The importance of "The Three Languages of Perio" coding

Learning the "three langauges" of dental codeology will allow dental hygienists to help themselves, their patients, and the entire denial practice.

Sep 23rd, 2014
Dental Code Book Digangi

I had a flashback when I arrived in Chicago earlier this summer for the RDH Under One Roof event. The memory played out in my mind like a movie as I waited for my suitcase in the baggage claim area… It was 2005 in Chicago, and I’d just cleared customs after arriving in the U.S. for the first time from Brazil. My heart was racing as I wandered O’Hare airport trying to find the exit. I remember how scary and confusing it was trying to find my way in a completely new environment and knowing only a few words of English. After I had been in the U.S. for only a few moments, I discovered how important it would be for my success to learn the language – FAST!

Fast-forward nine years, and I realize I’m a student of language again, actually several languages this time. They are the diagnostic and coding languages of the AAP Classifications, the CDT Codes, and the AAP Treatment Types. I call them the “Three Languages of Perio” because what I’ve found is that not understanding the differences between these three systems of communication has caused a lot of confusion when it comes to diagnosing and treating periodontal disease. In fact, there is so much confusion that communication and documentation have become a major roadblock to effectively implementing a periodontal protocol that works in the dental office.

I was inspired to write this article after I heard Patti DiGangi’s amazing talk at RDH Under One Roof about her book “Dental Codeology – More Than Pocket Change.” Patti’s class was perfectly complemented by a separate workshop led by Ashley Grill, RDH, which explored the variation in terminology affecting periodontal diagnosis. I had the pleasure of speaking briefly with both of them. The conversations I’ve had with these great dental educators really opened my eyes to how important the way we communicate and document the treatment of periodontal disease is to our effectiveness.

Understanding these three “languages” will help dental hygienists become better clinicians by improving our ability to diagnose and treatment plan. We will have the knowledge and understanding to better educate patients and get them to accept treatment. When they use this language in their notes they will provide a more complete record so the front desk team can easily manage dental insurance claims.

My goal is to “translate” these languages for you so that you understand how, when, and where to use each one effectively. By the time you’re done reading this article, you’ll see why as a dental hygienist it is important for you to be fluent in all three. My hope is that once you understand how each of these systems of communication is used, you will commit to learning them so that you can become a better clinician, and communicate more effectively with your team members. Mastery of these languages will really boost your confidence as a dental hygienist.

Before we get into the details of each language, let me give you a quick overview. There are three “languages” – AAP classifications, AAP case types, the CDT diagnostic codes. Each language has its own primary different objectives.. Recognizing that objective can really help understand how and when to use each language. As clinicians our jobs have a predictable process. First we diagnose the condition of the patient, decide on the treatment, and after performing the treatment we document our efforts. You will see as you read this article that each language has been designed to help us achieve one of these three steps – AAP classifications is the language of diagnosis; AAP case types is the language of treatment; the CDT codes are the language of documentation.

Typically when using these languages our goal is one of two things. That is either 1) diagnose the condition of the patient and decide on the treatment or 2) document what we found in order to report to third parties for insurance or legal purposes. Each language is primarily designed for one of these objectives more than the other – diagnose or document.

In my years here in the U.S., I’ve become fluent in English (though I’m still learning), and consider myself to have intermediate skills in Spanish. Those of you who are multilingual may be familiar with the term “heart language.” This is your native tongue, your first language, and the one you’re most familiar with. For me that is Portuguese. When learning a new language, you almost always feel a need to translate back into your heart language in order to have a real sense of understanding.

What I’ve found is that dental practitioners have a different heart language when it comes to communicating in the “languages of perio.” The heart language is often based on job functions, and whether those job functions are diagnosis- and treatment-focused or documentation-focused. It could also simply be the language they learned first in their dental training. For example, general dentists and periodontists will likely be most familiar with the AAP classification language or AAP case type language, as both of these are diagnosis-focused. Office managers and front desk team members will likely be most familiar with the CDT code language, which is primarily focused on documentation. Hygienists are often somewhere in between. It depends on how they learned and who in the office they interact with the most. Out of all the team members, hygienists need to understand all three languages and be able to switch back and forth as needed.

The problem is, just like with English, Spanish, and Portuguese, there isn’t always a direct translation. If someone is not very familiar with all the languages, it is very easy to become confused.

In my early days in Chicago as an English student, I met friends from all over the world. When we all got together to explore the city, it was like a traveling United Nations convention. There were Brazilians, Columbians, Venezuelans, Germans, French, and Americans in our group. Sitting at a dinner table with this group made my head spin because there were so many accents, languages, and conversations flying around. If we wanted to communicate we had to stop and agree to speak English so everyone could participate. That also meant we had to slow down a bit because each of us had a different level of English mastery.

Communicating in a dental office can sometimes be like sitting at that international dinner table, especially for a dental hygienist who is bouncing back and forth between conversations with the dentist, front desk, patient, and possibly, a periodontist. You have to recognize who speaks what language and switch as required. If you’re all meeting together, you have got to slow down and decide which language is best to use based on your objective at the moment.

If you are a dental hygienist speaking with a doctor about diagnosing a patient and creating a treatment plan, the language of AAP classifications and case types will be most useful. Then you must switch gears and speak CDT coding language to connect with a financial coordinator or front desk team member to gather the documentation required for the insurance company and patient. Ideally you will draw from all three languages when you make your notes in the system.

A crash course in each language
If you’ve ever travelled abroad to a country that doesn’t speak your native language, you probably explored some options to try to quickly get the basics of the language for survival purposes. Bilingual dictionaries, travel guides, and mini language courses are tools that can give you the foundation to feel confident to make your way around. Think of these next parts of the article as your crash course in each “language of perio.”

AAP classification system
The AAP classification system was developed by The American Academy of Periodontology to identify types of periodontal diseases by taking into consideration age of onset, clinical appearance, rate of disease progression, pathogenic microbial flora, and systemic influences. Dentists, periodontists, and academics use it primarily to have a standardized way of communicating about the causes and conditions of periodontal disease. This is primarily a language of diagnosis. It is pretty comprehensive and can be a bit overwhelming. It has also been constantly evolving as the dental community studies and learns more about causes, manifestations, and consequences of periodontal disease.

The most recent revision was published in 1999. It divided the classifications into two major categories – gingival and periodontal disease. Each of these is then broken down further. You can learn a lot by familiarizing yourself with the classifications.

Gingival disease is classified into 10 different types that are based on cause of the disease. I’ve listed them here with the keywords you should memorize in bold.

I. Plaque-induced gingivitis
a. Gingival disease modified by systemic factors
b. Gingival disease modified by medications
c. Gingival disease modified by malnutrition
II. Non-Plaque-induced gingival diseases
a. Gingival disease of specific bacterial origin
b. Gingival diseases of viral origin
c. Gingival disease of fungal origin
d. Gingival disease of genetic origin
e. Gingival manifestations of systemic conditions
f. Traumatic lesions
g. Foreign body reactions

Not all gingival diseases are gingivitis. Though this may seem like a semantic game, the difference is very important. Understanding the AAP classifications of gingival disease can really offer some insight when trying to diagnose the confusing “danger zone” of 4 mm bleeding pockets with no bone loss. Waiting for bone loss is like waiting for a heart attack. Increased blood pressure or elavated cholesterol are somewhat akin to gingival disease, and they need treatment. Use these classifications as a guide to investigate the cause of the problem and evaluate the risk of the disease advancing to a periodontal disease. Notice that not all gingival disease is plaque-induced, so scaling alone is often not an adequate treatment plan. When you understand the root cause of the problem, you’re better able to create a treatment plan that will bring your patient to health. Plus, you will have the knowledge to explain to patients how their habits, hereditary factors, and total body health contribute to their oral health condition.

Periodontal disease is further classified into seven general categories with other subcategories. Again, just by familiarizing yourself with the classifications you will have a guide to really understanding the cause, manifestations, risk factors, and rate of progression of periodontal disease in your patients. The most definitive ways periodontal disease has been differentiated from gingival disease are bone loss and attachment loss. Chronic and aggressive classifications are about how fast the disease is progressing. Periodontal disease can become worse very quickly depending on a patient’s overall health and risk factors. You will need to take this into consideration when you create a treatment plan.

Periodontitis can be further classified as:
I. Chronic Periodontitis
a. Localized
b. Generalized (more than 30% of sites are involved)
II. Aggressive Periodontitis
a. Localized
b. Generalized (more than 30% of sites are involved)
III. Periodontitis as a manifestation of Systemic Diseases
a. Associated with hematological disorders
b. Associated with genetic disorders
c. Not otherwise specified (NOS)
IV. Necrotizing Periodontal Diseases
V. Abscesses of the Periodontium
VI. Periodontitis Associated with Endodontic Lesions
VII. Development or Acquired Deformities and Conditions

Studying the AAP classifications helped me gain a better understanding of the oral systemic connection. When you know the basics of each classification, you will be a better oral health detective. You will know what to look for and how to document it in the notes so that insurance companies have what they need to optimize coverage under an individual’s plan. You will be able to create a treatment plan that will get real results and be better for your patient. You will be able to better communicate to patients what's going on in their mouth and how that affects their overall health. When you help them make the connection between their lifestyle habits, family health risk factors, and overall health, you arm them with the information they need to change their behavior and make better health decisions. A great resources to gain a better mastery of the language of AAP classifications is

AAP/ADA case types
The American Dental Association (ADA) and the American Academy of Periodontology (AAP) developed this classification system in 1986. It is based primarily on the severity of attachment loss and measures disease severity only. It does not address cause or risk like the AAP classification system. The clinician uses the clinical and radiographic data gathered during an exam and classifies the patient into one of the four case types.

AAP/ADA case types are primarily a diagnosis treatment language, although it was designed to bridge the gap between diagnosis and documentation. These case types are commonly required for insurance billing. In addition, the ADA provides treatment recommendations for each case type, which is why you may also hear these case types referred to as treatment types. (We won’t discuss those recommendations here, but you can get a basic idea of those by reviewing my One Page Periodontal Protocol.)

The dental community in general is probably most familiar with case type language. It is used in dental hygiene education, you see it on most patient education brochures about periodontal disease, and it is used in treatment planning and insurance documentation. This is the easiest language to learn and a great place to start if you’re just getting comfortable with the diagnosis, treatment, and documentation of periodontal disease.

This language divides diagnoses into levels of severity. This is a snapshot of where the patient is now, healthwise. The severity of the progression of the disease is a highly influential factor for treatment planning.

Four case types
Type I – Gingival disease
Type II – Mild periodontal disease
Type III – Moderate periodontal disease
Type IV – Advanced periodontal disease

Health is included first in the list to show that the disease is progressive. This is the language you would use with patients to show where they are on the spectrum of health. By showing them their current state of health and the consequenses of not taking the right actions, you can create a sense of understanding and urgency. This is what it takes for treatment plan acceptance.

You will also want to include this diagnosis in your notes for insurance purposes. It is very important that as a clinician you make the classification into one of these four types. Without this decision you have only collected data about symptoms. Diagnosis is made when you make the classification about all of the data you’ve collected and define the patient’s current condition as either healthy or in one of the four stages of periodontal disease.

Case type language is a great foundation for everyone in the office to have a basic understanding of periodontal disease. This is a great common language to discuss a periodontal protocol. Keep in mind that although case type language offers a great place to start, it does not provide a complete diagnosis. You don’t want to rely only on it alone to create your treatment plan. Patients will have an understanding of where they are in the spectrum of health, but it is up to you to help them understand why and how they got there, and most importantly, how they can get back to a state of health.

CDT codes
Dental professionals must use HIPAA mandated CDT codes to report procedures and services on dental claims and in dental records. They are required to accurately document treatment recommended and performed on patients. Clearly, CDT codes are primarily a documentation language. Your manager and front desk team members will likely be quite fluent in this language. This is the language of insurance providers. This is the language that gets the office paid and protects it from liability.

An informal survey done by Dr. Robert Gellin revealed that many clinical practitioners have only a very basic understanding of CDT codes. They may be familiar with the codes but not have a real understanding of how and when the codes should be used. This hands-off attitude is the cause of much frustration between clinical and administrative team members, as well as patients trying to understand their out-of-pocket costs for care.

This crash course in the CDT coding language will help you understand why you need to have better command of the codes, which codes you need to know as a hygienist, and when to use them. As a hygienist, you don’t need to memorize the CDT book but you should be familiar with the most commonly used dental hygiene codes. If you familiarize yourself with these you should have a good foundation.

Some important points to remember about CDT code language
The American Academy of Periodontics, as well as the ADA, say a treatment plan should be developed according to professional standards and not according to the provisions of the dental insurance contract. Just because a code exists does not mean that the procedure is considered a standard of care or that it is covered by a benefits plan. Bottom line is it is up to each clinician to decide which treatment is appropriate, and to document that treatment to the best of their ability with the right codes.

You should work with your dentist to develop a comprehensive, written periodontal protocol. You will be able to preplan a treatment plan for each diagnosis that will give you a solid place to start. Then you can make adjustments based on the individual patient’s health history, risk factors, and oral hygiene habits.

It’s easy to become frustrated when there isn’t a code that perfectly matches treatment. This is where colllaboration helps. Expand the context and use additional information by creating a descriptive narrative.

Even today as I communicate in English, my second language, I sometimes get stuck because I don’t have a word for what I want to say. Sometimes there just isn’t an English word that accurately communicates what I’m thinking in Portuguese. I usually solve this problem by being more descriptive, adding more context, and sharing more specifics.

We sometimes have the same challenge with CDT codes, when there just isn’t a code that directly translates to the treatment provided. This is why having an extensive vocabulary in the other languages is helpful. We can add more detail about the situation and provide more clarity. This is what the narrative part of the insurance claims submission form is for. By making complete notes and using standardized language from AAP classifications and case types, we give the front desk team all they need to deal with the insurance companies.

That being said, coverage is not the responsibility of the dental hygienist. Our job is to identify, diagnose, educate, deliver treatment, and document accordingly. Each individual insurance provider determines terms of coverage. That means patients may not have their dental treatment covered by their policy. This is one more reason why mastery of the other languages is important. We can use our knowledge to confidently explain how important it is for patients to accept the treatment they need, even if they have to invest out of pocket.

Some great resources to gain a working mastery of the CDT Code language include thje Dental Codeology Series by Patti DiGangi, RDH, BS, and “Coding With Confidence” by Dr. Charles Blair.

Having a complete mastery of all three languages gives you the tools you need to be the best clinician you can be. You will have the knowledge to better understand what is going on with your patients, you’ll be able to confidently create a treatment plan that gets results, you will be able to communicate that treatment plan to your patients so they accept it, and you will be able to document your findings and actions in the right way so your front desk team can easily manage insurance companies. Ultimately, your mastery of all three of these languages of perio is critical to the entire dental office running smoothly and profitably.

Karoline Biami, RDH, is a Dental Hygiene Consultant, a practicing dental hygienist, an internationally trained dentist, and former dental assistant. She leverages her ability to see the practice of dentistry from multiple perspectives to help dental hygiene teams get focused, get systemized, and get massively profitable. Find out more about how she can help your team easily implement a Periodontal Program at

A special thank you to Patti DiGangi for her contributions and feedback to this article.

Armitage GC, Development of a Classification System For Periodontal Diseases And Conditions. A. Periodontol 1999; 4-6
Position Paper: "Diagnosis Of Periodontal Diagnosis" J. Periodontol 2003; 74: 1237-1247

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