First, it is very important to understand that you are not having a cleaning. You have a bacterial infection called periodontal disease. By measuring the pockets surrounding you teeth, evaluating the gum tissue, and reviewing your x-rays, your dentist and hygienist have discovered the infection in your gums.

As your dentist and hygienist mentioned, 1-3 mm pockets without bleeding and recession are typically considered healthy, 4 mm pockets with bleeding may indicate gingivitis or possibly even early periodontitis. 5mm+ pockets with multiple bleeding sites strongly indicate the presence of a bacterial infection called periodontal disease. These deep pockets are no accessible by brushing and flossing and require your dentist or hygienist to manually remove the infection with special instruments. The infection must be removed every 90-120 days to prevent further bone loss. Without adequate bone support tooth loss occurs.

Concerning your insurance benefits, it is true that most dental plans allow two cleanings a year for healthy patients. For patients with periodontal disease, however, you have separate benefits aimed at arresting the periodontal disease process and preventing additional bone loss. Depending on the premiums paid by you and/or your employer, periodontal benefits usually range from 30-80 percent. A deductible may also apply.

Once you have been diagnosed with periodontal disease, we are obligated to provide your dental plan with the appropriate billing codes, a copy of your periodontal measurements, and sometimes x-rays. Legally, as your dental care team, we cannot ignore the infection in your mouth. Be assured that we will do our best to see that you receive the dental benefits provided by your employer.

There have been numerous changes in dental benefit plans over the past few years. To give you an accurate estimate of your dental benefits we must first see a copy of your dental plan. If you bring in a copy of your dental plan, our business stall will gladly interpret it for you. Be aware that most dental plans expect employees to pay a portion of their periodontal visits. As a general rule, periodontal patients should expect to pay at lease 30-50 percent of their treatment needs over the course of the year since most dental plans require a deductible and co-payment on periodontal services.

As you know, our goal is to provide excellent dental care to all our patients. In good conscience, we cannot ignore a bacterial infection in your gums simply due to insurance limitation. With periodontal disease, the risk is too great. If left untreated, periodontal disease not only leads to tooth loss, it may also place you at increased risk for heart disease, respiratory disease, diabetes and, if pregnant, a premature, low birth weight baby.

If your dental benefits seem unreasonably low, we encourage you to contact your employer and express your concerns about the limitation of your dental plan so that future dental contracts are reviewed more closely. We are happy to provide any information you need to assist you in this effort.

Quite simply, our bodies change. Bacterial plaque can cause decay in our teeth or cause an infection in your gums called periodontal disease. When you come in for your cleaning and exam, your dentist evaluates both the health f your teeth and the health of your gums and bone support. Just as you maybe have developed a cavity since your last appointment, you may have also developed and infection in your gums which may be the beginning stages of periodontal disease.

There are many risk factors for developing periodontal disease, including: smoking, diabetes, heart disease, respiratory disease, pregnancy, osteoporosis, stress, radiation, chemotherapy medications, inadequate home care, hereditary predisposition, etc. Our goal is to protect your oral heath which is essential to your overall physical health.

It seems like such a simple request, and yet the consequences are very serious. The Health Care False Claim Act States: "No person shall knowingly make a false statement or false representation of a material fact to a health care payer for use in determining rights to a health care payment. Each claim that violates this subsection shall constitute a separate violation."

Dentist and hygienists have a legal responsibility to select the dental code the most accurately reflects the treatment rendered. To manipulate a code to obtain better benefits for a patient is a violation of the Health Care False Claim Act and draws the attention of the F.B.I. and U.S. Postal Inspectors because false claims sent via the U.S. Postal Service constitute mail fraud.

Dental insurance phone representative often tell patients the benefits available under their dental plans. While a phone representative may know the details of a patient�s dental plan, he/she often does not understand the legal responsibilities of the dental office. A dental representative may tell a patient what codes(s) will be paid under the terms of his/her contract, not realizing that the dentist and/or hygienist can lose her/her license if he/she manipulates treatment codes in order to obtain those benefits.

Changing a code is not the answer to dealing with denied dental services. The plan purchaser, usually one�s employer, must agree to increase benefits when negotiating the dental contract.


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