When dental insurance came into existence, a treatment code system was implemented to communicate between the provider (a dentist) and the insurer as to what procedures were completed for a patient.  The insurer would then, according to a “fee schedule” reimburse for that treatment code.   This system made sense…at least at the time it was initiated in the 1970’s.

As years go by, dental procedures change and ideally, as new technology and new and improved procedures are introduced, the insurance company’s fee schedule would change to include the new procedures.  However, this is usually not the case.  Insurance companies are resistant to changes in their coding system – it can take more than several decades to add a new procedure code to the list.  Why?  Because adding codes means additional claims are eligible for payment, and insurance companies would pay out more money.    

The out-of-date fee schedule is what I call the “insurance magnet”.  Periodontal providers, limited by a signed contract with an insurance company, are drawn toward rendering treatment within the confines of what has been included on the fee schedule.   If a procedure is not on the schedule, it is often not even considered as an option for that patient, even though it may be the appropriate treatment.  In essence, the coding system controls what treatment is rendered, as opposed to what providers diagnose or what patients might prefer. 

In short, the coding system, rather than the diagnosis, too frequently dictates the care.  Isn’t this a case of the tail wagging the dog? 

How can patients be sure they are given every option available?  By asking their provider, “ARE THERE ANY OTHER TREATMENT OPTIONS?  I WOULD LIKE TO KNOW – EVEN IF THEY ARE NOT COVERED BY MY INSURANCE”.  

If a periodontal provider does not offer to do alternative treatments, it may be time to seek a second opinion.

A recent article printed in the New York Times discusses relief from the misery of dentures with dental implants.

For Most, Implants Beat Dentures, but at a Price

“They fell out when I talked,” Mr. Panko, 56, a small-business owner in Woodridge, Ill., recalled.  “I couldn’t taste my food – in fact, I could hardly chew.  It was the most miserable time of my entire life.”

Mr. Panko, who lost his teeth in his early 50’s because of a hereditary form of periodontal disease, eventually replaced his dentures with something better: dental implants.  While many people wear dentures without discomfort, implants are now considered the preferred treatment for replacing lost teeth, said Dr. Robert Pick, an associate professor of surgery at the Feinberg School of Dental Medicine at Northwestern University.

The procedure is straightforward.  A surgeon places a titanium screw in the jaw bone, and prosthetic teeth are secured to the implant.  They don’t wiggle or slip, as dentures can, and are healthier for the gum and bone.  Most patients find implants easier to maintain than dentures.

“Best decision I ever made,” Mr. Panko said of his implants.  I could chew beer cans now”.

For all their advantages, implants are expensive.  Insurance coverage is usually minimal, and patients are often surprised by high out-of-pocket costs….Why so much?  Implants typically involve the work of both a surgeon and a dentist.  Several office visits may be needed to put in the screws and to add the prosthetic teeth.  More dental insurance plans are covering the costs, but the annual reimbursement limit is typically $1500, an amount that hasn’t changed in four decades….Still many patients find it a worthwhile investment.  Implants typically last a lifetime, with a failure rate of less than 5 percent.

Let’s say you lose one tooth.  If you opt for a bridge, which costs almost as much as an implant but is more often covered by insurance, the dentist will grind down the two adjacent teeth to create a structure that secures the replacement tooth.

The ground teeth become more vulnerable to decay and nerve damage, and there’s a good chance you will require a root canal in the future, said Dr. Karl Gruendl, a dentist in Fenton, Mo., who advises insurance plans.

A study done for Washington Dental Service, the largest insurance carrier in Washington State, found that over a five-year period the maintenance costs for people with bridges were higher than for those who had implants.

“For a single tooth replacement, over the long run we think it’s more beneficial to get the implant”, said Dr. Ron Inge, dental director for Washington Dental Service.  And that’s an insurance executive talking….

Implants also will help protect your bones over time.  “The screw in your jawbone will trick the body into thinking you still have teeth,” said Dr. Ira Cheifetz, president of the American Association of Maxillofacial Surgeon.  “The bone continues to grow and thrive.”

There is good news for the patients in Dr. Weingarden’s practice.  Dental implants generally cost less in Pittsburgh than other major cities across the country.

Dr. Weingarden also offers interest-free payment options.  Through dental implant technology, patients can rid themselves of the misery of dentures and regain the look, feel and function of their natural teeth.

For more information regarding dental implants, visit our website at

www.pittsburghimplantsandperio.com

For this article in its entirety visit www.nytimes.com

If you needed another reason to brush and floss, maybe this will help.

Researchers at New York University have found that gum disease may increase the risk of cognitive dysfunction associated with Alzheimer’s disease.

This NYU study provides fresh evidence that gum inflammation is associated with inflammation in the brain.

The research team, led by Dr. Angela Kamer, assistant professor of periodontology & implant dentistry, studied 20 years of data from Denmark that support the hypothesis of a link between periodontal disease and Alzheimer’s.

Those with gum disease at age 70 were nine times more likely to test in the lower range of brain function tests compared to those with little or no periodontal inflammation.

Other health factors that tend to lower test scores, such as obesity, cigarette smoking, and tooth loss related to gum inflammation, were factored in, but the strong association held true.

Kamer is working on a follow-up study, which will include a more ethnically diverse pool of people.

www.cbsnews.com

I have been a Patient Coordinator in the dental field for over 22 years now and I can tell you that dental treatment has evolved dramatically over those 22 years.  New products, new equipment and new techniques are introduced all the time, affording the dental patient the best opportunity ever for long term dental health.  Do you know what HASN’T changed much over the past 22 years?  Dental insurance.  Do you know why?  Because, dental insurance is designed to keep insurance companies financially healthy – not to keep patients dentally healthy. 

Twenty two years ago, most dental insurance programs provided patients an average benefit of $1000 per year for dental treatment.  Here we are 22 years later and what do most dental insurance programs offer per year?  $1000, of course.   The fact is that there is not one single product or service that hasn’t increased in cost over the years. Dental premiums certainly have.   So how could this same $1000 provide the same quality dental care it provided 22 years ago?   Obviously, it can’t.  But amazingly, patients still expect that they will receive quality dental care within the confines of what their dental insurance pays. 

In addition to the yearly limit set by dental insurance companies, reimbursement is also limited through use of specific dental “codes”.  Every procedure that is on the dental insurance company’s “list” has a code associated with it.  When a new dental procedure is introduced into the field of dentistry, one would assume that it would be assigned a code and added to the list.  Unfortunately, this is not the case.  It can take in excess of 10 years for insurance company’s to code a new procedure and sometimes the new procedures never make the list at all! 

Adding insult to injury, insurance companies dictate not only which procedures make the list, but also what percentage of the fee they reimburse on each procedure.  The goal of insurance companies is to pay as little as possible of the $1000 per patient, each year.  In other words, even though you GET $1000 per year, they certainly don’t want you to USE $1000 per year, and they make sure that you don’t.  Remember, the less they pay out, the more profitable they are.   

So the dental patient trustingly goes to the participating dental provider for care.  However, instead of providing treatment that may be more up-to-date, more conservative, more predictable, more comfortable or may even cost LESS, a participating practitioner, (because he has signed a contract with the insurance company), is more likely to plan treatment based on what is found on “the list”.   Participating providers may not even discuss (or perform) treatment options that are not on the list and patients often incorrectly assume, “if it isn’t on my insurance company’s list, then I must not need or want that treatment!”    

If only insurance companies would allow patients to spend the $1000 as they choose.  Dental providers could then offer patients ALL treatment options and patients could decide for themselves what level care they desire.  Unfortunately, this is not likely to happen, because patients would be much more likely to use their entire $1000 per year and the insurance companies would be much less profitable.   Bottom line, patients need to be aware of the limitations of their dental insurance’s list and they need to ask their provider about treatments options that may not be a part of that list.   Only then can they make a truly informed decision regarding their dental care.

For the vast majority of patients with periodontal disease, the goal of treatment is to remove the plaque, (bacteria) and calcified plaque (tartar or calculus), to eliminate the infection and prevent progressive damage.  The perioscope is a very small camera that is placed gently below the gum in the area of concern.  It illuminates the site and then magnifies it 48 times. 

Before the perioscope was available, periodontists were limited to a surgical approach, done with the use of loupes, (special glasses) that provide at most 4 times magnification.  Although 4x is fairly dramatic, it is only 1/12 the sensitivity of the perioscope. Visibility of the problem area is critical whether the treating doctor is using conventional surgical instruments or a laser, and can critically affect the outcome of treatment.  Improved visibility translates to a significantly higher percentage of the plaque and calculus being successfully removed and therefore a potentially better result than without the perioscope.   

It is important to note that the perioscope:

1. Is more conservative than surgery.  There is no cutting involved.
2. Is often even more effective than surgery thanks to the magnification.
3. Is not covered by dental insurance.  However, the perioscope costs less than surgery, and since there is always a  co-pay with surgery, it may actually cost you less than treatment covered by insurance.  

We are one of only two offices in the Pittsburgh area to offer the perioscope and we have been doing so since 2000.   To learn more about the perioscope, visit our website at www.pittsburghimplantsandperio.com or call us at 412-487-8288.

A.  More up-to-date
B.  Less invasive
C.  More effective
D.  Prevention oriented   

There is an abundance of evidence that shows that conservative, preventive care can greatly diminish or completely eliminate the need for periodontal surgery.  And if surgery is indicated, the surgical treatment is far more effective.  Because dental insurance does not allow adequate reimbursement for the most up-to-date treatments, a participating provider may be limited to providing outdated procedures, (usually recommending surgery immediately), just to maintain profitability.   

A perfect example of a conservative, preventive treatment option is the perioscope.  The perioscope is a high tech instrument that provides a non-surgical alternative to traditional periodontal surgery.  Dental insurance does not recognize the perioscope on its list of “covered procedures”.  Therefore, a participating dental provider would not offer patients this state-of-the-art treatment option; an option that avoids cutting, can be even more effective than surgery and costs less. 

Do yourself a favor – get a second opinion with a periodontal provider who offers the perioscope.  You may be surprised to find that you have other effective treatment options.   And please remember that although we are not on your provider list, we will still file your claims for coverage where applicable. 

To find out more, visit our website, www.pittsburghimplantsandperio.com

Methods:  Participants (668 males and 216 females; mean age: 54 +/- 8.5 years) were recruited (1997 through 2004) from two western New York county hospitals and completed an interviewer-administered questionnaire regarding lifestyle habits, clinical measurements, and a comprehensive dental examination.  The periodontal disease status was measured by the mean clinical attachment loss (AL).  Follow-up surveys assessed hospitalizations or medical procedures; cardiovascular events were validated by medical records.  A National Death Index (NDI) Plus search was conducted.  The outcome was recurrent fatal and non-fatal cardiovascular events (International Classification of Diseases codes 390-450). 

Results: After an average follow-up of 2.9 years, 154 events were reported.  Among never-smokers, the adjusted hazard ratio (95% confidence interval) for the mean clinical AL (millimeters) was 1.43 (1.09-1.89).  No associations were found in ever-smokers (clinical AL by smoking interaction: p <0.05). 

Conclusion: These findings indicate that periodontal disease may be an important factor in determining recurrent cardiovascular events in MI patients and not merely a marker for the effects of cigarette smoking.

J Periodontology 2010;81:502-511.

Methods: Immediately after childbirth, 1,207 women underwent an examination in which periodontal disease was assessed according to two alternative definitions: 1) four or more teeth with at least one site showing probing depth (PD) > or = 4mm and clinical attachment loss (AL) > or = 3mm, and 2) at least one site showing PD and clinical AL > or = 4mm.  For each of these definitions, two types of multivariate analysis were conducted: a linear regression analysis for the number of gestation weeks, and a more specific ordinal logistic regression analysis for the ordinal variable gestation time categorized as normal (term) (n=1,046 women) or mild-moderate (n=146 women) or extreme preterm (n=15 women). 

Results:  Periodontal disease was associated with fewer weeks of gestation by linear regression (definition 1: P = 0.012: definition 2: P<0.001 and with preterm (n=161: mild-moderate and extreme) or extreme preterm births (n=15) by ordinal logistic regression (definition 1: odds ratio [OR] = 1.83, 95% confidence interval [CI]: 1.28 to 2.62: definition 2: OR = 2.37, 95% CI: 1.62 to 3.46). 

Conclusion: Our findings suggest that periodontal disease is associated with a premature or extremely premature birth. 

J Periodontology 2010;81:350-358

History of periodontitis has been described as a risk indicator for peri-implantitis.  Risk assessments of implant therapy in well-defined patients are necessary to clarify this clinical relevance.  Roccuzzo et al. conducted a 10-year prospective, three-arm cohort study on implants in periodontally compromised patients.  One hundred twelve partially edentulous patients were divided into periodontally healthy patients (PHP), patients with moderate chronic periodontitis (moderate PCP), and patients with severe chronic periodontitis (severe PCP).  Two hundred sixty-four titanium plasma-sprayed implants were installed to support fixed prosthesis after successful completion of initial periodontal therapy.  Eleven patients (18 implants) were lost at the 10-year follow-up.  Clinical measures, radiographic bone changes, and adherence to supportive periodontal therapy (SPT) were recorded in 101 patients with 246 implants, (28 PHP, 37 moderate PCP and 36 severe PCP) at the 10-year follow up.  Results showed that 18 of the 246 implants were lost due to biological complications.  Full-mouth plaque score was similar in the three groups, but full-mouth bleeding score was higher in severe PCP.  The survival rate was 96.6%, 92.8%, and 90%, respectively, for PHP, moderate PCP and severe PCP.  Although there were no intergroup differences for mean bone loss,  (.075 +/- 0.88 mm in PHP, 1.14 +/- 1.11mm in moderate PCP, and 0.98 +/- 1.22mm in severe PCP), the percentage of sites with bone loss greater than or equal to 3mm indicated a statistically significant difference between PHP (4.7%) and severe PCP (15.1%).  A significantly high proportion of PCP who did not adhere to SPT had bone loss (11 of 18 patients) and implant loss (nine of 18 patients).  The authors concluded that patients with a history of periodontitis, especially those who do not adhere to SPT, are at a higher risk for implant loss and bone loss.  In summary, the results showed the importance of compliance to SPT in enhancing the long-term outcomes of implant therapy, particularly in subjects with periodontitis.  

Complete article can be found the Journal of Periodontology, Volume 81, Number 6, June 2010, page 797.

We now know that inflammation is the periodontal “red flag” which guides us in the detection, treatment and control of gum disease.  The AAP reports:

“Research has long suggested an association between gum disease and other health issues including heart disease, stroke and diabetes, but now scientists are beginning to shift their focus to understanding why these connections exist.  An emerging theory, and one gaining support from researchers worldwide, is that inflammation may link the mouth to the body.  Inflammation is the body’s instinctive reaction to fight off infection, guard against injury or shield against irritation.  Inflammation is often characterized by swelling, redness, heat and pain around the affected area.  While inflammation initially intends to heal the body over time, chronic inflammation can lead to dysfunction of the infected tissues, and therefore more severe health complications.

According to Dr. Susan Karabin, Past President of the American Academy of Periodontology and a practicing periodontist in New York City, periodontal disease is a textbook example of an inflammatory disorder: ‘for many years, dental professionals believed that gum disease was solely the result of a bacterial infection caused by a build-up of plaque between the teeth and under the gums.  While plaque accumulation is still a factor in the development and progression of gum disease, researchers now suspect that the more severe symptoms, namely swollen, bleeding gums; recession around the gum line, and loss of the bone that holds the teeth in place, may be caused by the chronic inflammatory response to the bacterial infection, rather than the bacteria itself’. 

American Academy of Periodontology-November 24, 2008

The success or failure of periodontal treatment is very much dependent upon control of the inflammation.  This requires a record keeping system designed to focus upon inflammation and its cause, not just the pockets.  This requires a time commitment from the clinician, devoted to helping the patient achieve plaque control effectiveness at home.  

Bottom line – be on the look out for inflammation.  If insurance limits the feasible amount of time you can devote to helping patients with their home care, make sure that the periodontist you work with is on top of inflammation!   

Questions or comments?  Feel free to contact us at 412-487-8288 or visit our website at www.pittsburghimplantsandperio.com