Dentures, Extractions, Emergency Response to Pain and Restorative Care

Program Guidelines

The PrevMED® Oral Health Maintenance Program includes the unique oral health needs of people living in skilled nursing facilities. Our goal is to provide our patients with the on-site care they need to control and prevent oral infection and harmful bacteria.

The OHM Program benefits include dentures, routine extractions, emergency response to acute pain and restorative care. This brochure contains detailed guidelines on these programs. Please read the guidelines carefully; they will help you understand the process and follow the procedures for each of these benefits. If you need further details or would like specific questions answered, please call the PrevMED Resident Service Center toll free at 1-888-604-0002.

Denture Program

Denture prostheses are a secondary benefit of the PrevMED® Oral Health Maintenance (OHM) Program offered to those patients currently without a denture or whose existing denture is deemed non-functional by a PrevMED Dentist. Patients enrolled in the OHM Program who are interested in having a denture fabricated, must request a denture and be evaluated by a PrevMED Dentist to determine if they are a good denture candidate.

Due to the diverse nature of people living in skilled nursing facilities, not all patients will benefit from a denture. It is important to note that dentures are not designed as a replacement for natural teeth, they are a prosthetic substitute. Natural teeth are very efficient in chewing food whereas dentures offer a significant reduction in chewing efficiency compared to natural teeth. Taking this into consideration, our Dentists will evaluate not only the patient’s oral physiology, but their behavior and cognitive faculties in determining whether the patient can adapt to wearing and caring for a denture.

OHM Program Health Plan Designation

Each PrevMED® OHM Program patient was evaluated by our Dentist during an initial Comprehensive Oral Exam and enrolled into one of our specially designed plans. The plan in which a patient is enrolled will determine their denture candidacy.

Natural Teeth Plan

Designed to maintain the health of each patient’s natural teeth.

Patients enrolled in this plan may be eligible for a denture.

Both Teeth & Denture Plan

Designed to maintain the health of each patient’s natural teeth and existing denture. Patients may be eligible for a full or partial denture depending on the PrevMED selected plan in which they are enrolled. If a patient undergoes the extraction of all remaining teeth, our PrevMED dentist will do a denture evaluation after approximately 10 weeks of healing to determine eligibility for dentures.

Existing Denture Plan

Designed to maintain the health of each patient’s oral cavity and his/her existing dentures. Replacement dentures are only provided due to loss, irreparable damage, or based on a PrevMED Dentist’s determination that the existing denture(s) is no longer functional and will not benefit from a reline. Patients must meet the clinical and financial eligibility requirements for a replacement denture.

New Denture Plan

Designed for the patient who has no remaining teeth, no existing dentures, but is a good denture candidate. Patients must meet the clinical and financial eligibility requirements for a denture.

Eligibility Criteria for the Denture Program

A denture candidate must be evaluated by Dentist. A dental hygienist is not qualified to make that evaluation. If a patient requests dentures, we will ask our Dentist to do an evaluation on their next scheduled visit to the facility.

Clinical Eligibility

  1. Oral Physiology: An adequate ridge of bone must be present in order for a denture to fit and function properly. It is common for this ridge of bone to deteriorate as people age.
  2. Behavior: Fabricating a denture requires a series of intricate steps. A combative or aggressive patient may not tolerate the denture oral impression or fittings necessary during the fabrication process.
  3. Cognitive Capacity: Learning to tolerate, speak and chew with a denture requires determination and practice. Patients lacking in appropriate cognitive capabilities may not adjust well to a denture. This could hinder their chewing rather than help.
  4. Current Denture Status: Patients with a functional denture will not be eligible for a replacement as long as the current denture is considered functional. If the denture is deemed nonfunctional, is lost or broken, the patient may be eligible for a replacement.

Patients with a marginally functional denture may be eligible for a soft chair-side reline twice per year or a hard lab reline every 12 months, at our Dentist’s discretion. (Replacement denture(s) may be fabricated 12 months following a hard reline.)

Financial Eligibility

–     The patient must be actively enrolled in the PrevMED® OHM Program.

–     The patient (or Responsible Party) must sign and return a Denture Fabrication Consent Form before the denture process begins.

–     The patient’s account must be current and up-to-date on payments.

–     Payments during the denture process must be kept current for the process to continue. Delinquent accounts may result in a delay in denture fabrication.

–     Following the delivery of a denture the patient (or Responsible Party) agrees to remain in the OHM Program for a period of 12 months or be subject to an early termination fee. This fee is $500 per denture or $1,000 per set and must be paid within 30 days of the policy’s cancellation. (The Responsible Party will not be liable for this fee if the patient passes away within the 12 month commitment period.)

Denture Fabrication Process

Following receipt of the signed denture consent form and verification of the patient’s eligibility the fabrication process may begin.

Typically it takes 8-16 weeks to complete the two to six steps required to fabricate a denture(s).

The timeline is based on several factors including; the fabrication step, the lab’s processing time, the patient’s availability and/or temperament during the dentist’s visit and the dentist’s schedule.

After the denture has been delivered it may be replaced once every 18 or 36 months depending on the PrevMED policy, provided the PrevMED Program payment are current.

Extractions

The PrevMED® OHM Program Extraction Benefit covers routine extractions that, in the opinion of our Dentist, can be safely performed in a non-operatory setting. Extractions included in this benefit are limited to teeth causing pain and/or infection. The medically compromised nature of many residents, complications associated with multiple medications and the fact that a nursing home setting is not the optimal environment to perform more significant extractions, are all factors that must be considered in determining the safety of an on-site extraction.

Clinical Eligibility for On-Site Extraction

Extractions considered routine may be performed on-site if the PrevMED Dentist determines it is safe to perform the procedure within a skilled nursing facility. The Dentist will use the following criteria in determining a patient’s clinical eligibility for an on-site extraction.

  1. Patient’s Medical History: The Dentist will review the patient’s list of medications and current medical history to determine whether an extraction can be safely performed on-site. With medically compromised patients, referral to a local oral surgeon’s office is probable.
  2. Symptoms: Extractions will only be performed on patients experiencing pain and/or infection. Extractions of asymptomatic teeth or extractions of teeth for dentures are not covered under this program.
  3. Behavior: The Dentist will determine, in his/her clinical opinion, whether the patient can tolerate an on-site extraction based on their overall behavior. Combative or aggressive patients may be referred to an oral surgeon for extractions.
  4. Difficulty of Extraction: Extractions considered invasive may be considered too risky to safely perform on-site. These procedures may be referred to a local oral surgeon.
  5. PrevMED will provide an out of network benefit for extractions, recommended by our dentist, that cannot be safely performed on site. This plan is limited to $150.00 per extracted tooth with a maximum benefit of $450.00 per year. Benefit will be paid directly to the provider. Any additional charges incurred by the resident in excess of the benefit as described above will be the sole responsibility of the resident, facility or responsible party.
  6. A signed Extraction Consent Form and Medical Consult Form are on-file with PrevMED prior to scheduling the extraction.

Extraction Services for Non-Enrolled Patients

Residents not enrolled in the OHM Program at a PrevMED facility will be eligible for fee-for-service extractions, within certain guidelines.

  1. The resident is experiencing pain and/or infection.
  2. Following evaluation, our PrevMED Dentist determines that the extraction can be safely performed on-site. Any patient the Dentist determines cannot safely have an extraction completed on-site will need to be referred to a local oral surgery office for treatment.
  3. A signed Extraction Consent Form and Medical Consult Form are on-file with PrevMED prior to scheduling the extraction.
  4. Payment for services must be received in-full prior toscheduling the procedure. (Services may include, for example; Limited Exam, X-Ray, Extraction)

Emergency Response to Acute Pain

Should a resident on the PrevMED® OHM Program experience dental discomfort, the facility DON, Physician or Charge Nurse may contact their designated PrevMED Registered Dental Hygienist (RDH) and request advice from a Dentist. The RDH will obtain the following information and relay the details to a PrevMED Dentist.

  1. The resident’s name and room number.
  2. The resident’s symptoms; discomfort, noticeable swelling, discoloration, etc. based on the DON/Physician/Charge Nurse’s observations.
  3. The resident’s medical history; what factors may be contributing to the patient’s discomfort as relayed by the DON/Physician/Charge Nurse.

Based on the RDH’s information, the Dentist will determine whether to contact the facility directly, schedule a visit or have the RDH return the call.

Should the Dentist elect to contact the facility directly he/she may recommend antibiotics and/or pain medication for the patient. An immediate visit by the Dentist may not be necessary or warranted until the patient has received the antibiotics. The Dentist will make this determination.

Non-Enrolled Residents

If the resident is not enrolled in the PrevMED® OHM Program, the Dentist may recommend antibiotics and/or pain medicine be prescribed by the patient’s attending physician rather than prescribing them directly.

Restorative Care:

Restorative services (i.e. fillings) are a secondary benefit of the PrevMED Program offered to those enrolled patients who, under the dentist’s discretion, would benefit from the prescribed restorative procedure.

Restorations are limited to one to four direct-fill surfaces (i.e. silver or tooth colored fillings), re-cementation of indirect restorations (i.e. crowns and/or inlays).

Providing dental treatment using portable equipment, within a nursing home environment has its limitations. Based on the patient’s ability to tolerate the prescribed treatment the dentist will determine whether restorations can be safely and successfully completed on-site.

Clinical Eligibility for On-Site Restorations:

  1. Patient’s Medical History: The dentist will review the patient’s list of medications and current medical history to determine whether a restoration can be safely performed on-site.
  2. Behavior: The dentist will determine, in his/her clinical opinion, whether the patient can tolerate an on-site restoration based on their overall behavior.
  3. Difficulty of Restorations: Restorations determined to be beyond the patients capability of tolerating will be recommended for treatment off site. (Off-site restorative treatment is not a covered benefit of the PrevMED program).
  4. A signed Restorative Consent Form is on file with PrevMED prior to scheduling the service.