D4346 Coding or Training Issues?

Patti DiGangi, RDH, BS


The new D4346 gingival inflammation code has brought opportunity to dental practices across the United States. We can finally treat gingivitis after decades of merely dumping gingival inflammation into the same category as health.

That’s the good news. At the same time, trying to integrate the new code into our already well-honed systems can bring confusion. I didn’t expect to write a book on a single code, yet most practitioners need A Gingivitis Code Finally!

Questions of all kinds regarding this new code come to me daily. A recent question about radiographic images challenged my thinking. The answer turned out to be less about the D4346 code and more about the hand-me-down training—when a member of the staff receives formal training on something and then tries to train someone else on the staff—so common in our practices.

Documentation for D4346

This new D4346 code can potentially ensure earlier intervention and disease prevention while also boosting the bottom line of the practice. Yet changes need to be made in our routines. There are many parts to understand, yet for this blog, we are going to look at the part of the code’s description that specifies: “in the absence of periodontitis.” The code is not age-based, which means we now need to show the absence of periodontitis for all ages. This means a perio chart for children as well as current radiographic images.

The 2015 American Academy of Periodontology Special Task Force paper on the diagnosis of periodontitis includes minimally documenting 6 readings probing and recession and radiographic bone height. Clinical attachment loss is the pocket depth plus recession and/or bone loss. Normal bone height measured from the alveolar crest to the cementoenamel junction should be 1.5 to 2 mm. This can only be determined with radiographic images. For D4346, inflammation must also be documented. 

Coding Accurately

Recently, I received this question about D4346: “When we switched from phosphor plates to digital sensors, we started to have problems with taking bite-wings on children. The sensor is so bulky, they cannot tolerate it in the normal bite-wing position. In order to get posterior images, the assistants have the children keep their mouth open. We take 4 images versus 2 bite-wings. I understand we need to code accurately for what we do. So, should we code for 4 PAX or 2 bite-wings?” Copies of the images were sent with the question.

Kudos to this practitioner for asking. New codes like D4346 give the opportunity for renewing and examining our systems. The truth is that the images taken were neither periapical nor bite-wings; they are inadequate as either. For them to be accepted as either was not a great choice. No doubt taking images in little mouths takes practice and patience. The story here is less about coding and more a learning curve with new technology. It appears to be a training issue.

Hand-Me-Down Training

In my most recent book, ROMA Manual on Dentistry, my co-author Dr. Benson Baty and I take a humorous look at the hand-me-down training that happens so often in practices. (Language warning) ROMA stands for Right Outta My Ass. The purpose of our book is to take a light-hearted approach to dentistry. At the same time, we challenge assumptions and traditions and look at the evidence with some ethical lessons thrown in for good measure. 

Once our school days are over, consistent training can become questionable, especially with new technology. In the daily increasing digital world, this can be problematic. When our practice moved to digital images, one of the hygienists was not there for the training, which is a rather typical circumstance in a multiple hygiene practice.

It was not of concern because the hygienist not in attendance took the best traditional images. The initial training was a full day of learning. When the absent hygienist returned, her lesson lasted about 10 minutes. The results of this hand-me-down training did not go well.


Technology is a big investment that can pay dividends in terms of the information it can provide. Your business is made up of individuals—individuals who need to be shown how to get the best from that system. 

Dental practices often settle for hand-me-down training. This can result in a disservice to our patients, frustration for the staff, and loss of productivity. The hygienist in this story fought the change to digital technology. She was the best at the traditional system and hated the uncomfortable feeling of the change. Hand-me-down training can cost a lot.

Abraham Maslow describes the four stages of skill development: unconscious incompetence, conscious incompetence, conscious competence, and unconscious competence.

Dental professionals feel they have attained this level of unconscious competency a few years into their clinical practice. Some new graduates like to think they have attained this level of competency by the end of their initial educational process. New technology challenges our feelings of competency. Training doesn’t waste time. It is an investment in future success.

Not a Coding Issue 

This practice has choices to make. It could go back to the phosphor plates. The hygienist could help the assistants, yet this is just more hand-me-down training. Technology companies offer a variety of training options as a place to start. Then it comes to the 3 P’s: practice, perseverance, and positive reinforcement.

That last one is possibly the most important. I had the joy of being there when my grandson took his first steps. He took about 5 steps and he fell. What did we did do? We cheered and said, “Hooray, buddy! Nice job! You can do it.” He got up and took 3 more steps and fell. Once again, we said, “Hooray, buddy! Nice job! You can do it.” Did we help him get up? Sure, we were there with supportive hands. And of course, in a very short time, he was off and running.

The same goes for dental professionals.

Ms. DiGangi believes dentistry is no longer just about fixing teeth; dentistry is oral med­icine. Her work helps dental professionals embrace the opportunities and understand the metrics that ac­curate insurance coding provides. The ADA recognized her expertise by inviting her to write a chapter in its CDT 2017 Companion book and again for its CDT 2018 Companion. She holds publishing and speaking licenses with the ADA for Current Dental Ter­minology©2017 and a license for SNODENT©2017 diagnostic coding. She is the author of the DentalCodeology series is of easy-to-read bite-size books. She can be reached at patti@dentalcodeology.com.

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