The potential harm of not following clinical practice guideline recommendations.

BACKGROUND: Clinical practice guidelines (CPGs) provide recommendations for clinicians on the basis of best evidence. CPGs are often not followed because of numerous barriers, including lack of awareness, inability to understand recommendations, and problems with implementation. CASE DESCRIPTION: A case report is presented in which treatment of a patient's incipient caries lesions may not have followed a CPG available to practitioners, recommending conservative nonrestorative medical interventions. The resulting treatment led to pain and the need for endodontic therapy and full-coverage restoration. PRACTICAL IMPLICATIONS: This case represents possible mismanagement leading to undue pain and additional costs that could have been avoided by being aware of, and following, the recommendations from CPGs.