In 2017, the American Dental Association developed a new code for hygiene care: D4346, or scaling in the presence of generalized moderate or severe inflammation – full mouth after oral evaluation. This is a form of treatment that dentists and hygienists worked for years to create. However, even five years later, most dental offices are not utilizing this code.
Many hygienists who perform this treatment as a routine part of their hygiene care question why, and the answer is simple: Many offices do not know how to utilize this code with their established hygiene and periodontal program. This article will offer insight into this new code to help hygienists add this treatment into their care program and take their treatment planning to the next level.
The What and Who
First, let’s talk about “what” and “who” – what is this treatment code, what does it mean, and who can it be performed on? As the name says, D4346 is scaling in the presence of gingivitis.
The CDT code entry description defines this code as “The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis.”1
Before this code was developed in 2017, there was no treatment code for gingivitis. Many patients with gingivitis, which is a disease, were being treated as healthy patients with a routine prophylaxis. The D4346 code is reserved for patients who solely have gingivitis with no signs of periodontitis.
Let’s now discuss the “how” – how is this treatment diagnosed? This treatment is first diagnosed as if a hygienist were to be diagnosing periodontal therapy – update the patient’s radiographs and complete a comprehensive periodontal assessment/charting.
Periodontal charting on a patient who needs D4346 will show moderate to severe bleeding with no bone loss or attachment loss. In addition to probing depths up to 4mm and bleeding upon probing, it is also recommended to chart suppuration, gingival recession, plaque, calculus, mobilities, and furcations.
The American Dental Association considers any patient who has 30% or more bleeding of the teeth – not the probing depths – to be a candidate for this treatment.2 Once the updated radiographs and the periodontal chart confirm that the patient has gingivitis absent of periodontitis, intraoral photos should be taken of the signs of gingivitis seen in the mouth – infected tissue, bleeding, and deposits of calculus and plaque. These photos are great for patient education and are also a good idea to have in the patient’s chart should their insurance company request them.
In addition to diagnosing the treatment, many hygienists may question how to explain this treatment to their patients. When explaining this treatment, it is always recommended to use terminology that is easy for patients to understand. Most patients know the basis of what gingivitis is, and many hygienists have termed this treatment “gingivitis therapy.” The patient will recognize from this term that they have gingivitis.
Explain to the patient that they have increased bleeding, which is one of the first signs in the mouth of an active infection. It can also be explained what gingivitis is, how it occurs, and what can be done both as treatment in the office and as homecare to correct the problem and prevent it from recurring. It is important to explain to the patient that there are vast differences between gingivitis and periodontitis. Hygienists understand that gingivitis is reversible, while periodontitis can only be maintained, not reversed, and that gingivitis can lead to periodontitis if untreated.
It is important to explain this to the patient so they understand the importance of having the treatment completed and the risks if the treatment is not completed. It is the duty of the hygienist to explain the condition that the patient has to them, explain the treatment process, and explain the risks and the benefits of having the treatment performed.
The Where and Why?
What should you do when performing this treatment? The treatment protocol for D4346 is very different from D1110 as the patient has an active infection (D1110 is performed on a healthy patient who is maintaining their health). A topical or local anesthetic can be used based on the patient’s own needs and comfort level.
The hygienist can then begin the treatment process. An ultrasonic scaler is a great way to remove large deposits, and this should also be used to lavage all the teeth to clean out any soft or hard deposits causing gingivitis. Hand scaling can be performed along with flossing and polishing the teeth. Air polishing can be used for this therapy, but be cautious by using only a powder that is safe for subgingival treatment.
One of the most important parts of this therapy is giving the patient the oral hygiene instructions they need to assist the hygienist in maintaining their oral health at home. Detailed oral hygiene instructions are key for the patient to understand their own disease.
The hygienist can then schedule the patient back as they see fit, whether this is for a follow-up visit in four to six weeks or a recare appointment in three months. When the patient returns, it is important to always follow up with the patient on their homecare performance and encourage the patient to be honest and ask questions. At this point, a re-evaluation and D1110 will be performed. It’s important to note that periodontal maintenance is not a recommended procedure when the patient returns for recare visits since there is no evidence of attachment loss.1 The hygienist will perform treatment and schedule the patient back as necessary, whether this be in three months, four months, or six months.
It is important to note that if the patient is reporting they are following homecare instructions, but the status of their gingivitis is not improving, a referral to their primary care practitioner may be necessary as many systemic diseases show signs orally.
Evidence of Useful Treatment
One of the biggest questions hygienists hear from patients is, “Does my insurance cover this?” As health care providers, it is our duty to perform treatment based on the treatment that the patient needs – not what their insurance plan covers. Every plan reimburses differently, especially because this therapy is still new to coding.
This treatment is vastly different from a routine adult prophylaxis. Because it is not “just a regular cleaning,” the patient can differentiate that they have active disease. Our hope as hygienists is that, by the patient being told their mouth is not healthy, they will be more compliant with the recommended treatment and have better compliance with their home care.
Offices using this code as a part of their hygiene protocol can attest to how useful it is and the differences seen between performing the standard of care of the D4346 code or just continuing to perform an adult prophylaxis on a patient with gingivitis. Many dental professionals worked for years to create this code, and it is in our profession’s best interest to start using it!
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- ADA Guide to Reporting D4346. (2023, January 1). American Dental Association. https://www.mouthhealthy.org/~/media/ADA/Publications/Files/CDT_Code_D4346EducationGuidelines_V3_2017Oct25.pdf?la=en
- Raymond-Albritten, J. (2017, July 23). D4346: Dental Procedure Codes Filling the Gap. https://www.colgateprofessional.com/hygienist-resources/tools-resources/d4346-dental-procedure-code#