Am Dent Assoc 1999; 130:80-8421. IvlcGa rry T.1, Nimmo A, SkibaJF, et al: Class ifi cation system[or comple te edentulism . .J Prosthodont 1999;8:27-3922. Parameters or Care for the American Coll ege o[ Prosthodontists.]Prosthodont 1996;5:3-712010 CDEL Re-recognition of the Specialty Report 172 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix C.c.Prosthodontics Diagnostic Index(PDI)c. Dentate Patients2010 CDEL Re-recognition of the Specialty Report 173 of 279

Classification System for the CompletelyDentate PatientThomas J. McGarry, DDS; 1 Arthur Nimmo, DDS; 2 James F. Skiba, DDS; 3Robert H. Ahlstrom, DDS, MS; 4 Christopher R. Smith, DDS; 5Jack H. Koumjian, DDS, MSD; 6 and Gregory N. Guichet, DDS 7The American College of Prosthodontists (ACP) has developed a classification system designedfor use by dental professionals in the diagnosis and treatment of completely dentate patients. Thisclassification is the third in a series and is similar to the Classifications for Complete Edentulismand Partial Edentulism previously developed by the ACP. These guidelines are intended to aidpractitioners in the systematic diagnosis of each patient which, in turn, should lead to an appropriatetreatment. Four categories of a completely dentate situation are defined (Class I–IV), differentiated byspecific diagnostic criteria, with Class I representing an uncomplicated clinical situation and Class IVrepresenting the most complex clinical situation. Potential benefits of the system include (1) improvedintraoperator consistency, (2) improved professional communication, (3) insurance reimbursementcommensurate with complexity of care, (4) an improved screening tool for dental school admissionclinics, (5) standardized criteria for outcomes assessment and research, (6) enhanced diagnosticconsistency, and (7) a simplified aid in the decision-making process associated with referral.J Prosthodont 2004;13:73-82. Copyright C○ 2004 by The American College of Prosthodontists.INDEX WORDS: diagnosis, treatment planning, prosthodontics, dental education, outcomesassessment, quality assurance, treatment outcomes, patient risk profiles, restorative dentistryCOMPLETELY DENTATE patients needingprosthodontic treatment exhibit a wide rangeof physical variations and health conditions. Theabsence of organized diagnostic criteria for suchpatients has been a long-standing impedimentto the effective recognition of risk factors thatmay affect treatment outcomes. Whereas therehave been previous published classification ef-1 Private Practice, Oklahoma City, OK.2 Professor and Chair, Department of Prosthodontics, University ofFlorida College of Dentistry.3 Private Practice, Montclair, NJ.4 Private Practice, Reno, NV, and Associate Professor, Departmentof Removable Prosthodontics, University of the Pacific, San Francisco,CA.5 Associate Professor, Department of Clinical Surgery, University ofChicago.6 Clinical Associate Professor, Department of Restorative Dentistry,UCSF School of Dentistry and Private Practice, Palo Alto, CA.7 Private Practice, Orange, CA.Accepted February 17, 2004Presented at the Annual Sessions of the American Dental EducationAssociation in Chicago in 2001 and the American College of Prosthodontistsin New Orleans in 2001 and Orlando in 2002.This project was funded by the American College of Prosthodontists.Correspondence to: Thomas J. McGarry, DDS, 4320 McAuleyBoulevard, Oklahoma City, OK 73120. E-mail: mcgarry@qns.comCopyright C○ 2004 by The American College of Prosthodontists1059-941X/04doi: 10.1111/j.1532-849X.2004.04019.xforts, these have not been widely utilized. 1-4 Toaddress this problem, the American College ofProsthodontists (ACP) charged a subcommitteeon prosthodontic classification with the task ofdeveloping a classification system for the completelydentate patient consistent with the existingclassification systems for complete and partialedentulism. 5,6 A summary of the ClassificationSystem for Partial Edentulism is listed inTable 1.The classification system provides a frameworkfor the organization of clinical observations. Clinicalvariables that establish different levels forthe completely dentate patient are organized ina simplified, sequential progression designed tofacilitate consistent and predictable treatmentplanning decisions. This framework is structuredto accommodate increasing levels of diagnosticand restorative complexity. This structure maysuggest points at which referral to other specialistsis appropriate. The framework supportsdiagnostically driven treatment plan options andwill also be useful in an educational environmentfor triaging patients on entry into an institutionalsetting.A completely dentate patient is defined as anindividual with an intact continuous permanentdentition with no missing teeth or roots excludingJournal of Prosthodontics, Vol 13, No 2 (June), 2004: pp 73-82 732010 CDEL Re-recognition of the Specialty Report 174 of 279

74 Classification System for the Completely Dentate Patient McGarry et alTable 1. ACP Classification System for Partial EdentulismClass IThis classification level is characterized by being ideal or minimally compromised in: location and extent ofedentulous area which is confined to a single arch, abutment conditions, occlusal characteristics, and residualridge conditions. All 4 of the diagnostic criteria are favorable.• Location and extent of the edentulous area is ideal or minimally compromised• Edentulous area is confined to a single arch• Edentulous area does not compromise the physiologic support of the abutment• Edentulous area may include any anterior maxillary span that does not exceed 2 incisors, any anteriormandibular span that does not exceed 4 missing incisors, or any posterior span that does not exceed 2premolars or 1 premolar and a molar• Abutment condition is ideal or minimally compromised, with no need for preprosthetic therapy• Occlusion is ideal or minimally compromised with no need for preprosthetic therapy• Maxillomandibular relationship: Class I molar and jaw relationships• Residual ridge morphology conforms to the Class I complete edentulism descriptionClass IIThis classification level is characterized by being moderately compromised in: location and extent ofedentulous areas in both arches, abutment condition requiring localized adjunctive therapy, occlusalcharacteristics requiring localized adjunctive therapy, and residual ridge condition.• Location and extent of the edentulous area is moderately compromised• Edentulous areas may be in 1 or both arches• Edentulous areas do not compromise the physiologic support of the abutments• Edentulous areas may include:◦ any anterior maxillary span that does not exceed 2 incisors,◦ any anterior mandibular span that does not exceed 4 incisors◦ any posterior span (maxillary or mandibular) that does not exceed 2 premolars, or◦ one premolar and a molar or any missing canine (maxillary or mandibular)• Condition of the abutments is moderately compromised◦ Abutments in 1 or 2 sextants have insufficient tooth structure to retain or support intracoronal orextracoronal restorations◦ Abutments in 1 or 2 sextants require localized adjunctive therapy• Occlusion is moderately compromised◦ Occlusal correction requires localized adjunctive therapy◦ Maxillomandibular relationship: Class I molar and jaw relationships• Residual ridge morphology conforms to the Class II complete edentulism descriptionClass IIIThis classification level is characterized by being substantially compromised in: location and extent ofedentulous areas in both arches, abutment condition requiring substantial localized adjunctive therapy,occlusal characteristics requiring reestablishment of the occlusion without a change in the occlusal verticaldimension, and residual ridge condition.• Location and extent of the edentulous areas is substantially compromised• Edentulous areas may be present in 1 or both arches• Edentulous areas compromise the physiologic support of the abutments• Edentulous areas may include:◦ any posterior maxillary or mandibular edentulous area that is greater than 3 teeth or 2 molars◦ anterior and posterior edentulous areas of 3 or more teeth• The condition of the abutments is moderately compromised◦ Abutments in 3 sextants have insufficient tooth structure to retain or support intracoronal or extracoronalrestorations◦ Abutments in 3 sextants require more substantial localized adjunctive therapy, i.e., periodontal,endodontic, or orthodontic procedures◦ Abutments display fair prognosis• Occlusion is substantially compromised◦ Requires reestablishment of the entire occlusal scheme without an accompanying change in the occlusalvertical dimension◦ Maxillomandibular relationship: Class II molar and jaw relationships• Residual ridge morphology conforms to the Class III complete edentulism descriptionClass IVThis classification level is characterized by being severely compromised in: location and extent of edentulousareas with guarded prognosis, abutments requiring extensive therapy, occlusion characteristics requirereestablishment of the occlusion with a change in the occlusal vertical dimension, and residual ridge condition.• Location and extent of the edentulous areas results in severe occlusal compromise• Edentulous areas may be extensive and may occur in both arches• Edentulous areas compromise the physiologic support of the abutment teeth to create a guarded prognosis(Continued)2010 CDEL Re-recognition of the Specialty Report 175 of 279

June 2004, Volume 13, Number 2 75Table 1. Continued• Edentulous areas include acquired or congenital maxillofacial defects• At least 1 edentulous area has a guarded prognosis◦ Abutments are severely compromised◦ Abutments in 4 or more sextants have insufficient tooth structure to retain or support intracoronal orextracoronal restorations◦ Abutments in 4 or more sextants require extensive localized adjunctive therapy◦ Abutments have a guarded prognosis• Occlusion is severely compromised◦ Reestablishment of the entire occlusal scheme, including changes in the occlusal vertical dimension◦ Maxillomandibular relationship: Class II Division 2 or Class III molar and jaw relationships• Residual ridge morphology conforms to the Class IV complete edentulism description• Severe manifestations of local or systemic disease including sequelae from oncologic treatment• Maxillo-mandibular dyskinesia and/or ataxiaNOTE. Table 1 is based on McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Arbree NS. Classificationsystem for partial edentulism. J Prosthodont 2002;11:181-193. Used with permission.the third molars. This definition should be understoodto include patients who may have missingteeth or roots but who nevertheless have acontinuous symmetric dental arch of at least 12teeth, such as occurs in many post-orthodontictreatment patients who are missing a premolarin each quadrant. In such a dentate patient,the degree of loss and continuing degradation ofthe alveolar bone, adjacent teeth, and supportingstructures influences the level of difficultyin achieving adequate prosthodontic restoration.The quality of the supporting structures contributesto the overall condition and is taken intoaccount in the diagnostic levels of the classificationsystem.Widely recognized significant diagnostic criteriahave been identified. Selection of appropriatetreatment will be developed subsequently in a Parametersof Care document. 7 It is anticipated thatall 3 classifications, Complete Edentulism, PartialEdentulism and the Completely Dentate Patient,will be incorporated into existing electronic diagnosticand procedural databases (SNODENT,ICD, CPT, and CDT).The classification system offers the followingbenefits:1. Improved interoperator consistency2. Improved professional communication3. Insurance reimbursement commensurate withcomplexity of care4. An objective method for patient screening indental education5. Standardized criteria suitable for use in outcomesassessment and research6. Improved diagnostic consistency7. A simplified, organized aid in the decisionmakingprocess associated with referral.ApplicationsBefore treatment recommendations can be made,a diagnosis must be determined. Whereas thisclassification system cannot serve as a predictorof the success of the prosthodontic treatment,it will allow clinical outcomes to be evaluatedin terms of evidence-based criteria. When combinedwith the Parameters of Care document,this classification system will provide a basis forselecting diagnosis and treatment procedures.The experiences gained will enable updating ofthe Parameters of Care based on clinical outcomesevidence. The classification system will besubject to revision based on input from clinicians,as well as on new diagnostic and treatmentinformation.Review of the Diagnostic CriteriaThis section describes the 2 broad diagnostic categoriesrelevant to the classification of the completelydentate patient: tooth condition and occlusalscheme.Criteria 1. Tooth ConditionA. Ideal or minimally compromised toothcondition No localized adjunctive therapy required.2010 CDEL Re-recognition of the Specialty Report 176 of 279

76 Classification System for the Completely Dentate Patient McGarry et al Pathology that affects the coronal morphologyof 3 or fewer teeth in only 1 sextant. ∗B. Moderately compromised tooth condition Tooth condition—insufficient tooth structureto retain or support intracoronal orextracoronal restorations—in 1 sextant. Pathology that affects the coronal morphologyof 4 or more teeth in a sextant. Pathology may occur in 2 sextants and maybe present in opposing arches. Teeth require localized adjunctive therapy,i.e., a periodontal, endodontic, or orthodonticprocedure for a single tooth or in a singlesextant.C. Substantially compromised tooth condition Tooth condition—insufficient tooth structureto retain or support intracoronal orextracoronal restorations occurring in 2sextants. Pathology affecting the coronal morphologyof 4 or more teeth in 3–5 sextants. Pathology may occur in 3 sextants in thesame arch and/or in opposing arches. Teeth require localized adjunctive therapy,i.e., a periodontal, endodontic, or orthodonticprocedures for teeth in 2 sextants.D. Severely compromised tooth condition Tooth condition—tooth structure in 3 ormore sextants insufficient to retain or supportintracoronal or extracoronal restorations. Pathology affecting the coronal morphologyof 4 or more teeth in all sextants. Teeth requiring localized adjunctive therapy,i.e., periodontal, endodontic, or orthodonticprocedures in 3 or more sextants.Criteria 2. Occlusal SchemeA. Ideal or minimally compromised occlusalscheme.∗ A sextant is a subdivision of the dental arch. The maxillaryand mandibular arches may be subdivided into 6 areas orsextants. In the maxilla, the right posterior sextant extendsfrom tooth 1 to 5, the left posterior sextant extends from tooth12 to 16, and the anterior sextant extends from tooth 6 to 11. Inthe mandible, the right posterior sextant extends from tooth28 to 32, the left posterior sextant extends from tooth 17 to 21,and the anterior sextant extends from tooth 22 to 27. No preprosthetic therapy required. Contiguous, intact dental arches.B. Moderately compromised occlusal scheme Intact anterior guidance. Occlusal scheme requires localized adjunctivetherapy.C. Substantially compromised occlusal scheme Major therapy required to maintain entireocclusal scheme without any change in theocclusal vertical dimension.D. Severely compromised occlusal scheme Major therapy required to reestablish entireocclusal scheme including any necessarychanges in the occlusal vertical dimension.Classification System for theCompletely Dentate PatientClass I (Fig 1)The Class I classification level is characterized byan ideal or minimally compromised tooth conditionand occlusal scheme.1. Ideal or minimally compromised toothcondition No localized adjunctive therapy required. Pathology affecting the coronal morphologyof 3 or fewer teeth in a sextant.2. Ideal or minimally compromised occlusalscheme No preprosthetic therapy required. Contiguous, intact dental arches.Class II (Fig 2)The Class II classification level is characterized bymoderately compromised tooth conditions and/orocclusal scheme.1. Moderately compromised tooth condition Tooth condition—insufficient tooth structureavailable to retain or support intracoronalor extracoronal restorations—in 1sextant. Pathology affecting the coronal morphologyof 4 or more teeth in a sextant.2010 CDEL Re-recognition of the Specialty Report 177 of 279

June 2004, Volume 13, Number 2 77Figure 1. Class I patient: The patient in this figure is categorized as Class I because an ideal or minimallycompromised tooth condition and occlusal scheme is exhibited. A single large amalgam core restoration requires afull coverage restoration in 1 sextant. (A) Frontal view, maximum intercuspation. (B) Right lateral view, maximumintercuspation. (C) Left lateral view, maximum intercuspation. (D) Occlusal view, maxillary arch. (E) Occlusal view,mandibular arch. (F) Panoramic radiograph. Pathology may be present in 2 sextants andmay occur in opposing arches.2. Moderately compromised occlusal scheme Intact anterior guidance. Occlusal scheme requires localized adjunctivetherapy.Class III (Fig 3)The Class III classification level is characterizedby substantially compromised toothconditions requiring localized adjunctive therapyin multiple sextants and arches and/oran occlusal scheme requiring reestablishmentwithout a change in the occlusal verticaldimension.2010 CDEL Re-recognition of the Specialty Report 178 of 279

78 Classification System for the Completely Dentate Patient McGarry et alFigure 2. Class II patient: The patient in this figure is classified as Class II because 1 sextant exhibits 3defective restorations with an esthetic component. Additional variables of gingival architecture and individual toothproportions increase the complexity of diagnosis. (A) Frontal view, maximum intercuspation. (B) Right lateral view,maximum intercuspation. (C) Left lateral view, maximum intercuspation. (D) Occlusal view, maxillary arch. (E)Occlusal view, mandibular arch. (F) Panoramic radiograph.1. Substantially compromised tooth condition Tooth condition—insufficient tooth structureto retain or support intracoronal orextracoronal restorations—in 2 sextants. Pathology affecting the coronal morphologyof 4 or more teeth in 3 or more sextants. Pathology may occur in 3 sextants in thesame arch and/or in opposing arches. Teeth require localized adjunctive therapy,i.e., periodontal, endodontic, or orthodonticprocedure in 2 sextants.2. Substantially compromised occlusal scheme Major therapy required to maintain occlusalscheme without any change in the occlusalvertical dimension.2010 CDEL Re-recognition of the Specialty Report 179 of 279

June 2004, Volume 13, Number 2 79Figure 3. Class III patient: The patient in this figure is classified as Class III since large defective amalgamand composite restorations occur in 4 sextants. The remaining tooth structure is substantially compromised inmost posterior teeth. The occlusion is substantially compromised requiring reestablishment of the occlusal schemewithout a change in the occlusal vertical dimension. (A) Frontal view, maximum intercuspation. (B) Right lateralview, maximum intercuspation. (C) Left lateral view, maximum intercuspation. (D) Occlusal view, maxillary arch.(E) Occlusal view, mandibular arch. (F) Panoramic radiograph.Class IV (Fig 4)The Class IV classification level is characterized byseverely compromised tooth conditions requiringextensive therapy and/or reestablishment of occlusalscheme with change in the occlusal verticaldimension.1. Severely compromised tooth condition Tooth condition—insufficient tooth structureto retain or support intracoronal orextracoronal restorations—in 3 or moresextants.2010 CDEL Re-recognition of the Specialty Report 180 of 279

80 Classification System for the Completely Dentate Patient McGarry et alFigure 4. Class IV patient: The patient in this figure is categorized as a Class IV. Advanced attrition of the occlusalsurfaces occurs in more than 3 sextants. The occlusion is severely compromised with the need to reestablish occlusalvertical dimension and a proper occlusal scheme. (A) Frontal view, maximum intercuspation. (B) Right lateral view,maximum intercuspation. (C) Left lateral view, maximum intercuspation. (D) Occlusal view, maxillary arch. (E)Occlusal view, mandibular arch. (F) Panoramic radiograph. Pathology affecting the coronal morphologyof 4 or more teeth in all sextants. Teeth require localized adjunctive therapy,i.e., periodontal, endodontic, or orthodonticprocedure in 3 or more sextants.2. Severely compromised occlusal scheme Major therapy required to reestablish theentire occlusal scheme including any necessarychanges in the occlusal verticaldimension.Other characteristics of the Class IV patientmay include severe manifestations of local or systemicdisease, including the sequelae from oncologictreatment; maxillomandibular dyskensiaand/or atxia; or a refractory response (i.e., thepatient who presents with chronic complaints followingappropriate therapy.)2010 CDEL Re-recognition of the Specialty Report 181 of 279

June 2004, Volume 13, Number 2 81Table 2. Worksheet Used to Determine ClassificationClass I Class II Class III Class IVTeeth ConditionIdeal or minimally compromised—3 or less teeth in 1 sextantModerately compromised—4 or more teeth in 1 to 2 sextantsSubstantially compromised—4 or more teeth in 3 to 5 sextantsSeverely compromised—4 or more teeth, all sextantsOcclusal SchemeIdeal or minimally compromisedModerately compromised—anterior guidance intactSubstantially compromised—extensive rest/same OVDSeverely compromised—extensive rest/new OVDConditions Creating a Guarded PrognosisSevere oral manifestations of systemic diseaseMaxillomandibular dyskinesia and/or ataxiaRefractory patientxxxxxxxxxxxNote. Individual diagnostic criteria are evaluated and the appropriate box is checked. The most advanced finding determines thefinal classification.Guidelines for use of the worksheet1. Consideration of future treatment procedures must not influence the diagnostic level.2. Initial preprosthetic treatment and/or adjunctive therapy can change the initial classification level.3. If there is an esthetic concern/challenge, the classification is increased in complexity by one or more levels.4. In the presence of TMD symptoms, the classification is increased in complexity by one or more levels.5. It is assumed that the patient will receive therapy designed to achieve and maintain optimal periodontal health.6. Patients who fail to conform to the definition of completely dentate should be classified using the classification system forpartial edentulism.Guidelines for the Use of theClassification System for theCompletely Dentate PatientThe analysis of diagnostic factors will be facilitatedwith the use of a worksheet (Table 2). Aseach criterion is evaluated, a checkmark is placedin the appropriate box. In those instances in whicha patient’s diagnostic criteria overlap 2 or moreclasses, the patient is assigned to the more complexclass.The following additional guidelines should befollowed to ensure consistent application of theclassification system:4. The presence of temporomandibular disorders(TMD) symptoms raises the classification by 1or more levels in Class I and II patients.5. Periodontal health is intimately related to thediagnosis and prognosis for completely dentatepatients. For the purposes of this system, itis assumed that patients will receive therapydesigned to achieve and maintain periodontalhealth so that appropriate prosthodontic carecan be accomplished.6. Patients who fail to conform to the definitionof completely dentate should be classifiedusing the classification system for partialedentulism. 61. Consideration of future treatment proceduresmust not influence the choice of diagnosticlevel.2. Initial adjunctive therapy may change the originalclassification level. Classification may needto be reassessed after existing restorations areremoved.3. Esthetic concerns or challenges raise the classificationby 1 or more levels in Class I and IIpatients (see Fig 2).Closing StatementThe classification system for the completely dentatepatient is based on the most objective criteriaavailable to facilitate uniform use of the system.It is anticipated that such standardization shouldlead to improved communications among dentalprofessionals and third parties. This classificationsystem will serve to identify those patients mostlikely to require treatment by a specialist or a2010 CDEL Re-recognition of the Specialty Report 182 of 279

82 Classification System for the Completely Dentate Patient McGarry et alpractitioner with additional training and experiencein advanced techniques. This system shouldalso be useful in the development of researchprotocols to evaluate various treatment alternatives.With the increasing complexity of patienttreatment, this classification of the completelydentate patient, coupled with the classifications ofcomplete and partial edentulism, will help dentalschool faculty better assess entering patients toensure the most appropriate assignment. Based onuse and observations by practitioners, educators,and researchers, this system will be modified asneeded.AcknowledgmentThe authors thank Dr. John Zarb for his contributionsto this manuscript.References1. Braly BV: Occlusal analysis and treatment planning forrestorative dentistry. J Prosthet Dent 1972;27:168-1712. Turner KA, Missirlian DM: Restoration of the extremelyworn dentition. J Prosthet Dent 1984;52:467-4743. Lytle JD, Skurow H: An interdisciplinary classification ofrestorative dentistry. Int J Periodontics Restorative Dent1987;7:8-414. Douglass GD, Jenson L, Mendoza D: A practical guide toocclusal management for the general practitioner. J CalifDent Assoc 2000;28:792-7995. McGarry TJ, Nimmo A, Skiba JF, et al: Classificationsystem for complete edentulism. J Prosthodont 1999;8:27-396. McGarry TJ, Nimmo A, Skiba JF, et al: Classificationsystem for partial edentulism. J Prosthodont 2002;11:181-1937. McGarry TJ, Edge MJ, Gillis RE Jr, et al: Parameters ofcare for the American College of Prosthodontists.J Prosthodont 1996;5:3-702010 CDEL Re-recognition of the Specialty Report 183 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix DACP Oral Cancer ScreeningProgram2010 CDEL Re-recognition of the Specialty Report 184 of 279

ORALCANCERSCREENING,EXAMINATIONANDBACKGROUNDINTRODUCTIONPREFACEThisoralcancerscreeningprogramcontainsavideoshowinghowtoperformanoralcancerscreeningexaminationalongwithadescriptionoftheexaminationprocessthatidentifiesitsimportance,itspurpose,howitshouldbeperformed,andwhatcliniciansshouldbelookingforduringtheexamination.Theprogramalsocontainspertinentinformationregardingthoseatriskfororalcancer,theprocessofoncogenesis,theroleofradiographicexaminationsinoralcancerscreening,andthemanagementofsuspiciousorallesions.TheprogramhasbeendevelopedinconjunctionwithLomaLindaUniversitySchoolofDentistry;theUniversityofIllinois,ChicagoSchoolofDentistry;theUniversityofDetroitMercySchoolofDentistry;TuftsUniversitySchoolofDentalMedicine,andtheAmericanCollegeofProsthodontists.TheoralcancereducationandscreeningexaminationprogramwascoordinatedandundertakenbytheAmericanCollegeofProsthodontistsOralCancerEducation/ScreeningTaskForce.TheTaskForcewasappointedandchargedbyACPPresidentStephenCampbellinearly2007andincludesthefollowingmembers:TASKFORCEMEMBERSThomasJ.Vergo,Jr.,Chair,ACPOralCancerEducation/ScreeningTaskForce,ProfessorEmeritusTuftsUniversitySchoolofDentalMedicine,andPastPresident,AmericanAcademyofMaxillofacialProsthetics.thomasvergo01@earthlink.netClarkStanford:UniversityofIowaCollegeofDentistry,amemberoftheACPandoftheADA'sScientificAffairsCommitteeandaresearcher.clarkstanford@uiowa.eduMichaelKahn:TuftsUniversitySchoolofDentalMedicine,ChairandProfessor,OralandMaxillofacialPathologyDepartment.michael.kahn@tufts.eduDavidCarrier:MemberoftheACPandprivatepractitionerinprosthodontics.ddcarrier@fuse.netSaraGordon,UniversityofIllinoisatChicago,AssociateProfessor,DirectorofOralPathologyGraduateStudies,DepartmentofOralMedicine&DiagnosticSciences.gordonsa@uic.eduMichaelGlick:EditoroftheJADAM.glickm@ada.org 12010 CDEL Re-recognition of the Specialty Report 185 of 279

PeterStevenson‐Moore,PastChair&Head,DivisionofDentistry,DepartmentofDentistry,BritishColumbiaCancerAgency,Vancouver,Canada.stevenson‐moore@shaw.caJamesR.Geist,DDS,MS,ProfessorandChair,DepartmentofDiagnosticSciences,UniversityofDetroitMercySchoolofDentistryGEISTJR@UDMERCY.EDULindaM.Kaste,DDS,PhD,AssociateProfessorandDirectorofPre‐doctoralDentalPublicHealth,UIC,DepartmentofPediatricDentistry.KASTE@UIC.EDUBrianR.Hill,StageIVoralcancersurvivor,Founder/ExecutiveDirector,TheOralCancerFoundationInc.bhill@oralcancerfoundation.orgMarkLingen,DDS,PhD,AssociateProfessorandDirectorPathologyImageAnalysisFacility,UniversityofChicago.Mark.Lingen@uchospitals.eduRhondaF.Jacob,D.D.S.,M.S.,F.A.C.P.,ProfessorofDentalOncology,Director,ImplantsandImagingProgram,UniversityofTexasM.D.AndersonCancerCenter,rjacob@mdanderson.orgSreenivasKoka,D.D.S.,Ph.D.,ProfessorofDentistry,Chair,DentalSpecialtiesDepartment,MayoClinic,Koka.Sreenivas@mayo.eduMaxillofacialCommitteeoftheACP(theOfficersoftheAAMP)asanAdvisorySubcommittee.ADDITIONALRESOURCESAmericanCollegeofProsthodontistsAmericanAcademyofMaxillofacialProstheticsAmericanDentalAssociationBritishColumbiaCancerAgencyJournaloftheAmericanDentalAssociationJournalofProsthodonticsLomaLindaUniversity,SchoolofDentistryMayoClinicUniversityofDetroitMercy,SchoolofDentistryTheOralCancerFoundationTheUniversityofChicagoTheUniversityofIowaCollegeofDentistryTheUniversityofTexas,MDAndersonCancerCenterTuftsUniversityUniversityofIllinoisatChicagoPROGRAMCREDITSJoeArnett,MSITManager,EducationalSupportServicesLomaLindaUniversitySchoolofDentistryLomaLinda,CARyanBeckerMultimediaSpecialistLomaLindaUniversitySchoolofDentistryLomaLinda,CA 22010 CDEL Re-recognition of the Specialty Report 186 of 279

ChrisBornITProjectManagerLomaLindaUniversitySchoolofDentistryLomaLinda,CAStephenD.Campbell,DDS,MMSc2007ACPPresidentProfessorandHead,DepartmentofRestorativeDentistryUniversityofIllinoisatChicagoCollegeofDentistryChicago,ILDavidCarrier,DDSMemberoftheACPandprivatepractitionerinprosthodonticsCincinnati,OHJamesR.Geist,DDS,MSProfessorandChairDepartmentofDiagnosticSciencesUniversityofDetroitMercySchoolofDentistryDetroit,MIMichaelGlick,DMDProfessorofOralMedicineandAssociateDeanforOral‐MedicalSciences,SchoolofOsteopathicMedicineArizonaSchoolofDentistryandOralHealth,A.T.StillUniversityMesa,AZCharlesJ.Goodacre,DDS,MSDDeanLomaLindaUniversitySchoolofDentistryLomaLinda,CASaraGordon,DDS,MSc,FRCD(C)AssociateProfessor,OralMedicineandDiagnosticSciences,DirectorofOralPathologyGraduateEducation,AdjunctAssociateProfessor,DepartmentofPathology,CollegeofMedicineUniversityofIllinoisatChicagoChicago,ILBrianR.HillStageIVoralcancersurvivor,FounderandExecutiveDirectorTheOralCancerFoundationInc.NewportBeach,CAMichaelKahn,DDSChairandProfessor,OralandMaxillofacialPathologyDepartmentTuftsUniversitySchoolofDentalMedicineBoston,MA 32010 CDEL Re-recognition of the Specialty Report 187 of 279

LindaM.Kaste,DDS,PhDAssociateProfessorandDirectorofPre‐doctoralDentalPublicHealth,DepartmentofPediatricDentistryUniversityofIllinoisatChicagoChicago,ILSreenivasKoka,DDS,MS,PhDProfessorofDentistry,DivisionofProsthodonticsMayoClinicSchoolofMedicineRochester,MNMarkLingen,DDS,PhDAssociateProfessorandDirectorPathologyImageAnalysisFacilityUniversityofChicagoChicago,ILThomasJ.Salinas,DDS,MSProfessorofDentistry,DivisionofProsthodonticsMayoClinicSchoolofMedicineRochester,MNClarkStanford,BS,DDS,PhDProfessorUniversityofIowaCollegeofDentistryIowaCity,IAPeterStevenson‐Moore,BDS,MRCD(C)Chair,DivisionofDentistry,Head,DepartmentofDentistryBritishColumbiaCancerAgencyVancouver,BCThomasJ.Vergo,Jr.,DDSACPOralCancerEducation/ScreeningTaskForceChair,ProfessorEmeritusTuftsUniversitySchoolofDentalMedicineBoston,MA 42010 CDEL Re-recognition of the Specialty Report 188 of 279

THOSEATRISKFORORALCANCERWhoisatrisk? EstimatesandtablesEstimatesfor2007fromSEER(TheNationalCancerInstitute’sSurveillance,EpidemiologyandEndResults)http://seer.cancer.govprovidesthefollowinginformation: Diagnosisofcanceroftheoralcavityandpharynx:34,360cases(24180menand10,180women)Deathfromcanceroftheoralcavityandpharynx:7,550menandwomenDiagnosisofcancerofthetongue:9,800cases(6,930menand2,870women)Diagnosisofcanceroftheesophagus:15,560cases(12,130menand3,430women)Deathfromcanceroftheesophagus:13,940menandwomenOralcavityandpharynxincidencedata,deathrate,and5yearsurvivalforyears2000‐2004asrelatedtorace,gender,andage(Table1)Tongueincidencedata,deathrate,and5yearsurvivalforyears2000‐2004asrelatedtorace,gender,andage(Table2)Esophagusincidencedata,deathrate,and5yearsurvivalforyears2000‐2004asrelatedtorace,gender,andage(Table3)Incidenceratebyanatomicsite,race,andgenderforyears1998‐2002(Table4)Mortalityratebyanatomicsite,race,andgenderforyears1998‐2002(Table5)5‐yearsurvivalratesbystage,ageatdiagnosisandanatomicsiteforyears1995‐2001(Table6)Comparisonbyraceandstageatdiagnosisforsite‐specificoralcancercasesforyears1973‐2002(Table7)5‐yearrelativesurvivalratesforpersonswithoralcancerbygender,race,andsiteforyears1973‐2002(Table8)5‐yearrelativesurvivalratesforpersonswithtonguecancerbygenderandrace,andbystageatdiagnosisandage;dataforyears1973‐2002(Table9)Hispanicincidencerate,mortalityrate,andestimatedprevalencepercentonJanuary1,2004oftheSEER11populationdiagnosedintheprevious10years,byageatprevalenceandgender(Table10) 52010 CDEL Re-recognition of the Specialty Report 189 of 279

Comparative,causal,andpreventivedataMaleversusfemaledataThehigherincidenceinmalesisshowninTables1,2,3,4,5,8,9,10availableontheSEER(TheNationalCancerInstitute’sSurveillance,EpidemiologyandEndResults)Website:www.seer.cancer.govMorethantwiceasmanyoralorpharyngealmalignanciesoccurredinmalesthanfemalesinFloridabetween1998and1998(Tomar,Cancercausesandcontrol2204;15:601‐609).RecentstudiesofNIH‐AARP(NationalInstitutesofHealth–AmericanAssociationofRetiredPersons)DietandHealthStudy(prospective)reinforcesconcernsforequityinriskidentificationandmodificationforbothmenandwomen.Theincidenceratesofheadandneckcancerwerehigherinmenthaninwomenbutsmokingwasassociatedwithalargerrelativeincreaseinriskinwomenthanmen(Freedman,2007Cancer–epub8/27/07andprintedversionasFreedman,Cancer2007;110:1593‐1601).HispanicwomeninNewYorkStateandNewYorkCityhadlowerincidenceratesfororalcancerthanHispanicmen(Cruz,AmJPubHealth2006;96:2194‐2200).TobaccodataCigarette,cigar,andpipesmokingwereseparatelyimplicatedasriskfactorsforthedevelopmentoforalandpharyngealcancer.Therewasasharplyreducedriskofcancerinthosewhoquitsmokingandnoexcessriskwasnotedamongstthosewhoquitfor10yearsormore,indicatingthatsmokingprimarilyaffectsalaterstageoforopharyngealcarcinogenesis(Blot,CancerRes1988;48:3282‐3287).InaprospectiveNIH‐AARPDietandHealthStudyofesophagealsquamouscellcarcinoma(ESCC)andgastriccancers,anassociationwasfoundbetweencigarettesmokingandincreasedcancerriskateachofthesitesexamined.Comparedwithnonsmokers,currentsmokerswereatincreasedriskforESCC(HR=9.27,95%CI:4.04,21.29)(Freedman,AmJEpidemiol2007;165:1424‐1433).AlcoholdataAcase‐controlstudyoforalandpharyngealcancerdeterminedtherisksoforopharyngealcancerwereincreasedmorethan35‐foldinthosewhosmokedtwoormorepacksofcigarettesandmorethanfouralcoholicdrinksperday.Itwasestimatedthatsmokingandalcoholdrinkingcombinetoaccountforapproximatelythree‐fourthsoftheoralandpharyngealcancersthatoccurintheUnitedStates.Relativetothetypeofalcoholconsumed,theriskswerehigheramongthoseconsuminghardliquororbeerascomparedwiththoseconsumingwine.(Blot,CancerRes1988;48:3282‐3287)“Fordrinkersofmorethanthreealcoholicbeveragesperday,comparedwiththosewhoseintakewasuptoonedrinkperday,theauthorsfoundsignificantassociationsbetweenalcoholintakeandesophagealsquamouscellcarcinoma(ESCC)risk(HP=4.93,95%CI:2.69,9.03)(Freedman,AmJEpidemiol2007;165:1424‐1433). 62010 CDEL Re-recognition of the Specialty Report 190 of 279

Inaprospectivestudy(NIH‐AARPDietandHealthStudy)ofcancerintheoralcavity,theoropharynxandhypopharynx,andthelarynx,drinkingmorethan3alcoholicbeveragesperdaywasassociatedwithincreasedcancerriskinbothmenandwomen.However,consumptionofuptoonedrinkperdaymaybeassociatedwithreducedriskrelativetonondrinking.Thehazardratios“fortheassociationbetweenalcoholintakeandheadandneckcancerriskweresignificantlyhigherforwomenthanmen”(Freedman,BrJCancer2007;96:1469‐14740.SundataThelipisasiteaffectedbyexposuretosunlight,oftenasaresultofoccupationalorrecreationalexposure.Theage‐relatedincidenceoflipcancer(numberofnewcasesdiagnosedper100,000personaatrisk)2.1inwhitemalesand0.4inwhitefemales.Thecorrespondingincidencenumberinblackswas0.1formalesand0.2forfemales.Theincidencerateintheoralcavity(tongue,floorofthemouth,gingiva,andother)was5.3andthepharyngealincidencewas2.8(Table4).Thecombinedmaleandfemalemortalityratesforbothwhitesandblackswas0.0(Table5)(Morse,JAmDentAssoc2006;137:203‐212).Humanpapillomavirus(HPV)dataAcase‐controlledstudyof284subjectswhowererecentlydiagnosedwithoralsquamouscellcarcinomaconcludedthat“HPVtype16infectionmaycontributetothedevelopmentofasmallproportionoforalSCCsinthispopulation,mostlikelyincombinationwithcigarettesmoking”(Schwartz,JNatlCancerInst1998;90:1626‐1636).Inagroupof93recentlydiagnosespatientswithoralorpharyngealcancer,HPVwasfoundtoplayaroleinthedevelopmentoforalcancer(Smith,Laryngoscope1998;108:1098‐1103).“HPVappearstoplayanetiologicroleinmanycancersoftheoropharynxandpossiblyasmallsubgroupofcancersoftheoralcavity.ThemostcommonHPVtypeingenitalcancers(HPV16)wasalsothemostcommoninthesetumor”(Herrero,JNatlCancerInst2003;95:1772‐1783).TheprevalenceofoncogenicmucosalHPVishigherinyounger‐ageoralcavity/oropharynxcancercaseswhosesexualpracticesaretypicallyassociatedwithsexualtransmissionofthevirus”(Smith,IntJCancer2004;108;766‐772).“Thelatestmeta‐analysesoftheepistudiesaswellasthemulti‐centercase‐controlledstudieshaveconfirmedHPVasanindependentriskfactorfororalcancer,witharangeofoddsratiosbetween3.7and5.4.”Uptotheyear2002,22%of4,768oralcarcinomaswerereportedtocontainthehumanpapillomavirus.ThehighestprevalenceofHPVwasfoundintonsillarcarcinomas(Syriänen,JClinVirol2005;32suppl1;S59‐66).“OralHPVinfectionisstronglyassociatedwithoropharyngealcanceramongsubjectswithorwithouttheestablishedriskfactorsoftobaccoandalcoholuse.”CurrentsmokingwasfoundtoincreasetheoddsofpersistentoralHPVinfections.ThenaturalhistoryoforalHPVinfectionsmaybedistinctfromcervicalHPVinfections(D’Souza,IntJCancer2007;121:143‐150). 72010 CDEL Re-recognition of the Specialty Report 191 of 279

Race/EthnicitydataTables1‐9presentdifferencesamongrace/ethnicitygroups.Thepotentialfordeathfromoralcanceramongstblackswas1.7timesthatofwhites(Arbes,CancerCausesandControl1999;10:513‐523).Theincidenceofcancersoftheoralcavity,pharynx,andlarynxwerehigherforAfrican‐Americansthanwhites.Likewise,the5‐yearsurvivalratesweresignificantlylowerforAfrican‐Americans(Shavers,CancerandMetastatisReviews2003;22:25‐28).Datawereobtainedfrom21,481malignanciesoftheoralcavityandpharynxdiagnosedbetween1988and1998intheStateofFlorida.Blacksconsistentlyhadsurvivalratesthatwerepoorerthanwhitesandtherewasahigherincidenceofmetastasisamongblacks.Ninepercentoftumorsinwhiteshadmetastasizedatthetimeofdiagnosiswhereas19.7%ofthetumorsinblackshadmetastasized(Tomar,Cancercausesandcontrol2004;15:601‐609).Astudyoforalandpharyngealcancerfortheyears1996‐2002indicatedHispanicmenhadincidenceratesapproximately75%higherthannationalratesinNewYorkStateand89%higherthannationalratesinNewYorkCity.Incidenceratesformaleswere16%higherthannon‐HispanicWhitesinNewYorkStateand32%higherthanWhitesinNewYorkCity.NosubstantialdifferenceswererecordedforHispanicwomen.Mortalityratesweresimilartoincidenceratesforbothmenandwomen(Cruz,AmJPubHealth2006;96:2194‐2200).Disparitiesexistbetweenblackandwhitemales,particularlyregardingmortalityfromoralandpharyngealcancer(OPC).Age‐adjustedincidenceratesweremorethan20percenthigherforblackmalesthanwhitemaleswithlittledifferenceinblackandwhitefemales.Ageadjustedmortalityrates(AAMR)were82percenthigherforblackmalesthanwhitemaleswithsimilarratesforblackandwhitefemales(Morse,JAmDentAssoc2006;137:2‐3‐212).African‐Americanshadasignificantlyhigherproportionoforalcancer(mainlyinthetongue)thathadspreadtoaregionalnodeordistantsiteatthetimeofdiagnosisthanWhites.From1988to2002,theproportionsofthecancersthathadspreadwere70%forAfrican‐Americansand53%forWhites.Additionally,African‐Americanshadasignificantlyhigherproportionoftonguecancersthatweregreaterthan4millimetersindiameteratthetimeofdiagnosis.Theauthorsconcludedtherearesignificantracialdifferencesrelativetothestageofthecanceratthetimeitwasdiagnosedandthesurvivalrateamongadults.TheauthorsindicatedthelowersurvivalamongBlacksmaybeduetodifferencesintheaccessandutilizationofhealthcareservices(Shiboski,CommunityDentOralEpidemiol2007;35:233‐240).GeneticsdataThefollowingsixgeneswerecommontoallcarcinomacelllines:IgCmuheavychainconstantregion;semaphorin;T‐cellgrowthfactor;cAMP‐dependentproteinkinasebeta‐catalyticsubunit;desmocollin1A/1Bprecursor;andrecA‐likeproteinHsRad51.Allthesegeneswerealsodown‐regulatedin3ofthe6linesoforalcancercells.Theauthorsconcludedthatthedatasuggests“oralcancinomaswithdifferentetiologicalbackgroundscanbedistinguishedbytheirdifferentglobalgeneexpressionpatterns”(Ruutu,OncolRep2005;14:1511‐1517). 82010 CDEL Re-recognition of the Specialty Report 192 of 279

AgedataWhenexaminingdatafrom19agegroups,theyoungestagecategorieshadoralandpharyngealcancer(OPC)ratesthatweregenerallylessthan1per100,000personsperyear.Afteraboutthethirddecadeoflife,theratebegantoincreasenotablywiththegreatestincreasesoccurringinmalesandparticularlyBlackmales.Mortalityrateswereverylowduringtheearlydecadesoflifeandthenincreasedsharplyafterthethirddecade.TheoverallmedianageatthetimeOPCwasdiagnosedwas64yearsforWhitesand57yearsforBlacks(Morse,JAmDentAssoc2006;137:203‐212).FruitsandvegetableconsumptiondataAprospectivestudyof490,802participantsoftheNationalInstitutesofHealth(NIH)–AmericanAssociationofRetiredPersons(AARP)dietandhealthstudyidentifiedasignificantrelationshipbetweenfruitandvegetableintakeandreducedriskofesophagealsquamouscellcarcinoma(ESCC).Theprotectivefunctionoffruitswasstrongerthanvegetables(Freedman,IntJCancer2007;121:2753‐2760).Ameta‐analysiswhere16studiesmettheinclusioncriteriadeterminedthattheconsumptionoffruitsandvegetables“playsanimportantroleasaprotectivefactoragainstthedevelopmentoforalcancer.”Theauthorsnotedasignificant49%reductioninriskforeachdailyportionoffruitandasimilarsignificant50%reductionforvegetables(Pavia,AmJClinNutr2006;83:1126‐1134).WhenthejournalEvidenceBasedDentistryreviewedthisarticle,theycommentedthatiswasasignificantcontributiontoreviewingandsynthesizingtheevidenceregardingtheeffectofdietindevelopingoralcancer.Theyalsostatedthattheresultshaveimportantpublichealthandnutritionalimplicationsandfruitandvegetableconsumptionshouldbepartofboththepublichealthandchairsideapproachestooralcancerprevention(Conway,Evidence‐BasedDentistry2007;8:19‐20).BetelquiddataOnepublicationspresentedbothacase‐controlstudyfromPapua,NewGuineaplusametaanalysisofcurrentevidenceregardingthechewingofthisnut.Thenutchewingmayalsoincludeotherconstituentssuchastobaccoandspices.Thecase‐controlstudyconfirmedthatsmokingisastrongindependentriskfactorfororalcancer.Thechewingofbetelquidwithouttheconcurrentuseoftobaccowasalsofoundtobeanindependentbutweakerriskfactorthansmoking.Themeta‐analysispartofthepublicationincluded10studiesandconcludedthereisanincreasedriskoforalcancerinpatientswhochewbetelquidwithouttobacco(Thomas,IntJCancer2007;120:1318‐1323).Alargecase‐controlstudyinIndiaexaminedtheeffectofbetelquidchewingwithouttobaccoontheriskoforalprecancerssuchasleukoplakiaandoralsubmucousfibrosis.Thestudyincluded927casesofleukoplakia,170oralsubmucousfibrosiscases,100erythroplakiacases,and115multipleoralprecancercases.Therewere47,773controls.Theauthorsconcludedthatchewingbetelquidwithouttobaccoincreasestherisksassociatedwithvariousoralprecancers(Jacob,OralOncol2004;40:697‐704).ThispositionpaperdiscussestheuseofPaan(productwrappedinbetelleaf)andGutka(powderedmixture),indicatingtheyareanemergingthreatintheUS.ThepublicationindicatesthereisamarkedlyincreasedriskoforalcancerinSouthAsianimmigrantscomparedwithnativesinthenewareasofsettlement.SincePaanandGutkaarelegalintheUSandreadilyavailable,thereshouldbealarmabouttheextensiveuseofthesecarcinogenicmaterials(Changrani,JImmigrHealth2005;7:102‐3‐108). 92010 CDEL Re-recognition of the Specialty Report 193 of 279

Latedetectionanddelayedtreatment ‐SystematicreviewconclusionsAsystematicreviewwascompletedregardingthefactorsassociatedwithpatientdelaysinceasubstantialnumberofpatientsdelayseekingtreatmentaftertheirself‐discoveryofsymptomsoforalcancer.Itwasdeterminedthatthereasonsfordelaysarepoorlyunderstoodandthereisnotadequateresearchtoestablishdefinitiverelationships(Scott,CommunityDentOralEpidemiol2006;34:337‐343).InacommentaryontheScottpaperpublishedinEvidenceBasedDentistry,thatfollowingstatementwasmade:“Thereremainsalackofawarenessofmouthcanceramongstpatientsandprofessionalswhichmaycontributetopatientdelay.”ThecommentaryalsostatedthattreatmentdelaysraisetheissueastowhetherascreeningprogramshouldbeintroducedbutthecurrentUnitedKingdompolicy(www.library.nhs.uk/screening/viewResource.aspx?searchText=Oral+Cancer&resID=61087)isthatscreeningprogramsshouldnotbeofferedbuthealthprofessionalsshouldbeencouragedtoperformscreenings(Richards,Evidence‐BasedDentistry2007;8:21).Race/ethnicityCancersoftheoralcavity,pharynx,andlarynxweremoreadvancedatdiagnosisforAfrican‐AmericansandHispanicsthenWhites.The5‐yearsurvivalratesforthesesiteswerealsosignificantlylowerforAfrican‐AmericansthanCaucasians.African‐AmericanswerelesslikelytobetreatedfortheircancerthanHispanicsorCaucasians(Shavers,CancerandMetastasisReviews2003;22:25‐28).Inwhites,8.9%oftumorshadmetastasizedatthetimeofdiagnosiswhereas19.7%oftumorshadmetastasizedinblacksatthetimeofdiagnosis(Tomar,Cancercausesandcontrol2004;15:601‐609).ThefactorscontributingtothepoorersurvivalofBlackAmericanscomparedtoWhiteAmericanswerediagnosisatamoreadvancedstage,socioeconomicstatus,anddifferencesintreatment(Arbes,CancerCausesandControl1999;10:513‐523).OralcancerwasdiagnosedatamoreadvancedstageinBlacksandtheyhadlargertumorsatthetimeofdiagnosis.Theauthorsindicatedthatmany“manyAmericanswhodonothaveasourceofregulardentalcaremayreceiveprimarymedicalcare,andmayseeeitheraphysicianoranursepractitionereitherforroutinefollow‐uporonanemergencybasis.Therefore,primarycarephysiciansandnursepractitionerscouldplayanimportantroleintheinitialscreeningfororalcanceriftheyweretrainedinperforminganoralsoft‐tissueexamination(Shiboski,CommunityDentOralEpidemiol2007;35:233‐240).Afocusgroupapproachwasusedtoevaluateattitudes,knowledge,andhealth‐seekingbehavioursoffiveimmigrantminoritycommunities(Haitian,Caribbean,Latino,Korean,andChinese).Theyindicated“theprevalentmisinformationobservedamongallgroupswarrantsthepromptdevelopmentofculturallycompetentprogramsforcancercontrolwithimmigrantminorities”(Gany,EthnHealth2006;11:19‐39).Theonlinepopulationisbecomingincreasinglydiverse.Sincecancerinformationwebsitesareapopulardestination,onepublicationindicatesa“culturaldigitaldivide”existsandthattheInternetshouldfacilitateweb‐basededucationofimmigrants(Changrani,JCancerEduc2005;20:183‐186). 102010 CDEL Re-recognition of the Specialty Report 194 of 279

Whatisthestatusofcommunityscreening?RecommendationsandpolicypositionsANationalStrategicPlanningConferenceheldin1996publishedstrategiesdesignedtopreventandcontroloralandpharyngealcancerintheUnitedStates.Amongstthe10strategieswereonethatincludedencouragingMedicaid,Medicare,traditionalinsuranceplans,andmanaged‐careprogramstoconsideroralcancerexaminationsasintegralpartsofcomprehensivephysicalandoralexaminationsandonetodesignatefederalfundingforanationalprogramoforalcancerprevention,earlydetection,andcontrol(MMWRAugust28,1998/47(RR14)(http://www.cdc.gov/mmwr/preview/mmwrhtml/0054567.htm)In2003,aNationalScreeningCommitteeintheUnitedKingdomrecommendedthatopportunisticscreeningbyallhealthcareprofessionalsshouldbeencouraged.Theyneedtobeawareofthesignsandsymptomsoforalcancerandstandardreferralpathwaysshouldbedevelopedtominimizedelays(Improvingoutcomesfororalcancer,workshopsconvenedundertheauspicesoftheNationalScreeningCommittee,JJversion216/6/03).ThecurrentUnitedKingdomNationalScreeningpolicyposition(www.library.nhs.uk/screening/viewResource.aspx?searchText=Oral+Cancer&resID=61087)isthatscreeningprogramsshouldnotbeofferedbuthealthprofessionalsshouldbeencouragedtoperformscreenings(Richards,Evidence‐BasedDentistry2007;8:21).TheCanadianTaskForceonPreventiveHealthCareindicatedtheusefulnessoforalcancerscreeningislimitedbythelowprevalenceandincidenceoforalcancerinCanada,thepotentialforfalsepositivediagnoses,andpoorcompliancewithscreeningandreferral.Therefore,itwasdeterminedthereisnoevidencethatscreeningthegeneralpublicorhighriskindividualsleadstoareductioninmortalityormorbidityfromoralcancer(Hawkins,JCanDentAssoc1999;65:617‐627).OralHealthinAmerica:areportoftheSurgeonGeneralindicatedthereisnodefinitiveevidencesupportingtheoralcancerscreeningexaminationbutalsostatedpractitionersshouldregularlyperformoralcancerexaminationsonhigh‐riskindividuals(USDepartmentofHealthandHumanServices.OralHealthinAmerica:areportoftheSurgeonGeneral.Rockville,MD:DepartmentofHealthandHumanServices,NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,2000).In2004,theU.S.PreventiveServicesTaskForceissuedarecommendationstatementregardingscreeningfororalcancer.Theyfoundnonewgoodqualityevidencethatoralcancerscreeningimprovedthehealthoutcomesofeitheraverageorhigh‐riskindividuals.TheyalsostateditisunlikelycontrolledtrialswilleverbecompletedinthegeneralpopulationbecauseofthelowincidenceoforalcancerintheU.S.andthereisnoevidenceofharmsproducedfromscreening.Theyindicatedcliniciansshouldbealerttothepossibilityoforalcancerwhentreatingpatientswhousetobaccooralcohol(AgencyforHealthcareResearchandQuality–AHRQPub.No.05‐0564‐A,November2004).(Acopymaybeobtainedbycalling1‐800‐358‐9295ore‐mailahrqpub@ahrq.gov).TherecommendationisalsopostedontheWebsiteoftheNationalGuidelineClearinghouse(www.guideline.gov). 112010 CDEL Re-recognition of the Specialty Report 195 of 279

ClinicaltrialfindingsArandomizedcontrolledtrialfromIndiadeterminedvisualoralcancerscreeningscanreducemortalityinhigh‐riskindividuals(thosewhousetobaccooralcohol)butthetrialdidnothavesufficientstatisticalpowertodetermineiftherewasasignificantdeclineinmortalityamongstindividualswithouthigh‐riskhabits(Sankaranarayanan,Lancet2005;365:1927‐1933).Resultsfromthisstudywerealsopublishedpreviously(Mathew,BrJCancer1997;76:390‐394;Sankaranarayanan,Cancer2000;88:664‐673;andRamadas,OralOncol2003;39:580‐588).Evidence‐basedreviewsoftheeffectivenessoforalcancerscreeningsAsystematicreviewpublishedin2002determinedthereisinsufficientpublishedevidencetodeterminetheeffectivenessofpopulation‐basedinterventionsfortheearlydetectionofprecancersandcancers(Truman,AmJPrevMed2002;23(IS):21‐54).In2003,asystematicreviewconcludedtherewasinsufficientevidencetodeterminetheeffectivenessofcommunity‐basedvisualoralcancerscreeninginprovidingearlydetectionoforalcancer(Patton,OralOncology2003;39:7‐8‐723).ACochranesystematicreviewidentified100potentiallyrelevantpublicationsbutonlyonerandomizedcontrolledstudyfulfilledtheselectioncriteria.Withthislimitedevidenceandmethodologicalchallengesinthisonestudy,thereviewdeterminedthereisnotsufficientevidencetorecommendinclusionorexclusionoforalcancerscreeningprogramsforthegeneralpublicusingvisualexamination(Kujan,JDentEduc2005;69:255‐265)(Kujan,CochraneDatabaseofSystematicReviews2006,Issue3,Art.No.:CD004150.DOI:10.1002/14651858.CD004150.pub2.)In2006,asystematicreviewalsoexaminedtheonerandomizedcontrolledstudyidentifiedintheCochranesystematicreviewandalsodeterminedthestudydidnotproducesufficientevidenceinfavororagainstthepotentialbenefitsofanoralcancerscreeningprogram(Downer,OralOncology2006;42:551‐560).Inconclusion,multiplepublicationsindicatethereisinsufficientevidencetodeterminetheeffectivenessoforalcancerscreeningexaminations(Patton,OralOncology2003;39:708‐723;Downer,OralOncology2006;42:551‐560;Kujan,JDentEduc2005;69:255‐265)andtodeterminetheeffectivenessinhigh‐riskindividuals(Kujan,JDentEduc2005;69:255‐265).Cost‐effectivenessoforalcancerscreeningThecosteffectivenessoforalcancerscreeningwassimulatedusingadecisionanalysismodelbasedondataobtainedfromtwohospitalsregardingactualresourceuse.Theexpectedvaluewashigherinmalesthanfemalesbutalsovariedbasedonmalignanttransformationrate,treatmenteffects,andwillingnesstopay.Whilenoscreeningwasalwaysthecheapestoption,theauthorsconcludedthathigh‐riskscreeningingeneraldentalofficesmaybecost‐effective(Speight,HealthTechnologyAssessment2006;10(14):1‐14 122010 CDEL Re-recognition of the Specialty Report 196 of 279

ReferencesArbesSJ,OlshanAF.CaplanDJ,SchoenbackVJ,SladeGD,SymonsMJ.FactorscontributingtothepoorersurvivalofblackAmericansdiagnosedwithoralcancer(UnitedStates).CancerCausesandControl1999;10:513‐523.BlotWJ,McLaughlinJK,WinnDM,AustinDF,GreenbertRS,Preston‐MartinS,BernsteinL,SchoenbertJB,StenhagenA&FraumeniJFJr.Smokinganddrinkinginrelationtooralandpharyngealcancer.CancerResearch1988;48:3282‐3287.CDCPreventingandcontrollingoralandpharyngealcancerrecommendationsfromanationalstrategicplanningconference.MMWR1998:August;47(RR14)http://www.cdc.gov/mmwr/preview/mmwrhtml/00054567.htmConwayDI.Eachportionoffruitorvegetableconsumedhalvestheriskoforalcancer.EvidBasedDent2007;8(1):19‐20.CruzGD,SalazarCR,MorseDE.OralandpharyngealcancerincidenceandmortalityamongHispanics,1996‐2002:Theneedforethnoregionalstudiesincancerresearch.AmJPubHealth2006;96(12):2194‐2200.DownerMC,MolesDR,PalmerS,SpeightPM.Asystematicreviewofmeasuresofeffectivenessinscreeningfororalcancerandprecancer.OralOncology2006;42:551‐560.D’SouzaG.KreimerAR,ViscidiR,PawlitaM,FakhryC,KochWM,WestraWH,GillisonML.Case‐controlstudyofhumanpapillomavirusandoropharyngealcancer.NEnglJMed2007;356:1944‐56.HP2010;pages21‐22–21‐25Objective21‐6.Increasetheproportionoforalandpharyngealcancersdetectedattheearlieststage.Target:50%Baseline:35%oforalandpharyngealcancers(stage1,localized)weredetectedin1990‐95.Objective21‐7.Increasetheproportionofadultswho,inthepast12months,reporthavinghadanexaminationtodetectoralandpharyngealcancers.Target:20percentBaseline:13%ofadultsaged40yearsandolderreportedhavinghadanoralandpharyngealcancerexaminationin1998(ageadjustedtotheyear2000standardpopulation).JacobBJ,StraifK,ThomasG,RamadasK,MathewB,ZhangZ‐H,SankaranarayananR,HashibeM.Betelquidwithouttobaccoasariskfactorfororalprecancers.OralOncology2004;697‐704.KujanO,GlennyAM,OliverRJ,ThakkerN,SloanP.Screeningprogrammesfortheearlydetectionandpreventionoforalcancer.CochraneDatabaseofSystematicReviews2006,Issue3.Art.No.:CD004150.MorseDE,KerrAR.Disparitiesinoralandpharyngealcancerincidence,mortalityandsurvivalamongblackandwhiteAmericans.JADA2006;137(2):203‐212.PattonLL.Theeffectivenessofcommunity‐basedvisualscreeningandutilityofadjunctivediagnosticaidsintheearlydetectionoforalcancer.OralOncology2003;39:708‐723. 132010 CDEL Re-recognition of the Specialty Report 197 of 279

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THEPROCESSOFONCOGENESISIntroductionTremendousfinancialresourceshavebeendirectedtowardsattainingabetterunderstandingofcancerinordertodeveloptherapiesorlifestylechangestopreventandtreatthisdevastatingdisease.Mostdentistsunderstandthatadiagnosisofcancerinvolvescertainprocessessuchasdysregulatedgrowth,malignancy,metastasis,chemotherapy,radiotherapyandsurgery.Furthermore,mostdentistsappreciatethattheconsequencesofheadandneckcancerasitpertainstotissueloss,functionaldisturbances,changestosalivaryglandfunctionandestheticcompromiseareofgreatsignificancetopatientsandtheirfamiliesandfriends.However,manyarechallengedwhenaskedtoactuallydefinewhatmakesacellbecomeacancercell.Therefore,thischapterprovidesanoverviewofkeycellulareventsthatarenecessaryforacelltobecomeacancercell.Inanexcellentreviewpaperpublishedin2000andinsubsequentpublications,HanahanandWeinbergcontendthattherearesixhallmarksofacancercell.Listofthehallmarksofacancercell1. Self‐sufficiencyingrowthsignals2. Insensitivitytoanti‐growthsignals3. Limitlessreplicativepotential4. Evadingapoptosis5. Sustainedangiogenesis6. TissueinvasionandmetastasisItisimperativetounderstandthatpresenceofonetofiveofthesehallmarksisinsufficientforacelltobeacancercell.Indeed,allsixhallmarksarenecessaryandassuchareviewofeachofthehallmarkshasmeritascliniciansandpatientsstrivetocomprehendnewandexistingcancertherapiesandtobeabletoplacemodesoftherapeuticactioninthecontextofthediseasemechanisms,orhallmarks,beingtreated.Clearly,beyondtreatmentofcancer,themoreoneunderstandsaboutthediseaseitself,thebetteronecancreateinvitroandinvivoresearchmodelsthatcloselyapproximatethedisease.Cancerisarelativelyrarephenomenonwhenoneconsidersthevastnumberofcellsineachhumanbody.Withineachcell,thereexisteffectivemechanismsforpreventingormitigatingcellularmalfunction.Therefore,tobecomeacancercell,anormallyfunctioningcellmustnotonlybecomedysregulatedbutitmustalsofindwaystoevadeitsownbuilt‐indefensemechanisms.InasmuchasDarwinpresentedthe“survivalofthefittest”concepttoscientists,anorganismwhosecancerdefensemechanismsareneverbreachedremainscancer‐free.Atthecellularlevel,however,acancercellcanreplicatefasterthannormalcellsandcanfindways,atleastinitially,tonotonlysurvivebuttooutgrowthecellsofitshost.Ultimately,cancercellsoutgrowtheirhosttothepointwheremetastasescausecriticalorgandysfunctionanddeathoftheorganism.TheCellCycleBeforeadiscussionofHanahanandWeinberg’shallmarks,abriefreviewofthecellcyclewillbepresented(figure1).Thecellcyclenormallyconsistsoffour“phases”labeledG1phase(cellgrowth),Sphase(DNAsynthesis),G2phase(cellpreparestodivide)andMphase(celldivisionormitosisoccurs).Mphasecanbesubdividedfurtherintokaryokinesis(nuclear 152010 CDEL Re-recognition of the Specialty Report 199 of 279

division)inwhichchromosomesdivideandareseparatedandcytokinesis(celldivision)inwhichthecell’scytoplasmdividestocreatetwodaughtercells.InterphaseisatermusedtorefertoG1,SandG2phasescollectively.Inessence,thetimebetweencelldivisions(Mphases)isinterphase.GIphase,thefirstpartofinterphase,isthatpartofthecellcyclewhencellularfunctionsunrelatedtocelldivisionareactive.SphaseisconsideredtobeginwhenDNAsynthesisstartsandisconsideredtoendwhenDNAsynthesisiscomplete.Innormalcelldivision,attheendofSphase,thecell’sDNAcontenthasdoubled.UponcompletionofSphase,thecellentersG2phaseduringwhichmicrotubulesproductioniselevatedtopreparethecellforMphasewherecelldivisiontakesplace. Figure1Tosummarize,thereiscellgrowth(G1phase)followedbyDNAreplication(Sphase),thenpreparationforcelldivision(G2phase),andfinallycelldivision(Mphase).Acellthathasbecomesignificantlydysfunctionalmayactivate“self‐destruct”cellprogramsresultingincelldeathasaresultofapoptosis.Incontrast,cellsthatarerelativelyfunctionalbutquiescent[non‐proliferative]aresometimesreferredtoasbeinginG0phase.However,acellinG1mayemergeatalatertimeandonceagainproliferate.Inaddition,cellsthatarefullydifferentiatedmayfunctionnormallyforanextendedperiodoftimewithouttheabilitytobeginreplicationagain.Regulationofcellcycleprogressioninvolveshundredsofproteins,suchascyclinsandcyclindependentkinases(CDKs),andreliesonmanykeyprotein‐proteininteractionsaswellas 162010 CDEL Re-recognition of the Specialty Report 200 of 279

tightregulationoftranscriptionalevents.Aspreviouslymentioned,inanefforttoensurefidelityofthecellcycle,error‐preventionmechanismsarepresentTheSixHallmarksofaCancerCell1.Self‐sufficiencyingrowthsignalsInnormalcircumstances,foracelltoundergocelldivision,mitogenicstimuliintheformofproliferation‐inducingproteinsinteractwithcellsurfacereceptorstomanipulatekeyintracellularpathwaystobegincelldivision.Indeed,cellsrelyontheseextra‐cellularsignalstoproliferate.Indentistry,tissue‐guidedregenerationintheformofboneaugmentationisincreasinglymakinguseofproteinssuchasplatelet‐derivedgrowthfactors,insulin‐likegrowthfactorsandfibroblastgrowthfactorstoenhancecellularproliferationandhenceimprovetheaugmentationoutcome.Inaddition,theuseofplateletrichplasmaisbasedupontheassumptionthatthispreparationisespeciallyrichingrowthfactors.Cancercells,incontrasttonormalcells,acquiretheabilitytoproliferatewithlessdependenceonnormalextracellularsignals.Threemechanismscanbeemployed:increasedmitogenicsignalproductionbyadjacentcells(whichimpliestheabilitytocontrolnearbycells)orbythemselves;modifyingthenumberand/ortypeofcellsurfacereceptorsthatareresponsivetomitogenicsignals;andpresenceofintracellularoncogenesthatpermitbypassoftheneedforextracellularsignalingtoinducemitosis.2.Insensitivitytoanti‐growthsignalsJustasthereareextracellularsignalsthatinduceproliferation,thereareextracellularsignalsthatpreventproliferation.Theseanti‐proliferationsignalscanbeeithersolubleproteinsthatengagespecificcellsurfacereceptorsortheycanbecell‐cellinteractionsorcell‐extracellularmatrixinteractions.TheneteffectofallofthesemechanismsistopreventcellproliferationeitherbyinducingpassagetoG0(quiescence)orelsebycausingdifferentiationtothepointwhereacelllosesitsabilitytoproliferate.Therefore,acellintendingtoproliferateuntowardlyneedstoovercomeeitherorbothoftheseanti‐growthmechanisms.EmergencefromG1isakeyregulatorystepandpro‐proliferationandanti‐proliferationsignalsaffectthisemergencetoasignificantdegree.SomeofthemolecularmechanismsinvolvedinmaintainingtheG1statepertaintothefunctionoftheretinoblastomaproteinanditsassociatesthatactanti‐proliferatively.Disruptionorinactivationofretinoblastomaproteinpathwayfunctions“releasesthebrake”,asitwere,andproliferationcanoccur.Inaddition,whereasspecificoncogenescaninduceproliferationbybypassingtheneedforextracellulargrowthsignals,otheroncogenescanimpedeprogressionofacelltothedifferentiated,andhencenon‐proliferative,state.Inparticular,thec‐myconcogeneappearscapableofreleasingtherestraintsoncellproliferationduetoinductionofterminalcelldifferentiation.3.EvadingapoptosisApoptosis,programmedcelldeath,isavitalmechanismtoensurethatcells“pasttheirprime”areremovedfromthesceneleavingthehealthiest,andconsequentlythemostusefulcellstocarryoutfunctionsvitaltissues,organsandtheentirebody.Histopathologicalevidenceindicatesthatlowerratesofapoptosisareseenincancertumoursthaninneighboringunaffectedtissues. 172010 CDEL Re-recognition of the Specialty Report 201 of 279

Apoptosisoccursinacarefully‐scriptedmannerthatresultsinlossofcellmembraneintegrityandnucleardisruptionasaprecursortoprocessingofbreakdownproductsbyadjacentcells.Apoptosiscanbeinducedbyexternalfactorsthatuponbindingtospecificcellsurfacereceptorsactivatepro‐apoptoticsignaltransductionpathways.Inmostcells,apoptosisoccursviatwomainsignalingpathways.Theextrinsicpathwayinvolvestheactivationofthedeathreceptors,Fasandtumournecrosisfactorreceptors,whiletheintrinsicpathwayinvolvestheactivationofseveralprocaspasesandthemitochondrialreleaseofapoptogenicfactorssuchascytochromecandapoptosis‐inducingfactor(AIF)intothecytoplasm.Subsequently,acascadeofeventsdrivenprimarilybytheactivationofproteolyticcaspasesresultsintheprocessingofintracellularstructuralproteinsandregulatoryenzymesthatculminatesinapoptoticcelldeath.Thesomewhatfamousp53tumoursuppressorprotein,themyconcogene,theretinoblastomaproteinandtheBcl‐2familyofproteinsareallproposedtobeinvolvedinapoptosisregulationwiththeformerconsideredaneffectivesensorofDNAdamageandintracellularhypoxia.Forexample,somecancercellsappeartohavelostadegreeofp53‐inducedapoptosis.IndeedsomecancertherapiesareaimedattrickingcancercellsintoinitiatingapoptoticeventsandthisisnotsurprisinggiventhegoalofradiationtherapyandchemotherapytocauseDNAdamage.4.LimitlessreplicativepotentialItispostulatedthatallcellshaveafinitenumberofcelldivisionsafterwhichacellwilleitherdieorbecomesenescentandthisappearstobetrueformostcells.Oneoftenhearsof“Hayflick’sLimit”inscientificcircles,atermbornfromobservationsthatincellculture,fibroblastscannotreplicateadinfinitumandseemtoonlybeabletodoubleaspecificnumberoftimeswithfiftytosixtytimesoftenproposedasanaveragenumber.However,acancercell,withitsabilitytoreplicateseeminglyoutofcontrol,overcomesthisbiologicallimitationofreplicativesenescencebydisablingtheretinoblastomaproteinandthep53familyofproteins.Replicationscontinueuntilthecellreachesastageof“crisis”inwhichalmostallcellsdie.Yet,thereareexceptionsalbeitrare(1in10million)thatsurvive“crisis”andbecome“immortal”,i.e.thecellshavelimitlessreplicativepotential.Itisthesespecialsurvivors,whohavesomehowevadedtwomajorimpedancestotheirsurvival,thatcanmultiplyandpromotetumorgrowth.Whencellsdivide,telomeres,arepetitivesegmentofDNAlocatedattheterminalendofchromosomes,protectschromosomesfromdestructionordamage.Duringmultiplecelldivisions,telomeresbecomeprogressivelyshortenedandultimatelytheyarenolongerabletoprovidethechromosomalprotectionthatisneededtofacilitateadditionalreplicationsandpreventcellsfromentering“crisis”.Cancercellsappearareabletomaintaintelomereseitherbyupregulationofthetelomeraseenzyme(seeninapproximately90%ofcancers)orelsebyinter‐chromosomalDNAexchanges,aprocessreferredtoas“alternativelengtheningoftelomeres”orALTthatisobservedinapproximately10%ofcancers.Regardlessofthemechanismsemployedbyanygiventypeofcancer,theneteffectistopreventcellsfromreachingcrisiswhichinturnsprovidesforalargerpoolofcellsfromwhichimmortalizedcellsmayemerge.5.SustainedangiogenesisClearlyacadreofcellsthatformsamalignanttumorneedsnutrientstosustainitselfandtoexpand.Theanalogywouldbetoaninvadingarmythatcannotmoveorpushforwardwithoutapropersupplyofresourcesintheshapeoffoodandfuel.Simply,physicochemicallimitationsmeanthatcapillariesmustlieincloseproximitytotumorcellsandsomecancercells,even 182010 CDEL Re-recognition of the Specialty Report 202 of 279

withalloftheotherhallmarksinplace,arelikelytobesomewhatstuntedifanutrientsupplyissuboptimal.Indeed,incipienttumourscangrowonlytoasizeofapproximately2mmindiameterbeforebecomingdependentuponaccesstobloodbornenutrients.Insimilarfashiontomanybiologicalprocesses,therearemoleculesandinteractionsthatactivateangiogenesisthroughmodulationofendothelialcellactivityaswellasinhibitangiogenesisandnormaltissuesareregulatedtoprovidefortheappropriatebalance.Specificmoleculesthatactivateangiogenesisarethevascularendothelialgrowthfactors(VEGFs)andthefibroblastgrowthfactors(FGFs)thatactuponendothelialcellsandtheirprecursorstopromoteproliferationandsprouting.Alltold,thereareovertwodozenangiogenicmoleculessofaridentifiedandasimilarnumberwithinhibitoryeffects.Interactionsbetweencancercellsanditsextracellularmatrix(ECM)arealsoimportantforpromotingangiogenesis.ThefamilyofECMproteinscalledintegrinshasapivotalroleinmanybasictissuefunctionsandespeciallyinregulatingangiogenesis.Certainintegrinspromoteangiogenesisandothersthwartnewcapillaryformation.Againtheinterplaybetweenpromotingandinhibitingeffectsiskeytothefinaloutcome.Cancercellsdemonstratetheabilitytocontroltheirenvironmenttosupportangiogenesisandtherebybringaboutthenutrientsourcesovitaltocontinuedsustenance.Notsurprisingly,cancercellsbringaboutthisshiftintheequilibriumbyalteringthebalanceofangiongenesisinducersandinhibitors.ThiscancomeaboutbyincreasedsecretionofVEGFsand/orFGFsorbyregulatingthereleaseofFGFsfromECM.Furthermore,changesintheexpressionpatternofintegrinsalsocanpushthebalanceofpowertowardsthesideofangiogenesis.Ironically,woundcarespecialistslooktoangiogenesisasameansofimprovinghealingwhereastheoncologistwouldprefertoinhibitangiogenesis.Theclinicalchallengesofthesetwosituationsdemanddiametricallyopposedgoalsandtreatmentstrategies.6.TissueinvasionandmetastasisSomeestimatessuggestthatapproximately90%ofcancer‐relatedmorbidityresultsfromtheadverseeffectsofmetastasis.Simplyput,ifcancercellsdidnothavetheabilitytoinvadetissueandmetastasizetodistantsitesinthebody,cancerdeathswoulddropby90%.ReturningtotheearlierDarwiniananalogy,onecanviewmetastasesascoloniesofcancercellslookingfornewsourcesofnutrients.Therefore,understandingthemechanismsoftissueinvasionhasbecomeapriorityincancerresearchandpreventingtissueinvasionapriorityintherapies.CellscanbeviewedasbeingtetheredtotheirsurroundingECM.Fortissueinvasiontooccur,thistetheringmustweakenandECMmustberemovedtoprovideapathforcellularmovement.Formetastasistooccur,cancercellsmustbeabletore‐tetherandgeneratesufficientconnectivitywithECMinordertosuccessfullyestablishanewcolonyofcells.Cellsusecadherinstomaintaincell‐cellinteractionsandtheyuseintegrinstomaintaincell‐ECMrelationships.Inaddition,intracellularsignalingpathwaysthatregulatecellfunctionaremodulatedbybothcadherinandECMinteractions.EpithelialcellcancersaretypifiedbylossofE‐cadherinfunctionality,therebyenhancingcellinvasivity.Differentconfigurationsofintegrins,baseduponcompositionofdifferentalphaandbetasubunits,arenumerous.Whereasalteredcadherinprofilesandintegrinarrangementsleadtoadysregulatedcell‐cellandcell‐ECMenvironmentrespectively,cellsmustalsobeabletocreateapaththroughECMtoreachbloodvesselsandsubsequentlymetastasize.Thisprocessofpathgenerationrelies 192010 CDEL Re-recognition of the Specialty Report 203 of 279

heavilyonsecretionofproteasescapableofdegradingECMandthereisevidencethatthewilycancercellcaninducesurroundingcellstoalsodegradeECMandfacilitateitsownescape.SummaryThescientificliteratureofferstremendousadditionaldetailoneachofthesixhallmarksandthischapterprovidesonlyabriefdescriptionofthesehallmarksthatarenecessaryandsufficientforanormalcelltoconvertintoacancercell.Thereadershouldbeawarethatthereisaverycomplexinterplaybetweenthemechanismsandpathwayspertinenttoeachhallmarkanditishighlylikelythatwearestillfarfromunderstandingtheseinteractionsandhowbesttomanagetheminordertopreventcancerfromoccurringorfromcontrollingitonceitdoesoccur.Nevertheless,itcanbeonlycurrentknowledgethatdrivesthegenerationofinvitroandinvivocancermodelsaswellasthecreationofnovelandfocusedtherapiesaimedattacklingoneormoreofthehallmarks.ReferenceHanahanD,WeinbergRA.Thehallmarksofcancer.Cell2000;100:57‐70. 202010 CDEL Re-recognition of the Specialty Report 204 of 279

THERADIOGRAPHICEXAMINATIONCanradiographicexaminationshelpdetectcancer?Thediagnosisofmalignanciesoftheheadandneckisoftenfacilitatedbytheuseofradiographictechniques.Someofthese,suchasintraoral,panoramicprojectionsandotherextraoralradiographs,arereadilyavailableindentalpracticesandcanbeemployedandinterpretedbydentists.Volumetricorcone‐beamcomputedtomography(CBCT)canbeperformedbyOralandMaxillofacialRadiologists,whilecomputedtomography(CT)andmagneticresonanceimaging(MRI)arecarriedoutinhospitalsormedicalimagingcenters.Bonescintigraphypermitsidentificationofthephysiologicchangescausedbycancerbeforethediseasecauseschangesinmorphology.Dentistsshouldbeknowledgeableabouttheadvantagesanddisadvantagesoftheseimagingmodalitiestoappropriatelyselectthetechniquesthatwillmosteffectivelyleadtoadiagnosis.Canradiographshelpdetectsofttissuecancersaswellaslesionsinbone?Whiledentalradiographyisgenerallyconsideredtobevaluableindepictingchangesinbone,teeth,andtheperiodontalligaments,manyofthetechniqueslistedabovecandemonstratemalignantlesionsinsofttissuesandadjacentstructures.Therefore,primarycancersoftheoralsoftandhardtissues,aswellasmetastaticmalignanciestotheorofacialstructures,canoftenbedemonstratedradiographically.Anunderstandingoftheradiographicpatternsproducedbythecancersthatafflicttheheadandneckisessentialtoproperlyinterpretthesignsofdisease.Oneofthepurposesofthissectiontodiscusstheradiographicmodalitiesthatarebeneficialinthediagnosisofmalignantdiseasesandtosummarizethecharacteristicradiographicfeaturesthatleadtothedifferentialordefinitivediagnosisofmalignancies.SelectioncriteriainradiographyTheconceptofselectioncriteriaunderliesthechoiceofradiographsaspartofthediagnosticprocess.Selectioncriteriaareguidelinesthathelpthedentistexercisejudgmentonwhichradiographstorequest,andatwhattimeintervals,toobtainthemaximumdiagnosticinformationwhileminimizingtheriskofradiation‐inducedbiologicdamagetothepatient.TheAmericanDentalAssociationhasendorsedtheselectioncriteriawrittenbyanexpertpanelofdentistsandresearchers(WhiteSC,AtchisonKA,HewlettER,FlackVF.EfficacyoftheFDAguidelinesforprescribingradiographsfordetectingdentalandintraosseousconditions.OralSurgOralMedOralPatholOralRadiolEndod1995;80:108‐14.BrooksSL,AtchisonKA.Guidelinesforprescribingdentalradiographs.In:WhiteSC,PharoahMJ.OralRadiology,5thed.St.Louis,Mosby,2003,pp265‐80).Thekeyprincipleinapplyingselectioncriteriaisthatradiographsshouldbeorderedonlyafterthedentisthasreviewedthepatient’smedicalanddentalhistoryandperformedaclinicalexamination.SignificanthistoricalfindingsThedentistmustquestionthepatientcarefullytoobtainahistoryofprimaryormetastaticmalignancyintheheadandneck.Apositiveresponsemightpromptaradiographicexaminationifaccompaniedbysuggestivesignsorsymptoms.Apatientwithahistoryofadenocarcinomaoftheprostateglandwhocomplainsofpainordysesthesiaofthelowerjawandlip,orwhoexhibitsenlargementofthejawordisplacementofteeth,mightbeacandidateforradiographicevaluationbasedonasuspicionofmetastaticprostatecancer. 212010 CDEL Re-recognition of the Specialty Report 205 of 279

SignificantclinicalfindingsAthoroughdescriptionofthechangesincolor,contour,consistency,andfunctionthatarerepresentativeofmalignanciesinsofttissueshasbeenprovidedelsewhereinthispublication.CTandMRIareoftenperformedtodeterminethenatureandextentoftheselesions.Butitshouldbekeptinmindthatmalignanciesthatoriginateinsofttissuescanextendormetastasizetobone,sodentistsshouldconsiderradiographicexaminationofthejawsifsuspicionsariseaboutboneinvolvementwithsofttissuetumors.Varioussignsandsymptomsmayrepresentlesionscentrallylocatedinthejawsandwouldleadtotheexposureofradiographs.Shiftingorlooseningofteethorexpansionofthejawsintheabsenceofinflammatorydisease,jawpainorparaesthesiaofthelip,andclinicalevidenceofnon‐inflammatoryandnon‐reactivemaxillarysinusdiseaseareamongtheominousfindingsthatshouldalertthedentisttotheneedforradiographs.Shouldradiographsbeexposedroutinelytoscreenpatientsforcancer?Isitwisetoroutinelyorderradiographstohuntforoccultdiseaseintheabsenceofsuggestivehistoricalorexaminationfindings?Evidencesuggeststhatthepresenceofmalignantdiseaseisusuallyaccompaniedbysignsandsymptomsthatwouldwarrantradiographicexamination(BrooksSL,AtchisonKA.Guidelinesforprescribingdentalradiographs.In:WhiteSC,PharoahMJ.OralRadiology,5thed.St.Louis,Mosby,2003,pp265‐80).Whileunsuspectedabnormalitieshavebeendetectedonradiographsexposedwithoutsuspiciousfindings,theyarealmostalwaysinsignificant,andthechanceoffindingevidenceofanunsuspectedmalignancyonaradiographisextremelysmall(StephensRG,KogonSL,SpeechleyMR,DunnWJ.Acriticalviewoftherationaleforroutine,initialandperiodicradiographicsurveys.JCanDentAssoc1992;58(10):825‐8,831‐2,835‐7).Thisisprobablyduetotherelativelylowsensitivityofradiographyinvisualizingverysubtlechangesintissue.Prevailingopiniondoesnotfavorroutinescreeningradiographsinthesearchformalignantdisease.HowcanIdecidewhichradiographictechniquestouse?Oncethedecisionhasbeenmadetoperformorrequestaradiographicexamination,thedentistmustselectthetechniquesthatwillmosteffectivelyvisualizethestructureinquestion.Veryoften,morethanonetypeofimagingshouldbeusedtotakeadvantagesofthebenefitsofdifferentprojections.1. Periapicalradiographshaveahighdegreeofspatialresolutionthatenablesdetectionofsubtlechangesinboneoralterationsofthedentalsupportingstructures.AdentistmightchooseaPAtovisualizealterationsinthePDLortoseefinedetailsofchangeinthealveolarprocess.However,theseradiographsarelimitedintheirareaofcoverage.2. Occlusalradiographsprovidethesamehighresolutionasperiapicals,andcoverlargeramountsoftissue.Theyaregoodchoicestoexaminethepalate,ortomorecompletelydepictanabnormalitythatispartiallyrevealedonPAradiographs.Occlusalscanalsohelpidentifybuccal‐lingualexpansionofthejaws,providingtherightangleviewsneededtolocalizeabnormalitiesinthreeplanesofspace.3. Panoramicradiographsallowvisualizationoflargerareasofthedentoalveolarcomplexandsurroundingstructures.Thisisagoodoptiontorevealthefullextentoflargelesionsandtheirinternalandexternalradiographiccharacteristics.Panoramicsalsorevealotherfeatures,suchastoothdisplacementorresorption, 222010 CDEL Re-recognition of the Specialty Report 206 of 279

thinningorperforationofthecortices,periostealreactions,andextensionintothemandibularneurovascularbundleormaxillarysinus.Butpanoramicsareinherentlydistortedandhavepoorerspatialresolutionthanintraoralprojections.Additionally,lesionsmaybemissediftheyexistoutsidetheimagelayerofthepanoramicradiograph.4. Otherextraoralprojections,suchasposterior‐anteriororlateralobliquejawandlateralskullradiographs,WatersprojectionsandreverseTowneradiographs,candepictarchitecturalchangesinregionsthatarenotreadilyseenonpanoramics.Theycanbeusedtolocalizediseasesinthreeplanesofspacewithright‐angleprojections,whichisrecommendedincasesofjawexpansion.Buttheseprojectionsarecharacterizedbysuperimpositionofanatomicalstructuresandlowspatialresolution.5. Volumetricorcone‐beamcomputedtomographyisanimagingmodalitythatisbecomingwidelyavailableindentistry.Theseradiographsdepicthardtissuesthroughoutthedentoalveolarcomplexandskullinallplanesofspaceand,asaformofcomputedtomography,theyeliminatesuperimpositionofunwantedstructures.ConebeamCThasthebenefitsofextraoralradiographywithoutmostofthelimitations.Ithasproventobequitevaluableinrevealingcriticalfeaturesofneoplasticdiseasesofthejawsandadjacentstructures.CBCTimagescanalsobereformattedinto3‐dimensionalrendering,whichishelpfulinplanningsurgeryandreconstruction.However,theydonotproducegoodviewsofsofttissues;unlikeconventionalCT,thereisnosofttissuewindowingforCBCT.Whatotherimagingtechniquesareusedtodiagnoseheadandneckcancer?Thefollowingradiographicmodalitiesarenotperformedbydentists,butareoftenrequestedwhenmalignancyoftheheadandneckissuspectedonthebasisofclinicalfindingsorotherradiographicexaminations:1. Computedtomographyvisualizeshardandsofttissuediseasesinmultiplelevelsthroughouttheheadandneck,andisindicatedfordetectionoftheextentoflesionsinsofttissuesandtheirinvasionintoboneaswellasfordiagnosisofprimaryosseousmalignancies(MancusoAA:Imaginginpatientswithheadandneckcancer.InMillionRR,CassisiNJ(eds):ManagementofHeadandNeckCancer,ed2.Philadelphia,JBLippincottCompany,1994,pp43‐59).OnemajorlimitationofCTisitspoorspatialresolution,whichprecludesdetectionofsubtlealterationsinhardtissues.2. Magneticresonanceimaginghasexcellentsofttissuecontrastthroughouttheskullinmultiplesections.Itisanidealtechniquefordetectionofcancerinthesofttissuesoftheheadandneckandproducesnoknownbiologicrisk,sinceionizingradiationisnotused(MancusoAA:Imaginginpatientswithheadandneckcancer.InMillionRR,CassisiNJ(eds):ManagementofHeadandNeckCancer,ed2.Philadelphia,JBLippincottCompany,1994,pp43‐59).3. Bonescintigraphyinvolvesinjectionofaradionuclideboundtoacompoundthatisabsorbedbythetissueunderinvestigation.Emissionofgammaradiationfromsitesoflocalizationoftheradionuclideindicatesthepresenceofdisease,oftenbeforeitbecomesmanifestonconventionalradiographs.Scintigraphyhasbenefitsinrevealingsmallmetastasesinthemaxillaeandmandible. 232010 CDEL Re-recognition of the Specialty Report 207 of 279

RadiographicFeaturesSuggestiveofCancerintheJawsMalignantlesionsmayariseprimarilyinthemaxillaeormandible,extenddirectlyintothejawsfromprimarysitesinoralsofttissues,ormetastasizetothejawsfromdistantlocations.Certainradiographicsignssuggestthepresenceofcancerinthejaws(GeistJR.Imagingmalignantlesionsoftheheadandneck.OralMaxillofacSurgClinNAmer2001;13(4):697‐712.WoodRE.Malignantdiseasesofthejaws.In:WhiteSC,PharoahMJ.OralRadiology,5thed.St.Louis,Mosby,2003,pp458‐84.FarmanAG,NortjeCJ,WoodRE:OralandMaxillofacialDiagnosticImaging.St.Louis,Mosby,1993,pp1‐64)NumberandlocationoflesionsNeoplasmsaregenerallysolitarylesions.However,somemalignanciessuchasmultiplemyelomaaremultifocal,andmetastasesfromdistantsitescanoccasionallybefoundinmorethanonelocationinthejaws.Mostmalignantlesionsarenotfoundinassociationwiththeteeth,exceptfortherarecasesofcarcinomaarisinginpre‐existingodontogeniccystsortumors.Manycancersdevelopoutsideofthealveolarprocesses,butcanextendintothetoothbearingregions.Figure1InternalcharacteristicsMalignantneoplasmsaregenerallyosteolytic,withtumorcellsproliferatingattheexpenseofthenormalbones.Somelesions,suchasmultiplemyeloma,lymphomasinbone(e.g.,Burkitt 242010 CDEL Re-recognition of the Specialty Report 208 of 279

lymphoma)andprimarycarcinomas,areentirelyradiolucent(Figure1).Manycancers,however,arecharacterizedbyproductionofhardtissueorinductionofreactiveboneformationinandaroundthelesion.Osteosarcomaandchondrosarcomagenerallyproducemixedradiographicpatternswithneoplasticboneandcartilageinterspersedwiththesofttissuetumormasses(Figure2).Somemetastaticmalignancies,notablyprostateandbreastcancer,canstimulateformationofboneperipherally(Figure3).Itshouldalsobenotedthattheterms“radiolucent”and“radiopaque”arerelative.Asofttissuetumordestroyingthemaxillaisradiolucentincontrasttotheadjacentbone,butthesamelesionextendingintothemaxillarysinusproducesafaintradiopacityagainstthebackgroundoftheairspace. Figure2 252010 CDEL Re-recognition of the Specialty Report 209 of 279

Figure3PeripheryofabnormalitiesTheaggressiveandrapidgrowthpatternexhibitedbymostmalignanttumorsproducesapoorlydefined,indistinctborderinmostcases(Figs1‐4).Themarginsarealsousuallyirregular,reflectiveoftheunevenproliferationofmalignancies.Someexceptionsareknown,however.Chondrosarcomaoccasionallyexhibitsanindolentgrowthpatternandcanproduceawelldefinedleadingedge. 262010 CDEL Re-recognition of the Specialty Report 210 of 279

Figure4EffectsonadjacentstructuresWideningoftheperiodontalligament,especiallyifasymmetrical,canrepresentthespreadofaprimarymalignancysuchasosteosarcomaorchondrosarcomaalongthepathofleastresistancefromthealveolarprocessintothePDL.Gingivalcarcinomacanalsodemonstratethispattern.Periapicalradiographsareidealfordetectingthesechanges,butmayneedtobesupplementedwithocclusalsorpanoramicsforlargerlesions.Displacementorresorptionofteethcanresultfromthepressureofaspaceoccupyinglesions.Whilethesechangesaremostoftentheconsequenceofcystsorbenignneoplasms,theycanalsoresultfromthepresenceofmalignanttumors,includingosteosarcoma,chondrosarcoma,andodontogeniccarcinoma.Intraoralandpanoramicradiographsgenerallycanrevealthesealterations.Expansionofjawsisahallmarkoftumors,benignandmalignant.Ingeneral,malignantneoplasmswillcauserapidenlargementthatmaybepainful.Panoramicscandepictexpansioninthesuperior‐inferiordimension,butadditionalprojections(occlusals,extraoralradiographs,orCBCT)areneededtovisualizebuccal‐lingualoranterior‐posteriorexpansion. 272010 CDEL Re-recognition of the Specialty Report 211 of 279

Thinningand/orperforationofcorticalborderscanbecausedbyneoplasms.Slowlygrowingbenigntumorsexertgradualpressureonbone,resultinginsmooth,uniformresorption.Malignanciestendtopursueamoreaggressivegrowthpattern.Insteadofgentlyresorbingthecortices,theyoftencauseerraticdestructionandperforatethecortex(Figure1).Periostealreactionssometimesresultfrommalignantdisease.Layeredthickeningoftheperiosteumcanindicatesimplyaproliferativeperiostitiscausedbyperiapicalinflammation,butonoccasion,aggressiveormalignantlesionssuchasLangerhanscelldiseaseorEwingsarcomacanberesponsible.Osteosarcomacaninduceasimilarproliferation,alongwithinternaldestructionofthejaw.Bonecansometimesbeproducedatrightanglestothecortex,producingthe“sunburst”appearance.Occlusalradiographs,extraoralimagesandCBCTorCTarevaluableinshowingthisabnormality.Whilethisperiostealreactionisoftenregardedastypicalofosteosarcoma,itisoftennotfoundinosteosarcomasofthejaw,andcanbeproducedbyotherdiseases.Figure5Destructionofthemaxillarysinuswallscanoftensignifyinflammatorydiseasearisingeitherwithinthesinusorasaconsequenceofodontogenicinfection.Insomecases,however,malignanciesarethecausativeagents.Destructionofthesinuswallinassociationwithradiopacityinthesinuslumencanindicateantralcarcinoma(Figure5),whileabreachofthewallwithadestructivepatterninthealveolarprocessmightsuggestextensionintothesinus 282010 CDEL Re-recognition of the Specialty Report 212 of 279

fromaprimarylesioninboneorthesofttissuesofthepalate.Diseaseinthemaxillarysinusmaybeseenonpanoramicradiographs.Extraoralimages,suchasWatersandlateralskullradiographs,andCBCTorCTarealsohelpfulinvisualizingtheentiresinus(Figure6).Figure6RadiographicFeaturesSuggestiveofCancerintheSoftTissuesMalignantdiseasesofepitheliumorunderlyingsofttissuesintheheadandneckcanbeviewedradiographicallywithCTandMRI.Theclinicalfindingsthatsuggestmalignancyinthegingivae,softandhardpalatalmucosa,buccalmucosa,floorofthemouth,tongue,neckandsalivaryglandsarepresentedinanothersectionofthisbrochure.DentistswhosuspectthesediseaseswouldnotordinarilyreferpatientsdirectlyforCTorMRIinvestigation,butinsteadwouldreferthemtoaspecialistinOralandMaxillofacialSurgeryortoaphysician.AdetaileddescriptionoftheradiographiccharacteristicsasseenonCTorMRIisthereforenotwarranted.However,abriefdiscussionoftheabilitiesoftheseimagingsystemsmayhelpthedentalprofessionalunderstandwhytheyareoftennecessary(GeistJR.Imagingmalignantlesionsoftheheadandneck.OralMaxillofacSurgClinNAmer2001;13(4):697‐712).Mostoralcancersariseonthetongueandfloorofthemouth.MRIisbettersuitedthanCTindetectingtumorsintheintrinsiclingualmusculaturebecausethesetissuesaresimilaronCT 292010 CDEL Re-recognition of the Specialty Report 213 of 279

whereasthegreatersofttissuecontrastofMRIdistinguishesthem.CTandMRItogetherareveryhelpfulindelineatingtheextentoftumorsinthefloorofthemouthandadjacenttissues,andCTinasofttissuewindowwithenhancementhasbeenshowntobebeneficialindetectingperineuralextensionoftumors.MRIisusefulindepictingextensionoftumorsintothemedullaryportionofthejaws,wheretheyproducelowintensitydarksignalsincontrasttothebrightsignalofthefattybonemarrow.CTisprobablybetterinshowingsubtleerosionofcorticalbonecausedbymalignantinvasionbecausecorticalboneproducesnosignalinMRI.SalivaryglandtumorsinthepalateareoftenexaminedwithCTtodeterminetheextentofthelesionsbeyondthehardpalate.CTwithorwithoutMRIcanaidinthedetectionofspreadthroughthepalatinecanalorintothepterygopalatinefossa,whichisnecessarytoplanresectionmargins.CTisoftenusedincasesofcancerinthebuccalmucosatoidentifyextensionintothemusclesofmastication.Itisalsovaluableinexaminingpatientswithmalignanciesofthetonsilsandoropharynxbecausesofttissuewindowingisusuallysuccessfulindistinguishingtumormassesfromthedifferentsofttissuesofthesestructures.CTisalsohelpfulinvisualizingthenecrosisthatcharacterizesmetastatictumorsinthecervicallymphnodesasdistinctfromthesurroundingnormaltissue.ReferencesWhiteSC,AtchisonKA,HewlettER,FlackVF.EfficacyoftheFDAguidelinesforprescribingradiographsfordetectingdentalandintraosseousconditions.OralSurgOralMedOralPatholOralRadiolEndod1995;80:108‐14.BrooksSL,AtchisonKA.Guidelinesforprescribingdentalradiographs.In:WhiteSC,PharoahMJ.OralRadiology,5thed.St.Louis,Mosby,2003,pp265‐80.StephensRG,KogonSL,SpeechleyMR,DunnWJ.Acriticalviewoftherationaleforroutine,initialandperiodicradiographicsurveys.JCanDentAssoc1992;58(10):825‐8,831‐2,835‐7.MancusoAA:Imaginginpatientswithheadandneckcancer.InMillionRR,CassisiNJ(eds):ManagementofHeadandNeckCancer,ed2.Philadelphia,JBLippincottCompany,1994,pp43‐59.GeistJR.Imagingmalignantlesionsoftheheadandneck.OralMaxillofacSurgClinNAmer2001;13(4):697‐712.WoodRE.Malignantdiseasesofthejaws.In:WhiteSC,PharoahMJ.OralRadiology,5thed.St.Louis,Mosby,2003,pp458‐84.FarmanAG,NortjeCJ,WoodRE:OralandMaxillofacialDiagnosticImaging.St.Louis,Mosby,1993,pp1‐64. 302010 CDEL Re-recognition of the Specialty Report 214 of 279

THEORALCANCERSCREENINGEXAMINATIONTheimportanceoforalcancerscreeningOnepersondiesoforopharyngealcancerintheUSAeveryhour.Thisdiseasestrikesabout30,000Americanseachyear,andkillsnearlyhalfofthemwithin5years.Theoralcancerpatienthasamuchgreaterchanceofacureandoflivinganormallifeiftheirdiseaseisdetectedearly.Forthisreason,thedentistisdefinitelyinapositiontosavelives.Thedentistmaybetheonlypractitionerthattheedentulouspatientvisits;thispatientmayotherwisegodecadeswithoutahealthprofessionalexaminingtheiroralregion.Alsotheedentulousandpartiallyedentulouspatientismorelikelytobeanoldermale,andasmokerorformersmoker,importantconsiderationsintheassessmentofrisk(AmericanCancerSociety).Whatisthepurposeoforalcancerscreening?ThepurposeoftheOralCancerScreeningExamistodetectanytissueabnormalitiesthatcouldpotentiallybeorbecomeamalignancy,noworinthefuture.Itneedstobepartofthedailyroutineinthedentist’sofficeforanumberofreasons:ethical,health‐related,economic,andlegal.Detectionoforalcancerandindeedsystemicdiseasesisarecognizedpartofthelegalscopeofdentalpractice,andfailuretodiagnoseisafrequentcauseofmalpracticeclaims.Oralcancerscreeningisnotremuneratedwellundercurrentfeestructures,butpatientsarefrequentlyimpressedandpleasedbythethoroughnessandthoughtfulnessofthedentistthatwatchesoutfortheirhealthinthismanner.Whoshouldbescreenedfororalcancer?Theoralcancerexamshouldbeperformedatanypatientatriskfororalcancer.Inpracticalterms,thisincludeseverypatientseenatthedentist’soffice.Thehigh‐riskpatientfororalcancerisgenerallyolder,male,andasmokerorex‐smoker,andotherriskfactorsincludefrequentuseofalcohol,useofbetelnutproducts(morelikelyintheAsianpatient),poordiet,andahistoryofapreviousheadandneckcancer.However,justaboutanyprosthodonticpatientcoulddeveloporalcancer;agrowingnumberoforalcancerpatientsareyoungerandlackthetraditionalrisk(Cancer).Doesoralcancerscreeningreallymakeadifference?ArecentstudyinLancetlookedat168,000patients,ofwhomabout87,000receivedoneormorevisualscreenings.Overa9‐yearperiod,thescreenedgroupdemonstrateda32%reductioninmortality,andtheauthorssuggestthatvisualscreeningalonehasthepotentialtosaveatleast37,000livesannually.(SankaranarayananR,etal.).WhatshouldaclinicianlookforThepurposeoftheexaminationistodetectanyareathatlooksoutoftheordinaryandforwhichthecliniciandoesnothaveadefiniteclinicaldiagnosis.AhandychecklististolookforChangesinColor,Contour,Consistency,andFunction.Changes:Howlonghasthelesionbeenpresent?Isitstable?Cancerisaggressive.Thus,amalignancytendstobegrowingandchangingovertime.Occasionallyamalignancymayariseinapreviouslybenignorpremalignantlesion,soalongstandinglesionthatwaspreviouslystableandhasbeguntochangeincolor,contour,consistencyorfunctionshouldringalarmbells.Ofcourse,inanidealworldwewoulddetectandremovethelesionsbeforethemalignanttransformationtakesplace,soanyunusual 312010 CDEL Re-recognition of the Specialty Report 215 of 279

lesionthatdoesnotshowsignsofresolutionwithintwoweeksshouldbeconsideredforfurtherinvestigation.Color:Red,white,orpigmentedlesionsLesionslookwhitewhentheepitheliumisthickened,andtheylookredwhentheepitheliumisthinnedoreroded,orwhenextrabloodvesselsarepresent.Theseareallchangesthatcanheraldpremalignancyormalignancy.Changesinpigmentationcanbecausedbyincreasedmelanocyticwhichcouldbeneoplastic.Whitelesionsarethemostcommonandareofteneasilydiagnosedasaspecificdiseaseentity.Howevermostoralcancerstartedoutasaninnocuous‐lookingwhitelesion,soanyunexplainedoratypicalwhitelesiondeservesfurtherinvestigation.(Figure1)Redlesionsarelesscommon,andarelativelyhighproportionofunexplainedredlesionsarepotentiallydangerous,particularlyinhigh‐risklocationssuchasthelateraltongueandfloorofthemouth(Figure2).Theruleofthumb“SeeRed,Beware”isusefultokeepinmind.Coloredlesionsmaybebecauseofbloodorbloodproducts,foreignmaterial,ormelaninpigmentation(Figure3).Forpigmentedlesions,youmaywishtoapplytheAmericanCancer 322010 CDEL Re-recognition of the Specialty Report 216 of 279

Society’sABCDERule:lookforAsymmetry,Borderirregularity,Colorvariation,Diameterlargerthan6mm,andEvolutionovertime(AbbassiNRetal.).Thelentigomaligna,aprecursortooneformofmelanoma,mayslowlyspreadacrosstheskin’ssurfaceforupto15yearsbeforeinvading,whichcreatesafalsesenseofsecurity,butalsopresentsalongwindowofopportunityforearlydetection(FlotteTJ,MihmMC).Contour:IrregularsurfacecharacteristicsWhenoralmucosaproliferates,itsincreasedbulkneedstobeaccommodated.Itmaypileuponthesurface,orinfiltrateunderneaththesurface,orboth.Thismasscanusuallybepalpatedandseen.Oraldysplasiaandcancerofteninitiallypresentascorrugatedorverrucousareas,resultingfromtheaccumulationofexcessiveepithelialcellsonanunchangedfoundationofconnectivetissue(Figure4). 332010 CDEL Re-recognition of the Specialty Report 217 of 279

Adome‐shapedlesionisusuallylocatedunderneaththesurface,notarisingfromanovergrowthofsurfaceepithelium,andthelevelofitsdepth,andhencetissueoforigin,maybeguesstimatedbyapplyingtheCircleRuleasshownin(Figure5).Consistency:InduratedWhenepithelialcancerinvadestheunderlyingconnectivetissue,thesurfaceepitheliumbecomesbounddowntotheunderlyingconnectivetissueresultinginaninduratedtextureasshownin(Figure6).Invasivecancersoftenexhibitaheaped‐upshoulderandsometimesanulceratedcenter,andthisalsoaccountsfortheirredandwhiteappearance.Whencancercellsinvadethroughlymphaticorbloodvesselwalls,theymayenterthecirculationandmetastasizetodistantareas,andmaybedetectedasfirminduratedlymphnodes. 342010 CDEL Re-recognition of the Specialty Report 218 of 279

Function:Paraesthesia,paralysis,painEpitheliumdoesnotcontainanynerves;thesestructureslieintheunderlyingconnectivetissue.However,whensquamouscellcarcinomainvadestheconnectivetissue,itmayinvadenervesheaths,alteringtheirfunction.Thismaybeapparentasnumbnessorparaesthesia,oralternatelyasspontaneouspain,oftenstabbingorelectricalinnature.Ifamotornerveisaffected,theremaybeparalysisofregionalmotorfunction,forexamplethetonguemaydeviatetotheaffectedsidewhenthepatientstickstheirtongueout.Whenshouldanoralcancerscreeningexaminationbeperformed?Everypatientshouldbescreenedfororalcancerattheinitialexamination,andeverytimeare‐examinationisperformed,ideallyatleastonceayear.Theoralcancerscreeningexamtakesaslittleas90seconds(HorowitzAM).Whereshouldanoralcancerscreeningbeperformed?Bothdentistsanddentalhygienists,dependingonthedentalofficepreferencesandstatelicensinglaws,canperformoralcancerscreening.Inmanyjurisdictions,adentalhygienistisnotpermittedtoperformdiagnosis.Twosetsofeyesareoftenbetterthanone,soinmanyofficesboththedentalhygienistandthedentistwillperformanoralcancerscreeningexaminationwhentheyseethepatient,whileinotherofficesanyunusualfindingsbythehygienistwillbefollowedupbythedentist.Outlineandsynopsisofanoralcancerscreeningexamination• Importanceofmedicalhistory• Reviewfamilyhistory• Reviewriskfactors• Suggestlifestylemodificationsthatmightreducerisk• Askpatientaboutchangestheyhavenoted• Advisepatientyouwillperforminganoralcancerscreeningexamination• Observepatientforchangesinfunction• Referasneeded• Keystoagoodexamination• Followsameroutineeverytime• Don’tgetsidetracked• Useallyoursenses(sight,sound,touch,smell)• Learnnormalandabnormal• Changestolookfor• Contour• Color• Consistency• Function• Standardtechniques• Inspection• Palpation• Auscultation• Percussion• Trans‐illumination• Probing• Other 352010 CDEL Re-recognition of the Specialty Report 219 of 279

• Basicarmamentarium• Goodlighting• Mirror• 2X2gauze• Dentalexplorer• Periodontalprobe• Tonguedepressor• Eyeprotectionforpatient• Importanceofgoodvisibility• Knowledgeornormalanatomy• HowshouldanoralcancerscreeningexaminationbeperformedImportanceofhistoryHistorytakingisthefirststep,andshouldincludeafamilyhistoryofcancer,areviewofriskfactorsfororopharyngealcancersincludingpastandpresenttobaccouse,alcoholconsumption,andotherlifestylefactors.Finally,itisveryusefultoaskthepatientiftheyhavenoticedanyunusualchangesintheirmouthincludingpatches,sores,lumps,orfunctionalchanges.Thehistorytakingprocessalsoofferstheopportunitytodiscusswiththepatientthatyouareabouttoperformanoralcancerscreening,andtosuggestlifestylemodifications(especiallytobaccocessation)thatmightreducefuturerisk.Thisisalsoagoodtimetoobservethepatientforchangesinfunctionincludingmotordeficits,ahoarsevoice,visualchangesandhearingloss,whichmaypromptyoutoreferthepatientforfurtherevaluation.ExtraoralexaminationThismaybeperformedwiththepatientuprightorrecumbent,butisoftenbestachievedwiththepatientsittingcomfortablyateyelevelinagoodlight.Asymmetryandchangesincolor,contour,consistency,andfunctionarethemantraasyoufirstlook,andthenpalpatetheregion.Alternatingbetweenobservationandpalpationallowsyoutogainavisualunderstandingofthestructure'sshapeandsize,helpsyoutoavoidsurprisingthepatientandyourselfbysuddenlypalpatingapainfulstructure,andpreventsyoufromalteringalesionbypalpationbeforeyougettoseeit.(BrandJ,etal.).Figure7 362010 CDEL Re-recognition of the Specialty Report 220 of 279

Examinetheentireheadandneckincludingtheeyes,ears,nose,skullandscalp.Theeyesshouldtracknormallyandshouldbefreeofswellinganddrainage.Thenoseshouldbepalpated,andtheanteriorportionofthenarescanbeobserved.Theearsshouldbeinspectedandpalpated,includingthepinna,lobe,auricleandvisibleportionsoftheexternalauditorycanal.Theneckshouldalsobeexaminedatthistime.Thepatientshouldberestingagainsttheheadrestinarelaxedposition,andhavingthepatientgentlydrooptheirheadforwardmayenhanceneckpalpation.Bimanuallypalpatetheneck,comparingtherightandleftsidesforasymmetry,lookingforenlargedpainlesslymphnodesandotherabnormalmasses.Thesubmentalnodesareconvenientlypalpatedwiththefingertips(figure7,figure8).Thesubmandibularnodesarepalpatedextraorallybetweenthefingersandthelingualaspectofthemandible,andintraorallyusingglovedfingerstopressagainstthestructuresusingtheotherhandbelowontheoutsideoftheskin.Thejugularchainsarepalpatedusingdeeplyplacedfingersoneithersideofthesternocleidomastoidmusclefromitsoriginattheclavicletoitsinsertionatthemastoidprocess,includingthepreauricular,parotid,andretroauricularnodes.Includetheanteriorscaleneandsupraclavicularnodesabovetheclavicles,andthedelphiannodesneartheinferiormidlineoftheneck(figure9).Palpatethespinalaccessorynodes,movingthetissuesacrossthetrapeziusmusclebodytoaiddetection.Figure8 372010 CDEL Re-recognition of the Specialty Report 221 of 279

Figure9Thefrontoftheneckisexaminednext,includingthelarynx,salivaryglands,thyroidgland,andcarotidarteries.Anenlargedcarotidbifurcationmaybedifferentiatedfromalymphnodebythepresenceofapronouncedpulse.Palpatethelarynxforsignsofenlargementorimmobility.Thethyroidglandisnotnormallypalpable,andshouldmovefreelyupanddownwhileswallowing.Thiscanbeobserved,withthepatientturningtheirheadtofirsttowardsonesideandthentheotherwhileswallowing,andthenpalpatedinthesamemanner(figure10).Alsonotethepresenceofanythyroidnodulesormasses(figure11).Figure10 382010 CDEL Re-recognition of the Specialty Report 222 of 279

Figure11IntraoralexaminationTheintraoralexaminationistypicallyperformedwiththepatientlyinginthedentalchair,butcanalsobeadequatelyachievedwiththepatientsittingupright.Allremovableprosthesesshouldbetakenoutbeforethisexamination.Thelipsshouldbeevaluatedbothopenandclosed,firstvisuallyincludingthevermilionborder,commissures,andmucosa.Theyarenextpalpatedbilaterallyandbidigitallybetweenthethumbandfingers.Thelipvermilionisafrequentsiteformalignancy,anddysplasticchangesareobservedinmanyolderadultsintheformofactiniccheilitis.Inthiscommonpremalignantcondition,thevermilionborder(particularlyonthelowerlip)becomesblurredandilldefined;thevermilionmucosaispuffywithroughscalyleukoplakiaorerythroleukoplakia(figure12).Indurationmaysignaltheonsetofsquamouscellcarcinoma. 392010 CDEL Re-recognition of the Specialty Report 223 of 279

Figure12Thebuccalmucosaisviewedbyretractingitwithatonguebladeorfingerswhilethemouthisinarelaxedopenposition.Theparotidglandsshouldbepalpatedaspartofthisstep.Theresultsofbidigitalpalpationshouldbecomparedbetweentherightandleftsides.Thecolor,contour,consistencyandfunctionofthealveolarprocessesandgingivaareassessed,aswellasthatofthehardpalate.Onesignoforalsquamouscellcarcinomathatissometimesoverlookedisatooththatexperiencesbonelossoutofproportiontotherestofthearch,intheabsenceofadefiniteetiologysuchasacrackedroot.Anotherisapoorlyhealingextractionsite.Anysubmucosalswellingsshouldbeidentifiedandaccountedfor;thehardpalateisthemostcommonintraoralsiteforminorsalivaryglandtumors,whichmaybebenignormalignant,andisalsoasitewherelymphomamayoccur. 402010 CDEL Re-recognition of the Specialty Report 224 of 279

Figure13Thesoftpalate,uvula,andtonsillarpillarsmaybemoreofachallengetoviewintheirentirety,butitshouldbethoroughlyinspectedaswellasgentlypalpatedifpossible.Thetonsilsandpharyngealwallsshouldbeexamined,withattentionpaidtomassesaswellasasymmetry.Tonguedepressionisanaidinthisexamination,aswellashavingthepatientsay“ahhh”whilegentlybreathinginandout.Somepatientscannothelpresistingthisphaseoftheexamination,andifthepatient’scooperationisrequestedinadvance,thecliniciancouldmakesurethelightisoptimallyplacedandusethetonguedepressortoactivatethegagreflex,affordingabriefviewofthearea.Thisisnotrecommendedasthefirst‐lineexaminationtechnique,butasthefallbacktechniquewhenothersfail.Atonguedepressorisnotalwaysstrongenoughtowrestleanobstinatetongue,inwhichcasetheuseofamirrorasatonguedepressorisrecommended.Withoutthiseffort,cancerssuchasthatshowninfigure13maygoundetected.Thislesion(photocourtesyofDrRoseGeist)continuedtoenlargeduring 412010 CDEL Re-recognition of the Specialty Report 225 of 279

epeatedvisitsforadjustmentofanill‐fittingcompleteupperdenture,untilitwasfinallydetectedafterreferralforapersistentearache.Unexplainedearachecanbeassociatedwithpharyngealcancers.Squamouscellcarcinomaandlymphomaarethemostcommonmalignanciesofthetonsil.Twosymmetricallyenlargedtonsils(figure14)arelessfrequentlyneoplasticthanoneasymmetricallyenlargedtonsil,butahistoryshouldbeelicitedandappropriatefollow‐uporreferralneedstobeconsidered.Thesoftpalateandtonsillarpillarsmayalsogiverisetosquamouscellcarcinoma;benignlymphoidnodulesandpapillomas(figure15)aremorecommonbutaresmall,non‐aggressive,andwelldemarcated.Figure14 422010 CDEL Re-recognition of the Specialty Report 226 of 279

Figure15Examinationofthetongueisthenextorderofbusiness,andsinceabouthalfofalloralcancersoccuronthelateralandventraltongue,thisareadeservesspecialcare.Thetongueshouldbepulledforwardgently,gettingafirmgripwithgauze,inordertovisualizepastthecircumvallatepapillaetothebaseofthetongue.Alaryngealmirrorishelpfultoseethisarea,oradentalmirrormaybeusedlesssuccessfully.Illuminatedmirrorsareespeciallyhelpful.Thebaseofthetongueshouldbepalpatedtowhateverdegreeispossible.Theentiredorsaltongueshouldbevisuallyinspected,aswellasthelateralandventraltonguealongitsentirelength.Afterinspection,theoraltongueshouldthenbepalpated.Failuretoadequatelycompletethisstepcouldallowthedentisttomissmoreposteriormalignanciessuchasthatshowninfigure16. 432010 CDEL Re-recognition of the Specialty Report 227 of 279

Figure16Whileredandinduratedlesionsandmassesshouldcertainlyalarmtheclinician,innocuouswhitelesionsaresometimesdismissedas“lichenplanus”.Suchalesion,whichwaspresentinonlythisonesite,thelateraltongue,isshowninfigure17(courtesyofDrTomDaley).Onbiopsy,itprovedtobeepithelialdysplasia.Thepresenceofsuchalesionwithoutapparentcause(particularlyinahigh‐risklocationand/orinahigh‐riskpatient)shouldtriggerareferralforpotentialbiopsy.Figure17 442010 CDEL Re-recognition of the Specialty Report 228 of 279

Figure18Finally,thefloorofthemouthneedstobeinspectedandpalpated.Aboutone‐thirdofintraoralcancersoccurinthissite.Twohandsareusedtopalpatethisarea,oneinsidethemouthandonebelowthechin.Thesublingualandsubmandibularglandsarealsoassessedatthistime.Thefloorofthemouthisanunusualsiteforleukoplakia,asitisnotusuallysubjecttotrauma,soanywhitelesionneedscarefulappraisalandstrongconsiderationforbiopsy(figure18).Redlesions,particularlywithinduration,areatevenhigherriskandanearlyinvasivesquamouscellcarcinomathataroseinared‐and‐whitelesionisshowninfigure19(photocourtesyofDrA.K.ElGeneidy). 452010 CDEL Re-recognition of the Specialty Report 229 of 279

Figure19ConclusionsTheprosthodonticpatientmaybeathigherriskthanaverageforundetectedprecancerousandmalignantorallesions,becauseofthefeaturesthatputpatientsatrisk(age,sunexposure,tobacco,alcoholandothers)andbecauseedentulouspatientsmayseekdentalcarelessfrequently.Allpatientsshouldhaveanoralcancerexaminationatleastonceperyearandpreferablytwiceperyear.Anyunexplainedfindingsorlesionsthatfailtoresolvewithintwoweeksshouldbestronglyconsideredforbiopsy.Withestablishmentofacarefulroutine,thedentistisinanexcellentpositiontodetectcancerearlyandsavelives. 462010 CDEL Re-recognition of the Specialty Report 230 of 279

MANAGEMENTOFSUSPICIOUSORALLESIONSIntroductionTheultimateresponsibilityfororalscreening,diagnosisandfollow‐uprestswiththedentist.Ifageneraldentistoraspecialistdeterminesthathis/herpatientrequiresabiopsyorsomeotherdiagnostictestingthenitisrecommendedthattheappointmentbemadewhilethepatientisstillintheoffice.Aconfirmationletter,fax,ore‐mailsubsequentlyshouldbesenttothereferredspecialist,anoralandmaxillofacialpathologist,outliningthereferringdentist’sconcernsandarequestforthereferredspecialisttosendawrittenreportofthespecialist’sevaluationofthepatient.Itisrecommendedthatbiopsyspecimensoftheoralcavity’sindigenoustissuesandcontiguousstructuresshouldbesubmittedtooralandmaxillofacialpathologistsforevaluationwheneverpossible.Somegeneralmedicalpathologistsareunfamiliarwiththehistopathologicalsubtletiesofodontogenicandoraltissues,whichcanleadtomisdiagnoses.Allofficesperformingbiopsiesshouldhavereasonablepoliciesandproceduresinplacetoensuretimelyreview,documentationandfollow‐upactionsforreturnedbiopsyreports.Noninvasivescreeningtechniques(e.g.exfoliativecytologysmear,liquidbrushcytology,brushbiopsy,chemiluminescence,autofluorescence)shouldnotbeconsideredasubstituteforgold‐standardsurgicalbiopsyofarchitecturallyintacttissuewhenthereisaconcernaboutmalignancy.BiopsyindicationsItisgenerallyviewedbythecourtsasanindicationthatadiagnosticbiopsyneedstobeperformedassoonaspossibleifthereisnoimprovementintheclinicalfeaturesofalesionortheclinicaldiagnosisbecomesuncertaininthejudgmentofareasonableandprudentdoctor.Thereforebiopsyalesionif:Thereisnoidentifiableetiologyandtheareaofconcernspersistsformorethan10‐14daysdespitelocaltherapy.Itisfeltthattheareahasmalignantorpremalignantcharacteristicsduetothefollowingcharacteristics:• Theareahasgrownorisgrowingrapidlyfornoobviousreason• Theareaisared,whiteorpigmentedmucosallesionorcombinationoftheseforwhichacauseordiagnosisisnotevident• Thesuspiciousareafeelsfirmlyattachedorfixedtoadjacentstructures• Theareaofconcernislocatedinahigh‐riskareafordevelopmentoforalcancer(e.g.,floorofmouth,tongue)• Thereisaneedtoconfirmaclinicaldiagnosticsuspicion• Theareadoesnotrespondtoroutineclinicalmanagementoverareasonableperiod• Theareaisasourceofextremeconcerntothepatient(i.e.,patient’sfearaboutapersistentlesionisgreaterthantheconcernaboutundergoingaminorsurgicalprocedure)ManagementofleukoplakiafollowingbiopsyLeukoplakiasinlow‐riskareaswithnohistologicevidenceofdysplasiamaybeobservedforaslongastheyarepresent.However,ifchangesdevelopsuchasredness,ulcerationorpebbledsurfacemorphology,thenasecondbiopsyshouldbeimmediatelyscheduled.Alesionwithmilddysplasiamaysometimesbeobservedclosely,however,ifitisinahigh‐risksiteand 472010 CDEL Re-recognition of the Specialty Report 231 of 279

amenabletoexcisionthenitshouldalwaysberemoved.Alesionwithmoderate‐to‐severedysplasiashouldalwaysbeexcised.Biopsyshouldonlybeavoidedwhentheprocedurewouldsignificantlyendangerthehealthorsafetyofthepatient.LengthofobservationofanundiagnosedlesionThefrequencyandlengthoffollow‐upisinfluencedbymanyfactorssoonlygeneralizedguidelinescanbeproposed(i.e.,neitherrigidprofessionalguidelinesnorlegalstandards).However,thereissubstantialagreementintheliteraturethatanyundiagnosedlesionusuallyshouldbefollowedfor7‐14days,withorwithoutlocaltreatment.Ifthelesiongrows,developsalterationsincharacteristicordoesnotrespondtotherapythenbiopsyisclearlyindicatedIfthehistopathologicdiagnosisdoesnotyieldanysuspicionofmalignantorpremalignantchangesbutclinicalconcernremains,thedentistandoralpathologistshouldconfertodecidewhetheritisappropriatetoperformanotherbiopsy,removetissuefromanotherarea,removealargerspecimenorsimplyobservethesiteovertime.Ifthelesionhasnotdisappearedbuthasnotchangedinappearanceorsurfacecharacteristicsthentheclinicianmustdecidewhethertobiopsyorifthelesionshouldbere‐evaluatedperiodically.Ifthedecisionismadetonotbiopsyalesionwithalowindexofclinicalsuspicionthenaprovisionaldiagnosisshouldbeformulatedandrecordedinthepatient’sdentalrecord.Withinformedconsentofthepatient,arrangementsshouldbemadetoperiodicallymonitorthelesionforchanges.Iftheclinicianisinexperiencedandunsureofthebestclinicalcoursethenreferraltoanoralandmaxillofacialpathologist,oralandmaxillofacialsurgeonorotherspecialistforasecondopinionisadvisable.Ingeneral,thepatientshouldbere‐examinedcarefullywithinonemonthandthenatthree,sixand12monthsaftertheinitialexamination.Ifsignificantchangesarenotedatanyoftheseexaminationsthenabiopsyshouldbearrangedimmediately.Afteroneyear,mostunchangedlesionscanbemonitoredeverysixmonths,andaftertwoyears,mostcanbemonitoredsemiannuallyorannuallyaspartofthepatient’sroutinedentalexamination.Thepatientshouldbeadvisedthattheycontactthedentalofficeifanychangesarenotedintheareaofthelesionbeforethenextscheduledvisit.ReferencesAlexanderRE,WrightJM,ThiebaudS.Evaluating,documentingandfollowinguporalpathologicalconditions.JADA2001;132:329‐35KingRC,McGuffHS.Biopsy:alifesavingmeasure.TexDentJ1996;113:45.NevilleBW,DammDD,AllenCM,BouquotJE.OralandMaxillofacialPathology,2ndedition,W.B.SaundersCo.,2002.PetersonLG,EllisE,HuppJR,TuckerMR,eds:Contemporaryoralandmaxillofacialsurgery.3rded.St.Louis:Mosby:1998:512‐32.WrightJM.Areviewandupdateoforalprecancerouslesions.TexDentJ1998;115:15‐9. 482010 CDEL Re-recognition of the Specialty Report 232 of 279

Tables1through10ThoseatriskTable1 492010 CDEL Re-recognition of the Specialty Report 233 of 279

Table2 502010 CDEL Re-recognition of the Specialty Report 234 of 279

Table3 512010 CDEL Re-recognition of the Specialty Report 235 of 279

Table4Table5 522010 CDEL Re-recognition of the Specialty Report 236 of 279

Table6 532010 CDEL Re-recognition of the Specialty Report 237 of 279

Table7Table8 542010 CDEL Re-recognition of the Specialty Report 238 of 279

Table9Table10 552010 CDEL Re-recognition of the Specialty Report 239 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix EContinuing ProsthodonticsEducation Courses2010 CDEL Re-recognition of the Specialty Report 240 of 279

CPE Course History From 2000-2010Date Name of Course Location # of Attendees CE Credits Course Director/sNovember 15-18, 2000 Annual Session 2000 Kamuela, HI 981 45 Dr. Ana Diaz-ArnoldOctober 31, 2001- November 3, 2001 Annual Session 2001 New Orleans, LA 1077 52 Dr. Lyndon CooperNovember 6-9, 2002 Annual Session 2002 Orlando, FL 1164 55David Felton DDS, MS,FACPDecember 15-17, 2002 Implant Training Course Loma Linda, CA 13January 30- February 1, 2003 Implant Training Course 6June 12-14, 2003 Implant Training Course Chapel Hill, NC 8October 8-11, 2003 Annual Session 2003 Dallas, TX 1152 40 Dr. John SorensenNovember 13-15, 2003 Prosthodontic Review Course 2003 Chicago, IL 262 24 Dr. Kenneth MalamentDecember 14-16, 2003 Implant Training Course Loma Linda, CA 7January 15-17, 2003 Implant Training Course Boston, MA 14March 4-5, 2004 Creating a New vision for Prosthodontic Education 160September 10-11, 2004 Complete Denture Update 2004 Amherst, NY 175 14 Dr. Frank LaucielloOctober 27-30, 2004 Annual Session 2004 Ottawa, ON 927 51 Stephen Campbell DDSNovember 18-20, 2004 Prosthodontic Review Course 2004 Chicago, IL 149 23 Dr. Kenneth HilsonDecember 12-14, 2004 Implant Training Course Loma Linda, CA 8August 26-27, 2005 Complete Denture Update 2005 Mahwah, NJ 1 12.25Brien Lang, DDS LisaLang, DDSFrank Lauciello, DDSRobert Kreyer CDTDonald Yancey CDTSeptember 23-24, 2005 Complete Denture Update 2005 3 12Dr. David A. Felton, Dr.Thomas D. Taylor, Dr.Jeffrey J. Sitterle, Dr.Frank Lauciello, Donald J.YanceyOctober 26-29, 2005 Annual Session 2005 Los Angeles, CA 773 22.5 Dr. Steven EckertNovember 17-19, 2005 Prosthodontics Update 2005 Chicago, IL 171 22 Dr. Kenneth MalamentMay 5-6, 2006 Complete Denture Update 2006 Mahwah, NJ 43 12 Dr. Frank LaucielloSeptember 15-16, 2006 Complete Denture Update 2006 Atlanta, GA 55 12 Dr. Frank LaucielloNovember 1-4, 2006 Annual Session 2006 Miami, FL 1055 24 Dr. Lily T. GarciaDecember 10-12, 2006 Introduction to Implant Surgery Loma Linda, CA 9 19 Dr. Charles GoodacreJanuary 18-20, 2007 Foundation of Implant Prosthodontics Atlanta, GA 73 22Charles Goodacre DDS,Christopher B. Marchack,D.D.S., Roy Yanase,D.D.S.March 23-24, 2007 Complete Denture Update 2007 St. Paul, MN 84 14David Felton DDS, MS,FACP, Robert KreyerCDT, Frank LaucielloDDS, Patrick Lloyd DDS,MS, Thomas Taylor DDS,MSDApril 12-14, 2007 Prosthodontics Update 2007: State-of-the-Art Boston, MA 152 22 Kenneth A. Malament2010 CDEL Re-recognition of the Specialty Report 241 of 279

September 13-15,2007 Implant Surgical Therapy: Part One of Two Chicago, IL 11 15Stephen Campbell DDS,Kent Knoernschild DMD,MS, Maria Lavda DMD,MSOctober 30-November 4, 2007 Annual Session 2007 Scottsdale, AZ 1227 20.5Dr. Stephen Campbell- ASChairApril 25, 2008 The Thaddeus V. Weclew Annual Memorial Lecture Chicago, IL 14 6.5 Dr. Stephen CampbellMay 30-31, 2008 Educator's Meeting in May 2008 1 N/AAugust 15-16, 2008 Esthetic Continuum 2008 Seattle, WA 111 10 Dr. Ariel RaigrodskiOctober 29- November 1, 2008 38th Annual Session of the ACP Nashville, TN 938 19.5 Dr. Clark M. StanfordMarch 27-28, 2009 Prosthodontics Update 2009 Chicago, IL 108 17.5 Dr. Kenneth A. MalamentApril 3-4, 2009 Invite Only Spring Educators Meeting Rosemont, IL 90 Dr. Charles GoodacreMay 8-9, 2009 Removable Partial Denture Course Chicago, IL 40 18.25 Dr. David A. FeltonSeptember 25-26, 2009 Marketing Your Prosthodontic Practice Philadelphia, PA 26 10 Stewart Gandolf, MBANovember 4-7, 2009 39th Annual Session of the ACP San Diego, CA 1076 26.5 Dr. Jonathan WiensNovember 7, 2009 Bone Graft for Implant Site Development- A Cadaver Workshop San Diego, CA 43 5 Dr. Bach LeeDecember 1, 2009 Color and Shade Selection for Prosthodontists-Webinar N/A 5 1.5 Dr. Charles GoodacreMarch 19-20, 2010 Proven Strategies for Prosthodontic Practice Growth Baltimore, MD 30 10 Roger P. Levin, DDSApril 9-10, 2010 Spring 2010 Educator's Meeting by Invitation Rosemont, IL 91Dr. Cooper & Dr.GoodacreApril 16-17, 2010 The Art and Science of Modern Dental Ceramics New York, NY 26 15Kenneth A. Malament,DDSApril 30- May 1,2010 Marketing Your Prosthodontic Practice Los Angeles, CA N/A 10 Stewart Gandolf, MBAMay 21-22, 2010 Complete Denture Update Course Atlanta, GA N/A 15 Frank R. Lauciello, DDSSeptember 24, 2010 Immediate Placement/Immediate Loading in Full Arch Restorations Chicago, IL N/A 7 Paul E. Scruggs, DDS.November 3-6, 2010 40th Annual Session of the ACP Orlando, FL N/A N/A Lawrence E. Brecht, DDSNovember 6, 2010 Bone Graft for Implant Site Development- A Cadaver Workshop Orlando, FL N/A 5 David L. Guichet, DDS.November 2-5, 2011 41st Annual Session of the ACP Scottsdale, AZ N/A N/A N/AOctober 31- November 3, 2012 42nd Annual Session of the ACP Baltimore, MD N/A N/A N/A2010 CDEL Re-recognition of the Specialty Report 242 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix FCODA Accreditation StandardsFor Advanced Specialty EducationPrograms in Prosthodontics2010 CDEL Re-recognition of the Specialty Report 243 of 279

Commission on Dental AccreditationAccreditation Standards forAdvanced SpecialtyEducation Programs inProsthodonticsProposed deletions are strickenProposed additions are underlined2010 CDEL Re-recognition of the Specialty Report 244 of 279

Accreditation Standards forAdvanced Specialty Education Programs inProsthodonticsCommission on Dental AccreditationAmerican Dental Association211 East Chicago AvenueChicago, Illinois 60611-2678(312) 440-4653www.ada.orgProsthodontics is the dental specialty pertaining to the diagnosis, treatment planning,rehabilitation and maintenance of the oral function, comfort, appearance and health of patientswith clinical conditions associated with missing or deficient teeth and/or oral and maxillofacialtissues using biocompatible substitutes. (Adopted April 2003)Copyright©1998Commission on Dental AccreditationAmerican Dental AssociationAll rights reserved. Reproduction is strictly prohibited without prior written permission.2010 CDEL Re-recognition of the Specialty Report 245 of 279

Accreditation Standards forAdvanced Specialty Education Programs in ProsthodonticsDocument Revision HistoryDate Item ActionJuly 30, 1998 Accreditation Standards for Advanced SpecialtyEducation Programs in ProsthodonticsJanuary 1, 2000 Accreditation Standards for Advanced SpecialtyEducation Programs in ProsthodonticsJanuary 29, 1999 Accreditation Status DefinitionsJuly 1, 1999 Accreditation Status DefinitionsJanuary 29, 1999 Standards on Clinical Program (Standards 4-21, 4-22, 4-23, 4-24, 4-25, and 4-26)January 1, 2000 Standards on Clinical Program (Standards 4-21, 4-22, 4-23, 4-24, 4-25, and 4-26)July 28, 2000 Intent Statements added to Selected StandardsJanuary 30, 2001 Mission StatementJanuary 30, 2001 Policy on Advanced StandingJuly 27, 2001 Standard on Advanced StandingJuly 1, 2002 Standard on Advanced StandingFebruary 2, 2002 Initial Accreditation Status DefinitionJanuary 1, 2003 Initial Accreditation Status DefinitionAugust 1, 2003 Intent Statement deleted from Standard 1,Program AdministratorAugust 1, 2003 Policy on Enrollment Increases in DentalSpecialty ProgramsJanuary 30, 2004 Policy on Enrollment Increases in DentalSpecialty ProgramsJanuary 30, 2004 Intent Statement to Standard 1 on MajorChange (“student enrollment” deleted)January 30, 2004 Intent Statement and Examples of Evidence toStandard 2July 30, 2004 Standards on Didactic and Clinical Program(Standards 4-5 through 4-24)January 1, 2005 Standards on Didactic and Clinical Program(Standards 4-5 through 4-24)January 28, 2005 Examples of Evidence to Standard 2 (for nonboardcertified directors)July 29, 2005 Term and Definition Student/ResidentJuly 29, 2005 Standards to Ensure Program Integrity(Standards 1, 2, and 5)AdoptedImplementedRevised and AdoptedImplementedRevised and AdoptedImplementedAdopted andImplementedRevised and AdoptedRevised and AdoptedRevised and AdoptedImplementedAdoptedImplementedRevised and AdoptedAdoptedImplementedRevised and AdoptedAdopted andImplementedRevised and AdoptedImplementedRevised, Adopted andImplementedAdopted andImplementedAdoptedProsthodontics Standards- -2010 CDEL Re-recognition of the Specialty Report 246 of 279

Document Revision History (continued)January 1, 2006 Standards to Ensure Program Integrity(Standards 1, 2, and 5)January 27, 2006 Intent Statement to Standard 2July 28, 2006 Examples of Evidence for Standard 1Intent Statement for Standard 5July 26, 2007 Standards to Ensure Program IntegrityExamples of Evidence Modified(Standard 1)July 26, 2007 Name Change: The Joint Commission onAccreditation of Healthcare Organizationschanged to The Joint CommissionImplementedAdopted andImplementedAdopted andImplementedAdopted andImplementedAdopted andImplementedProsthodontics Standards- -2010 CDEL Re-recognition of the Specialty Report 247 of 279

Table Of ContentsMission Statement of the Commission on Dental Accreditation 4 6Accreditation Status Definitions 5 7Preface 6 8Policy on Enrollment Increases in Dental Specialty Programs 7 9PAGEDefinition of Terms Used in Prosthodontics Accreditation Standards 8 10Standards1 - INSTITUTIONAL COMMITMENT/PROGRAM EFFECTIVENESS 11 13AFFILIATIONS 12 142 - PROGRAM DIRECTOR AND TEACHING STAFF 14 163 - FACILITIES AND RESOURCES 15 184 - CURRICULUM AND PROGRAM DURATION 17 20DIDACTIC PROGRAM: BIOMEDICAL SCIENCES 18 21DIDACTIC PROGRAM:PROSTHODONTICS AND RELATED DISCIPLINES 18 21CLINICAL PROGRAM 19 22MAXILLOFACIAL PROSTHETICS: 20 24PROGRAM DURATION 20 24DIDACTIC PROGRAM 20 24CLINICAL PROGRAM 21 255 - ADVANCED EDUCATION STUDENTS/RESIDENTS 22 26ELIGIBILITY AND SELECTION 22 26EVALUATION 23 27DUE PROCESS 23 27RIGHTS AND RESPONSIBILITIES 23 276 - RESEARCH 24 28Prosthodontics Standards- -2010 CDEL Re-recognition of the Specialty Report 248 of 279

Mission Statement of theCommission on Dental AccreditationThe Commission on Dental Accreditation serves the public by establishing, maintaining andapplying standards that ensure the quality and continuous improvement of dental and dentalrelatededucation and reflect the evolving practice of dentistry. The scope of the Commission onDental Accreditation encompasses dental, advanced dental and allied dental education programs.Commission on Dental AccreditationRevised: January 30, 2001Prosthodontics Standards-6-2010 CDEL Re-recognition of the Specialty Report 249 of 279

Accreditation Status DefinitionsPrograms Which Are Fully OperationalAPPROVAL (without reporting requirements): An accreditation classification granted to aneducational program indicating that the program achieves or exceeds the basic requirements foraccreditation.APPROVAL (with reporting requirements): An accreditation classification granted to aneducational program indicating that specific deficiencies or weaknesses exist in one or more areas ofthe program. Evidence of compliance with the cited standards must be demonstrated within 18months if the program is between one and two years in length or two years if the program is at leasttwo years in length. If the deficiencies are not corrected within the specified time period,accreditation will be withdrawn, unless the Commission extends the period for achieving compliancefor good cause.Programs Which Are Not Fully OperationalINITIAL ACCREDITATION: Initial Accreditation is the accreditation classification granted toany dental, advanced dental or allied dental education program which is in the planning and earlystages of development or an intermediate stage of program implementation and not yet fullyoperational. This accreditation classification provides evidence to educational institutions, licensingbodies, government or other granting agencies that, at the time of initial evaluation(s), thedeveloping education program has the potential for meeting the standards set forth in therequirements for an accredited educational program for the specific occupational area. Theclassification "initial accreditation" is granted based upon one or more site evaluation visit(s) anduntil the program is fully operational.Prosthodontics Standards-7 -2010 CDEL Re-recognition of the Specialty Report 250 of 279

PrefaceMaintaining and improving the quality of advanced education in the nationally recognized specialty areas ofdentistry is a primary aim of the Commission on Dental Accreditation. The Commission is recognized by thepublic, the profession, and the United States Department of Education as the specialized accrediting agency indentistry.Accreditation of advanced specialty education programs is a voluntary effort of all parties involved. Theprocess of accreditation assures students/residents, specialty boards and the public that accredited trainingprograms are in compliance with published standards.Accreditation is extended to institutions offering acceptable programs in the following recognized specialtyareas of dental practice: dental public health, endodontics, oral and maxillofacial pathology, oral andmaxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatricdentistry, periodontics and prosthodontics. Program accreditation will be withdrawn when the trainingprogram no longer conforms to the standards as specified in this document, when all first-year positionsremain vacant for a period of two years or when a program fails to respond to requests for programinformation. Exceptions for non-enrollment may be made by the Commission for programs with “approvalwithout reporting requirements” status upon receipt of a formal request from an institution stating reasonswhy the status of the program should not be withdrawn.Advanced education in a recognized specialty area of dentistry may be offered on either a graduate orpostgraduate basis.Accreditation actions by the Commission on Dental Accreditation are based upon information gained throughwritten submissions by program directors and evaluations made on site by assigned consultants. TheCommission has established review committees in each of the recognized specialties to review site visit andprogress reports and make recommendations to the Commission. Review committees are composed ofrepresentatives selected by the specialties and their certifying boards. The Commission has the ultimateresponsibility for determining a program’s accreditation status. The Commission is also responsible foradjudication of appeals of adverse decisions and has established policies and procedures for appeal. A copyof policies and procedures may be obtained form the Director, Commission on Dental Accreditation, 211 EastChicago Avenue, Chicago, Illinois 60611.This document constitutes the standards by which the Commission on Dental Accreditation and itsconsultants will evaluate advanced programs in each specialty for accreditation purposes. The Commissionon Dental Accreditation establishes general standards which are common to all dental specialties, institutionand programs regardless of specialty. Each specialty develops specialty-specific standards for educationprograms in its specialty. The general and specialty-specific standards, subsequent to approval by theCommission on Dental Accreditation, set forth the standards for the education content, instructional activities,patient care responsibilities, supervision and facilities that should be provided by programs in the particularspecialty.General standards are identified by the use of a single numerical listing (e.g., 1). Specialty-specific standardsare identified by the use of multiple numerical listings (e.g. 1-1, 1-1.2, 1-2).Prosthodontics Standards-8-2010 CDEL Re-recognition of the Specialty Report 251 of 279

Policy on Enrollment IncreasesIn Dental Specialty ProgramsThe Commission on Dental Accreditation monitors increases in enrollment. The purpose formonitoring increases in enrollment through review of existing and projected program resources(faculty, patient availability, and variety of procedures, physical/clinical facilities, and allied supportservices) is to ensure that program resources exist to support the intended enrollment increase. Anincrease in enrollment must be reported to and approved by the Commission prior to itsimplementation. Failure to comply with the policy will jeopardize the program’s accreditationstatus.(CDA: 08/03:22)Prosthodontics Standards-9-2010 CDEL Re-recognition of the Specialty Report 252 of 279

Definitions of Terms Used in Prosthodontics Accreditation StandardsThe terms used in this document (i.e. shall, must, should, can and may) were selected carefully andindicate the relative weight that the Commission attaches to each statement. The definitions of thesewords used in the Standards are as follows:Must or Shall: Indicates an imperative need and/or duty; an essential or indispensable item;mandatory.Intent: Intent statements are presented to provide clarification to the advanced specialty educationprograms in prosthodontics in the application of and in connection with compliance with theAccreditation Standards for Advanced Specialty Education Programs in Prosthodontics. Thestatements of intent set forth some of the reasons and purposes for the particular Standards. As such,these statements are not exclusive or exhaustive. Other purposes may apply.Examples of evidence to demonstrate compliance include: Desirable condition, practice ordocumentation indicating the freedom or liberty to follow a suggested alternative.Should: Indicates a method to achieve the standards.May or Could: Indicates freedom or liberty to follow a suggested alternative.Levels of Knowledge:In-depth: A thorough knowledge of concepts and theories for the purpose of critical analysisand the synthesis of more complete understanding.Understanding: Adequate knowledge with the ability to apply.Familiarity: A simplified knowledge for the purpose of orientation and recognition ofgeneral principles.Levels of Skills:Proficient: The level of skill beyond competency. It is that level of skill acquired throughadvanced training or the level of skill attained when a particular activity is accomplished withrepeated quality and a more efficient utilization of time.Competent: The level of skill displaying special ability or knowledge derived from trainingand experience.Exposed: The level of skill attained by observation of or participation in a particular activity.Prosthodontics Standards-10-2010 CDEL Re-recognition of the Specialty Report 253 of 279

Other Terms:Institution (or organizational unit of an institution): a dental, medical or public health school, patientcare facility, or other entity that engages in advanced specialty education.Sponsoring institution: primary responsibility for advanced specialty education programs.Affiliated institution: support responsibility for advanced specialty education programs.Advanced specialty education student/resident: a student/resident enrolled in an accreditedadvanced specialty education program.A graduate program is a planned sequence of advanced courses leading to a masters or doctoraldegree granted by a recognized and accredited educational institution.A postgraduate program is a planned sequence of advanced courses that leads to a certificate ofcompletion in a specialty recognized by the American Dental Association.Student/Resident: The individual enrolled in an accredited advanced education program.Postdoctoral: Can be equated with Advanced.Residency Program: A planned sequence of advanced courses integrated into a hospital setting thatleads to a certificate of completion in a specialty recognized by the American Dental Association.Prosthodontic Specific TermsRemovable Prosthodontics – is that branch of prosthodontics concerned with the replacement ofteeth and contiguous structures for edentulous or partially edentulous patients by artificial substitutesthat are removable from the mouth.Fixed Prosthodontics – is that branch of prosthodontics concerned with the replacement and/orrestoration of teeth by artificial substitutes that are not removable from the mouth.Implant Prosthodontics – is that branch of prosthodontics concerned with the replacement of teethand contiguous structures by artificial substitutes partially or completely supported and/or retainedby alloplastic implants.Maxillofacial Prosthetics – is that branch of prosthodontics concerned with the restoration and/orreplacement of stomatognathic and associated craniofacial structures by artificial substitutes.Prosthodontics Standards-11-2010 CDEL Re-recognition of the Specialty Report 254 of 279

Educationally Qualified: An individual is considered Educationally Qualified after the successfulcompletion of an advanced educational prosthodontics program, which is accredited by theCommission on Dental Accreditation .Board Eligible: An individual is Board Eligible when his/her application has been submitted to andapproved by the Board and his/her eligibility has not expired.Diplomate: Any dentist who has successfully met the requirements of the Board for certification andremains in good standing.Prosthodontics Standards-12-2010 CDEL Re-recognition of the Specialty Report 255 of 279

STANDARD 1 - INSTITUTIONAL COMMITMENT/PROGRAM EFFECTIVENESSThe program must develop clearly stated goals and objectives appropriate to advanced specialtyeducation, addressing education, patient care, research and service. Planning for, evaluation of andimprovement of educational quality for the program must be broad-based, systematic, continuousand designed to promote achievement of program goals related to education, patient care, researchand service.The program must document its effectiveness using a formal and ongoing outcomes assessmentprocess to include measures of advanced education student/resident achievement.Intent: The Commission on Dental Accreditation expects each program to define its own goals andobjectives for preparing individuals for the practice of prosthodontics and that one of the programgoals is to comprehensively prepare competent individuals to initially practice prosthodontics. Theoutcomes process includes steps to: (a) develop clear, measurable goals and objectives consistentwith the program’s purpose/mission; (b) develop procedures for evaluating the extent to which thegoals and objectives are met; (c) collect and maintain data in an ongoing and systematic manner;(d) analyze the data collected and share the results with appropriate audiences; (e) identify andimplement corrective actions to strengthen the program; and (f )review the assessment plan, reviseas appropriate, and continue the cyclical process.The financial resources must be sufficient to support the program’s stated goals and objectives.Intent: The institution should have the financial resources required to develop and sustain theprogram on a continuing basis. The program should have the ability to employ an adequate numberof full-time faculty, purchase and maintain equipment, procure supplies, reference material andteaching aids as reflected in annual budget appropriations. Financial allocations should ensure thatthe program will be in a competitive position to recruit and retain qualified faculty. Annualappropriations should provide for innovations and changes necessary to reflect current concepts ofeducation in the advanced specialty discipline. The Commission will assess the adequacy offinancial support on the basis of current appropriations and the stability of sources of funding forthe program.The sponsoring institution must ensure that support from entities outside of the institution does notcompromise the teaching, clinical and research components of the program.Examples of evidence to demonstrate compliance:Written agreement(s)Contract(s)/Agreement(s) between the institution/program and sponsor(s) related to facilities,funding, and faculty financial support.Major changes as defined by the Commission must be reported promptly to the Commission onDental Accreditation. (Guidelines for Reporting Major Changes are available from the CommissionOffice.)Prosthodontics Standards-13-2010 CDEL Re-recognition of the Specialty Report 256 of 279

Intent: Major changes have a direct and significant impact on the program’s potential ability tocomply with the accreditation standards. Examples of major changes that must be reported include(but are not limited to) changes in program director, clinical facilities, program sponsorship orcurriculum length. The program must report such major changes in writing to theCommission within thirty (30) daysAdvanced specialty education programs must be sponsored by institutions, which are properlychartered, and licensed to operate and offer instruction leading to degrees, diplomas or certificateswith recognized education validity. Hospitals that sponsor advanced specialty education programsmust be accredited by The Joint Commission or its equivalent. Educational institutions that sponsoradvanced specialty education programs must be accredited by an agency recognized by the UnitedStates Department of Education. The bylaws, rules and regulations of hospitals that sponsor orprovide a substantial portion of advanced specialty education programs must assure that dentists areeligible for medical staff membership and privileges including the right to vote, hold office, serve onmedical staff committees and admit, manage and discharge patients.The authority and final responsibility for curriculum development and approval, student/residentselection, faculty selection and administrative matters must rest within the sponsoring institution.The position of the program in the administrative structure must be consistent with that of otherparallel programs within the institution and the program director must have the authorityresponsibility, and privileges necessary to manage the program.AFFILIATIONSThe primary sponsor of the educational program must accept full responsibility for the quality ofeducation provided in all affiliated institutions.Documentary evidence of agreements, approved by the sponsoring and relevant affiliatedinstitutions, must be available. The following items must be covered in such inter-institutionalagreements:a. Designation of a single program director;b. The teaching staff;c. The educational objectives of the program;d. The period of assignment of students/residents; ande. Each institution’s financial commitment.Intent: The items that must be covered in inter-institutional agreements do not have to be containedin a single document. They may be included in multiple agreements, both formal and informal (e.g.,addenda and letters of mutual understanding).Prosthodontics Standards-14-2010 CDEL Re-recognition of the Specialty Report 257 of 279

Policy Statement on Accreditation of Off-Campus SitesWhen an institution, which has a program accredited by the Commission on Dental Accreditation,plans to initiate a similar program in which all or the majority of the instruction occurs at anotherlocation, the Commission must be informed. In accordance with the Policy on Reporting MajorChanges in Accredited Programs, the Commission must be informed in writing within thirty (30)days.The Commission on Dental Accreditation must ensure that the necessary education as defined by thestandards is available, and appropriate supervision by faculty is provided to all students/residentsenrolled in an accredited program. When an institution has received approval to offer its accreditedprogram at more than one site, the Commission will conduct site visits to the off-campus locationswhere 20% or more of the students’/residents’ clinical instruction occurs or if other cause exists forsuch a visit.The Commission recognizes that dental assisting and dental laboratory technology programs utilizenumerous extramural dental offices and laboratories to provide students/residents withclinical/laboratory practice experience. In this instance, the Commission will randomly select andvisit several facilities during the site visit to a program.All programs accredited by the Commission pay an annual fee. There are variations in fees fordifferent disciplines, based on actual accreditation costs, including the utilization of on- and offcampuslocations. The Commission office should be contacted for current information on fees.Commission on Dental Accreditation Policy, July 1998Prosthodontics Standards-15-2010 CDEL Re-recognition of the Specialty Report 258 of 279

STANDARD 2 - PROGRAM DIRECTOR AND TEACHING STAFFThe program must be administered by a director who is board certified in the respective specialty ofthe program. (All program directors appointed after January 1, 1997, who have not previouslyserved as program directors, must be board certified.)Intent: The director of an advanced specialty education program is to be certified by an ADArecognizedcertifying board in the specialty. Board certification is to be active. The boardcertification requirement of Standard 2 is also applicable to an interim/acting program director. Aprogram with a director who is not board certified, but who has previous experience as aninterim/acting program director in a Commission-accredited program prior to 1997 is notconsidered in compliance with Standard 2.Examples of evidence to demonstrate compliance include:For board certified directors: Copy of board certification certificate; letter from boardattesting to active/current board certification.(For non-board certified directors who served prior to January 1, 1997: Current CVidentifying previous directorship in a Commission on Dental Accreditation- or Commissionon Dental Accreditation of Canada-accredited advanced specialty program in the respectivediscipline; letter from the previous employing institution verifying service.)The program director must be appointed to the sponsoring institution and have sufficient authorityand time to achieve the educational goals of the program and assess the program’s effectiveness inmeeting its goals.2-1 The program director must have primary responsibility for the organization and execution ofthe educational and administrative components to the program.2-1.1 The program director must devote sufficient time to:a. Participate in the student/resident selection process, unless the program issponsored by federal services utilizing a centralized student/resident selectionprocess;b. Develop and implement the curriculum plan to provide a diverse educationalexperience in biomedical and clinical sciences;c. Maintain a current copy of the curriculum’s goals, objectives, and contentoutlines;d. Maintain a record of the number and variety of clinical experiencesaccomplished by each student/resident;e. Ensure that the majority of faculty assigned to the program are educationallyqualified prosthodontists;f. Provide written faculty evaluations at least annually to determine theeffectiveness of the faculty in the educational program;Prosthodontics Standards-16-2010 CDEL Re-recognition of the Specialty Report 259 of 279

g. Conduct periodic staff meetings for the proper administration of theeducational program; andh. Maintain adequate records of clinical supervision.2-2 The program director must encourage students/residents to seek certification by theAmerican Board of Prosthodontics.2-3 The number and time commitment of the teaching staff must be sufficient toa. Provide didactic and clinical instruction to meet curriculum goals and objectives; andb. Provide supervision of all treatment provided by students/residents through specificand regularly scheduled clinic assignments.Prosthodontics Standards-17-2010 CDEL Re-recognition of the Specialty Report 260 of 279

STANDARD 3 - FACILITIES AND RESOURCESInstitutional facilities and resources must be adequate to provide the educational experiences andopportunities required to fulfill the needs of the educational program as specified in these Standards.Equipment and supplies for use in managing medical emergencies must be readily accessible andfunctional.Intent: The facilities and resources (e.g.; support/secretarial staff, allied personnel and/or technicalstaff) should permit the attainment of program goals and objectives. To ensure health and safety forpatients, students/residents, faculty and staff, the physical facilities and equipment should effectivelyaccommodate the clinic and/or laboratory schedule.The program must document its compliance with the institution’s policy and applicable regulationsof local, state and federal agencies including but not limited to radiation hygiene and protection,ionizing radiation, hazardous materials, and bloodborne and infectious diseases. Policies must beprovided to all students/residents faculty and appropriate support staff and continuously monitoredfor compliance. Additionally, policies on bloodborne and infectious diseases must be madeavailable to applicants for admission and patients.Intent: The program may document compliance by including the applicable program policies. Theprogram demonstrates how the policies are provided to the students/residents faculty andappropriate support staff and who is responsible for monitoring compliance. Applicable policystates how it is made available to applicants for admission and patients should a request to reviewthe policy be made.Students/Residents, faculty and appropriate support staff must be encouraged to be immunizedagainst and/or tested for infectious diseases, such as mumps, measles, rubella and hepatitis B, priorto contact with patients and/or infectious objects or materials, in an effort to minimize the risk topatients and dental personnel.Intent: The program should have written policy that encourages (e.g., delineates the advantages of)immunization of students/residents, faculty and appropriate support staff.All students/residents, faculty and support staff involved in the direct provision of patient care mustbe continuously recognized/certified in basic life support procedures, including cardiopulmonaryresuscitation.Intent: Continuously recognized/certified in basic life support procedures means the appropriateindividuals are currently recognized/certified.The use of private office facilities as a means of providing clinical experiences in advanced specialtyeducation is not approved, unless the specialty has included language that defines the use of suchfacilities in its specialty-specific standards.Intent: Required prosthodontics clinical experiences do not occur in private office facilities.Practice management and elective experiences may be undertaken in private office facilities.Prosthodontics Standards-18-2010 CDEL Re-recognition of the Specialty Report 261 of 279

3-1 Physical facilities must permit students/residents to operate under circumstances prevailingin the practice of prosthodontics.3-1.1 The clinical facilities must be specifically identified for the advanced educationprogram in prosthodontics.3-1.2 There must be sufficient number of completely equipped operatories to accommodatethe number of students/residents enrolled.3-1.3 Laboratory facilities must be specifically identified for the advanced educationprogram in prosthodontics.3-1.4 The laboratory must be equipped to support the fabrication of most prosthesesrequired in the program.3-1.5 There must be sufficient laboratory space to accommodate the number ofstudents/residents enrolled in the program, including provisions for storage ofpersonal and laboratory armamentaria.3-2 Radiographic equipment for extra-and intraoral radiographs must be accessible to thestudent/resident.3-3 Lecture, seminar, study space and administrative office space must be available for theconduct of the educational program.3-4 Library resources must include access to a diversified selection of current dental, biomedical,and other pertinent reference material.3-4.1 Library resources must also include access to appropriate current and back issues ofmajor scientific journals as well as equipment for retrieval and duplication ofinformation.3-5 Facilities must include access to computer, photographic, and audiovisual resources foreducational, administrative, and research support.3-6 Adequate allied dental personnel must be assigned to the program to ensure clinical andlaboratory technical support.3-7 Secretarial and clerical assistance must be sufficient to meet the educational andadministrative needs of the program.3-8 Laboratory technical support must be sufficient to ensure efficient operation of the clinicalprogram and meet the educational needs of the program.Prosthodontics Standards-19-2010 CDEL Re-recognition of the Specialty Report 262 of 279

STANDARD 4 – CURRICULUM AND PROGRAM DURATIONThe advanced specialty education program must be designed to provide special knowledge andskills beyond the D.D.S. or D.M.D. training and be oriented to the accepted standards of specialtypractice as set forth in specific standards contained in this document.Intent: The intent is to ensure that the didactic rigor and extent of clinical experience exceeds predoctoral,entry level dental training or continuing education requirements and the material andexperience satisfies standards for the specialty.The level of specialty area instruction in the graduate and postgraduate programs must becomparable.Intent: The intent is to ensure that the students/residents of these programs receive the sameeducational requirements as set forth in these Standards.Documentation of all program activities must be assured by the program director and available forreview.If an institution and/or program enrolls part-time students/residents, the institution must haveguidelines regarding enrollment of part-time students/residents. Part-time students/residents muststart and complete the program within a single institution, except when the program is discontinued.The director of an accredited program who enrolls students/residents on a part-time basis mustassure that: (1) the educational experiences, including the clinical experiences and responsibilities,are the same as required by full-time students/residents; and (2) there are an equivalent number ofmonths spent in the program.PROGRAM DURATION4-1 A postdoctoral program in prosthodontics must encompass a minimum of 33 months.4-2 A postdoctoral program in prosthodontics that includes integrated maxillofacial trainingmust encompass a minimum of 45 months.4-3 A 12-month postdoctoral program in maxillofacial prosthetics must be preceded bysuccessful completion of an accredited prosthodontics program.CURRICULUM4-4 The curriculum must be designed to enable the student/resident to attain skills representativeof a clinician proficient in the theoretical and practical aspects of prosthodontics. Advancedlevel instruction may be provided through the following: formal courses, seminars, lectures,self-instructional modules, clinical assignments and laboratory assignments.4-4.1 Written goals and objectives must be developed for all instruction included in thiscurriculum.Prosthodontics Standards-20-2010 CDEL Re-recognition of the Specialty Report 263 of 279

4-4.2 Content outlines must be developed for all didactic portions of the program.4-4.3 Students/Residents must prepare and present diagnostic data, treatment plans and theresults of patient treatment.4-4.4 The amount of time devoted to didactic instruction and research must be at least 30%of the total educational experience.4-4.5 A minimum of 60% of the total program time must be devoted to providing patientservices, including direct patient care and laboratory procedures.4-4.6 The program may include organized teaching experience. If time is devoted to thisactivity, it should be carefully evaluated in relation to the goals and objectives of theoverall program and the interests of the individual student/resident.DIDACTIC PROGRAM: BIOMEDICAL SCIENCES4-5 Instruction must be provided at the understanding level in each of the following:a. Oral pathology;b. Applied pharmacology;c. Craniofacial anatomy and physiology; andd. Risk assessment for oral disease;d e. Infection control; andf. Wound healing.4-6 Instruction must be provided at the familiarity level in each of the following:a. Craniofacial growth and development;b. Immunology; andc. Oral microbiology;d. Risk assessment for oral disease; ande. Wound healing.Intent: Students will have the didactic background that supports the various aspects ofcomprehensive prosthodontic therapy they provide or guide during their clinical experienceswith dentate, partially edentulous and completely edentulous patients. This fundamentaldidactic background is necessary whether the student provides therapy or serves as thereferral source to other providers. It is expected that such learning would be directlysupportive of requisite clinical curriculum proficiencies and competencies.DIDACTIC PROGRAM: PROSTHODONTICS AND RELATED DISCIPLINES4-7 Instruction must be provided at the in-depth level in each of the following:a. Fixed prosthodontics;b. Implant prosthodontics;c. Removable prosthodontics, andd. Occlusion.Prosthodontics Standards-21-2010 CDEL Re-recognition of the Specialty Report 264 of 279

Intent: Students will have in depth knowledge in all aspects of prosthodontic therapy toserve their leading role in the management of patients from various classification systemssuch as the Prosthodontic Diagnostic Index for edentulous, partially edentulous and dentatepatients. This includes surgical and post-surgical management of the implant patient.4-8 Instruction must be provided at the understanding level in each of the following:a. Biomaterials;b. Geriatrics dentistry;c. Maxillofacial prosthetics;d. Preprosthetic surgery; including surgical principles and procedures;e. Evidence-based decision-makinge. Implant placement including surgical and post-surgical managementf. Temporomandibular disorders and orofacial pain;g. Medical emergencies;h. Diagnostic radiology;i. Research methodology; andj. Emerging science and technologyj. Prosthodontic patient classification systems such as the ProsthodonticDiagnostic Index (ACP Classification Systems) for edentulous, partiallyedentulous and dentate patients.4-9 Instruction must be provided at the familiarity level in each of the following:a. Endodontics;b. Periodontics;c. Orthodontics;d. Sleep disorders;e. Sedation;e f. Intraoral photography;f g. Practice management;g. Behavioral sciences;h. Ethics;i. Biostatistics;j. Scientific writing; andk. Teaching methodology.CLINICAL PROGRAM4-10 The program must provide sufficient clinical experiences for the student/resident to beproficient in the comprehensive treatment of a wide range of complex prosthodontic patientswith various categories of need.4-11 The program must provide sufficient clinical experiences for the student/resident to beproficient in:a. Collecting, organizing, analyzing, and interpreting diagnostic data;b. Determining a diagnosis;Prosthodontics Standards-22-2010 CDEL Re-recognition of the Specialty Report 265 of 279

c. Developing a comprehensive treatment plan and prognosis;d. Critically evaluating the results of treatment; ande. Effectively utilizing the professional services of allied dental personnel, including butnot limited to, dental laboratory technicians, dental assistants, and dental hygienists.4-12 The program must provide sufficient clinical experiences for the student/resident to beproficient in the comprehensive diagnosis, treatment planning and rehabilitation ofedentulous, partially edentulous and dentate patients.a. Clinical experiences must include a variety of patients within a range ofprosthodontic classifications, such as in the Prosthodontic Diagnostic Index (ACPClassification Systems) for edentulous, partially edentulous and dentate patients.b. Clinical experiences must include rehabilitative and esthetic procedures ofvarying complexity.c. Clinical experiences must include treatment of geriatric patients, including patientswith varying degrees of cognitive and physical impairments.d. This may include defects, which are due to genetic, functional, parafunctional,microbial or traumatic causes.Intent: Students/Residents should will be proficient in the use of adjustable articulators todevelop an integrated occlusion for opposing arches; complete and partial coveragerestorations, restoration of endodontically treated teeth, fixed prosthodontics, removablepartial dentures, complete dentures, implant supported and/or retained prostheses, andcontinual care and maintenance of restorations. Students will diagnose and treat patientsusing advances in science and technology.4-13 The program must provide sufficient dental laboratory experience for the student/resident tobe competent in the laboratory aspects of treatment of complete edentulism, partialedentulism and dentate patients.4-14 Students/Residents must be competent in the prosthodontic management of patients withtemporomandibular disorders and/or orofacial pain.4-15 Students/Residents must be exposed to patients requiring various maxillofacial prostheticservices.4-16 Students/Residents must participate in all phases of implant treatment including implantplacement.Intent: It is anticipated that students/residents will act as first assistant and/or primarysurgeon for some of their own patients.4-17 Students/Residents must be exposed to preprosthetic surgical procedures.Intent: Surgical procedures should include contouring of residual ridges, gingivalrecontouring, placement of dental implants, and removal of teeth.Prosthodontics Standards-23-2010 CDEL Re-recognition of the Specialty Report 266 of 279

4-18 Students/Residents must be exposed to patient management through sedation.Intent: Students/Residents will observe procedures for patients who are sedated.4-19 Students/Residents must be competent in oral/head/neck cancer screening and patienteducation for prevention.Intent: Students/Residents will be competent in clinical identification of potential pathosisand referral to a specialist. Students will also educate patients to promote oral/head/neckcancer prevention.MAXILLOFACIAL PROSTHETICSNote: Application of these Standards to programs of various scope/length is as follows:a. Prosthodontic programs that encompass a minimum of forty-five months that includeintegrated maxillofacial prosthetic training: all sections of these Standards apply;b. Prosthodontic programs that encompass a minimum of thirty-three months: allsections of these Standards apply except sections 4-18 through 4-24 inclusive; andc. Twelve-month maxillofacial prosthetic programs: all sections of these Standardsapply except sections 4-5 through 4-17, inclusive.PROGRAM DURATION4-184-20 An advanced education program in maxillofacial prosthetics must be provided with a fortyfivemonth integrated prosthodontic program which includes fixed prosthodontic, removableprosthodontic, implant prosthodontic and maxillofacial prosthetic experiences; or a one-yearprogram devoted specifically to maxillofacial prosthetics which follows completion of aprosthodontic program.DIDACTIC PROGRAM4-194-21 Instruction must be provided at the in-depth level in each of the following:a. Maxillary defects and soft palate defects, which are the result of disease or trauma(acquired defects);b. Mandibular defects, which are the result of disease or trauma (acquired defects);c. Maxillary defects, which are naturally acquired (congenital or developmentaldefects);d. Mandibular defects, which are naturally acquired (congenital or developmentaldefects);e. Facial defects, which are the result of disease or trauma or are naturally acquired;f. The use of implants to restore intraoral and extraoral defects;g. Maxillofacial prosthetic management of the radiation therapy patient; andh. Maxillofacial prosthetic management of the chemotherapy patient.Prosthodontics Standards-24-2010 CDEL Re-recognition of the Specialty Report 267 of 279

4-204-22 Instruction must be provided at the familiarity level in each of the following:a. Medical oncology;b. Principles of head and neck surgery;c. Radiation oncology;d. Speech and deglutition; ande. Cranial defects.CLINICAL PROGRAM4-214-23 Students/Residents must be competent to perform maxillofacial prosthetic treatmentprocedures performed in the hospital operation room.4-224-24 Students/Residents must gain clinical experience to become proficient in the pre-prosthetic,prosthetic and post-prosthetic management and treatment of patients with defects of themaxilla and mandible. Clinical experience regarding management and treatment shouldinclude:a. Patients who are partially dentate and for patients who are edentulous;b. Patients who have undergone radiation therapy to the head and neck region;c. Maxillary defects of the hard palate, soft palate and alveolus;d. Mandibular continuity and discontinuity defects; ande. Acquired, congenital and developmental defects.4-234-25 Students/Residents must gain clinical experience to become competent in the pre-prosthetic,prosthetic and post-prosthetic management and treatment of patients with defects of facialstructures.4-244-26 Students/Residents must demonstrate competency in interdisciplinary diagnostic andtreatment planning conferences relevant to maxillofacial prosthetics, which may include:a. Cleft palate and craniofacial conferences;b. Clinical pathology conferences;c. Head and neck diagnostic conferences;d. Medical oncology treatment planning conferences;e. Radiation therapy diagnosis and treatment planning conferences;f. Reconstructive surgery conferences; andg. Tumor boards.Prosthodontics Standards-25-2010 CDEL Re-recognition of the Specialty Report 268 of 279

STANDARD 5 - ADVANCED EDUCATION STUDENTS/RESIDENTSELIGIBILITY AND SELECTIONDentists with the following qualifications are eligible to enter advanced specialty educationprograms accredited by the Commission on Dental Accreditation:a. Graduates from institutions in the U.S. accredited by the Commission on Dental Accreditation;b. Graduates from institutions in Canada accredited by the Commission on Dental Accreditation ofCanada; andc. Graduates of foreign dental schools who possess equivalent educational background andstanding as determined by the institution and program.Policy on Advanced StandingThe Commission supports the principle, which would allow a student/resident to complete aneducation program in less time providing the individual’s competency level upon completion of theprogram is comparable to that of students/residents completing a traditional program. Further, theCommission wishes to emphasize the need for program directors to assess carefully, for advancedplacement purposes, previous educational experience to determine its level of adequacy. It isrequired that the institution granting the degree or certificate be the institution that presents theterminal portion of the educational experience. It is understood that the advanced credit may beearned at the same institution or another institution having appropriate level courses.Commission on Dental Accreditationrevised: January 30, 2001Specific written criteria, policies and procedures must be followed when admittingstudents/residents.Intent: Written non-discriminatory policies are to be followed in selecting students/residents. Thesepolicies should make clear the methods and criteria used in recruiting and selectingstudents/residents and how applicants are informed of their status throughout the selection process.Admission of students/residents with advanced standing must be based on the same standards ofachievement required by students/residents regularly enrolled in the program. Transferstudents/residents with advanced standing must receive an appropriate curriculum that results in thesame standards of competence required by students/residents regularly enrolled in the program.Examples of evidence to demonstrate compliance include:policies and procedures on advanced standingresults of appropriate qualifying examinationscourse equivalency or other measures to demonstrate equal scope and level of knowledgeProsthodontics Standards-26-Adopted: July 27, 2001Implementation Date: July 1, 20022010 CDEL Re-recognition of the Specialty Report 269 of 279

EVALUATIONA system of ongoing evaluation and advancement must assure that, through the director and faculty,each program:a. Periodically, but at least semiannually, evaluates the knowledge, skills and professional growthof its students/residents, using appropriate written criteria and procedures;b. Provide to students/residents an assessment of their performance, at least semiannually;c. Advances students/residents to positions of higher responsibility only on the basis of anevaluation of their readiness for advancement; andd. Maintains a personal record of evaluation for each student/resident which is accessible to thestudent/resident and available for review during site visits.Intent: (b) Student/Resident evaluations should be recorded and available in written form.(c) Deficiencies should be identified in order to institute corrective measures.(d) Student/Resident evaluation is documented in writing and is shared with the student/resident.DUE PROCESSThere must be specific written due process policies and procedures for adjudication of academic anddisciplinary complaints, which parallel those established by the sponsoring institution.RIGHTS AND RESPONSIBILITIESAt the time of enrollment, the advanced specialty education students/residents must be apprised inwriting of the educational experience to be provided, including the nature of assignments to otherdepartments or institutions and teaching commitments. Additionally, all advanced specialtyeducation students/residents must be provided with written information which affirms theirobligations and responsibilities to the institution, the program and program faculty.Intent: Adjudication procedures should include institutional policy which provides due process forall individuals who may potentially be involved when actions are contemplated or initiated whichcould result in disciplinary actions, including dismissal of a student/resident (for academic ordisciplinary reasons). In addition to information on the program, students/residents should also beprovided with written information which affirms their obligations and responsibilities to theinstitution, the program, and the faculty. The program information provided to thestudents/residents should include, but not necessarily be limited to, information about tuition,stipend or other compensation; vacation and sick leave; practice privileges and other activityoutside the educational program; professional liability coverage; and due process policy andcurrent accreditation status of the program.Prosthodontics Standards-27-2010 CDEL Re-recognition of the Specialty Report 270 of 279

STANDARD 6 - RESEARCHAdvanced specialty education students/residents must engage in scholarly activity.Prosthodontics Standards-28-2010 CDEL Re-recognition of the Specialty Report 271 of 279

COUNCIL ON DENTAL EDUCATION AND LICENSURE2011 PERIODIC REVIEWOF DENTAL SPECIALTY EDUCATION AND PRACTICEPROSTHODONTICS – Appendix GACP Resolutions and Commentson CODA Proposed Changes inthe Definitions, April 23, 20092010 CDEL Re-recognition of the Specialty Report 272 of 279

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