Developing Narratives For Soft Tissue Grafts

The American Academy of Periodontology (AAP) has made its position clear: radiographs are not helpful in determining the need for soft tissue grafts, and periodontal pocket measurements provide little value in documenting soft tissue pathology. Even so, some dental insurance carriers still require radiographs and complete periodontal charting when dental practices submit soft tissue graft claims.

In the sample soft tissue graft letter provided at its Comprehensive Periodontal Insurance Workshops, the AAP points to the ADA/FDA radiographic guidelines, which reiterate that patients should not be exposed to radiation when radiographs provide no diagnostic benefit. In addition, the AAP questions the rationale of requiring probing depth measurements for soft tissue graft claims given the fact that bone loss associated with recession typically occurs on facial or lingual tooth surfaces rather than interproximal surfaces.

In the Fall 2005 publication of the Beacon, the American Association of Dental Consultants (AADC) reported that its members agree that x-rays do not assist in determining the need for soft tissue grafts. If radiographs and pocket depths are not useful in establishing the necessity for a soft tissue graft, what documentation is relevant to dental consultants?

Based on information compiled from the AAP, AADC, and various dental carriers, claims for soft tissue grafts should ideally include a separate attachment that addresses the following, as applicable to each patient’s case:

• Tooth number and location of mucogingival defect
• Amount of recession
• Amount of attached gingiva
• Amount of keratinized tissue
• A statement concerning progressive recession
• Presence of marginal inflammation
• Influence of frenum
• Indications of root sensitivity
• Cervical caries, abrasion, or abfraction
• Relationship to orthodontic or restorative care
• A statement that the procedure is reconstructive and not cosmetic in nature

And even though the AAP questions the value of probing depths in reviewing soft tissue graft claims, remember that some dental carriers require a complete and current periodontal charting. Complete charting includes pocket depths, recession readings, furcas, bleeding points, mobility, etc. What is “current” varies from carrier to carrier. Some carriers consider “current” to be charting performed within three months, some within six months, and others consider charting within a year to be current enough. All agree that photographs are very helpful in adjudicating soft tissue graft claims, and some carriers say the reasonthey require radiographs is simply to verify that the tooth being treated is present and has a good prognosis. Let’s look at each of the issues listed above separately:

Tooth number and location of mucogingival defect

In addition to identifying the number of the tooth receiving the graft, it is important to identify the area of recession (e.g., lingual or facial).

Amount of recession

The amount of recession should be stated in millimeters. Recession involves the displacement of gum tissues around the teeth, which results in more tooth exposure since the root surface is now visible. Exposed root surfaces equate to loss of attachment since bone is meant to cover root surface. There are four primary causes of recession:

1. Periodontal disease due to bacteria in the gingival crevice that release toxins and cause infection, which can cause gums to recede.
2. Trauma due to incorrect tooth brushing/flossing or inappropriate oral habits (e.g., chewing on pencils). Trauma can also occur from ill-fitting dental restorations and/or removable partial dentures. Traumatic injuries and the use of chewing tobacco can also result in soft tissue recession.
3. Osseous surgery removes some gingival tissue. Hence there is recession—gingiva below the CEJ.
4. Morphology—the shape and thickness of the gingiva and bone covering a tooth can determine if an area is prone to recession. Thin bone and scalloped gingiva can predispose an area to recession.

Amount of attached gingiva

The amount of attached gingiva should also be stated in millimeters. “Minimal attached gingiva” or “inadequate attached gingiva” are generally not acceptable because carriers consider them too subjective.

Attached gingiva is the part of the gingiva that is firmly attached to the bone or tooth. Unattached or “free” gingiva refers to the gingiva that is coronal to the attached gingiva and forms the unattached soft tissue boundary for the gingival sulcus or pocket.1 When healthy, attached gingiva protects the underlying bone from the day to day trauma associated with eating, toothbrushing, etc.

When a patient has a periodontal infection or has thin or insufficient attached gingiva, the attached gingiva can recede over time. Insufficient attached gingiva can lead to gradual loss of bone because bone levels also recede when gums recede.

Amount of keratinized tissue

The term “keratinized tissue” refers to the keratinized free gingiva and the keratinized attached gingiva together. This is the tissue coronal to the mucogingival junction. Some dental consultants haveexpressed concern that many soft tissue graft claims do not differentiate between attached gingiva and keratinzed gingiva, noting that there can be 2-3mm of keratinized gingiva but zero attached gingiva.

A statement concerning progressive recession

Carriers may want to know if there has been an increase in the amount of recession over a finite period of time. If the patient was referred by a general dentist, the periodontist can simply state that the patient or referring dentist noted progressive recession, if applicable.

Presence of marginal inflammation

Gingival margin inflammation combined with soft tissue recession and no attached gingiva indicates a mucogingival problem and the need for gingival augmentation2.

Influence of frenum

A lack of attached gingiva is sometimes associated with a high frenum attachment, which exaggerates the pull on the gum margin. The frenum is made up of muscle fibers covered by mucous membrane that attaches the cheek, lips, and tongue to associated dental mucosa. Sometimes it is attached very near the free gingival margin and can pull on the attached mucosa and cause recession. When the frenum is the cause, a frenectomy is performed. This involves surgically releasing the frenum and moving it apically so it won’t pull on the gum. A gingival graft can be performed to cover the area of recession. Most dental plans will not pay for a soft tissue graft and a frenectomy at the same session.

Indications of root sensitivity

Does the patient complain of sensitivity to hot or cold foods and liquids due to exposed roots? Is the sensitivity getting worse? Has a desensitizer already been used and failed?

Cervical caries, abrasion or abfraction

Is there evidence of cervical caries, abrasion, or abfraction?

Relationship to orthodontic or restorative care

Is this an orthodontic patient? Is recession involved on a tooth supporting an existing bridge? Is the recession near a subgingival restoration? When the need for intracrevicular restoration is combined with minimal or no attached gingiva, gingival augmentation is indicated.

A statement that the procedure is reconstructive, not cosmetic in nature

Dental consultants reviewing soft tissue claims are looking for evidence that the soft tissue graft is necessary to gain keratinized tissue to protect exposed roots from decay, reduce tooth sensitivity, and inhibit further recession. If the evidence is not provided in a brief narrative, consultants will assume it is for cosmetic purposes and deny payment.

1-3. Rose, L. , et al, Periodontics, Medicine, Surgery, and Implants 2004: 412-419.

SOFT TISSUE GRAFT PROCESSING POLICY EXAMPLES

Typical Delta Dental Policies

• Benefits are provided for sites that exhibit recession or attachment loss.
• Benefits are available only when billed for natural teeth.
• Tooth numbers and tooth surfaces must be indicated.
• When multiple soft tissue grafts are provided within a single quadrant, benefits are limited to two sites per quadrant (unless there are unusual circumstances).
• Delta considers soft tissue grafts to include three months of postoperative care and surgical re-entry for three years. Exceptional cases are considered on a by-report basis.
• Delta considers D4270 (pedicle graft) to include any frenectomy and/or distal wedge performed in the same area on the same date.
• When a subepithelial connective tissue graft (D4273) is submitted, some Delta Dental plans will pay an alternate benefit allowance for a free soft tissue graft (D4271). The balance is patient responsibility.
• Soft tissue grafts are not a benefit when performed for cosmetic reasons. The fee is patient responsibility.

Typical MetLife Policies

• Identify the tooth number, amount of recession, amount of attachment loss, amount of keratinized gingiva, and location and extent of the mucogingival defect.
• At least 3mm of recession is required to pay for a soft tissue graft. An exception may be allowed for an orthodontic patient with recession.
• MetLife pays for one soft tissue graft when grafts are placed on two contiguous teeth. For example, two teeth equal one benefit, three teeth equal two benefits, etc. If six consecutive teeth are grafted (e.g., teeth #19-#24), MetLife will pay for three grafts.
• If grafts are placed on two consecutive teeth, MetLife will combine the fees submitted for the two grafts and will typically pay 80% of its allowable fee.