“DENTISTRY 101”

National Oral Health

Conference
April 30, 2005
Pittsburgh, Pennsylvania
 Itinerary
• The mouth and its parts
• Dental disease-decay, periodontal
• DentistryDentistryDentistryDentistryDentistry
• The business of dentistry
• Policy Drivers
• Hot topics
The Mouth and Its
Parts
The Mouth and Parts
 Enamel
Dentin

Gingiva (gum)

Pulp

Nerve and
blood vessels

Cementum and
periodontal
ligament
http://users.forthnet.gr/ath/abyss/dep1142.htm
 The Dental Arch
• Maxillary (upper) Arch: part of the
skull, incapable of movement.
• Mandibular (lower) Arch: capable of
movement.

The action of the temporomandibular

joint brings the mandibular arch into
contact with the maxilla as we talk,
chew or swallow.
 Teeth
• Deciduous, primary, “baby”
• Permanent
 Healthy Primary Teeth are
Important
• Chewing and
nutrition
• Development of
the permanent
teeth
• Facial structure
• Speech
development
 Deciduous Teeth
Central Incisor

Lateral Canine
Incisor

2nd Molar
Upper arch
Maxillary 1st
Molar

Lower arch
Mandibular
Deciduous Teeth
Notation
 Deciduous Teeth

Eruption Schedule
 The Primary Arch
Upper Teeth ERUPT SHED
Central incisor 8-12 mos 6-7 yrs
Lateral incisor 9-13 mos 7-8 yrs
Canine 16-22 mos 10-12 yrs
1st molar 13-19 mos 9-11 yrs
2nd molar 25-33 mos 10-12 yrs

Lower Teeth
2nd molar 23-31 mos 10-12 yrs
1st molar 14-18 mos 9-11 yrs
Canine 17-23 mos 9-12 yrs
Lateral incisor 10-16 mos 7-8 yrs
Central incisor 6-10 mos 6-7 yrs
Eruption
Eruption
 Function
incisors cuspids

bicuspids(premolars)

molars
 Tooth Numbering System
Permanent Dentition
• A number from 1-32 identifies each tooth
in sequential order across both arches.

– Tooth #1 is the upper right third molar, and

numbering continues across the upper arch to
the upper left third molar, #16.

– Tooth # 17 is the lower left third molar and

this sequence continues around the lower arch
to the patient’s lower right third molar, #32.
Upper
Right

Lower
Left
 Quadrant

• One of four equal

sections into which
the dental arches
can be divided.
Each quadrant
begins at the
midline of the arch
and extends
distally (back) to
the last tooth.
 Tooth Surfaces
• Mesial: toward the midline of the
dental arch.
• Distal: toward the back of the dental
arch, away from the midline.
• Lingual: closest to the tongue.
• Facial: near the cheek:
– Labial: anteriors
– Buccal: posteriors
 Tooth Surfaces, Cont.
• Occlusal: top (biting) surfaces of
premolars and molars.
• Incisal: thin biting surface of incisors and
cuspids.
 Teeth
Incisal

Buccal Mesial
Mesial

Lingual
Upper arch
Maxillary
Distal
Occlusal

Lower arch
Mandibular

Labial
Dental disease
 Decay
• Contributing factors
• Demineralization
• Remineralization
• Fluoride
• Risk assessment
• Management
How Does Decay Develop?
PLAQUE a sticky patch of bacteria,* saliva, food
& tissue cells on the tooth.
*Streptococcus mutans
bacteria found in the mouth primarily involved in
the decay process.

Food sugars are processed by S. mutans.

Tooth acids are produced and start

eating away at the tooth.
Plaque + Food + Tooth = Decay
Bacteria:
S. mutans
Food
Plaque

Tooth

Decay
Progression of Decay
 Early Childhood Caries
ECC
• Presence of 1 or more carious lesions,
missing (due to caries) or filled tooth
surfaces in any primary tooth in a
child 71 months of age or younger
 Early Childhood Caries
ECC (cont’d)
• 4-20 teeth involved
• Caries that have possibly exposed
pulps
• Possible dental abscesses
• Acute/chronic pain
 Early Childhood Caries
ECC (cont’d)
• Higher risk of new carious lesions in both primary
and permanent teeth
• Hospitalization and ER visits
• Increased treatment costs and time
• Delay in physical development
• Loss of school days
• Increased days of restricted activity
• Diminished ability to learn
• Diminished oral health related quality of life

Reference Manual AAPD, 2004

 Treatment of ECC
• Multiple stainless steel crowns
• Composite restorations
• Extractions
• Space maintainers
• Possibly treatment in a hospital
setting
 Risk Assessment
“A diagnostic process where clinical,
historical and social risk factors are
used to determine the likelihood
whether a child will have dental
disease.”
 Risk Assessment-Relapse
Factor of ECC
• 79%o of ECC children compared
w/29% of non-ECC children developed
new carious lesions at subsequent
recall visits.
• 1/5 of ECC children treated under
general anesthesia required
retreatment within 2 years.
 AAPD Caries Risk
Assessment Tool (CAT)
http://www.aapd.org/mem
bers/referencemanual/
pdfs/02-
03/P_CariesRiskAssess.
pdf
Recommendations for Pediatric Oral Health
Care

• http://www.aapd.org/
media/policies.asp
RECOGNIZING EARLY
DECAY
WHITE SPOT LESIONS
=
Subsurface
demineralization
 Subsurface Lesion/demineralization

Intact
Plaque enamel

Body of subsurface
lesion

Advancing Lesion
Peter Milgrom DDS
Northwest/Alaska Center to Reduce Oral Health Disparities
University of Washington, Seattle
 Remineralization
Plaque
Intact enamel

Remineralization
 Peter Milgrom DDS
University of Washington, Seattle
 Peter Milgrom DDS
University of Washington, Seattle
 Peter Milgrom DDS
University of Washington, Seattle
 Caries Risk Analysis
(young children)
• There is visible plaque on the teeth.
• There are cavities, white spots or enamel
hypoplastic areas on the teeth.
• There is a history of decay in the family.
• The child is low birth weight or
premature.
 Caries Risk Analysis

• Untreated cavities in last 2 yrs

• Orthodontics or removable partials
• Reduced salivary flow or medications
that reduce saliva
• Frequency of carbohydrate intake
• Fluoride use
 What We Know
• Transmissibility
• Fluoride effectiveness
• Bacterial challenge
• Restoration
• And…
 Breaking the Chain
• Risk assessment
• Early detection
• Fluoride and other antibacterial
therapy
• Sealants
• Minimally invasive restorative
techniques
 ONGOING BALANCE

Protective Factors Pathologic Factors

Salivary flow Strep mutans

Proteins Carbohydrates
Fluoride Reduced salivary flow

No caries Caries
 Oral Health Disparities
• Tooth decay is the most prevalent
chronic disease of childhood-5 times
more frequent than asthma.

• 25% of children suffer 80% of all

tooth decay.
Periodontal Disease
Healthy Gums

Www.dentalgentlecare.com-Dr. Dan Peterson

 Gingivitis

Www.dentalgentlecare.com-Dr. Dan Peterson

 Periodontitis

www.dentalgentlecare.com-Dr. Dan Peterson

 Advanced Periodontitis

www.dentalgentlecare.com-Dr. Dan Peterson

Restoring Carious and
Missing Teeth
 Black’s Classification of
Caries
• Class I.
– Cavities occurring in pit and fissure defects in
occlusal surfaces of bicuspids and molars,
lingual surfaces of upper incisors, and facial and
lingual grooves sometimes found on occlusal
surfaces of molar teeth.

1
 Black’s Classification of
Caries, cont.
• Class II.
– Cavities in proximal
surfaces of bicuspids 2
and molars.

• Class III.
– Cavities in proximal 3
surfaces of incisors
and cuspids not
requiring removal of incisal angle.
 Black’s Classification of
Caries, cont.
• Class IV.
– Cavities in proximal
4
surfaces of incisors
and cuspids that require removal of incisal
angle.
• Class V.
– Cavities in gingival third of labial, lingual, or
buccal surfaces.
5
 1

3 5
 Amalgam Fillings

MOD

MO/DOL

DO
Composite Fillings
Crowns
Fixed Bridge
Endodontics
root canals

http://www.doctorspiller.com
Implants
Partial Denture
Denture
Orthodontics
 Orthodontic Assessments
• http://www.dent.ohio-
state.edu/orthoresources/cd/index.htm

http://websrvr.dmas.virginia.gov/manuals/den/appendixf_de
n.pdf. Salzman Index

• Ohio:
http://emanuals.odjfs.state.oh.us/emanuals/medicaid/DEN/
@ebt-
link;cs=default;ts=default;pt=3790?target=IDMATCH(ID,O
DHS3630);book=
Diagnosis
 Bitewing X-Rays

Interproximal view of the

coronal portion of the tooth
Bitewing Xrays
Full Mouth X-Rays
Full Mouth Xrays
Panorex
Periapical Xrays
Occlusal Xray
 Summary-Radiographs

• Bitewing: cavity detecting

• Full mouth: pa’s & bitewings
• Occlusal: palate & floor of the
mouth
• Panorex: teeth & general area
• Periapical (PA): single film, shows
root
 Transillumination
Transillumination enables you
into see fractures, caries,
subgingival calculus, root
canal openings and more.
Transillumination is an easy,
inexpensive and fast
diagnostic tool you will soon
find to be indispensable in
your practice!
Laser Fluorescence
 Diagnodent

DIAGNOdent has the great

advantage of detecting caries
in the very early stage by
measuring the laser
fluroescence within the tooth
structure.
Precise results without x-ray
exposure.
Dentists!…and the
business of
dentistry
 Dentist Specialty Boards
• Public Health
• Endodontics
• Oral and Maxillofacial Pathology
• Oral and Maxillofacial Radiology
• Oral and Maxillofacial Surgery
• Pedodontics
• Periodontics
• Prosthodontics
• Orthodontics
 Dental Specialties
• Endodontics: CDT-5 codes D3000-D3999,
the treatment of the pulp and periapical
tissues.
• Oral Surgery: CDT-5 codes D7000-D7999,
the surgical treatment of the oral/facial
region.
• Orthodontics: CDT-5 codes D8000-
D8999, treatment related to the jaw,
position of the teeth and the oral and
facial muscles:
– Concerned with function and appearance.
 Dental Specialties, Cont.
• Pediatrics: the treatment of children.
• Periodontics: CDT-5 codes D4000-D4999
treatment of diseases of the supporting
structures of the teeth.
• Prosthodontics: extensive restorations of
teeth using crowns, bridges and
replacement of missing teeth:
– Removable prosthodontics: CDT-5 codes
D5000-D5899 restorations that can be
removed.
– Fixed prosthodontics:CDT-5 codes D2710-
D2799 & D6200-D6999, are restorations that
can not be removed (implant related).
 Who They Are
“General Dentist: is an individual who has
successfully completed from a dental
training leading to a DDS or DMD degree,
which qualifies that individual to be
licensed to accept the professional
responsibility for the diagnosis, treatment
management, and overall coordination of
services that meet patients’ oral health
needs, and who has not announced a
limitation of practice to any specialty areas
recognized by the ADA.”
 Who They Are (cont’d)
“Pediatric dentistry is an age-defined
dental specialty that provides both
primary and comprehensive
preventive and therapeutic oral
health care for infants and children
through adolescence, including those
with special health care needs..”
 Factoids
• 79% Graduates are general
practitioners
• 21% Graduates are specialists
– Pedodontists <3% practicing dentists
• Provide approx. 30% of children’s oral health
care
• Provide a disproportionate amount of care to
children covered by Medicaid and SCHIP
 ADEA Dental Education at a Glance

4618

4443
 Specialty Training

Pediatric 368 141

http://www.adea.org/CPPA_Materials/2004_Dental_Ed_At_A_Glance.pdf
Dental Specialists in Kansas,
2000
Wisconsin Counties with at
Least One Pediatric Dentist
 HIPAA Impact
• Standardized code sets (CDT5)
• Standardized electronic billing (837d)
• Movement towards standardized
paper claim (ADA2002)
 CDT Coding
“Current Dental terminology, fifth
edition (CDT-5)…is effective for
services provided on or after
January 1, 2005…has been designated
as the national standard for reporting
dental services by the Federal
Government under HIPAA…”
 CDT Coding
• Diagnostic D0100-D0099
• Preventive D1000-D1999
• Restorative D2000-D2999
• Endodontics D3000-D3999
• Periodontics D4000-D4999
• Prosthetics Removable D5000-D5899
• Maxillofacial Prosthetics D5900-D5999
• Implant services D6000-D6199
• Prosthodontics, fixed D6200-D6999
• Oral and maxillofacial surgery D7000-D7999
• Orthodontics D8000-D8999
• Adjunctive General Services D9000-D9999
Dental Practice

• Solo/start-up
• Associate
• Income
Start-up Costs-MN
 Associate
General Compensation Formula
(Production Based)

Gross Production
-Adjustments
-Uncollectibles (Charge Back)
Collections
-Lab Charges
-((Professional expenses))
Income Produced
Apply percentage (30% – 35%)
-Professional expenses))
Net (Spendable) Income (before taxes)
Associateship Arrangements in Dental Practice-Dave Willis, DMD, MBA, CFP
 Associate-Let’s add the
numbers

Assume salary based on 30% of

collections
Assume 95% collection rate
Assume 10+ percent lab fee rate
 Associate-Let’s add the
numbers
• If salary desired is $100,000
• Then $315,000 needed assuming
95% collection.
• Add $35,000 to accommodate lab
fees.
• Total production of $350,000 =
$100,000 salary
 Dental School Debt

Average Debt of all Aver Debt of Students with

Students upon Graduation Debt upon Graduation

All Dental $118,750 All Dental $132,532

Schools Schools
Public $ 93,622 Public $103,149

Private/State $147,950 Private/State $167,676

related related
 Medical School Debt
Mean Level of Educational debt
for medical school graduates in
2002
•19% of medical students had
no debt
•$91,389 for public schools
•$123,780 for private schools
www.amsa.org
 Dentist/Physician Income
Comparison
On average, general dentists in
2000, the most recent year for
which comparative data are
available, earned $166,460...
Wall Street Journal April 05:Careers
 Dentist/Physician Income
Comparison
-compared with $164,100 for
general internal-medicine doctors,
$145,700 for psychiatrists,
$144,700 for family-practice
physicians, and $137,800 for
pediatricians. All indications are
that dentists have at least kept
pace with physicians since then...
Wall Street Journal April 05:Careers
 Dentist/Physician Income
Comparison
ADA estimates work hour per week
for dentists approximately 40 hours

AMA estimates work hour per week

for physicians 50-55

Income difference is understated

Wall Street Journal April 05:Careers
Policy Drivers-The Dark
Side

• Pay
• Paperwork
• Patients
Policy Drivers-The Dark
Side
• Pay
– percent
– percentile
– capitation
– co-pays
– coverage
Policy Drivers-The Dark
Side
• Paperwork
– prior
authorization
– claims
– coverage
Policy Drivers-The Dark
Side
• Patients
– attendance
– compliance
– complicated
Policy Drivers-The Dark
Side-one days schedule
• 12 scheduled, 2 no-shows
• 10 smokers
• 8 taking more than 1
medication
• 2 not taking scheduled
medication
• 1 drug seekers
Policy Drivers-The Dark
Side
• Dental offices
are single owner
or small group
• May not have
dedicated billing
staff/paper
shops?
Policy Drivers-The Dark
Side
• Service insurance
with limited and
very defined
benefits
• May be cash only
business
• Poor electronic
interface between
office and claims
processor
 Policy Drivers
• Existing policy
• Budget constraints
• Political drivers-Governor/legislature
• Fraud and Audit
 Reimbursement
Provider
Competing All over
Programs the map
Consumer

Agency =
Politics
Court FED/State
Rulings Rules
Fraud/Audit
 Upcoding
• D7140-extraction, erupted tooth or
exposed root (elevation and/or forceps
removal.
• Wisconsin fee $39.37
• D7210-surgical removal of erupted tooth
requiring elevation of mucoperiosteal flap
and removal of bone and/or section of
tooth. Includes cutting of gingiva and bone,
removal of tooth structure and closure.
• Wisconsin Fee$85.54
 Upcoding

Occlusal-Billed as OBL Actual OBL

D2140-$32.75 D2160-$52.67
 Avoid Fraud
• Evaluating mobile providers of nursing-home dental
care
– Appropriate services for elderly or edentulous
patients compared to services delivered
– Approximate time required to perform patient
care - to compare workload and claims volume
 Avoid Fraud
• Clear Policy
• Objective guidelines/handbook
– Measurable clinical data
» x-rays, crown root ratios, clinical notes

• Clinical audits
• Post-pay audit
 Policy Drivers
Existing Thought

• The traditional treatment is repair of

the damage produced by the disease
without identification of the
causative agent. We are only treating
the terminal end of the disease!
 Policy Drivers

• Evidenced base
• Outcome based
• Disease management
• Clinical and utilization
data
 Examples of Use of Basic
Clinical Knowledge in
Policymaking
• Reimbursing fluoride varnish applied in primary-
care settings
– Dental disease process, role of fluoride
– Development of primary and permanent
dentition
– Patient utilization of medical vs. dental care for
very young children
– Cost of fluoride vs. treatments for decayed
primary teeth (e.g. prefab SSC crowns,
sedation)
 Examples of Use of Basic
Clinical Knowledge in
Policymaking

• Cost of urgent/emergent care in non-

dental settings
 Examples of Use of Basic
Clinical Knowledge in
Policymaking
• Other health costs related to lack of
dental services
– low birth outcomes
– aspiration pneumonia in medically
compromised patients
– diabetes
– heart disease
–?
 Medicaid Systems &
Provider Billing
• Standardized code • Keep
set (CDT5) handbook/policies
updated,
communicate
• Make Medicaid changes to staff
policies for billing • Communicate
as close to those of eligibility
private dental requirements/
insurance as changes to billing
possible and registration
staff
 Hot topics

Fuego, Antigua, Guatemala, March 26, 2002

Bob March 25, x
2002

ART
fluoride varnish, xylitol,
evidence based outcomes
Overcoming obstacles to
access
 Urgent Care Dental In-State
Emergency Provider Data Sheet

• Mechanism for non-certified

providers to provide urgent care
• Intended to alleviate an urgent need,
not limited to one tooth
• Intended to reduce backlog of urgent
needs
• Complete data sheet/ADA claim form
“It’s easy!”
 Websites
• http://www.aapd.org/media/policies.asp
• http://dhfs.wisconsin.gov/Medicaid/index.
htm?ref=hp
• http://www.wphca.org/Wisconsin%20MA%
20Dental%20Facts%2003.pdf
 Thank-you!
Robert Dwyer, DDS
Chief Medical Officer
Division of Health Care
Financing
dwyerra@dhfs.state.wi.us
608.264.6754
“you have questions?”