May 1, 2004
A discussion about dental insurance often leads to a failure to communicate about the very reason you're talking to each other — good oral health.

by Sheri French, RDH

Are you and your patients trapped in the "dental insurance box?" It's easy to let that happen; in fact, I plead guilty myself. When we allow dental insurance codes to determine the quality of our treatment rather than determine what will best restore the patient to health, we are in the wrong box. Part of our frustration in treating patients according to their insurance benefits stems from the lack of adequate codes to describe periodontal disease.

Dental insurance is a contract between the insurance company and (usually) an employer to provide benefits or assistance to help defray the cost of dental treatment. We know that dental insurance maximums in coverage are at nearly the same level they were in 1960, more than 40 years ago. Benefits provided by insurance companies are not even making an attempt to keep up with the increased costs of providing dental care. I suggest that the dental insurance companies are also in the "wrong box" — paying the minimum amount of benefit they can without regard for the individual patient.

Insurance codes (CDT-4) are a method of communicating with the dental plan regarding the services rendered. They are not suggestions for a treatment plan, not a standard of care, not even parameters of accepted care. They are standardized communication tools that are not definitive.

For example, if you look at the preventive code 1110 (prophylaxis), many of us believe that there should be a different code to treat gingivitis since it is part of the disease process. Yet, in the FAQ section of the CDT-4, it is suggested that this code should be used to treat gingivitis if there is no bone loss. It doesn't make sense to use the same code to prevent disease and treat disease. We must overcome the mindset that the codes dictate treatment. Acceptable parameters of care are defined by the American Academy of Periodontology and you can access them at www.perio.org.

As hygienists, we have very few codes available to us. (See side bar for current CDT-4 codes.) What is a poor hygienist to do? We must treatment plan the patient's care based on the dental hygiene assessment and diagnosis.

Early intervention in the periodontal disease process requires particular attention to data collection and health assessment. This will include reviewing the medical history, taking the vital signs, consulting the physician of record when necessary, performing the oral cancer screening, taking radiographs, doing a comprehensive periodontal

charting, and evaluating all of the available information. What treatment will be necessary? Prophylaxis, debridement, four quadrants of scaling and root planing?

Step outside the dental insurance codes for a moment. Instead, understand the patient's oral health status and what is required to preserve or restore it. Remember, bleeding is an indicator of disease, but absence of bleeding does not necessarily indicate health. If you can case type the disease, using AAP guidelines, treatment planning will become much easier.

Without a doubt, most of our patients could learn more about their mouths. In fact, the AAP Parameters of Care lists patient education as the first step in a treatment plan for active therapy for plaque-induced gingivitis. Involve the patient in this co-discovery process.

Once they recognize that a problem exists and is not going to go away without treatment, the next logical step is to enroll in that treatment. So insurance doesn't "cover" it. Does that mean disease does not exist? Absolutely not! Once you have linked oral health to total health, the patient is much more likely to accept treatment over and beyond what insurance benefits will assist with. Practitioner and patient alike will do well to remember that the insurance company's business is collecting premiums and paying stockholders, and our business is providing oral health care. Now that the patient has been involved in the co-diagnosis of the problem, it is very likely he or she will want to proceed with treatment.

And what will that treatment include? Debridement or the complete removal of all bacterial plaque and calculus, both above and below the gum line, is the first step and may be accomplished in one or a series of appointments. There are viable arguments for full mouth disinfection performed within 24 hours. But certainly most of us would agree that the initial phase of treatment should not be extended over too long a period. The traditional four quadrants may not always result in optimal tissue health, especially if the deposits are heavy or contributing factors exacerbate the infection. Just as some people require more time to recuperate from a cold, certain patients will benefit from repetitive periodontal therapy. Tissue response should dictate the endpoint of active treatment — not the cookbook approach of four one-hour appointments for scaling and root planing.

Again, I will refer to the AAP Parameters: "...where the periodontal condition does not respond, treatment may include additional sessions of oral hygiene instruction and education, additional or alternative methods and devices for plaque removal, medical/dental consultation, additional tooth debridement, increasing the frequency of prophylaxis, microbial assessment, and continuous monitoring and evaluation to determine further treatment needs."1

Research clearly shows the value of a three-month interval for hygiene care; however, even that may be too long for some patients. As for the traditional six-month recall, there is not one research study validating the twice-yearly dental visit. Toothpaste commercials and the old Amos and Andy radio show are responsible for that urban myth. We must base the interval on the immune response of the particular patient. Likewise, your explanation to the patient must be individualized to each person. Addressing patients by name frequently and using their medical history to explain the concerns you have regarding their dental status will go a long way in making them feel special and appreciated.

So your dental hygiene treatment plan may look like this. After the initial exam, take full mouth radiographs, complete periodontal charting, and schedule four to six visits of periodontal debridement using antimicrobials and/or locally delivered chemotherapeutic agents. Leave the treatment plan open-ended to allow for repetitive therapy on unresponsive areas. Three to four weeks later, schedule a re-evaluation appointment to assess tissue response, followed by a continuing care schedule based upon the level of home care compliance and the patient's immune response to the bacterial infection being treated.

Documentation should be concise but thorough enough that another practitioner can easily discern the health status of the patient, what treatment was rendered, and what is planned next. The fees will need to be based on your time and materials used. You should have an idea of what an hour in your chair is worth based on office overhead. Charge appropriately for your time and expertise. Since the treatment plan is open-ended, quote a range of fees. If the response is adequate, you may not need all the appointments planned and the patient goes away feeling good about succeeding.

The appropriate time to consider dental codes is at dismissal and check out time. Choose the most appropriate one for what you did today and submit it (with a narrative, if necessary). Most insurance plans will not provide any benefit beyond four quadrants of scaling and root planing, and gingivitis benefits are also questionable.

So we have the choice of either giving away the additional therapeutic debridement, attempting to "prophy" our patients to health, or telling the patient to do more at home and seeing them again in three to six months. You don't want to wait to treat disease until permanent bone loss is evident. Telling this to your patient is helpful in explaining that gingivitis therapy will not be covered. The dental insurance plan may or may not provide assistance, but if you have educated and created value for your patient, they will often elect to proceed with the treatment.

What code will you use for appointments if more than four quadrants of scaling and root planing or periodontal debridement are needed? You can reuse the 4341 code, with a narrative explaining the need for retreatment, or you can use one of the "by report" codes. They still won't pay for it, so don't be bound by what insurance covers or doesn't cover. Provide the treatment warranted by the patient's current oral health status and explain to them again, if necessary, that their tissues have not resolved to optimal health so more treatment is needed.

Is there anywhere else in medicine that active infection would be tolerated because the first round of treatment didn't resolve it? Remember that we should never prejudge what a patient may want or afford. The preconception of a patient's financial ability to afford treatment or of their dental IQ may cause dental problems to go undiagnosed when we allow ourselves to be caught in the insurance box. Our job is to offer the very best care we can and it may just be that we need to get out of the insurance box to do that.

The codes

D1110 prophylaxis — adult, is defined as: "A dental prophylaxis performed on transitional or permanent dentition that includes scaling and/or polishing procedures to remove coronal plaque, calculus and stains." (The "and/or" after scaling has been removed since publication.) While this is listed under preventive codes, the FAQ section of the CDT-4 advises that it may be used to treat gingivitis if there is no bone loss.

The next three codes are classified as non-surgical periodontal services:

D4341 periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant, code 4341: "This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in others."

D4342 periodontal scaling and root planing - one to three teeth per quadrant. See D4341 descriptor.

D 4355 full mouth debridement to enable comprehensive evaluation and diagnosis: "The removal of subgingival and/or supragingival plaque and calculus. This procedure does not preclude the need for additional procedures."

D4910 periodontal maintenance: "This procedure is for patients who have previously been treated for periodontal disease. Typically, maintenance starts after completion of active (surgical or non-surgical) periodontal therapy and continues at varying intervals, determined by the clinical diagnosis of the dentist, for the life of the dentition. It includes removal of the supra and subgingival microbial flora and calculus, site specific scaling and root planing where indicated, and/or polishing the teeth. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered."

The author's tip

Recently, I discovered a flip-down mirror that attaches to the overhead dental light. I simply pull it down and ask patients if they can see their teeth. The standard response is for them to check out their smile.

For some reason, they are much more receptive and engaged with this mirror than when I used to hand them a mirror during the examination. As they see the bleeding points (which I explain are not healthy responses), see the color changes, and see the probe disappearing under the gum line, it begins to dawn on them that something is not right, and they begin to ask questions.

Giving information as a response to an inquiry is much better received than the usual lecture about how this wouldn't be so uncomfortable if they had flossed. Patients read about the systemic link between periodontal disease and heart disease and diabetes in consumer publications, so they are not surprised when you link them.

With their health history in mind, you can further educate them by creating value for your periodontal or preventive services. Educating the patient about what is going on in his or her own mouth is probably the most important service you can provide.

Sheri French, RDH, has enjoyed a variety of roles in dental hygiene, including administrator, change agent, educator, and clinician.She has spent the last 12 years in a small town practice treating her neighbors and friends. Sheri welcomes comments at [email protected].

1 www.perio.org Parameters of Care; accessed 1//1/04
2 CDT-4 Current Dental Terminology