Filling the ‘code gap’: The new gingival inflammation code (D4346)

Limitations in coding have sent the message that gingival inflammation is not important until severe bone loss occurs. A new gingival inflammation code, D4346, offers an exciting way out of this difficulty.

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Empty chair time, particularly in the hygiene chair, creates a high cost to dental practices everywhere. Professionals can think patients believe dental care is becoming too expensive, but research shows patient priorities are changing. What worked successfully in the past often doesn’t work today. Technology and a new CDT code can give patients more reasons to want to return regularly.

Savvy dental consumers

Dental patients are consumers. We love and value the relationships we build with them. The truth is these connections don't hold the same sway as they once did.

Deloitte Center for Health Solutions (www2.deloitte.com) performed a 2012 survey of health-care consumer attitudes. Their major finding is health-care consumers are not alike. There isn’t a one-size-fits-all approach to connecting with them. They can be divided into six broad categories:

  1. Casual and cautious (34%): Not engaged, no current needs, cost-conscious
  2. Content and compliant (22%): Happy with physician, hospital, and health plan; trusting and follows care plans
  3. Online and onboard (17%): Online learner, happy with care but interested in alternatives and technologies
  4. Sick and savvy (14%): Consumes considerable health-care services and products, partners with physician to make treatment decisions
  5. Out and about (9%): Independent, prefers alternatives, wants to customize services
  6. Shop and save (4%): Active, seeks options and switches for value, saves for future health costs

This research has specific applications to dentistry when analyzing and trying to plug holes in the hygiene schedule. Whatever the percentages, there is great opportunity for savvy dental practices to recognize and act on these trends.

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What hygiene schedule holes cost

The discussion of consumers is one facet, but let's dig a little deeper. Kristine A. Hodsdon, RDH, MSEC, executive coach at Hygiene Mastery (hygienemastery.com), talks about the cost of unfilled or open hours in a hygiene schedule. She suggested using the following equation to figure this out.

# of hours/day x days/week = ____ x fee/procedure x 12 months

The important portion of this equation, which is italicized and underlined, is the fee per procedure. This is key to the opportunity for filling hygiene schedules productively. What procedures are in the mix?

A CDC study titled “Prevalence of Periodontitis in Adults in the United States” estimates that 47.2%, or 64.7 million, American adults have mild, moderate, or severe periodontitis, the more advanced form of periodontal disease. In adults 65 and older, prevalence rates increase to 70.1%. The question then arises: Does the equation you just used reflect 50% of your production is periodontal care? An even more significant question is this: How much of the other 50% is treating gingival disease under D1110/D1120 prophylaxis codes?

You can readily imagine your patient presenting with inflamed, hemorrhagic gingiva, light to moderate subgingival calculus, and generalized pseudo-pocketing. It happens at least several times every day. For the entire history of CDT coding, there have been no truly accurate codes for the treatment of this patient’s needs. There have been no codes between a prophylaxis and scaling and root planning. There has always been a gap.

Problems the code gap has created

This gap influences the thinking of both patients and practitioners in many ways. The routine procedure performed is the same whether the patient is healthy or has active disease coded as D1110/D1120. This leads to nonverbal message that until there is bone loss, the health implications are not serious. This is like knowing someone has high blood pressure but not identifying and treating it until a heart attack occurs. This why a new code for care of moderate to severe gingival inflammation is important.

The body of research confirming that inflammation anywhere in the body is a significant factor in many of the chronic diseases of aging (e.g., heart disease, diabetes, cancer, Alzheimer’s disease). These chronic diseases can start at any age. We know the mouth is a significant source of inflammation. Recognizing and identifying inflammation is the first step in treatment.

New code recognizes importance of inflammation

Specifically diagnosing and treating gingival disease and having a CDT code to accurately describe this care will go a long way toward practitioners and patients realzing and embracing the difference between the preventive and therapeutic care previously lumped under a single code.

The new CDT 2017 code reads:

D4346 scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation

There are many parts to understand to use this code accurately. “Generalized moderate or severe inflammation” is emphasized here as the key to the diagnosis of gingival disease, the use of this new code, and a different message to patients.

Generalized moderate or severe gingival inflammationhas not been traditionally quantified. The ADA and AAP suggest documenting using the Löe and Silness gingival inflammation index:

  • Type 0: No inflammation
  • Type 1: Mild inflammation—slight change in color and slight edema but no bleeding on probing
  • Type 2: Moderate inflammation—redness, edema, and glazing, bleeding on probing
  • Type 3: Severe inflammation—marked redness and edema, ulceration with tendency to spontaneous bleeding

To code treatment using D4346, it also must be determined if inflammation is localized or generalized. The code D4346 is only accurate if greater than 30% of the sites have Type 2 or 3 inflammation. This quantification can give a new message. (To learn more, check out the e-book DentalCodeology: A Gingivitis Code Finally! or visit DentalCodeology.com.)

Communicating a different message

The new message is that treating early disease is important. It gives all types of patients reasons to return, yet this message needs to be tailored to each consumer whether the person is “casual and cautious,” “online and onboard,” “out and about,” or even the other 40% of already convinced patients. Delivering the message individually in a readily available way brings greater success. We need to send the right message to the right person at the right time so that person feels like they are our only patient.

This means using technology—we live in a digital world. A 2015 study shows, most people would rather text than talk. Americans spend about 26 minutes a day texting. That compares to spending about six minutes a day on voice calls. We don’t need recall/recare systems. We need total patient management systems like Solutionreach (solutionreach.com).

SolutionReach helps fill the gaps that commonly occur in the care delivery stream. The innovative technology of cloud-based tools makes it simple to consistently deliver valuable, personalized communication that will engage and educate your patients, with significantly less effort and time.

This technology helps us do what we like the most—get personal with our patients in new ways. Think of the possibilities this new code holds. This is a big change from what dentistry has been doing. With change comes challenges. Rather than relying on brochures in the office, use technology to educate patients through newsletters, social media, and blog posts. Be their best resource of up-to-date oral-systemic health. Be assessable: the more easily people can reach us, the more they feel our care.

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Filling the gaps

D4346 is filling a huge gap in our codes; several “planets” are coming into alignment within its gravitational pull:

  • We can finally treat gingivitis after decades of merely being able to diagnose it. We can close the loop and elevate the standard of care.
  • New research is pointing to the connection between oral disease and medical conditions. The timing is perfect.
  • There is no age restriction, so this code is not only relevant to virtually all patients, it ensures early intervention and disease prevention. What a concept!
  • Gingivitis is contagious. CDT4346 can help us prevent its spread with families, among loved ones, etc. This may be the next best thing to a vaccine.
  • The code increases the medical relevance of treating gingivitis and can be a catalyst for increased hygienist/nurse and dentist/physician collaboration.
  • Cloud-based, mobile friendly technology makes it easy to educate, inform and schedule our patients.

Yet, despite all this positive momentum, the full potential of CDT 4346 to fill the holes in patient schedules is wasted if it is not properly adopted and implemented. We must make room for it in our cluttered hygiene closets. There are no more excuses for not treating gingivitis.


Patti DiGangi, RDH, BS, is an international speaker passionate about prevention working with dental professionals to improve practice profitability. She is the author of the 2016 book A Gingivitis Code Finally! the fifth book in the DentalCodeology series of bite-size books for busy people. She authored a chapter in CDT 2017 Companion. Patti holds publishing and speaking licenses with the American Dental Association for Current Dental Terminology and SNODENT Diagnostic Coding. She is a proud member of the National Speakers Association. She can be reached at Patti@DentalCodeology.com

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