I need help starting a conversation with my dentist on why dental hygiene care needs to be completed before restorative work is begun. I work with a dentist who completes work prior to dental hygiene care and sometimes doesn’t schedule the patient with a dental hygienist at all.
The answer of whether to complete restorative procedures prior to preventive ones, or vice versa, really depends on a variety of factors, which should incorporate the use of evidence-based decision making (EBDM). These considerations include clinical circumstances, clinician experience, patient preferences, and scientific evidence.1 As such, the sequence of appointments may not be the same for every patient.
When using EBDM to assist in formulating a treatment plan, clinicians also need to consider the varying importance of presented problems, their urgency, and possible solutions—all while meeting the patient’s needs and demands. A phased approach is typically followed. Although the literature and textbooks label these phases differently, they basically consist of the following priorities for appointment scheduling:
- Phase 1: Emergency treatment and addressing the chief complaint
- Phase 2: Disease control of dental caries and gingival and periodontal diseases
- Phase 3: Restore function and esthetics
- Phase 4: Re-evaluation and maintenance (recare)
Although phases are delineated, they are not mutually exclusive and can be combined with emergency and initial restorative procedures.2
The question remains, how are appointments prioritized and made to flow in a logical manner? In general, periodontal procedures should precede restorative procedures as their completion improves the health of the tissues, which can result in better outcomes when performing restorative care.3 On occasion, a gross debridement is initially indicated in order to complete a comprehensive exam. In this instance, the Current Dental Terminology Code D4355 can be used, which allows for full-mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit.4
Of course, there are specific dental circumstances when restorative procedures should precede preventive care. As previously mentioned, any pain or areas requiring urgent care should be addressed first. Certain functional and esthetic considerations may also be addressed prior to preventive procedures when indicated. For example, fractured teeth may not be painful but they may have sharp margins or they may be in an anterior region, thus esthetically unpleasing to the patient.
There is no obvious or absolute answer whether restorative or preventive procedures should be completed first in a treatment plan. What is important is that clinicians formulate a treatment plan using EBDM. In doing so, the appropriate treatment is the one that uses the clinician’s professional experience and judgment, and meets the needs and desires of the patient. This should be the philosophy of all offices in order to bring the dental team together to facilitate the best possible patient care.
- Forrest JL, Miller SA. Evidence-based decision making in action: finding the best clinical evidenceJ J Contemp Dent Prac. 2002;3:1–21.
- Newsome P, Smales R, Yip K. Oral diagnosis and treatment planning: part 1. Br Dent J. 2012;213;15–19.
- Sivakumar A, Thangaswamy V, Ravi V. Treatment planning in conservative dentistry. J Pharm Bioallied Sci. 2012;4(Suppl 2):S406–S409.
- American Dental Association. D4355—ADA Guide to Reporting Full Mouth Debridement. Available at: ada.o/g/~/media/ ADA/Publications/Files/D43_5_ADAGuidetoReportingFullMouthDebridement_v1_2018Jan.pdf?la=en. Accessed April 20, 2021.
From Dimensions of Dental Hygiene. May 2021;19(5):46.