Narrative Support suggestions for Dental

by  Christine Taxin, President - Links2Success
Feb 25th, 2016

Suggestions for narrative support for use in Box 19 CMS-1500 and Box 35 of the ADA Dental Claim Form

Narrative Support Choices for Consideration:

• Periodontal Bacteria

-Certain periodontal bacteria may be locally invasive, cause tissue destruction, invade host cells and enter the blood stream. Possible introduction into the bloodstream may complicate certain systemic situations such as cardiovascular disease, diabetes, preterm and low birth weight babies and other systems

• Diabetes Mellitus (DM)

-Current evidence suggests that diabetes mellitus DM is associated with an increased prevalence and severity of gingivitis and periodontitis. Periodontitis may increase the risk for worsening glycemic control in diabetic patients, as well as increasing the risk for diabetic complications. The resulting increase levels of inflammation can result in impairments in the body’s ability to manage blood sugar levels. Reference: Diabetes Mellitus and Periodontal Diseases: Mealey, Oates; J. Periodontology 2006.

• Periodontal Bacteria

-Certain periodontal bacteria may be locally invasive, cause tissue destruction, invade host cells and enter the blood stream. Possible introduction into the bloodstream may complicate certain systemic situations such as cardiovascular disease, diabetes, preterm and low birth weight babies and other systems

• Inflammatory Disease

-Research has connected C-reactive protein and other cytokines and chemokines to periodontal disease. The literature shows that gum disease is a significant cause of elevations in CRP levels.

• Diabetes Mellitus (DM)

-Current evidence suggests that diabetes mellitus DM is associated with an increased prevalence and severity of gingivitis and periodontitis. Periodontitis may increase the risk for worsening glycemic control in diabetic patients, as well as increasing the risk for diabetic complications. The resulting increase levels of inflammation can result in impairments in the body’s ability to manage blood sugar levels. Reference: Diabetes Mellitus and Periodontal Diseases: Mealey, Oates; J. Periodontology 2006.

• Preterm Births

-Hormonal changes and pregnancy gingivitis requires aggressive treatment as research has shown that periodontal disease may be significantly related to preterm low birth weight. Reference: Periodontal Therapy May Reduce the Incidence of Preterm Birth and Low Birth Weight Infants: Journal of Periodontology, 2007, Vol. 78 No. 5.

• Cardiovascular Disease

-Studies find a direct association between cardiovascular disease and periodontal bacteria. Even small amounts of an inflammatory stimulus can provoke a substantial amount of C-reactive protein (CRP) production which then circulates throughout the body in the bloodstream. Periodontal disease is a primary cause of inflammation in the body and may be predictive of heart disease. References: Moise Devarieus, MD, PhD, Columbia University; NIH News; April 6, 2006; Conclusion: “…older adults who have higher proportions of four periodontal disease-­‐causing bacteria (A.a., P.g., T.f., T.d.) inhabiting their mouths also tend to have thicker carotid arteries, a strong predictor of stroke and heart attack”

• Patient History and Diagnosis:

is a year old with a suspected diagnosis of due to the following symptoms and clinical findings.

1. Z85 Personal history of malignant neoplasm

2. Z67 Personal history of other diseases and conditions

NOTE: Use one of the periodontal codes and back up with a medical code that describes patient’s health history: i.e. Heart, Diabetic, Organ Issues or any other issues.

• Family History

These symptoms, as well as the examination are indicative of . The only way to confirm a diagnosis of is to perform this test.

These codes are not to be used as primary example: Z80 family history of primary malignant neoplasm

• Molecular testing plays an important role in making a definitive diagnosis in cases of suspected

to treat the patient appropriately. An accurate diagnosis provides the following benefits to the patient:

i.e. List what the outcome of treatment with Oral DNA as a tool that helps with diagnostics and Treatment.

i.e. Patient has a medical issue (for example-diabetes, heart disease, auto immune disease) may pose additional risk from the infection thru the oral cavity. The lab test allows for knowing type of infection present and customizing the treatment.

• Autoimmune disease affects up to 50 million Americans, according to the American Autoimmune Related Diseases Association (AARDA). An autoimmune disease develops when your immune system, which defends your body against disease, decides your healthy cells are foreign. As a result, your immune system attacks healthy cells. Depending on the type, an autoimmune disease can affect one or many different types of body tissue. It can also cause abnormal organ growth and changes in organ function.

There are as many as 80 types of autoimmune diseases. Many of them have similar symptoms, which makes them very difficult to diagnose. It’s also possible to have more than one at the same time. Autoimmune diseases usually fluctuate between periods of remission (little or no symptoms) and flare-ups (worsening symptoms). Currently, treatment for autoimmune diseases focuses on relieving symptoms because there is no curative therapy.

Autoimmune diseases often run in families, and 75 percent of those affected are women, according to AARDA. African Americans, Hispanics, and Native Americans also have an increased risk of developing an autoimmune disease.

The following are some of the more common autoimmune diseases: Look for these when you are doing your health history.

•  rheumatoid arthritis: inflammation of joints and surrounding tissues
•  systemic lupus erythematosus: affects skin, joints, kidneys, brain, and other organs
•  celiac sprue disease: a reaction to gluten (found in wheat, rye, and barley) that causes damage to the lining of the small intestine
•  pernicious anemia: decrease in red blood cells caused by inability to absorb vitamin B-12
•  vitiligo: white patches on the skin caused by loss of pigment
•  scleroderma: a connective tissue disease that causes changes in skin, blood vessels, muscles, and internal organs
•  psoriasis: a skin condition that causes redness and irritation as well as thick, flaky, silver-white patches
•  inflammatory bowel diseases: a group of inflammatory diseases of the colon and small intestine
•  Hashimoto’s disease: inflammation of the thyroid gland
•  Addison’s disease: adrenal hormone insufficiency
•  Graves’ disease: overactive thyroid gland
•  reactive arthritis: inflammation of joints, urethra, and eyes; may cause sores on the skin and mucus membrane
•  Sjögren’s syndrome: destroys the glands that produce tears and saliva causing dry eyes and mouth; may affect kidneys and lungs
•  type 1 diabetes: destruction of insulin producing cells in the pancreas
•  Use of Medicated Rinse before you provide scaling: Example: Chlorine Dioxide. Chlorine dioxide causes the destruction of spores, bacteria’s, viruses and other pathogen organisms. Studies demonstrate that use of a cholrine dioxide-containing mouth rinse significantly reduces volatile sulfur compound concentration. Reference: Compend,Contin Educ.dent.,21 March 2000

Laser Assisted Periodontal Therapy

• A study for laser assisted periodontal therapy (laser decontamination plus scaling and root planning) showed the highest number of attached fibroblasts, with the highly attached fibroblast prevailing while reducing the occurrence of bacteremia. Conclusion: CO2 laser treatment combined with mechanical instrumentation constitutes a useful tool to condition the root surface and increase fibroblast attachment to root surfaces thus reducing pockets and periodontal diseases.
• Reference: j. Periodontology. 2002 Nov. Dentistry Today March 1998: “ND:YAG – Assisted Periodontal Curettage to Prevent Bacteremia Before Cardiovascular Surgery
• Implants

Since implants are not routine dental care, file implant claims with medical first, if the prevailing diagnosis is medical in nature. We`re seeing many states passing laws that do not allow jawbone and/or jaw joint treatment to be excluded if bones and joints in other parts of the body are covered. Know your state laws so you can include for treatment of implants or TMD

Can medications affect my dental treatment?

Yes, medications can impact your dental health. In fact, each time you visit your dentist, be sure to give him or her complete, up-to-date information about any recent hospitalizations or surgery, recent illnesses and/or any changes in your health since your last visit, and any changes in any medications you may be taking.

Regarding medications, be sure to write down and bring with you a list of the names of current drugs you are taking, their dosages, and frequency of use. Include any over-the-counter products you may be using, as well as any herbal products and supplements. All of these issues will need to be considered by your dentist in order to devise a safe and effective treatment plan for you.

• First link of oral bacteria and preterm birth found in human
• In pilot study by Case Western Reserve University and Metro Health Medical Center
• A 37-year-old-mother, who gave birth to a low-weight preemie at 24 weeks, exhibited the first- found link in a human between bacteria found in the mouth and the amniotic fluid of a woman in preterm labor.
• Using new DNA finger-printing techniques to find bacteria that cannot be cultured and grown in the lab, researchers from Case Western Reserve University School of Dental Medicine and the Department of Obstetrics and Gynecology at Metro Health Medical Center in Cleveland made the discovery.
• They report their finding in the Journal of Clinical Microbiology online article, "Transmission of an Uncultivated Bergeyella Strain from the Oral Cavity to the Amniotic Fluid in a Case of Preterm Birth" in the April issue.
• Yiping Han, the lead researcher and a Case microbiologist in the Department of Biological Sciences at the Case School of Dental Medicine, has spent approximately three years searching for this link.
• Assisting in her investigation were Akihiko Ikegami, Nabil Bissada and Raymond Redline from Case and Graham Ashmead and Melissa Herbst from the Department of Obstetrics at Case School of Medicine and MetroHealth Medical Center.
• The researchers report that they found the link during a pilot study of 34 women undergoing amniocentesis at MetroHealth.
• The women in their second or last trimester had sought testing for genetics, fetal development or suspected infections.
• Six of the women delivered before 30 weeks and had a higher risk for possible infections. Only the one mother had an infection.
• But Han points out that in this small study it was one in six of the mothers under 30 weeks and in the overall population could mean many more women with infections that bring on early labor or the need to induce labor to protect the baby from an infection during the pregnancy.
• Women can contract intrauterine infections vaginally while pregnant. Another pathway of infection has been suspected through the mouth in pregnant mothers where the oral bacteria enter the blood through bleeding gums.
• Han said the infections play a bigger role in premature deliveries prior to 30 weeks than those that happen later in pregnancy and can result in babies born with many health challenges and who struggle to thrive at their low-birth weights.
• According to 2003 statistics from the March of Dimes, hospital charges for newborns without complications averaged $1,700. In contrast, hospital costs for infants born too soon to too small average a startling $77,000. Also in 2003, hospital charges for all infants totaled $36.7 billion. Nearly half of that, $18.1 billion, was for babies with a diagnosis of prematurity or low birth weight. Today 1,300 babies in the U.S. will be born prematurely. While doctors have made tremendous advances in caring for babies born too soon and too small, scientists have not yet developed effective ways to help prevent premature delivery.
• Finding why mothers give birth prematurely is important for the health of the baby and mother and to drive down medical costs, said Han.
• The mother, who had the presence of Bergeyella, came to MetroHealth when in preterm labor and dilated at 24 weeks. She was induced after it was determined by low glucose levels and elevated white blood cell counts in her amniotic fluid that she had an infection. An examination of the placenta, fetal lining and umbilical cord following the birth supported the infection.
• Han's tests of the amniotic fluid found the Bergeyella bacteria.
• This study continues Han's research into the suspicion that oral bacteria, once entering the blood, can cause a host of health problems including preterm labor.
• She confirmed the harm oral bacteria can cause in a mice study in April 2004 when she injected the common oral bacteria of Fusobacterium nucleatum into the blood of pregnant mice. It resulted in premature delivery for the mouse mothers and fetal death for some of their fetuses.
• The pilot study is one of the first studies done on humans.
• The mother, who had the presence of Bergeyella, regularly visits the dentist and showed no signs of post-partum periodontal disease—a suspected facilitating condition for bacteria to enter the bloodstream.
• "If periodontal disease is not present, then this raises more questions about how the bacteria got into the amniotic fluid," said Han.
•  Bergeyella is one of the 700 bacteria found in the mouth. It is also one of approximately 60% of the bacteria that cannot be grown in a culture, and until now, could not be studied. Since new techniques like PCR (polymerase chain reaction) became available to track the DNA of the bacteria, it now allows for the study of those other bacteria

What is Molecular testing?

Molecular genetic testing is performed to identify a specific mutation of the CYP2C19 gene located on chromosome 10, responsible for encoding the cytochrome P450, family 2, subfamily C, polypeptide 19. This complex polypeptide is part of a mixed function oxidase system that metabolizes xenobiotics (compounds foreign to the body such as drugs and toxins) and also bioactivates and synthesizes substances such as cholesterol, steroids, and other lipids. A large phenotypical variability factor is present due to genetic polymorphism. The common variants are categorized as normal-fully functional (*1), decreased or non- functioning (*2, *3), decreased or partial-functioning (*4, *5, *6, *7, *8), or increased-partial functioning (*17). Genetic testing may be ordered for individuals undergoing certain drug therapy (antiepileptics, proton pump inhibitors, antidepressants) to identify gene mutations which alter the metabolism of the compound leading to an adverse drug response or effect.

Writing a medical necessity:

Guidelines are developed for selected therapeutic or diagnostic services found to be safe, but proven effective in a limited, defined population of patients or clinical circumstances. They include clinical coverage criteria based on current literature review, consultation that provide the diagnostic tests to back conditions that provide a medical necessity diagnosis.. Medical necessity guidelines are updated annually, or more frequently if new evidence becomes available that suggests needed revisions.

When using any of the Medical Necessity Treatments always include:

1. periodontal pockets (before and after results)

2. Periodontal Pathogens (before and after results)

3. periodontal bleeding (before and after results)

4. Lower CRP If it was high

5. Lower HbA1c if it was high

Whenever sending a letter of medical necessity try to include a reference or material that backs your treatment.