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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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     Indian Health Manual

Part 2, Chapter 3:  Manual Exhibit 2-3-E

Dental Services - Levels of Service
  1. LEVEL I
    1. Emergency Care.  Emergency dental services are those that are necessary to relieve or control acute oral conditions such as:  serious bleeding, a potentially life-threatening difficulty, maxillofacial fractures, swelling and severe pain, or other signs of oral infection.  Other conditions that the patient may determine to require urgent attention are also classified as LEVEL I care (e.g., prosthetic repairs).  Procedures commonly reported are listed below:
      1. Emergency (limited examination)
      2. One or more periapical radiographs
      3. Simple extractions
      4. Temporary or sedative restorations
      5. Re-cement crowns or bridges
      6. Prosthetic repairs and adjustments
      7. Endodontic access preparation
      8. Drain oral abscess
      9. Reduction of jaw fractures
    1. Primary Dental Care.   The procedures classified under primary care are those that prevent the onset of oral disease.  Clinical services to individual patients and community-based preventive services or activities are included in LEVEL II care.  The primary care services most frequently provided are:
      1. Clinical Services
      2. Preventive plan and education to promote “self-care”
      3. Adult prophylaxis (routine or difficult)
      4. Child prophylaxis (not a toothbrush prophy)
      5. Topical fluoride
      6. Sealants by tooth or quadrant
      7. Periodontal maintenance (recall) procedures
      8. Athletic mouth guard
      9. Community-based Services
      10. Water fluoridation activities
      11. Group health education/health promotion activities
      12. Supplemental fluoride program status during current month
    1. Secondary Dental Care.  Secondary Dental Care -LEVEL III services are those deemed necessary for routine diagnosis and primary treatment to control the early stages of disease.  This level also includes the treatment of certain advanced conditions that are limited in scope (e.g., anterior endodontics, stainless steel crowns).  The procedures generally are not highly complex in nature and often more than one of these services can be completed in one appointment.  The LEVEL III procedures commonly reported include the following:
      1. Initial or periodic oral exam
      2. Bite wing and/or panoramic radiographs
      3. Diagnostic costs
      4. Space maintainers
      5. Amalgam restorations (1, 2,3 surface)
      6. Composite restorations (1, 2,3 surface)
      7. Stainless steel crowns (primary teeth only)
      8. Therapeutic pulpotomy (primary teeth only)
      9. Anterior endodontics (one canal)
      10. Periodontal scaling/root planning (for 4-6 mm pockets)
      11. Biopsy, excision of lesion
    1. Limited Rehabilitation.  Rehabilitative care is that which restores oral structures to an improved condition and form.  Limited Rehabilitation is defined by the IHS as those dental procedures that involve more advanced disease conditions and are more complex and costly to provide than LEVEL III care in controlling disease and restoring function.  The following LEVEL IV services are those most frequently utilized:
      1. Complex amalgam (4 or more surfaces)
      2. Cast onlays or crowns with or without porcelain
      3. Post and core restoration
      4. Crown buildups
      5. Acid etch (Maryland) bridge
      6. Bicuspid Endodontics (two canals)
      7. Apicoectomy/Retrograde
      8. Filling Gingival flap with root planning/curettage of deep pockets
      9. Denture reline (laboratory)
      10. Limited/Interceptive Orthodontics
  5. LEVEL V
    1. Rehabilitation.  The dental services classified into this level are rehabilitative procedures that require more clinical chair time, additional knowledge and skill of the care provider, and usually greater expense than the limited rehabilitative services listed under LEVEL IV care.  LEVEL V services usually require multiple appointments to complete and they are usually associated with rehabilitative plan for the entire mouth.

      These and LEVEL VI services generally require a substantial patient contribution (co-payment) to cover professional fees in dental insurance programs.  The IHS does not cover the co-payment for those patients that have insurance coverage.  The IHS does not have the authority to charge dental fees to Indian beneficiaries but will provide prosthetic services or other services with the patient paying the dental laboratory fees or fees for other support involved in the direct treatment of a dental case.  The laboratory or other bills are to be provided to the patient and the patient must pay them directly to the provider.  The LEVEL V services most frequently needed are:

      1. Molar endodontics (3 or more canals)
      2. Periodontal surgery in deep pockets (6+ mm)
      3. Complete and partial dentures
      4. Denture rebase (laboratory)
      5. Fixed bridgework (retainers and pontics)
      6. Surgical extractions (impactions)
      7. Analgesia (e.g., nitrous oxide)
    1. Complex Rehabilitation.  Complex Rehabilitation LEVEL VI includes those services that usually require more time, skill, and cost than the rehabilitative procedures classified under LEVELS IV AND V.  A substantial portion of patients may require referral to specialists for complex rehabilitative treatments; however, referrals must be justified by special circumstances that warrant the associated higher costs.  LEVEL VI services may not predictably improve the overall prognosis for many patients.  Thus, careful patients’ selection is a critical factor in the provision of LEVEL VI care.  Complex rehabilitation includes the following procedures:
      1. Cephalometric or TMJ radiographs
      2. Occlusal adjustment (complete)
      3. Periodontal Surgery, osseous or soft tissue grafts, repositioning flaps
      4. Over dentures
      5. Consultation
      6. Precision attachment prosthetics
      7. Comprehensive Orthodontics (class I, II or III occlusal, fixed appliances (usually full-bonding), orthodontic care followup visits, post-treatment stabilization
      8. Surgical extractions (bony impactions)
      9. Unusual and complex oral surgery
      10. Maxillofacial prosthetics
      11. I-V sedation, general anesthesia
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