Glossary of Dental Terms
bad faith insurance practices: The failure to deal with a beneficiary of a dental benefit plan fairly and in good faith; or an activity which impairs the right of the beneficiary to receive the appropriate benefit of a dental benefits plan or to receive them in a timely manner. Some examples of potential bad faith insurance practices include: evaluating claims based on standards which are significantly at variance with the standards of the community; failure to properly investigate a claim for care; and unreasonably and purposely delaying and/or withholding payment of a claim. See prompt payment laws.
balance billing: Billing a patient for the difference between the dentist's actual charge and the amount reimbursed under the patient's dental benefit plan.
barrier membrane: Usually a thin, sheet-like usually non-autogenous material used in various surgical regenerative procedures.
behavior management: Techniques or therapies used to alter or control the actions of a patient who is receiving dental treatment. Examples include use of a papoose board, education or anxiety relief techniques.
beneficiary: A person who is eligible for benefits under a dental benefit contract. See also covered person, insured, and member.
benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan.
benefit booklet: A booklet or pamphlet provided to the subscriber that contains a general explanation of the benefits and related provisions of the dental benefit program. Also known as a Summary Plan Description.
benefit plan summary: The description or synopsis of employee benefits as required by ERISA that is to be distributed to the employees.
benign: The mild or non-threatening character of an illness or the non-malignant character of a neoplasm.
bicuspid: A premolar tooth; a tooth with two cusps.
bilateral: Occurring on, or pertaining to, both right and left sides.
biologic materials: Agents that alter wound healing or host-tumor interaction. Such materials can include cytokines, growth factor, or vaccines, but do not include any actual hard or soft tissue graft material. These agents are added to graft material or used alone to effect acceleration of healing or regeneration in hard and soft tissue surgical procedures. Also known as biologic response modifiers.
biopsy: Process of removing tissue for histologic evaluation.
birthday rule: When a dependent child's parents both have dental coverage, this rule states that the primary program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary v. secondary coverage, but it may be superseded by a court order such as a divorce agreement.
bitewing radiograph: Interproximal radiographic view of the coronal portion of the tooth/teeth. A form of dental radiograph that may be taken with the long axis of the image oriented either horizontally or vertically, that reveals approximately the coronal halves of the maxillary and mandibular teeth and portions of the interdental alveolar septa on the same image.
bleaching: Process of lightening of the teeth, usually using a chemical oxidizing agent and sometimes in the presence of heat. Removal of deep seated intrinsic or acquired discolorations from crowns of vital and non-vital teeth through the use of chemicals, sometimes in combination with the application of heat and light. Bleaching has been achieved through short and long term applications of pastes or solutions containing various concentrations of hydrogen peroxide and carbamide peroxide. Normally applied externally to teeth; may be used internally for endodontically treated teeth.
bonding: Process by which two or more components are made integral by mechanical and/or chemical adhesion at their interface.
bounded tooth space: See tooth bounded space.
bridge: See fixed partial denture.
bruxism: The parafunctional grinding of the teeth.
buccal: Pertaining to or toward the cheek (as in the buccal surface of a posterior tooth).
bundling of procedures: The systematic combining of distinct dental procedure codes by third-party payers that results in a reduced benefit for the patient/beneficiary.
by report: A written description of the service provided that is prepared when the term "by report" is included in a procedure code nomenclature; may be requested by a third-party payer to provide additional information for claims processing.
cafeteria plan: Employee benefit plan in which employees select their medical insurance coverage and other nontaxable fringe benefits from a list of options provided by the employer. Cafeteria plan participants may receive additional, taxable cash compensation if they select less expensive benefits.
calculus: Hard deposit of mineralized substance adhering to crowns and/or roots of teeth or prosthetic devices.
canal: A relatively narrow tubular passage or channel.
root canal - Space inside the root portion of a tooth containing pulp tissue.
mandibular canal - The passage which transmits vessels and nerves through the jaw to branches that distributes them to the teeth.
cantilever extension: Part of a fixed prosthesis that extends beyond the abutment to which it is attached and has no additional support.
capitation: A capitation program is one in which a dentist or dentists contract with the programs' sponsor or administrator to provide all or most of the dental services covered under the program to subscribers in return for payment on a per-capita basis.
caries: Commonly used term for tooth decay.
carious lesion: A cavity caused by caries.
carrier: See third-party.
case management: The monitoring and coordination of treatment rendered to patients with specific diagnoses or requiring high cost or extensive services. May include complex treatment plans or discussion between multiple practitioners.
A process of identifying patients with special health care needs, developing a healthcare strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum health care outcome in an efficient and cost-effective manner.
cast: See diagnostic cast or study model.
cavity: Missing tooth structure. A cavity may be due to decay, erosion or abrasion. If caused by caries; also referred to as carious lesion.
cement base: Material used under a filling to replace lost tooth structure.
cementum: Hard connective tissue covering the outer surface of a tooth root.
Centers for Medicare and Medicaid Services (CMS): The federal agency responsible for administering the Medicare, Medicaid, State . Children's Health Insurance Program (SCHIP), HIPAA, and the Clinical Laboratory Improvement Amendments (CLIA) programs. CMS is part of the U.S. Department of Health and Human Services.
cephalometric image: A standardized, extraoral projection utilized in the scientific study of the measurements of the head.
ceramic: see porcelain/ceramic.
claim: A request for payment under a dental benefit plan; a statement listing services rendered, the dates of services, and itemization of costs. The completed request serves as the basis for payment of benefits.
claim form: A form, paper or electronic, used to report dental procedures to a third-party payer in order to file for benefits under a dental benefit program. The paper claim form was developed by the American Dental Association.
claimant: Person or authorized provider who files a claim for benefits. Patient or certificate holder who files a claim for benefits.
claims payment fraud: The intentional manipulation or alteration of facts or procedure codes submitted by a treating dentist resulting in a lower payment to the beneficiary and/or the treating dentist than would have been paid if the manipulation had not occurred.
claims reporting fraud: The intentional misrepresentation of material facts concerning treatment provided and/or charges made, in that this misrepresentation would cause a higher payment.
Classification of Metals: See metals, classification of (source: ADA Council on Scientific Affairs).
cleft palate: Congenital deformity resulting in lack of fusion of the soft and/or hard palate, either partial or complete.
clenching: The clamping and pressing of the jaws and teeth together in centric occlusion, frequently associated with psychological stress or physical effort.
clinical crown: That portion of a tooth not covered by tissues.
closed panel: A dental insurance benefit plan which requires the eligible patients to receive their dental care from a specific dentist who has contractually agreed to the terms, payments and benefits of the plan. Usually only a limited number of dentists in an area are allowed to participate in these types of plans.
closed reduction: The re-approximation of segments of a fractured bone without direct visualization of the boney segments.
CMS: See Centers for Medicare and Medicaid Services.
COB: See coordination of benefits.
Code on Dental Procedures and Nomenclature (Code): A listing of dental procedure codes and their descriptive terms published by the American Dental Association (ADA); used for recording dental services on the patient record as well as for reporting dental services and procedures to dental benefit plans. The Code is printed in a manual titled Current Dental Terminology (CDT).
coinsurance: A provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. The percentage of a covered dental expense that a beneficiary must pay (after the deductible is paid). A typical coinsurance arrangement is one in which the third party pays 80% of the allowed benefit of the covered dental service and the beneficiary pays the remainder of the amount due the dentist. Percentages vary and may apply to table of allowance plans; maximum allowable benefit plans and direct reimbursement programs.
complete denture: A prosthetic for the edentulous maxillary or mandibular arch, replacing the full dentition. Usually includes six anterior teeth and eight posterior teeth.
complete series:A n entire set of radiographs. A set of intraoral radiographs usually consisting of 14 to 22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone crest (source: FDA/ADA radiographic guidelines).
composite: A dental restorative material made up of disparate or separate parts (e.g. resin and quartz particles).
compound fracture: Break in bone which is exposed to external contamination.
comprehensive oral evaluation: See evaluation.
Consolidated Omnibus Budget Reconciliation Act (COBRA): Legislation relative to mandated benefits for all types of employee benefit plans. The most significant aspects within this context are the requirements for continued coverage for employees and/or their dependents for 18 months who would otherwise lose coverage (30 months for dependents in the event of the employee's death).
consultation: In a dental setting, a diagnostic service provided by a dentist where the dentist, patient, or other parties (e.g., another dentist, physician, or legal guardian) discuss the patient's dental needs and proposed treatment modalities.
contiguous: Adjacent; touching.
contract: A legally enforceable agreement between two or more individuals or entities that confers rights and duties on the parties. Common types of contracts include: 1) contracts between a dental benefit organization and an individual dentist to provide dental treatment to members of an alternative benefit plan. These contracts define the dentist's duties both to beneficiaries of the dental benefit plan and the dental benefit organization, and usually define the manner in which the dentist will be reimbursed; and 2) contracts between a dental benefit organization and a group plan sponsor. These contracts typically describe the benefits of the group plan and the rates to be charged for those benefits.
contract dentist: Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible persons.
contract fee schedule plan: A dental benefit plan in which participating dentists agree to accept a list of specific fees for dental treatment provided.
contract practice: A dental practice or organization that has a contractual arrangement with an insurer for the provision of services under an insurance contract.
contract term: Usually a 12 months period of time for which a contract is written and during which a group's deductibles, maximums and other provisions apply. This may or may not be the same as a calendar year. Also known as the benefit year.
contributory program: A dental benefit program in which the enrollee shares in the monthly premium of the program with the program sponsor (usually the employer). Generally done through payroll deduction.
coordination of benefits (COB): A method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.
copayment: Beneficiary's share of the dentist's fee after the benefit plan has paid.
coping: A thin covering of the coronal portion of the tooth usually without anatomic conformity. Custom made or pre-fabricated thimble-shaped core or base layer designed to fit over a natural tooth preparation, a post core, or implant abutment so as to act as a substructure onto which other components can be added to give final form to a restoration or prosthesis. It can be used as a definitive restoration or as part of a transfer procedure.
core buildup: the replacement of a part or all of the crown of a tooth whose purpose is to provide a base for the retention of an indirectly fabricated crown.
coronal: Refers to the crown of a tooth.
cosmetic dentistry: Those services provided by dentists solely for the purpose of improving the appearance when form and function are satisfactory and no pathologic conditions exist [source: ADA policy "Cosmetic Dentistry (1976:850)].
cost containment: Features of a dental benefit program or of the administration of the program designed to reduce or eliminate certain charges to the plan.
cost sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and charges over the amount reimbursed by the dental benefit plan.
coverage: Benefits available to an individual covered under a dental benefit plan.
covered charges: Services and supplies which are reimbursed in whole or in part under the conditions of the dental benefit plan, subject to all the terms and conditions of the agreement or insurance policy. Charges are subject to any contractual agreements, exclusions and limitations. Any charges not covered by the plan are considered non-covered charges.
covered person: An individual who is eligible for benefits under a dental benefit program.
covered services: Services for which payment is provided under the terms of the dental benefit contract.
cracked tooth syndrome: A collection of symptoms characterized by transient acute pain experienced when chewing.
crown: An artificial replacement that restores missing tooth structure by surrounding the remaining coronal tooth structure, or is placed on a dental implant. It is made of metal, ceramic or polymer materials or a combination of such materials. It is retained by luting cement or mechanical means. (American College of Prosthodontics; The Glossary of Prosthodontic Terms). See also abutment crown, anatomical crown, clinical crown.
crown lengthening: A surgical procedure exposing more tooth for restorative purposes by apically positioning the gingival margin and removing supporting bone.
culture and sensitivity test: Clinical laboratory test which identifies a microorganism and the ability of various antibiotics to control the microorganism.
curettage: Scraping and cleaning the walls of a real or potential space, such as a gingival pocket or bone, to remove pathologic material.
Current Dental Terminology (CDT): The ADA reference manual that contains the Code on Dental Procedures and Nomenclature and other information pertinent to patient record keeping and claim preparation by a dental office; published biennially (e.g., CDT 2009-2010).
Current Procedural Terminology (CPT): A listing of descriptive terms and identifying codes developed by the American Medical Association (AMA) for reporting practitioner services and procedures to medical plans and Medicare.
cusp: Pointed or rounded eminence on or near the masticating surface of a tooth.
cuspid: Single cusped tooth located between the incisors and bicuspids.
cyst: Pathological cavity, usually lined with epithelium, containing fluid or soft matter.
odontogenic cyst–Cyst derived from the epithelium of odontogenic tissue (developmental, primordial).
periapical cyst–An apical inflammatory cyst containing a sac-like epithelium-lined cavity that is open to and continuous with the root canal.
cytology: The study of cells, including their anatomy, chemistry, physiology and pathology.
debridement: Removal of subgingival and/or supragingival plaque and calculus which obstructs the ability to perform an evaluation.
decay: The lay term for carious lesions in a tooth; decomposition of tooth structure.
deciduous: Having the property of falling off or shedding; a term used to describe the primary teeth.
deductible: The amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. Deductible may be an annual or one-time charge, and may vary in amount from program to program. See family deductible.
deep sedation: See definition under anesthesia.
dental assessment: A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment.
dental benefit organization: Any organization offering a dental benefit plan. Also known as dental plan organization.
dental benefit program: The specific dental benefit plan being offered to enrollees by the sponsor.
dental enrollment credentialing: A formal process that defines the standards and requirements for participation in third-party programs. The process verifies professional qualifications in order to allow licensed dentists to provide services to members of these programs.
dental home: The ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient, which includes comprehensive oral health care, beginning no later than age one, pursuant to ADA policy.
dental prepayment: A method of financing the cost of dental services prior to receiving the services.
dental prophylaxis: See prophylaxis.
dental service corporation: A legally constituted, not-for-profit organization that negotiates and administers contracts for dental care. Delta Dental Plans and Blue Cross & Blue Shield Plans are such organizations.
dentin: Hard tissue which forms the bulk of the tooth and develops from the dental papilla and dental pulp, and in the mature state is mineralized.
dentistry: The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.
dentition: The teeth in the dental arch.
adolescent dentition–In orthodontic coding, refers to the stage of permanent dentition prior to cessation of growth.
deciduous dentition–Refers to the deciduous or primary teeth in the dental arch.
permanent dentition (adult dentition) – Refers to the permanent teeth in the dental arch.
transitional dentition–Refers to a mixed dentition; begins with the appearance of the permanent first molars and ends with the exfoliation of the deciduous teeth.
denture: An artificial substitute for some or all of the natural teeth and adjacent tissues.
denture base: That part of a denture that makes contact with soft tissue and retains the artificial teeth.
dependents: Generally spouse and children of covered individual, as defined by terms of the dental benefit contract.
diagnostic cast: A replica of teeth and adjoining tissues created digitally or by a casting process (e.g., plaster into an impression). “Study model” is another term used for such a replica. Diagnostic casts have various uses, most often the examination of relationships between oral tissues to determine how those relationships will effect form and function of a dental restoration or appliance being planned or to determine whether tissue treatment or modification might be necessary before a pre-definitive impression is taken to ensure optimal performance of the planned restoration or appliance.
diagnostic imaging: A visual display of structural or functional patterns for the purpose of diagnostic evaluation. May be photographic or radiographic.
diastema: A space, such as one between two adjacent teeth in the same dental arch.
direct pulp cap: Procedure in which the exposed vital pulp is treated with a therapeutic material, followed with a base and restoration, to promote healing and maintain pulp vitality.
direct reimbursement: A self-funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice.
direct restoration: A restoration fabricated inside the mouth.
discectomy: Excision of the intra-articular disc of a joint.
displaced tooth: A partial evulsion of a tooth; may be mesial, distal, facial, lingual or incisal.
distal: Surface or position of a tooth most distant from the median line of the arch.
downcoding: A practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported, except where delineated in contract agreements.
dressing: Medication, bandages or other therapeutic material applied to a wound.
DRGs (diagnosis related groups): A system of classifying hospital patients on the basis of diagnosis, consisting of distinct groupings. A DRG assignment to a case is based on the patient's 1) principal diagnosis; 2) treatment procedures performed; 3) age; 4) gender; and 5) discharge status.
dry socket: Localized inflammation of the tooth socket following extraction due to infection or loss of blood clot; osteitis.
dual choice program: A benefit package from which an eligible individual can choose to enroll in either an alternative dental benefit program or a traditional dental benefit program.
Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT): A federal program that provides comprehensive health care for children through periodic screenings, diagnostic and treatment services.
ECF: See extended care facility.
edentulous: Without teeth.
eligibility date: The date an individual and/or dependents become eligible for benefits under a dental benefit contract. Often referred to as effective date.
eligible person: See beneficiary.
Employment Retirement Income Security Act (ERISA): A federal act, passed in 1974, which established new standards and reporting/disclosure requirements for employer-funded pension and welfare benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from most state insurance laws, although the courts have held that the states can regulate the medical care provided under such plans, as by requiring mandatory review of adverse HMO determinations.
enamel: Hard calcified tissue covering dentin of the crown of tooth.
endodontics: Endodontics is the branch of dentistry which is concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues. Its study and practice encompass the basic and clinical sciences including biology of the normal pulp, the etiology, diagnosis, prevention and treatment of diseases and injuries of the pulp and associated periradicular conditions.
endodontist: A dental specialist who limits his/her practice to treating disease and injuries of the pulp and associated periradicular conditions.
enrollee: Individual covered by a benefit plan. See beneficiary.
enteral: See definition under anesthesia.
entity: Something that exists as a particular and discrete unit. Persons and corporations are equivalent entities under the law.
EOB: See explanation of benefits.
EPSDT: See Early and Periodic Screening, Diagnosis and Treatment Program.
equilibration: Reshaping of the occlusal surfaces of teeth to create harmonious contact relationships between the upper and lower teeth; also known as occlusal adjustment.
ERISA: See Employment Retirement Income Security Act.
established patient: A patient who has received professional services from a dentist or another dentist of the same specialty who belongs to the same group practice, within the past three years, subject to state laws.
evaluation: The patient assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions. Please refer to specific oral evaluation code descriptors for more complete definitions.
Evidence-Based Dentistry: An approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific data relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences.
evulsion: Separation of the tooth from its socket due to trauma. See avulsion.
excision: Surgical removal of bone or tissue.
exclusions: Dental services not covered under a dental benefit program.
Exclusive Provider Organization (EPO): A type of preferred provider organization under which employees must use providers from the specified network of dentists to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation.
exfoliative: Refers to a thin layer of epidermis shed from the surface.
exostosis: Overgrowth of bone. See torus.
expiration date: In dentistry, the date on which the dental benefit contract expires; the date an individual ceases to be eligible for benefits.
explanation of benefits: A written statement to a beneficiary from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan.
extended care facility: A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Several levels of care may be provided—skilled, intermediate, custodial, or any combination.
extension of benefits: Extension of eligibility for benefits for covered services, usually designed to ensure completion of treatment commenced prior to the expiration date. Duration is generally expressed in terms of days.
extraoral: Outside the oral cavity.
extracoronal: Outside the crown of a tooth.
extraction: The process or act of removing a tooth or tooth parts.
exudate: A material usually resulting from inflammation or necrosis that contains fluid, cells, and/or other debris.
facial: The surface of a tooth directed toward . the cheeks or lips (i.e., the buccal and labial surfaces) and opposite the lingual surface.
family deductible: A deductible that is satisfied by combined expenses of all covered family members. For example, a program with $25 deductible may limit its application to a maximum of three deductibles, or $75 for the family, regardless of the number of family members. See deductible.
fascial: Related to a sheet or band of fibrous connective tissue enveloping, separating or binding together muscles, organs and other soft tissue structures of the body.
fee: The monetary value ascribed to a procedure delivered by a dentist to a patient. There are various terms that include the word or concept of a fee that are defined as follows.
full fee–The fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist's professional judgment. A contractual relationship does not change a dentist's full fee. It is always appropriate to report the full fee for each service reported to a third party payer.
maximum plan benefit – The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region.
usual fee–The fee which an individual dentist most frequently charges for a specific dental procedure independent of any contractual agreement. It is always appropriate to modify this fee based on the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances.
Usual, Customary and Reasonable Fees–These are three separate terms that are often incorrectly used interchangeably, synonymously or as a single term abbreviated as "UCR" when describing dental benefit plans. Definitions of these three terms are posted online at http://www.ada.org.
fee-for-service–A method of reimbursement by which the dentist establishes and expects to receive his or her full fee for the specific service(s) performed.
fee schedule–A list of the charges established or agreed to by a dentist for specific dental services.
filling: A lay term used for the restoring of lost tooth structure by using materials such as metal, alloy, plastic or porcelain.
fixed partial denture: A prosthetic replacement of one or more missing teeth cemented or otherwise attached to the abutment teeth or implant replacements.
flexible benefits: A benefit program in which an employee has a choice of credits or dollars for distribution among various benefit options, e.g., health and disability insurance, dental benefits, childcare, or pension benefits. See cafeteria plans; flexible spending account.
flexible spending account: Employee reimbursement account primarily funded with employee designated salary reductions. Funds are reimbursed to the employee for health care (medical and/or dental), dependent care, and/or legal expenses, and are considered a nontaxable benefit.
foramen: Natural opening into or through bone.
fracture: The breaking of a part, especially of a bony structure; breaking of a tooth.
franchise dentistry: Refers to a system for marketing a dental practice, usually under a trade name, where permitted by state laws. In return for a financial investment or other consideration, participating dentists may also receive the benefits of media advertising, a national referral system, and financial and management consultation.
freedom of choice: The concept that a patient has the right to choose any licensed dentist to deliver his or her oral health care without any type of coercion.
frenum: Muscle fibers covered by a mucous membrane that attaches the cheek, lips and or tongue to associated dental mucosa.
full fee: see fee.
furcation: The anatomic area of a multirooted tooth where the roots diverge.
gate keeper system: A managed care concept used by some alternative benefit plans, in which enrollees select a primary care dentist, usually a general practitioner or pediatric dentist, who is responsible for providing non-specialty care and managing referrals, as appropriate, for specialty and ancillary care.
general anesthesia: See anesthesia.
genetic test: Laboratory technique used to determine if a person has a genetic condition or disease or is likely to get the disease.
gingiva: Soft tissues overlying the crowns of unerupted teeth and encircling the necks of those that have erupted.
gingivectomy: The excision or removal of gingiva.
gingivitis: Inflammation of gingival tissue without loss of connective tissue.
gingivoplasty: Surgical procedure to reshape gingiva.
glass ionomer: Polyelectrolyte cement in which the solid powder phase is a fluoride-containing aluminosilicate glass powder to be mixed with polymeric carboxylic acid. The cement can be used to restore teeth, fill pits and fissures, lute and line cavities. It is also known as glass polyalkenoate cement, ionic polymer cement, polyelectrolyte cement.
gold foil: Thin pure gold leaf that is self adhering when condensed into a cavity. One of the oldest restorative techniques, it is compacted or condensed into a retentive cavity form.
graft: A piece of tissue or alloplastic material placed in contact with tissue to repair a defect or supplement a deficiency.
allograft–Graft of tissue between genetically dissimilar members of the same species. Donors may be cadavers, living related or living unrelated individuals. Also called allogenic graft or homograft.
autogenous graft–Taken from one part of a patient's body and transferred to another.
guided tissue regeneration (GTR): A surgical procedure that uses a barrier membrane placed under the gingival tissue and over the remaining bone support to enhance regeneration of new bone.
Health Care Financing Administration (HCFA): See Centers for Medicare and Medicaid Services.
Health Insurance Portability and Accountability Act (HIPAA) of 1996: A federal law that includes Administrative Simplification Provisions that require all health plans, including ERISA, as well as health care clearinghouses and any dentist who transmits health information in an electronic transaction, to use a standard format. The HIPAA standard electronic dental claim also requires use of the ADA's Code on Dental . Procedures and Nomenclature code set. Paper transactions are not subject to this requirement.
Health Maintenance Organization (HMO): A legal entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for health care services and may be required to remain in the program for a specified amount of time.
Healthcare Provider Taxonomy: The code that identifies the type of health care provider involved in furnishing services to beneficiaries.
hemisection: Surgical separation of a multi-rooted tooth.
HIPAA: See Health Insurance Portability and Accountability Act of 1996.
histopathology: The study of disease processes at the cellular level.
hold harmless clause: A contract provision in which one party to the contract promises to be responsible for liability incurred by the other party. Hold harmless clauses frequently appear in the following contexts:
1) Contracts . between dental benefit organizations and an individual dentist often contain a promise by the dentist to reimburse the dental benefit organization for any . liability the organization incurs because of dental treatment provided to beneficiaries of the organization's dental benefit plan. This may include a promise to pay the dental benefit organization's attorney fees and related costs; and
2) Contracts between dental benefit organizations and a group plan sponsor may include a . promise by the dental benefit organization to assume responsibility for disputes between a beneficiary of the group plan and an individual dentist when . the dentist's charge exceeds the amount the organization pays for the service on behalf of the beneficiary.
If the dentist takes action against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization, the dental benefit organization will take over the defense of the claim and will pay any judgments and court costs.
homologous: See graft.
hyperplastic: Pertaining to an abnormal increase in the number of cells in an organ or a tissue with consequent enlargement.
imaging, diagnostic: This would include, but is not limited to, CAT scans, MRIs, photographs, radiographs, etc.
immediate denture: Prosthesis constructed for placement immediately after removal of remaining natural teeth.
impacted tooth: An unerupted or partially erupted tooth that is positioned against another tooth, bone, or soft tissue so that complete eruption is unlikely.
implant: Material inserted or grafted into tissue.
dental implant – A device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement.
endosteal (endosseous): Device placed into the alveolar and basal bone of the mandible or maxilla and transecting only one cortical plate.
eposteal (subperiosteal): Subperiosteal implant that conforms to the superior surface of an edentulous area of alveolar bone.
transosteal (transosseous): Device with threaded posts penetrating both the superior and inferior cortical bone plates of the mandibular symphysis and exiting through the permucosa. It may be intraoral or extraoral.
implant index: See radiographic/surgical implant index.
implantation, tooth: Placement of an artificial or natural tooth into an alveolus.
inappropriate fee discounting practices: Intentionally engaging in practices which would force a dentist, who does not have a participating provider agreement, to accept discounted fees or be bound by the terms and conditions set forth in the participating provider contract.
Some examples of inappropriate fee discounting practices include: issuing reimbursement checks which, upon signing, result in the dentist accepting the amount as payment in full; using claim forms which, upon signing, require the dentist to accept the terms of the plan's contract; issuing insurance cards which state that the submittal of a claim by a dentist means that he or she accepts all terms and conditions set forth in the participating provider contract; and sending communications to patients of nonparticipating dentists which state that he or she is not responsible for any amount above usual, customary and reasonable fees as established by the plan.
incentive program: A dental benefit program that pays an increasing share of the treatment cost, provided that the covered individual utilizes the benefits of the program during each incentive period (usually a year) and receives the treatment prescribed. For example, a 70%-30% copayment program in the first year of coverage may become an 80%-20% program in the second year if the subscriber visits the dentist in the first year as stipulated in the program. Most frequently, there is a corresponding percentage reduction in the programs copayment level if the covered individual fails to visit the dentist in a given year (but never below the initial copayment level).
incisal: Pertaining to the biting edges of the incisor and cuspid teeth.
incisal angle: One of the angles formed by the junction of the incisal and the mesial or distal surfaces of an anterior tooth; called the mesioincisal and distoincisal angle respectfully.
incision and drainage: The procedure of incising a fluctuant mucosal lesion to allow for the release of fluid from the lesion.
incisor: A tooth for cutting or gnawing; located in the front of the mouth in both jaws.
indigent: Those individuals whose income falls below the poverty line as defined by the federal Office of Management and Budget (OMB).
indemnification schedule: See table of allowances.
indemnity plan: A non-network dental plan that reimburses the member or dentist at a certain percentage of charges for services rendered, often after a deductible has been satisfied. Indemnity plans typically place no restrictions on which dentist a member may visit. Indemnity plans are also referred to as fee-for-service plans.
indirect pulp cap: Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin.
indirect restoration: A restoration fabricated outside the mouth.
Individual Practice Association (IPA): A legal entity organized and governed by individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations.
inlay: An intracoronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which restores some of the occlusal surface of a tooth, but does not restore any cusp tips. It is retained by luting cement. (American College of Prosthodontics; The Glossary of Prosthodontic Terms)
insurer: The party in an insurance contract that promises to pay a benefit if a specified loss occurs. Usually an insurance company.
insured: Person covered by the program. See beneficiary.
intentional reimplantation: The intentional removal, radicular repair and replacement of a tooth into its alveolus.
International Classification of Diseases (ICD): Diagnostic codes designed for the classification of morbidity and mortality information for statistical purposes; for the indexing of hospital records by disease and operations; and for data storage and retrieval.
interproximal: Between the adjoining surfaces of adjacent teeth in the same arch.
intracoronal: Referring to "within" the crown of a tooth.
intraoral: Inside the mouth.
ISO Tooth Numbering System: See Specification No. 3950.
jaw: A common name for either the maxilla or the mandible.
JO: Designation of the ANSI/ADA/ISO tooth numbering system on the dental claim form. See Specification No. 3950.
JP: Designation of the Universal/National tooth numbering system on the dental claim form.
keratin: A protein present in all cuticular structures of the body, such as hair, epidermis and horns.
keratinized gingiva: The oral surface of the gingiva extending from the mucogingival junction to the gingival margin. In gingival health, the coronal portion of the sulcular epithelium may also be keratinized.
labial: Pertaining to or around the lip. See facial.
laminate veneer: A thin covering of the facial surface of a tooth usually constructed of tooth colored material used to restore discolored, damaged, misshapen or misaligned teeth.
least expensive alternative treatment (LEAT): A type of cost containment measure used by many third-party payers. Under a LEAT clause, when there are multiple treatment options for a specific condition, the plan will only pay for the least expensive treatment.
lesion: An injury or wound; area of diseased tissue.
liability: An obligation to pay an amount in money, goods, or services to another party.
limitations: Restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. See exclusions.
limited oral evaluation: See evaluation
line angle: An angle formed by the junction of two planes; used to designate the junction of two surfaces of a tooth, or of two walls of a tooth cavity preparation.
lingual: Pertaining to or around the tongue; surface of the tooth directed toward the tongue; opposite of facial.
local anesthesia: See definition under anesthesia.
locus: A site or location.
maintenance, periodontal: Therapy for preserving the state of health of the periodontium.
malar: Pertaining to the cheek bone; see zygomatic bone.
malignant: Having the properties of dysplasia, invasion, and metastasis.
malocclusion: Improper alignment of biting or chewing surfaces of upper and lower teeth.
managed care: Any contractual arrangement where payment or reimbursement and/or utilization are controlled by a third party. The term "managed care" refers to a cost containment system that directs the utilization of health benefits by: a.) restricting the type, level and frequency of treatment; b.) limiting the access to care; and c.) controlling the level of reimbursement for services.
mandible: The lower jaw.
Maryland bridge: Fixed partial denture featuring conservative retainers which are resin bonded to abutments.
maxilla: The upper jaw.
maximum plan benefit – The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region.
Medicaid: A federal assistance program established as Title XIX under the Social Security Act of 1965 which provides payment for medical care for certain low income individuals and families. The program is funded jointly by the state and federal governments and administered by states.
medically necessary care: The reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing.
medicament: Substance or combination of substances intended to be pharmacologically active, specially prepared to be prescribed, dispensed or administered by authorized personnel to prevent or treat diseases in humans or animals.
medicament, topical: Pharmacological substance especially prepared to be applied on tissues of the oral cavity.
Medicare: A federal insurance program enacted in 1965 as Title XVIII of the Social Security Act that provides certain inpatient hospital services and physician services for all persons age 65 and older and eligible disabled individuals. The program is administered by the Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA).
member: An individual enrolled in a dental benefit program. See beneficiary.
membrane: See barrier membrane.
mesial: Nearer the middle line of the body or the surface of a tooth nearer the center of the dental arch.
metals, classification of: (source: ADA Council on Scientific Affairs).
The noble metal classification system has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of metal content and listed in order of biocompatibility.
High Noble Alloys—Noble Metal Content > 60% (gold + platinum group*) and gold > 40% Au)
Titanium and Titanium Alloys—Titanium (Ti) > 85%.
Noble Alloys—Noble Metal Content > 25% (gold + platinum group*).
Predominantly Base Alloys—Noble Metal Content) < 25% (gold + platinum group*).
*metals of the platinum group are platinum, palladium, rhodium, osmium and ruthenium
microabrasion: Mechanical removal of a small amount of tooth structure to eliminate superficial enamel discoloration defects.
microorganisms: A minute living organism, such as a bacterium, fungus, yeast, virus or rickettsia.
molar: Teeth posterior to the premolars (bicuspids) on either side of the jaw; grinding teeth, having large crowns and broad chewing surfaces.
moulage: A positive reproduction of a body part formed on a cast from a negative impression.
mouthguard: Individually molded device designed primarily to be worn for the purpose of helping prevent injury to the teeth and their surrounding tissues. Sometimes called a mouth protector.
mucous membrane: Lining of the oral cavity as well as other canals and cavities of the body; also called "mucosa."
National Association of Insurance Commissioners (NAIC): Professional or trade association for state departments of insurance (http://www.naic.org).
National Provider Identifier (NPI): This is an identifier assigned by the federal government to all providers considered to be HIPAA covered entities. Dentists who are not covered entities may elect to obtain an NPI at their discretion, or may be enumerated if required by a participating provider agreement with a third-party payer, or applicable state law/regulation.
An NPI is unique to an individual dentist or dental entity, and has no intrinsic meaning. There are two types of NPI available to dentists and dental practices:
Type 1 Individual Provider—A health care practitioner who is a single human being. ALL dentists are eligible to apply for Type 1 NPIs, regardless of whether they are covered by HIPAA.
Type 2 Organization Provider—A health care provider that is an organization, such as a group practice or corporation. Individual dentists who are incorporated may enumerate as Type 2 providers, in addition to being enumerated as a Type 1. All incorporated dental practices and group practices are eligible for enumeration as Type 2 providers.
On paper, there is no way to distinguish a Type 1 from a Type 2 in the absence of any associated data; they are identical in format. Additional information on NPI and enumeration can be obtained from the ADA's Internet Website: http://www.ada.org/goto/npi.
necessary treatment: A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient's oral health. Such determinations are based on the professional diagnostic judgment of the dentist, and the standards of care that prevail in the professional community.
non-autogenous: A graft from donor other than patient.
noncontributory program: A method of payment for group coverage in which the sponsor pays the entire monthly premium for the program.
non-covered charges: See covered charges.
nonduplication of benefits: Term used to describe one of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent.
nonparticipating dentist: Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care to members of a dental benefit program.
NPI: See National Provider Identifier.
obturate: With reference to endodontics, refers to the sealing of the canal(s) of tooth roots during root canal therapy procedure with an appropriately prescribed material such as gutta percha in combination with a suitable luting agent.
obturator: A disc or plate which closes an opening; a prosthesis that closes an opening in the palate.
occlusal: Pertaining to the biting surfaces of the premolar and molar teeth or contacting surfaces of opposing teeth or opposing occlusion rims.
occlusal radiograph: An intraoral radiograph made with the film, phosphorous plate, emulsion or digital sensor being held between the occluded teeth.
occlusal surface: A surface of a posterior tooth or occlusion rim that is intended to make contact with an opposing occlusal surface. (The Journal of Prosthodontic Dentistry; The Glossary of Prosthodontic Terms; July 2005, page 57)
occlusion: Any contact between biting or chewing surfaces of maxillary (upper) and mandibular (lower) teeth.
odontogenic: Refers to tooth-forming tissues.
odontogenic cyst: See cyst.
odontoplasty: Adjustment of tooth length, size, and/or shape; includes removal of enamel projections.
onlay: A dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface. It is retained by luting cement. (American College of Prosthodontics; The Glossary of Prosthodontic Terms)
open enrollment: The annual period in which employees can select from a choice of benefit programs.
open panel: This type of dental benefits plan allows covered patients to receive care from any dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as freedom of choice plans.
open reduction: Re-approximation of fractured bony segments accomplished through cutting the adjacent soft tissues and bone to allow direct access.
operculectomy: Removal of the operculum.
operculum: The flap of tissue over an unerupted or partially erupted tooth.
oral: Pertaining to the mouth.
oral and maxillofacial pathologist: A dental specialist whose practice is concerned with recognition, diagnosis, investigation and management of diseases of the oral cavity, jaws, and adjacent structures.
oral and maxillofacial pathology: Oral pathology is the specialty of dentistry and discipline of pathology that deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions. It is a science that investigates the causes, processes, and effects of these diseases. The practice of oral pathology includes research and diagnosis of diseases using clinical, radiographic, microscopic, biochemical, or other examinations.
oral and maxillofacial radiologist: A dental specialist whose practice is concerned with the production and interpretation of images and data produced by all modalities of radiant energy used for the diagnosis and management of diseases, disorders and conditions of the oral and maxillofacial region.
oral and maxillofacial radiology: Oral and maxillofacial radiology is the specialty of dentistry and discipline of radiology concerned with the production and interpretation of images and data produced by all modalities of radiant energy that are used for the diagnosis and management of diseases, disorders and conditions of the oral and maxillofacial region.
oral and maxillofacial surgeon: A dental specialist whose practice is limited to the diagnosis, surgical and adjunctive treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and maxillofacial regions.
oral and maxillofacial surgery: Oral and maxillofacial surgery is the specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
oral diagnosis: The determination by a dentist of the oral health condition of an individual patient achieved through the evaluation of data gathered by means of history taking, direct examination, patient conference, and such clinical aids and tests as may be necessary in the judgment of the dentist.
oral health literacy: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions.
orthodontist: A dental specialist whose practice is limited to the interception and treatment of malocclusion and other neuromuscular and skeletal abnormalities of the teeth and their surrounding structures.
orthodontics and dentofacial orthopedics: Orthodontics and dentofacial orthopedics is the dental specialty that includes the diagnosis, prevention, interception, and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures.
orthognathic: Functional relationship of maxilla and mandible.
orthotic device: Apparatus used to support, align, prevent or correct deformities, or to improve the function of movable parts of the body.
OSHA: Abbreviation for Occupational Safety and Health Administration. Federal agency in the US responsible for making and enforcing employee safety regulations.
osteoplasty: Surgical procedure that modifies the configuration of bone.
osteotomy: Surgical cutting of bone.
overbilling: The misrepresentation of a fee as higher than actual charges; for example, when a patient is charged one fee and an insurance company is billed a higher fee to benefit the patient's co-payment, or to increase a fee to a patient solely because the patient is covered under a dental benefits plan.
overcoding: Reporting a more complex and/or higher cost procedure than was actually performed.
overdenture: A removable prosthetic device that overlies and may be supported by retained tooth roots or implants
palate: The hard and soft tissues forming the roof of the mouth that separates the oral and nasal cavities.
palliative: Action that relieves pain but is not curative.
panoramic radiograph: An extraoral projection whereby the entire mandible, maxilla, teeth and other nearby structures are portrayed on a single image, as if the jaws were flattened out.
papoose board: A behavior management technique utilizing immobilization to control the actions of a patient who is receiving dental treatment.
parafunctional: Other than normal function or use.
parenteral: See definition under anesthesia
partial denture: Usually refers to a prosthetic device that replaces missing teeth. See fixed partial denture or removable partial denture.
participating dentist: See contract dentist.
patient: An individual who has established a professional relationship with a dentist for the delivery of dental health care. For matters relating to communication of information and consent this term includes the patient's parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case.
payer: A self-insured employer, insurance company, governmental agency or other party responsible for payment of health care claims of covered persons.
pediatric dentist: A dental specialist whose practice is limited to treatment of children from birth through adolescence, providing primary and comprehensive preventive and therapeutic oral health care; formerly known as a pedodontist.
pediatric dentistry: Pediatric Dentistry is an age-defined 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.
pedodontist: See pediatric dentist.
peer review: An evaluation of the quality and conduct of an individual's work by the individual's professional equals (peers) in order to resolve questions or disputes regarding the quality, or conduct of the work. Peer review, when applied to dentistry, is a process, consistently structured and implemented by organized dentistry, in which a dentist's professional equals (peers) resolve questions or disputes (regarding the quality or appropriateness of care provided by the dentist or the fairness of the fee the dentist charged in an individual case) by retrospectively evaluating the quality or appropriateness of care in relation to professional norms or criteria or evaluating the fee charged in relation to the dentist's fee for the given complexity and level of care provided.
Peer Review Organization (PRO): An organization established by an amendment of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), to provide for the review of medical services furnished primarily in a hospital setting and/or in conjunction with care provided under the Medicare and Medicaid programs. In addition to their review and monitoring functions, these entities can invoke sanctions, penalties, or other corrective actions for noncompliance in organization standards.
percentile: The number in a frequency distribution below which a certain percentage of fees will fall. For example, the 90th percentile is the number that divides the distribution of fees into the lower 90% and the upper 10%, or that fee level at which 90% of dentists charge that amount or less, and 10% more.
periapical: The area surrounding the end of the tooth root.
periapical abscess: See abscess.
periapical cyst: See cyst.
periapical radiograph: A radiograph made by the intraoral placement of film, phosphorous plate, emulsion or digital sensor, for disclosing the apices of the teeth.
pericoronal: Around the crown of a tooth.
periodic oral evaluation: See evaluation.
periodontal: Pertaining to the supporting and surrounding tissues of the teeth.
periodontal abscess: See abscess.
periodontal disease: Inflammatory process of the gingival tissues and/or periodontal membrane of the teeth, resulting in an abnormally deep gingival sulcus, possibly producing periodontal pockets and loss of supporting alveolar bone.
periodontal pocket: Pathologically deepened gingival sulcus; a feature of periodontal disease.
periodontics: Periodontics is that specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues.
periodontist: A dental specialist whose practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth.
periodontitis: Inflammation and loss of the connective tissue of the supporting or surrounding structure of teeth with loss of attachment.
periodontium: tissue complex comprising gingival, cementum, periodontal ligament, and alveolar bone which attaches, nourishes and supports the tooth.
periradicular: Surrounding a portion of the root of the tooth.
permanent dentition: Refers to the permanent or adult teeth in the dental arch.
pin: A small metal rod, cemented or driven into dentin to aid in retention of a restoration.
plaque: A soft sticky substance that accumulates on teeth composed largely of bacteria and bacterial derivatives.
point of service: A health plan allowing the member to choose to receive a service from a participating or non-participating provider, usually with different benefits levels associated with the use of participating providers.
pontic: The term used for an artificial tooth on a fixed partial denture (bridge).
porcelain/ceramic: Refers to pressed, fired, polished or milled materials containing predominantly inorganic refractory compounds including porcelains, glasses, ceramics and glass-ceramics.
post: Rod-like component designed to be inserted into a prepared root canal space so as to provide structural support. This device can either be in the form of an alloy, carbon fiber or fiberglass, and posts are usually secured with appropriate luting agents.
posterior: Refers to teeth and tissues towards the back of the mouth (distal to the canines); maxillary and mandibular premolars and molars. The designation of permanent posterior teeth in the Universal/National tooth numbering system include teeth 1 through 5 and 12 through 16 (maxillary), and 17 through 21 and 28 through 32 (mandibular); primary teeth in the Universal tooth numbering system are designated A, B, I and J (maxillary), and K, L, S and T (mandibular).
post-treatment review: See audit.
preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract. See also precertification, predetermination.
precertification: Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program. See preauthorization, predetermination.
precision attachment: Interlocking device, having a male component integrated into a removable prosthesis that fits precisely into a female component embedded in the body of abutment teeth or implant abutments, to stabilize or retain the prosthesis when it is seated in the mouth.
predetermination: A process where a dentist submits a treatment plan to the payer before treatment begins. The payer reviews the treatment plan and notifies the dentist and patient of one or more of the following: patient's eligibility, covered services, amounts payable, co-payment and deductibles and plan maximums.
pre-existing condition: Oral health condition of an enrollee which existed before his/her enrollment in a dental program.
Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discounted fees for cost savings.
prefiling of fees: The submission of a participating dentist's full fees for the purpose of establishing, in advance, that dentist's full fees and the fees in a geographic area to determine benefits under a dental benefit program.
premedication: The use of medications prior to dental procedures.
premium: The amount charged by a dental benefit organization for coverage of a level of benefits for a specified time.
premolar: See bicuspid.
prepaid dental plan: A method of financing the cost of dental care for a defined population, in advance of receipt of services.
prepaid group practice: See closed panel.
pretreatment estimate: See predetermination.
preventive dentistry: Aspects of dentistry concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries.
primary dentition: The first set of teeth; see deciduous.
primary payer: The third party payer determined to have initial responsibility in a benefit determination.
prior authorization: See predetermination.
prompt payment laws: Also known as fair claims practice regulations. Enacted state by state, prompt payment laws set standards for the prompt, fair and equitable settlements of insurance claims by requiring that a set amount of interest be paid on "clean claims" that are paid beyond the established timeframe. "Clean claim" means a claim for payment of covered health care expenses that is submitted to a payer on the carrier's standard claim form using the most current published procedural codes, with all the required fields completed with information sufficient to adjudicate the claim in accordance with the payer's published filing requirements. These laws need to be analyzed on a case by case basis to determine whether a lawsuit has to be filed by the state department of insurance.
proof of loss: Verification of services rendered or expenses incurred by the submission of claim forms, radiographs, study models, and/or other diagnostic material. Documentary evidence required by a payer to prove a valid claim exists. It usually consists of a claim form completed by the patient's treating dentist.
prophylaxis: Removal of plaque, calculus and stains from the tooth structures. It is intended to control local irritational factors.
prospective review: Prior assessment by a payer or payer's agent that proposed services are appropriate for a particular patient, and/or the patient and the category of service are covered by a benefit plan. See preauthorization, precertification, predetermination, second-opinion program.
prosthesis: Artificial replacement of any part of the body.
definitive prosthesis–Prosthesis to be used over an extended period of time.
dental prosthesis–Any device or appliance replacing one or more missing teeth and/or, if required, associated structures. (This is a broad term which includes abutment crowns and abutment inlays/onlays, bridges, dentures, obturators, gingival prostheses.)
fixed prosthesis–Non-removable dental prosthesis which is solidly attached to abutment teeth, roots or implants.
fixed-removable prosthesis–Combined prosthesis, one or more parts of which are fixed, and the other(s) attached by devices which allow their detachment, removal and reinsertion by the dentist only.
interim prosthesis–A provisional prosthesis designed for use over a limited period of time, after which it is to be replaced by a more definitive restoration.
removable prosthesis–Complete or partial prosthesis, which after an initial fitting by a dentist, can be removed and reinserted by the patient.
prosthodontics: Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible substitutes.
prosthodontist: A dental specialist whose practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes.
provisional: Formed or preformed for temporary purposes or used over a limited period; a temporary or interim solution; usually refers to a prosthesis or individual tooth restoration.
public health dentist: A dentist whose practice is limited to the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts.
public health dentistry: Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis.
pulp: Connective tissue that contains blood vessels and nerve tissue which occupies the pulp cavity of a tooth.
pulp cap: See direct pulp cap; indirect pulp cap.
pulp cavity: The space within a tooth which contains the pulp.
pulpectomy: Complete removal of vital and non-vital pulp tissue from the root canal space.
pulpitis: Inflammation of the dental pulp.
pulpotomy: Removal of a portion of the pulp, including the diseased aspect, with the intent of maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing.
purchaser: Organization or entity, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population.
quadrant: One of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth.
radicular: Pertaining to the root.
radiographic/surgical implant index: An appliance, designed to relate osteotomy or fixture position to existing anatomic structures.
radiograph: An image or picture produced on a radiation sensitive film, phosphorous plate, emulsion or digital sensor by exposure to ionizing radiation.
rebase: Process of refitting a denture by replacing the base material.
recalcification: Procedure used to encourage biologic root repair of external and internal resorption defects. See apexification.
reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, to offset expenses incurred for a service covered by the dental benefit plan.
reimplantation, tooth: The return of a tooth to its alveolus.
reinsurance: Insurance for third-party payers to spread their risk for losses (claims paid) over a specified dollar amount.
Relative Value System: Coded listing of professional services with unit values to indicate relative complexity as measured by time, skill, and overhead costs. Third-party payers typically assign a dollar value per unit to calculate provider reimbursement.
reline: Process of resurfacing the tissue side of a removable prosthesis with new base material.
removable partial denture: A removable partial denture is a prosthetic replacement of one or more missing teeth that can be removed by the patient.
resin, acrylic: Resinous material of the various esters of acrylic acid, used as a denture base material, for trays or for other restorations.
resin-based composite: See composite.
resin infiltration: Application of a resin material engineered to penetrate and fill the sub-surface pore system of an incipient caries lesion to strengthen, stabilize, and limit the lesion's progression, as well as mask visible white spots.
retail store dentistry: Refers to dental services offered within a retail, department or drug store operation. Typically, space is leased from the store by a separate administrative group that, in turn, subleases to a dentist or dental group providing the actual dental services. The dental operation generally maintains the same hours of operation as the store and appointments often are not necessary. Considered to be a type of practice, not a dental benefit plan model.
retainer:
orthodontic retainer–Appliance to stabilize teeth following orthodontic treatment.
prosthodontic retainer–A part of a prosthesis that attaches a restoration to the abutment tooth, implant abutment, or implant.
retrograde filling: A method of sealing the root canal by preparing and filling it from the root apex.
retrospective review: A post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed.
revision: The act of revising; second or more surgical procedure for correction of a condition.
risk pool: A portion of provider fees or capitation payments withheld as financial reserves to cover unanticipated utilization of services in an alternative benefit plan.
root: The anatomic portion of the tooth that is covered by cementum and is located in the alveolus (socket) where it is attached by the periodontal apparatus; radicular portion of tooth.
residual root–Remaining root structure following the loss of the major portion (over 75%) of the crown.
root canal: The portion of the pulp cavity inside the root of a tooth; the chamber within the root of the tooth that contains the pulp.
root canal therapy: The treatment of disease and injuries of the pulp and associated periradicular conditions.
root planing: A definitive treatment procedure designed to remove cementum and/or dentin that is rough, may be permeated by calculus, or contaminated with toxins or microorganisms.
rubber dam: A barrier technique used to prevent the passage of saliva or moisture, or to provide an isolated operative field.
salivary gland: Exocrine glands that produce saliva and empty it into the mouth; these include the parotid glands, the submandibular glands and the sublingual glands.
scaling: Removal of plaque, calculus, and stain from teeth.
schedule of allowances: See table of allowances.
schedule of benefits: A listing of dental services and the maximum benefit amounts an insurer will pay for a given service. Specificity will vary by benefit plan.
sealant: A resinous material designed to be applied to the occlusal surfaces of posterior teeth to prevent occlusal caries.
second-opinion program: An opinion about the appropriateness of a proposed treatment provided by a practitioner other than the one making the original recommendation; some benefit plans require such opinions for selected services.
sedative filling: A temporary restoration intended to relieve pain.
self-funded plan: A benefit plan in which the plan sponsor bears the entire risk of utilization. Some plans may be partially self-funded, if the sponsor employs indemnified stop-loss insurance to protect against the risk of unanticipated higher utilization. Third party administrators may provide claims processing and other administrative services, without bearing any of the risk of utilization of the plan.
self insurance: Setting aside of funds by an individual or organization to meet anticipated dental care expenses or its dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated are used to provide dental benefits directly instead of purchasing coverage from an insurance carrier.
semi-precision attachment: A device, one component of which is fixed to an abutment or abutments and the other is integrated into a fixed or removable prosthesis in order to stabilize and/or retain it.
service corporations: Dental benefit organizations established under not-for-profit state statutes for the purpose of providing health care coverage, e.g., Delta Dental Plans, Blue Cross and Blue Shield Plans.
sextant: One of the six relatively equal sections into which a dental arch can be divided, for example: tooth numbers 1-5; 6-11; 12-16; 17-21; 22-27; 28-32. Sometimes used for recording periodontal charting.
sialodochoplasty: Surgical procedure for the repair of a defect and/or restoration of portion of a salivary gland duct.
sialography: Inspection of the salivary ducts and glands by radiograph after the injection of a radiopaque medium.
sialolithotomy: Surgical procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally.
site: A term used to describe a single area, position, or locus. For periodontal procedures, an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions.
space maintainer: A passive appliance, usually cemented in place, that holds teeth in position.
Specification No. 3950: This schema (ANSI/ADA/ISO Specification No. 3950–1984 Dentistry Designation System for Tooth and Areas of the Oral Cavity) is designed to identify areas of the oral cavity as well as uniquely number permanent and primary dentition. Supernumerary teeth are not yet identified using this standard. For more information see Appendix to Section 3 of this CDT manual.
splint: A device used to support, protect, or immobilize oral structures that have been loosened, replanted, fractured or traumatized. Also refers to devices used in the treatment of temporomandibular joint disorders.
statistically-based utilization review: A system that examines the distribution of treatment procedures based on claims information. In order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics, and geographic location.
stomatitis: Inflammation of the membranes of the mouth.
stop-loss: A general term referring to that category of coverage that provides insurance protection (reinsurance) to an employer for a self-funded plan.
stress breaker: That part of a tooth-borne and/or tissue-borne prosthesis designed to relieve the abutment teeth and their supporting tissues from harmful stresses.
study model: Plaster or stone model of teeth and adjoining tissues; also referred to as diagnostic cast. See diagnostic cast.
succedaneous tooth: A permanent tooth that replaces a primary (deciduous) tooth.
summary plan description: See benefit plan summary.
supernumerary teeth: Extra erupted or unerupted teeth that resemble teeth of normal shape.
suture: Stitch used to repair incision or wound.
table of allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such service, but does not necessarily represent the dentist's full fee for that service.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA): Legislation (Public Law 97-248) affecting health maintenance organizations and the Medicare and Medicaid programs. Provides regulations for the development of HMO risk contracting with the Medicare program and, through amendment, established new provisions for the foundation and operation of peer review organizations.
temporary removable denture: An interim prosthesis designed for use over limited period of time.
temporomandibular (TMJ): The connecting hinge mechanism between the base of the skull (temporal bone) and the lower jaw (mandible).
temporomandibular joint dysfunction (TMD or TMJD): Abnormal functioning of temporomandibular joint; also refers to symptoms arising in other areas secondary to the dysfunction.
termination date: See expiration date.
therapeutic: Of or pertaining to therapy or treatment; beneficial. Therapy has as its goal the elimination or control of a disease or other abnormal state.
third-party: The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provides other administrative services. Also known as administrative agent, carrier, insurer or underwriter.
Third-Party Administrator (TPA): Claims payer who assumes responsibility for administering health benefit plans without assuming any financial risk. Some commercial insurance carriers and Blue Cross & Blue Shield plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO) contracts.
third-party payer: An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.
tissue conditioning: Material intended to be placed in contact with tissues, for a limited period, with the aim of assisting the return to a healthy condition.
Title XIX: Portion of the Social Security Act that provides for federal grants to the states for medical assistance programs, commonly known as Medicaid.
tomography: An X-ray technique that produces an image representing a detailed cross section of tissue structures at a predetermined depth.
tooth bounded space: A space created by one or more missing teeth that has a tooth on each side.
torus: A bony elevation or protuberance of bone. See exostosis.
tracheotomy: A surgical procedure to create an opening in the trachea (windpipe) to aid in breathing.
transitional: Relating to a passage or change from one position, state, phase or concept to another.
transitional dentition: Refers to a mixed dentition; begins with the appearance of the permanent first molars and ends with the exfoliation of the deciduous teeth.
transplantation: Surgical placement of biological material from one site to another.
transplantation of tooth: Transfer of a tooth from one socket to another, either in the same or a different person.
transseptal: Through or across a septum.
treatment plan: The sequential guide for the patient's care as determined by the dentist's diagnosis and is used by the dentist for the restoration to and/or maintenance of optimal oral health.
trismus: Restricted ability to open the mouth, usually due to inflammation or fibrosis of the muscles of mastication.
tuberosity: A protuberance on a bone.
unbundling of procedures: The separating of a dental procedure into component parts with each part having a charge so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure.
unerupted: Tooth/teeth that have not penetrated into the oral cavity.
unilateral: One-sided; pertaining to or affecting but one side.
Universal/National tooth numbering system: A system that assigns a unique number (from 1-32) to permanent teeth, and a unique letter (A-T) for primary teeth.
upcode: Reporting a more complex and/or higher cost procedure than was actually performed. Also known as overcoding.
Usual, Customary and Reasonable Fees: See fee.
usual fee: See fee.
utilization: The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. Also, an expression of the number and types of services used by the members of a covered group over a specified period of time.
utilization management: A set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices.
utilization review, statistically based: A system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics, and geographic location.
waiting period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for a given benefit.
wax pattern: A wax form that is the positive likeness of an object to be fabricated.
worker's compensation: A benefit paid to an employee who suffers a work-related injury or illness.
veneer: See laminate veneer.
vertical bitewing: A dental image with a central projection on which the teeth can close, holding it in a vertical position for the radiographic examination of several upper and lower teeth simultaneously.
vertical dimension: The vertical height of the face with the teeth in occlusion or acting as stops.
vestibuloplasty: Any of a series of surgical procedures designed to increase relative alveolar ridge height.
viral culture: A collection of specimen for the purpose of incubating a virus for identification
xerostomia: Decreased salivary secretion that produces a dry and sometimes burning sensation of the oral mucosa and/or cervical caries.
x-ray: See radiograph.
yeast: A general term for a fungus occurring as a . unicellular, nucleated organism that usually reproduces by budding. Some yeasts may reproduce by fission, many producing mycelia or pseudomycelia.
zygomatic bone: Quadrangular bone on either side of face that forms the cheek prominence. See malar.