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In order to provide dental services of the highest quality to the most people with the resources available to the Facility Dental Program, priorities must be established. The purpose of these priorities is to maximize the benefits of dental care to as many eligible patients as possible. This facility adheres to the IHS guidelines for service priorities. In accordance with the IHS’s 2007 Oral Health Program Guide, the following is a summary of available dental services in order of highest priority to lowest priority for the Facility, with examples of common services in each level.


Dental Service Priorities

Schedule of Services (IHS Oral Health Guide: Section V)

Level I — Emergency Care

Includes those dental services which are necessary to relieve or control acute oral conditions, such as: serious bleeding, a potentially life-threatening difficulty, maxillo-facial fractures, and swelling and severe pain, or other signs of infection. Other conditions which the patient may determine to require urgent attention are also classified as Level I care (e.g., prosthodontic repairs).

Procedures which are frequently reported in this category of care are listed below:

• Emergency oral examination (limited to problem area)

• One or more periapical radiographs associated with the problem

• Simple tooth extractions

• Temporary or sedative restorations

Palliative procedures

• Prescription medications for pain and infection

• Endodontic access preparations

• Draining of oral abscesses

• Denture repairs and other urgent repairs

Level II — Primary (Preventive) Dental Care

The procedures classified as primary care are those which prevent the onset of oral disease. Clinical services to individual patients and community health activities are included in Level II care.

The primary care services most frequently provided are:

• Adult prophylaxis with or w/o topical fluoride

• Child prophylaxis with or w/o topical fluoride

• Sealants by tooth or quadrant

• Preventive (self-care) training

Periodontal recall procedures

• Athletic mouthguards

• Water fluoridation activities

• Group education

• Tracking of number of children receiving supplemental fluorides per month

Level III — Secondary Dental Care

Level III services are those deemed necessary for routine diagnosis and treatment to control the early stages of disease. Level III procedures are generally not complicated in nature, and one or more of these services can usually be completed in one appointment.

The Level III procedures commonly reported include the following:

• Initial or periodic oral exam

• Bitewing and panoramic radiographs

• Diagnostic casts

Space maintainers

• Amalgam restorations (1,2,3-surface)

• Composite restorations (1,2,3-surface)

• Stainless steel crowns (primary teeth only)

• Therapeutic pulpotomy (primary teeth only)

• Anterior endodontics (one canal)

• Periodontal scaling/root planing

• Biopsy, excision of lesion

Level IV — Limited Rehabilitation

Rehabilitative care is that which restores oral structures to an improved condition and form. Limited rehabilitation is defined by the IHS as those dental procedures which are more complex and costly to provide than Level III care in controlling disease and restoring function.

The following Level IV services are those most frequently utilized:

• Complex amalgams (4 or more surfaces)

• Cast onlays or crowns with or w/o porcelain

Post and core restoration

• Crown buildups

• Acid etch (Maryland) bridge

• Bicuspid endodontics (two canals)

• Apicoectomy/retrograde filling

• Gingivoplasty

• Limited/interceptive orthodontics

Level V — Rehabilitation

The dental services classified into this level are rehabilitative procedures which require more clinical chairtime, additional knowledge and skill of the care provider, and usually greater expense than the limited rehabilitative services listed under Level IV care. Level V services usually require multiple appointments to complete, are usually associated with a rehabilitative plan for the entire mouth, and generally require a substantial patient copayment to cover professional fees in dental insurance and other third party programs.

The Level V services most frequently provided are:

• Molar endodontics (3 or more canals)

• Periodontal surgery (mucogingival and osseous)

• Complete and partial dentures

• Denture rebase (laboratory)

• Fixed bridgework (retainers and pontics)

• Surgical extractions (impactions)

• Analgesia (e.g., nitrous oxide)

Level VI — Complex Rehabilitation

Level VI includes those services which usually require more time, skill, and cost than the rehabilitative procedures classified under Levels IV and V. A substantial portion of patients may require referral to specialists for complex rehabilitative treatment; however, referrals must be justified by special circumstances which warrant the associated higher costs. Level VI services may not predictably improve the overall prognosis of many patients. Thus, careful patient selection is a critical factor in the provision of Level VI care.

Complex rehabilitation includes the following procedures:

• Cephalometric or TMJ radiographs

• Occlusal adjustment (complete)

• Periodontal surgery

osseous or soft tissue grafts

– repositioned flaps

• Overdentures

• Consultation for speciality services

• Precision attachment prosthetics

• Comprehensive orthodontics (Class I, II, or III)

– case analysis & work-up

– fixed appliances (usually full-banding)

– orthodontic care follow-up visits

– post-treatment stabilization

• Surgical extractions (bony impactions) and unusual or complex oral surgery

• Maxillo-facial prosthetics

• Intravenous (IV) sedation, general anesthesia

Level X — Exclusions

Level X comprises those services which are not classified as billable procedures in programs serving American Indians/Alaska Natives.

Excluded services have one or more of the following characteristics, as determined by the Indian Health Service:

• A highly variable rate of success

• Difficult to monitor in terms of appropriateness or effectiveness

• Not universally defined or accepted for reporting purposes

• Included as part of other reportable services (thus they need not be reported separately)

• Involve the use of materials or techniques which are obsolete or which may not be the most cost-beneficial

• Codes used only for management purposes on an optional basis (e.g. broken appointments, non-clinical administrative activity)

The following procedures are examples of exclusions which are frequently reported:

• Caries susceptibility tests

• Oral hygiene instruction (included in prophylaxis)

• Removable unilateral space maintainers

• Silicate restorations

• Gold foil restorations

• Cast inlay (2-surface)

• Porcelain inlays or crowns

• Full resin or resin/metal crowns

• Direct pulp caps

Endodontic implants, hemisection

• Gingival curettage

• Coronal splinting

• Unilateral cast partials

Chairside denture relines

• Alveolar/mandibular implants

• Prosthetic stress breakers

• Tooth implant/transplant

• Myo-functional therapy

• Pulpotomy in permanent tooth

• Odontoplasty

Behavior management

• Broken appointments

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