Part 2, Chapter 3: Manual Exhibit 2-3-C
Indian Health Service Schedule of Dental Services (Levels of Care)
The Schedule of Dental Services was developed by the Indian Health Service (IHS) Division of Oral Health to assist community dental programs in managing their resources effectively to provide access to care in a “demand care” setting. The schedule categorizes all types of dental services into Levels of Care, a priority-based listing that is outlined below and described on the following pages.
Services that alleviate pain or prevent disease are given a higher priority than those intended to prevent or contain disease, or correct damage caused by disease. Thus, emergency care has the highest priority (Level I), while providing access to complex rehabilitative care (Level V) is given the lowest priority for expending the available resources.
- Level I Emergency Oral Health Services
- Level II Preventive Oral Health Services
- Level III Basic Oral Health Services
- Level IV Basic Rehabilitation Oral Health Services
- Level V Complex Rehabilitation Oral Health Services
- Level IX Exclusions
The majority of treatment needs in American Indian/Alaska Native (AI/AN) communities falls within the first three levels, sometimes called “basic care,” which comprise the most cost-effective services to provide on a community-wide basis. As additional funds become available for dental care, the schedule can be used to expand access to care beyond basic services in an orderly, equitable, and cost-effective manner.
The schedule forms a consistent structure for program planning as well as for the treatment planning of individual patients. However, it is intended to be a flexible tool which can be adapted to the situation of each community and of dental patients. Factors such as the availability of alternate resources, community water fluoridation, patient age, and the prognosis for success, as well as other conditions, each play a role in determining how the schedule should be applied to individuals and target groups. The general principle for implementing the schedule is always to use the available resources for providing the greatest health benefit to the greatest number of people for the longest time possible.
Description of the IHS Schedule of Dental Services Levels of Care Structure
Level I: Emergency Oral Health Services
Emergency dental services are those necessary for the relief of acute conditions. Emergency dental care services include all necessary laboratory and preoperative work including examination, radiographs, and appropriate anesthesia. Emergency dental services shall include but not be limited to the following:
- Control of oral and maxillofacial bleeding in any condition when loss of blood will jeopardizethe patient's well being. Treatment may consist of any professionally accepted proceduredeemed necessary.
- Relief of life-threatening respiratory difficulty and improvement of the airway (respiratory system) from any oral or maxillofacial dental condition. Treatment may consist of any professionally accepted procedure deemed necessary.
- Relief of severe pain accompanying any oral or maxillofacial dental conditions affecting the nervous system, limited to immediate palliative treatment, but including extractions where professionally indicated.
- Immediate and palliative procedures that include but are not limited to: (1) fractures, subluxations and avulsions of teeth, (2) fractures of jaw and other facial bones (reduction and fixation only), (3) temporomandibular joint subluxations, (4) soft tissue injuries, (5) broken dentures, and (6) chipped tooth.
- Initial treatment for acute infections.
Procedures that are frequently reported in this category of care are listed below:
- Emergency oral examination (limited to problem area)
- One or more periapical radiographs associated with the problem
- Simple tooth extractions
- Temporary or sedative restorations
- Palliative procedures
- Prescription medications for pain and infection
- Endodontic access preparations
- Draining of oral abscesses
- Denture repairs and other urgent repairs
Level II: Preventive Oral Health Services
The listed services are those which prevent the onset of the dental disease process. Some of the services provided to individuals are modified by IHS definitions, exclusions, limitations, and processing policies. Please refer to the appropriate sections for further descriptions of exclusions, limitations, and processing policies.
The preventive oral health services most frequently provided are:
- Adult prophylaxis with or w/o topical fluoride
- Child prophylaxis with or w/o topical fluoride
- Sealants by tooth or quadrant
- Preventive (self-care) training
- Periodontal recall procedures
- Athletic mouthguards
- Water fluoridation activities
- Group education
- Tracking of number of children receiving supplemental fluorides per month
Level III: Basic Oral Health Services
Basic dental care includes those services provided early in the disease process and which limit the disease from progressing further. They include most diagnostic procedures, simple restoration of diseased teeth, early treatment of periodontal disease, and many surgical procedures needed to remove or treat oral pathology.
The Level III procedures commonly reported include the following:
- Initial or periodic oral exam
- Bitewing and panoramic radiographs
- Diagnostic casts
- Space maintainers
- Amalgam restorations (1,2,3-surface)
- Composite restorations (1,2,3-surface)
- Stainless steel crowns (primary teeth only)
- Therapeutic pulpotomy (primary teeth only)
- Anterior endodontics (one canal)
- Periodontal scaling/root planing
- Biopsy, excision of lesion
Level IV: Basic Rehabilitative Oral Health Services
Basic rehabilitation services are those necessary to contain the disease process after it is established or improve the form and/or restore the function of the oral structures. The word “function” as used here includes some psychosocial considerations as well as the mastication of food. These services are more difficult to provide since the disease process is well established. The investment of resources will have a good cost-effectiveness because the procedures are directed at containment or basic rehabilitation. They include but are not limited to complex restorative procedures (onlays, cores, and crowns), the majority of endodontic procedures, most advanced periodontal procedures, prosthodontic appliances that restore function, pre-prosthetic surgery, and most interceptive or limited orthodontic procedures.
The following Level IV services are those most frequently utilized:
- Complex amalgams (4 or more surfaces)
- Cast onlays or crowns with or w/o porcelain
- Post and core restoration
- Crown buildups
- Acid etch retainers (Maryland Bridge)
- Bicuspid endodontics (two canals)
- Apicoectomy/retrograde filling
- Gingivoplasty
- Limited/interceptive orthodontics
Level V: Complex Rehabilitative Oral Health Services
The complex rehabilitation services listed in Level V are those that require significant time, special skill or cost to provide. Certain patients will require referral to dental care providers skilled in providing the specific procedure and/or which have limited their practice to that specific specialty area. Generally the patient must present special circumstances that would warrant the added time and transportation associated with specialty referral. Level V services may not improve the overall prognosis for most patients so patient selection is of critical importance when considering the provision of these services.
The Level V services most frequently provided are:
- Molar endodontics (3 or more canals)
- Periodontal surgery (mucogingival and osseous)
- Complete and partial dentures
- Denture rebase (laboratory)
- Fixed bridgework (retainers and pontics)
- Implants
- Surgical extractions (impactions)
- Analgesia (e.g., nitrous oxide)
- Cephalometric or TMJ radiographs
- Occlusal adjustment (complete)
- Periodontal surgery
- Overdentures
- Consultation for specialty services
- Precision attachment prosthetics
- Comprehensive orthodontics (Class I, II, or III)
- Surgical extractions (bony impactions) and unusual or complex oral surgery
- Maxillo-facial prosthetics
- Intravenous (IV) sedation, general anesthesia
Level IX: Exclusions
These services have been determined to be of limited benefit in the treatment of oral disease or maintenance or oral health. These services have a variable rate of success, are difficult to monitor from an appropriateness or effectiveness standpoint, are not universally defined or accepted as the preferred method of treatment. Some of the services listed under exclusions require heroic effort and therefore are questionable from a cost benefit standpoint. Other services use material which is obsolete or of disputable effectiveness. In other cases the services are considered part of treatment and do not warrant a separate fee or value. In certain other cases the IHS simply will not pay for the service.
The following procedures are examples of exclusions which are frequently reported:
- Removable unilateral space maintainers
- Silicate restorations
- Gold foil restorations
- Cast inlay
- Porcelain inlays or crowns
- Full resin or resin/metal crowns
- Direct pulp caps
- Unilateral cast partials
- Chairside denture relines
- Pulpotomy in permanent tooth
- Tooth transplantation
- Removable appliance therapy
- Behavior management
Limitations
Provisions have been added to the IHS Schedule of Dental Services to limit the frequency of certain procedures provided to individual patients. The limitations are similar to those accepted in contracts managed by most third party payers and therefore should be acceptable to most practicing dentists. The limitations are to be used in conjunction with applicable modifiers for specific services to assure that care is provided with optimal effectiveness.
The following table lists dental services which are subject to the specific limitations given:
| Procedure | Limitation |
|---|---|
| Initial oral exam | Once per patient |
| Periodic oral exam | Once per 6-month period |
| Full mouth radiographs | Once during 3-year period |
| Supplemental bitewings | Once per 6-month period |
| Prophylaxis | Once per 6 months, includes education |
| Topical fluoride | Selected patients with high caries activity |
| Crowns | Only when a less complex restoration is not possible (supported by x-rays) |
| Class II posterior composites | By report only |
| Periodontics | Limitations on type and frequency of services vary with disease severity |
| Prosthodontics | No replacement within 5 years |
| Chrome/acrylic material of choice |
Treatment Modifiers
To further enhance the appropriateness and effectiveness of oral health care for Native Americans, the Schedule of Dental Services contains modifiers that practitioners must consider before planning treatment. These modifiers are based upon differences between the needs and circumstances of individual patients. Factors such as the patient’s age, their health behavior or motivation, existing medical conditions, as well as other factors, may dictate the priority and extent of dental care that can be provided.
Following is a list of modifiers that may affect the provision of higher levels of care:
- Age of patient
- Arch integrity
−Strategic importance of teeth involved in treatment - Patient’s health behavior or motivation
−Compliance
−Willingness to receive treatment
−Dependability (history of keeping or breaking appointments) - Oral hygiene and periodontal status
−Activity of destructive disease - Caries activity
−Recurrent caries
−Smooth-surface lesions
−Root-surface lesions
−Pit and fissure lesions - Medical conditions
−Diabetes
−Other systemic conditions which may affect the patient’s ability to receive or respond todental therapy - Access to care
−Distance from clinic
−Availability of skilled provider
−Backlog of demand for lower levels of care
Missed Appointments
IHS is not responsible and will not pay for any cost associated with missed appointments. It is important that patients are aware of policies for those referring providers and work with the referring Service Unit to change or modify their appointment.
