Pseudopockets or True Periodontal Pockets?
(a.k.a. D4346 Scaling, or D4341 Scaling/Root Planing?)

[July 2016 Update: I created a separate page with a much more extensive discussion of the new D4346 code:
D4346 Scaling Code]

Why this issue matters:

• Dental insurance claims are frequently submitted for D4341/D4342 because the treatment performed is clearly above and beyond a preventative D1110 prophylaxis procedure.
• Often these claims are denied because most dental insurance plans will NOT pay scaling/root planing benefits for pseudopockets. Insurance companies follow the strict definitions below, and require documentation that roots are available to root plane.
• Until recently, there was no CDT code that accurately reflects treating patients with gingivitis/pseudopockets but no loss of attachment. These patients are not healthy, so a prophy code is not appropriate. They do not have roots to plane, so scaling and root planing code is not appropriate. A new code, effective 1/1/2017, fills this coding gap.

Understand what pocket depth means:

• Measured from the gingival margin to the base of the pocket.
• A pocket can deepen by:
  1. Migration of gingival margin in a coronal direction; or
  2. Migration of the gingival attachment in an apical direction.

Know the difference between Pseudopocket...

• Pocket develops because of gingival enlargement.
  • Causes of gingival enlargement can be gingival hyperplasia, edema, drug-induced, or hormones (pregnancy gingivitis).
• No loss of supporting periodontal tissues.
• No loss of connective tissue attachment.
• No apical migration of junctional epithelium.
  • Gingival margin migrates coronally.
• Base of pocket is coronal to alveolar bone crest (suprabony; supracrestal; supraalveolar).

... and True Periodontal Pocket

• Pocket develops because of migration of connective tissue attachment.
• Apical migration of junctional epithelium.
• Actual loss of supporting periodontal tissues.
• Actual loss of connective tissue attachment.
• Base of pocket can be coronal to alveolar bone crest (horizontal bone loss), or apical to alveolar bone crest (infrabony; subcrestal; intraalveolar; angular bone loss).

Understand what Clinical Attachment Level (CAL) means:

• CAL does not stand for "calibrated attachment level" or "clinical attachment loss".
• The greater the loss of clinical attachment, the larger the CAL measurement.
• Loss of clinical attachment level is associated with true periodontal pockets, but not necessarily with pseudopockets.
• There are three possible scenarios, and calculating CAL is different for each.
  1. Gingival margin is right at CEJ:
     • CAL = pocket depth
  2. Tooth has recession, and gingival margin is below/apical to the CEJ:
     • CAL = (pocket depth) PLUS (gingival margin level from CEJ)
  3. Gingival margin is above/coronal to CEJ:
     • CAL = (pocket depth) MINUS (gingival margin level)
• CAL is frequently measured and charted incorrectly. For dental practice management software to automatically calculate CAL correctly, then dental personnel must properly enter pocket depths AND gingival margin level, including using + and - correctly.
• There is a great illustration of CAL calculation here (PDF file).

Understand AAP Definitions:

• Pseudopocket: A deepening of the gingival crevice resulting primarily from an increase in bulk of the gingiva without apical migration of the junctional epithelium or appreciable destruction of the underlying tissue.
• Periodontal Pocket: A pathologic fissure between a tooth and the crevicular epithelium, and limited at its apex by the junctional epithelium. It is an abnormal apical extension of the gingival crevice caused by migration of the junctional epithelium along the root as the periodontal ligament is detached by a disease process.
• Suprabony Pocket: A periodontal pocket with a base coronal to the alveolar bone.
• Infrabony Pocket: A periodontal pocket that extends into an intrabony periodontal defect.

Scaling and Root Planing implications:

• D4341 or D4342 code is for Scaling AND ROOT PLANING. For root planing, by definition you need....roots. A healthy mouth has roots covered by periodontal attachment apparatus. For roots to be present to plane, they must be exposed in the sulcus, i.e. there must have been some loss of the clinical attachment.
• A pocket depth over 3mm does not necessarily equate to loss of clinical attachment level. Pockets can be deeper in gingivitis cases (pseudopockets) but no loss of clinical attachment, therefore no roots to plane.
• Bleeding does not necessarily equate to loss of clinical attachment level. Bleeding can be present in gingivitis cases but no loss of clinical attachment and therefore no roots to plane.
• Subgingival calculus does not necessarily equate to SRP need. There can be subgingival calculus but it can still be on the enamel. That is not root; that does not require root planing. Subgingival calculus on the root, however, does require root planing.
• The AAP website has a page on "Non-surgical periodontal treatment". In their SRP description it includes "...to smooth the tooth root". In other words, if no root is present, SRP is not being done. No root = no SRP.

CDT 2017 Code Comparisons:

D1110 Prophylaxis - adult.

• "Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors."

D4341 and D4342 Periodontal Scaling and Root Planing.

• "This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others."

D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation.

• "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. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures."
• Code goes into effect on January 1, 2017.
• See my more detailed discussion of proper use of this code at 4346 Dental Code page.