American Dental Association

Five Things Dentists and Patients Should Question

Released June 27, 2016; Last reviewed 2021

  1. 1

    Don’t recommend non-fluoride toothpaste for infants and children.

    The benefit of fluoride-containing toothpaste arises from its topical effect on dental enamel by interrupting enamel demineralization caused by bacterial acids and enhancing remineralization of the enamel surface. Anti-caries (anti-cavities) benefit begins with eruption of the first primary tooth.

    Brushing with non-fluoridated toothpaste provides no anti-caries benefit. Use of recommended amounts of fluoride toothpaste minimize risks of fluorosis, a whitish discoloration of enamel.

  2. 2

    Avoid restorative treatment as a first line of treatment in incipient (non-cavitated) occlusal caries without first considering sealant use.

    High quality evidence shows sealants are safe and effective in arresting caries progression in initial stage (incipient) non-cavitated, occlusal caries. Sealants offer a tooth-preserving treatment when compared to restorations, which may require removal of some healthy tooth structure, thereby weakening the tooth and increasing the risk that the tooth will eventually require more extensive treatment. Applying sealants as soon as initial stage caries is detected can improve outcomes by minimizing the later need for more extensive restorative care.

  3. 3

    Avoid protective stabilization, sedation or general anesthesia in pediatric patients without consideration of all options with the legal guardian.

    Some children do not respond to communicative behavior guidance techniques and require treatment of dental disease. Advanced behavior guidance techniques of sedation, protective stabilization, and general anesthesia offer risks and benefits often beyond the health knowledge of parents and other caretakers. Informed consent best practice requires a thorough, understandable explanation of these techniques and alternatives including deferral of treatment with its inherent risks.

  4. 4

    Avoid routinely using irreversible surgical procedures such as braces, occlusal equilibration and restorations as the first treatment of choice in the management of temporomandibular joint disorders.

    There is a lack of evidence that temporomandibular joint disorders (TMD) (defined as musculo-skeletal disorders, not the lesion of traumatic occlusion) are always progressive, and evidence exists that in many instances, patients with TMD have spontaneous remissions without treatment. Therefore, management is generally conservative and includes reversible strategies such as patient education, medications, physical therapy and/or the use of occlusal appliances that do not alter the shape or position of the teeth or the alignment of the jaws.

  5. 5

    Don’t replace restorations just because they are old.

    Dental restorations (fillings) fail due to excessive wear, fracture of material or tooth, loss of retention, or recurrent decay. The larger the size of the restoration and/or the greater the number of surfaces filled increases the likelihood of failure. Restorative materials have different survival rates and fail for different reasons, but age should not be used as a failure criteria.

Support for the ADA’s development of Choosing Wisely recommendations was provided by a grant from the Robert Wood Johnson Foundation.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their dentist.

The not-for-profit ADA is the nation’s largest dental association, representing more than 158,000 dentist members. The premier source of oral health information, the ADA has advocated for the public’s health and promoted the art and science of dentistry since 1859. The ADA’s state-of-the-art research facilities develop and test dental products and materials that have advanced the practice of dentistry and made the patient experience more positive. The ADA Seal of Acceptance long has been a valuable and respected guide to consumer dental care products. The monthly The Journal of the American Dental Association (JADA) is the ADA’s flagship publication and the best-read scientific journal in dentistry.

For more information about the ADA, visit For more information on oral health, including prevention, care and treatment of dental disease, visit the ADA’s consumer website

How This List Was Created

The American Dental Association (ADA) is a professional organization that supports the practice of evidence-based dentistry and routinely develops clinical guidelines for various clinical topics, including the use of dental sealants to prevent tooth decay and fluoride toothpaste for young children.

To create this list, the ADA’s Council on Access, Prevention and Interprofessional Relations established a Steering Committee consisting of ADA members representing evidence based experts in general dentistry and various disciplines within dentistry, including research, cariology, oral surgery, periodontology, public health, geriatrics and pediatric dentistry. Steering Committee liaisons included representatives from the ADA Council on Dental Practice, Council on Dental Benefit Programs, Council on Communications and Council on Scientific Affairs and representatives from dental specialty organizations.

The Steering Committee reviewed critical issues in dentistry to identify potential recommendation topics and developed, through an evidence-based process, a list of recommendation statements with supporting scientific evidence. Via an intense consensus process, the Steering Committee prepared a list of recommendation statements which were sent to the Council on Access, Prevention and Interprofessional Relations for review. The Council voted to recommend the final five recommendation statements on this list to the ADA Board of Trustees for its approval. The five recommendation statements were approved for distribution by member vote by the ADA Board.

ADA’s disclosure and conflict of interest policy can be found at


  1. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. Pediatr Dent 2014;36(6): 171-74.

    American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc. 2014 Feb;145(2):190-1.

    Wright JT, Hanson N, Ristic H, Whall CW, Estrich CG, Zentz RR. Fluoride toothpaste efficacy and safety in children younger than 6 years: a systematic review. J Am Dent Assoc. 2014 Feb;145(2):182-9

  2. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington H. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001830.

    Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B, Ismail A, Kohn W, Siegal M, Simonsen R; American Dental Association Council on Scientific Affairs. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008 Mar;139(3):257-68.

    Borges BC, de Souza Borges J, de Araujo LS, Machado CT, Dos Santos AJ, de Assunçao Pinheiro IV. Update on nonsurgical, ultraconservative approaches to treat effectively non-cavitated caries lesions in permanent teeth. Eur J Dent. 2011 Apr;5(2):229–36.

    Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E. Minimal intervention dentistry for managing dental caries – a review: report of a FDI task group. Int Dent J. 2012 Oct;62(5):223–43.

    Hesse D, Bonifácio CC, Mendes FM, Braga MM, Imparato JC, Raggio DP. Sealing versus partial caries removal in primary molars: a randomized clinical trial. BMC Oral Health. 2014 May 28;14:58.

    de Assunção IV, da Costa Gde F, Borges BC. Systematic review of noninvasive treatments to arrest dentin non-cavitated caries lesions. World J Clin Cases. 2014 May 16;2(5):137-41.

    Oral Health Services Guideline Initiative. Pit and fissure sealants: evidence-based guidance on the use of sealants for the prevention and management of pit and fissure caries. Cork (IR): Cork Oral Health Services Research Centre; 2010. 49 p.

  3. American Academy of Pediatrics; American Academy of Pediatric Dentistry, Coté CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006 Dec;118(6):2587-602.

    Academy of Pediatric Dentistry Council on Clinical Affairs, American. Guideline on protective stabilization for pediatric dental patients. Pediatr Dent. 2013 Sep-Oct;35(5):E169-73.

    Council on Clinical Affairs, American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2014;36(6):179-191.

    Council on Clinical Affairs, American Academy of Pediatric Dentistry. Policy on a patient’s bill of rights and responsibilities. Pediatr Dent 2014;36(6): 113-14.

    American Academy of Pediatric Dentistry. Guideline on protective stabilization for pediatric dental patients. Pediatr Dent. 2013 Sep-Oct;35(5):E169-73.

    American Academy of Pediatrics and American Academy of Pediatric Dentistry. Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures Pediatr Dent. 2008-2009;30(7 Suppl):143-59.

  4. Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J. Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008456.

    Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny A-M. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev. 2004;(1):CD002778.

    Treatment for Temporomandibular Joint Dysfunction: guidelines. Ottowa (ON): Canadian Agency for Drugs and Technologies in Health (CA); 2010 May 17. 6 p.

    De Boever JA, Nilner M, Orthlieb JD, Steenks MH; Educational Committee of the European Academy of Craniomandibular Disorders. Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. J Orofac Pain. 2008 Summer;22(3):268-78.

    de Souza RF, Lovato da Silva CH, Nasser M, Fedorowicz Z, Al-Muharraqi MA. Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012 Apr 18;4:CD007261.

    Guidelines: diagnosis & management of temporomandibular disorders & related musculoskeletal disorders. Toronto (ON): Royal College of Dental Surgeons of Ontario (CA); 11 p.

    Ernst E, White AR. Acupuncture as a treatment for temporomandibular joint dysfunction: a systematic review of randomized trials. Arch Otolaryngol Head Neck Surg. 1999 Mar;125(3):269-72.

    Forssell H, Kalso EJ. Application of principles of evidence-based medicine to occlusal treatment for temporomandibular disorders: are there lessons to be learned? J Orofac Pain. 2004 Winter;18(1):9-22; discussion 23-32.

    de Souza RF, Lovato da Silva CH, Nasser M, Fedorowicz Z, Al-Muharraqi MA. Interventions for the management of temporomandibular joint osteoarthritis. Cochrane Database Syst Rev. 2012 Apr 18;4:CD007261.

    Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev. 2003;(1):CD003812.

    Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD006541.

    de Leeuw R, Klasser GD. Orofacial pain: guidelines for assessment, diagnosis, and management. 5th Ed. Hanover Park: Quintessence Books; 2013. 312 p.

  5. Rasines Alcaraz MG, Veitz-Keenan A, Sahrmann P, Schmidlin PR, Davis D, Iheozor-Ejiofor Z. Direct composite resin fillings versus amalgam fillings for permanent or adult posterior teeth. Cochrane Database of Syst Rev. 2014, Issue 3. Art No: CD005620. DOI: 10.1002/14651858.CD005620.pub2.

    Fedorowicz Z, Carter B, de Souza RF, Chaves CA, Nasser M, Sequeira-Byron P. Single crowns versus conventional fillings for the restoration of root filled teeth. Cochrane Database Syst Rev. 2012 May 16;5:CD009109.

    Sharif MO, Merry A, Catleugh M, Tickle M, Brunton P, Dunne SM, Aggarwal VR, Chong LY. Replacement versus repair of defective restorations in adults: resin composite. Cochrane Database Syst Rev. 2014 Feb 8;2:CD005970.