Completing dental coding correctly based on the clinical diagnosis and the treatment performed is critical. If you are performing localized delivery of antimicrobial agents (LDAA), it might be time for the D4381 dental code.
D4381 is the code for "localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth," according to the American Dental Association Code on Dental Procedures and Nomenclature (CDT) as shared by Practice Booster. The antimicrobial agent must be FDA-approved and applied subgingivally into recurrent or residual periodontal pockets of at least 5 mm in depth. The agent's main purpose is to suppress pathogenic bacteria, and they are intended to remain in place long enough to provide a therapeutic benefit.
It is important to remember that periodontal pockets are often capable of healing with SRP alone. Once the patient returns for their first periodontal maintenance exam (coded as D4910), it can be determined if there is a need for further treatment, which may include LDAAs or referral for surgical therapy. D4381 should not be used with prophylaxis (D1110) or for implants since implants lack a periodontal ligament. If pocketing is present around an implant, the patient should be referred to a periodontist.
Before considering the use of LDAAs, it is important to evaluate the intended site. LDAAs should not be used if there is a possible open margin, a ledge on a crown or filling or a bone defect. They are also inadvisable if there is inflammation around a restoration caused by invasion of the biological width, according to Spear Education.
If a defective restoration is part of the problem, the restoration should be replaced, and potentially evaluated by a periodontist if biological shaping or crown lengthening is needed. Ideally, defective restorations should be identified at a regular comprehensive evaluation, and dealt with ahead of treatment and prior to evaluating for LDAA use. Applying LDAAs in a compromised site may cause recurrent periodontal infections that do not respond to LDAAs.
LDAAs may need to be applied to the same site years apart since pathogens can return with changes in home care, appointment frequency and the patient's systemic conditions. Patients with certain systemic diseases, such as diabetes mellitus, and certain periodontal risk factors or indicators can benefit from co-management. Patients who need frequent LDAA treatment should be referred to a periodontist and could also benefit from having their saliva tested for the presence of certain bacteria. It is important to look at the whole picture before applying LDAAs in order to treat your patient efficiently and effectively.
A patient might present with generalized 5 to 7 mm pockets in all four quadrants with moderate radiographic bone loss and bleeding upon probing. As recommended by the American Academy of Periodontology and reported by Practice Booster, treatment with SRP should be first followed by a four- to six-week periodontal maintenance period (D4910) to check on the progression of healing and pocket depth. If periodontal pockets remain at the D4910 appointment, the patient could be treated with LDAAs or surgical options.
If a current periodontal maintenance patient presents with a 6 mm pocket, the patient's history and systemic health should be evaluated. Check the patient's chart to see if the tooth has undergone restorative or periodontal work. If the patient has a true periodontal pocket that has not had extensive periodontal work, there is no defective restoration present, the patient has attended regular appointments and no systemic conditions are causing increased pocketing, then LDAAs may be appropriate. If a patient hasn't maintained their re-care frequency, then SRP would be indicated first, followed by a periodontal maintenance and reevaluation of the site and need for LDAAs.
It's helpful to mention the possible need for LDAAs at your patient's first SRP appointment to keep them informed about their care. Waiting until the patient's periodontal maintenance visit to apply LDAAs gives your practice time to check their insurance coverage. Your patient may respond well to SRP and not need further treatment. If they do need D4381, you will already be informed and able to answer questions about insurance.
Insurance coverage of D4381 often includes stipulations based on clinical findings and systemic health. Each insurance plan is different, and it's best to check with a provider to see what is covered. D4381 is a per tooth code. The fee submitted for a tooth should include all sites. Some insurance plans limit the reimbursement of LDAAs to one quadrant of SRP. If there are multiple teeth with multiple sites in the same quadrant, refer your patient to a periodontist.
Educating your patients about LDAAs can help them value your advice and feel prepared if their insurance does not completely cover the cost. Start the conversation about periodontal health at their very first appointment to boost patient compliance and understanding.
- Consider all aspects of the patient's systemic health and periodontal history before applying LDAAs.
- Start with SRP and re-evaluate at periodontal maintenance visits, and then determine whether LDAAs are indicated.
- Educate your patients on the importance of periodontal health.
Knowing how to use LDAAs effectively will help you provide the best course of periodontal treatment for your patients who need it.