Adam Burr, DDS
We’ve all had patient exams where we say to ourselves, “Where do I get started with this?” These are the patients who may have one tooth that hurts, decay on every other tooth, and a very limited budget to do anything. This article will highlight one approach to address our patients’ chief conditions, secondary conditions, use their insurance, provide exceptional care, and still generate revenue for our practices.
I have a patient, I’ll call him Rudy, who’s in his mid-30s, and he acknowledges with shame that years of neglect have left his mouth in terrible condition. He’s afraid he’ll end up with dentures and would like to avoid them. More urgently, he has a toothache that’s keeping him up at night. He works in construction, has a family, and has $1,500 in insurance coverage, but he doesn’t have the financial means to address fall of his dental needs. Clinically, every single tooth has initial or recurrent decay. Three or four teeth have a questionable pulpal diagnosis. Several teeth are not restorable.
Given all these challenges, Rudy is in a predicament that will affect his confidence, self-esteem, and health for the rest of his life. An unrestricted budget would allow for straightforward, phased treatment planning that would include emergent treatment, disease control, and definitive treatment, followed by elective treatment. An assortment of extractions, endodontics, periodontal treatments, implants, crowns, and fillings would reliably restore Rudy’s oral health.
During treatment planning, Rudy was not given a definitive treatment plan. He was not given a pages-long treatment estimate that would max out his insurance on the first or second tooth. Instead, we used the CDT codes outlined in this article.
1.
D3221—Pulpal debridement
Rudy could not afford to undergo definitive endodontic treatment on every requisite tooth while still staying within budget for the extractions and caries control. A pulpal debridement can be an efficient procedure to relieve pain, control infection, and stabilize a tooth for up to several months while other urgent treatment is completed. This procedure can be done in less than 10 minutes. First, proper isolation is obtained. Next, decay is removed, the pulp chamber is accessed, and extirpation is performed. Finally, irrigation with the appropriate hypochlorite mixture followed by intracanal placement of calcium hydroxide is performed.
When patients are in pain due to a pulpally involved, restorable tooth, yet can’t afford definitive endodontic treatment due to financial or other short-term constraints, dentists can consider adding this treatment to their arsenal.
2.
D1354—Interim caries-arresting medicament application
Patients who share Rudy’s dilemma have rampant decay. Definitive restorative treatment can cost thousands of dollars. Dentists do little good by maxing out patients’ insurance coverage by doing definitive treatment on only a few teeth and leaving the remaining active decay untreated. If we plan poorly for our patients, they will be left without benefits and with only a few good teeth and a poor long-term prognosis.
Consider reading the article “Silver diamine fluoride: The newest tool in your caries management toolkit”1 and purchasing Advantage Arrest from Elevate Oral Care LLC. Once we understand how to use this revolutionary product, our ability to truly arrest decay will open definitive treatment plans that previously weren’t available to patients like Rudy.
Remember, patients must give informed consent to use Advantage Arrest. It will darken teeth where active decay is present. Clinicians typically use it in areas that are already discolored. Once it’s properly explained, patients routinely accept the discoloration as a side effect in exchange for the ability to fit definitive treatment into their budgets and treatment timelines. Moreover, the discoloration can almost always be mitigated with the following treatment.
Once we understand how to use this revolutionary product, our ability to truly arrest decay will open definitive treatment plans that weren’t previously available to patients like Rudy.
3.
D2940—Protective restoration
The description of this code states it is to be used to
“. . . promote healing or prevent further deterioration.” This treatment isn’t to be done as an endodontic access closure, but it can be placed over a lesion treated with Advantage Arrest. Using an opaque glass ionomer can mask the discoloration caused by silver diamine fluoride in most areas.
Rudy received more than a dozen protective restorations. Most insurance plans cover this code under the preventive category. Contracted rates are typically within reason, and we can deliver these restorations quickly. If treated properly, an entire quadrant of protective restorations can be treated with one or two unit doses of the most common glass ionomers.
In Rudy’s case, tooth No. 6 required all three of these codes—3221, 1354, and 2940. The pulpal debridement was done. Decay around the canal orifice and the external margins was thoroughly removed. The remnant excavation was not aggressive. Advantage Arrest was applied followed by placement of the self-curing protective restoration.
4.
D2799—Provisional crown
In Rudy’s case, tooth No. 30 could not be reliably restored with just a protective filling. Instead, we did a provisional crown. This code is not to be used for routine temporary fabrication in conjunction with a definitive crown. Here, further treatment is necessary prior to completion of the final restoration.
This code is often not a covered benefit. A reasonable fee can be charged as the lab cost of the final restoration will be fully charged in the future. As an added benefit, the restorability of the tooth can be determined and the majority of the preparatory work is already completed.
5.
9630—Other drugs and/or medicaments, by report
Rudy was able to address his emergent needs and complete disease control for his entire dentition. All of this was done without going beyond his insurance benefit or personal budget. After further discussion, he needs several months to save money for his upcoming phases of definitive treatment. During this time, his home care is critical. Additional products need to be used daily to ensure the work that he’s had completed remains intact and free from recurrent decay.
Consider purchasing useful products such as MI Paste One or PreviDent 5000. These can be dispensed to patients with a reasonable markup in price. It is only through expert knowledge, consultation, and demonstration that these products should be prescribed and sold. Thus, charging patients a reasonable amount for our contribution to the product’s success is certainly warranted.
While you may not use these codes frequently, implementing them into your repertoire will enhance your ability to treat those cases where financial constraints limit patients’ abilities to complete definitive treatment modalities initially. Furthermore, this can be done with clinical efficiency and cost consciousness.
Most importantly, many patients need this type of treatment. We can greatly enhance our patients’ dental futures when we treat them while giving thought to both their financial and clinical realities.
Reference
1. Bendit J, Young DA. Silver diamine fluoride: The newest tool in your caries management toolkit. Dental Academy of Continuing Education website. https://www.dentalacademyofce.com/courses/3347/PDF/1707cei_Bendit_Young_web.pdf. Published July 2017.
Adam Burr, DDS, is a graduate of Loma Linda University School of Dentistry. He is an owner dentist supported by Pacific Dental Services in West Jordan, Utah, and a faculty member of the PDS Institute of Dentistry.
