Dental Terminology

Abscess - acute or chronic, localized inflammation associated with tissue destruction.

Abutment - tooth or root that retains or supports a bridge or a fixed or removable prosthesis.

Allowable charges - maximum dollar amount on which benefit payment is based for each dental procedure.

Amalgam - an alloy used in direct dental restorations; a "silver filling."

Appliance - device used to provide function or therapeutic (healing) effect. Fixed - one that is cemented to the teeth or attached by adhesive materials.

Attrition - the normal wearing down of the surface of a tooth from chewing.

Baby bottle tooth decay - severe decay in baby teeth due to sleeping with a bottle of milk or juice. The drink's natural sugars combine with bacteria in the mouth to produce acid that decays teeth.

Basic services - dental procedures concerned with the repair or restoration of individual teeth due to decay, trauma, impaired function, attrition, abrasion or erosion. Basic services may include oral surgery, endodontics (root canals), fillings, and periodontics (tissue/bone treatment).

Beneficiary - a person who receives benefits under a dental benefit contract.

Benefit - The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan.

Benefit Year - benefit coverage period, 12 months long, which runs one (1) year from the effective date of the policy.

Bitewing Radiograph - x-rays of the top and bottom molars and pre-molars to show decay between teeth or under fillings.

Bridgework  - Fixed -artificial teeth (pontics) retained with crowns or inlays cemented to the natural teeth, which are used as abutments. Removable - a partial denture, normally held by clasps, retained by attachments which permit removal of the denture.

Bruxism - involuntary clenching or grinding of the teeth.

Calculus - (tartar) hard deposit of mineralized material, or calcified plaque, that adheres to teeth.

Caries - tooth decay.

Certificate holder - person, usually the employee or responsible party, who represents the family unit covered by the dental benefit program; commonly referred to as a subscriber or enrollee. Other family members are referred to as "dependents."

Coordination of benefits (COB) - when an individual is covered by more than one insurance plan, the payment of claims is coordinated so that the plan designated primary pays first.

Coverage - benefits available to an individual covered under a dental benefit plan.

Covered person - individual who is eligible for benefits under a dental benefit program.

Covered services - service for which payment is provided under the terms of the dental benefit contract.

Crown - the artificial covering of a tooth with metal, porcelain or porcelain fused to metal; covers teeth that are weakened by decay or severely damaged or chipped.

Customary fee - the fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure.

Deciduous teeth - baby teeth or primary teeth.

Deductible - predetermined amount within a given time period that a member is required to pay toward covered services before the insurance company will make any payment. For example, a member might have to pay for the first $25 of covered services in a calendar year before the insurance company starts to pay.

Dental Hygienist - person who has been trained and licensed by the state to perform dental cleanings under the direction of a licensed dentist to remove calcareous deposits and stains from the surface of teeth, and in providing additional services and information on the prevention of oral disease.

Dependents - generally spouse and children of covered individual, as defined by terms of the dental benefit contract.

Eligible person - person who is qualified to receive benefits under a dental benefit program.

Employer sponsored plans - a plan is considered employer sponsored when the employer pays for at least 50% of the employee-only premium or at least 25% of the total premium.

Endentulous - having no teeth.

Endodontics - dental specialty concerned with treatment of the root and nerve of the tooth. An endodontist is a dental specialist in this field.

Enrollee - person who receives benefits under a dental benefit contract (also known as: beneficiary, covered person, insured, member).

Exclusions - Dental services not covered under a dental benefit program.

Expiration date - 1) date on which the dental benefit contract expires. 2) date and individual cease to be eligible for benefits.

Explanation of benefits (EOB) - The EOB is not a bill. The EOB details how the claim what processed and indicates the portion of the claim already paid to the dentist and the portion of the claim that is the responsibility of the insured (if applicable).

Family deductible - deductible which may be satisfied by the combined expense of all covered family members.

Fee-for-service - method of paying practitioners on a service-by-service rather than a "salaried basis"

Fee schedule - list of the charges established or agreed to by a dentist for specific dental services.

Fluoride - chemical compound that prevents cavities; makes the tooth surface stronger so that teeth can resist decay.

Gingivitis - inflammation of the gums surrounding the teeth caused by a buildup of plaque or food particles.

Halitosis - bad breath.

HIPAA - Health Insurance Portability and Accountability Act of 1996 - the law's primary intent is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs through simplification. Impressions- a negative reproduction of a given area of the mouth. Example: in bridgework, an impression of a tooth (abutment) which has been prepared for an inlay or crown.

Indemnity plan - reimburses providers on a fee-for-service basis for services covered by the group policy regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists (e.g., schedule of allowances, table of allowances, or reasonable and customary plans). Indemnity plans help to control costs through plan design provisions, contractual limitations and exclusions.

Individual deductible - amount of eligible expense a covered person must pay each year before the dental plan will make payment for eligible benefits.

Insured - person who receives benefits under a dental benefit contract (also known as: beneficiary, covered person, enrollee or member).

Insurer - organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries.

Limitations - restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided.

Major services - Dental procedures concerned with the restoration of teeth by cast restorations such as inlays, onlays, crowns, or veneers. Major services may also include endodontics (root canals) or periodontics (tissue/bone treatment)

Malocclusion - improper alignment of biting or chewing surfaces of the upper and lower teeth.

Maximum allowable charge - see maximum benefit.

Maximum allowance - the maximum dollar amount a dental program will pay toward the cost of a dental service as specified in the program's contract provisions (e.g., UCR, table of allowances).

Maximum benefit - maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specific time period (also known as: maximum allowable charge).

Maximum fee schedule - compensation agreement in which a participating dentist agrees to accept a prescribed sum as the total fee for one or more covered services (also known as: maximum allowable reimbursement).

Noncontributory Program - a method of payment for group coverage in which the entire monthly premium for the program is paid by the sponsor.

Non-duplication of Benefits - applies if a subscriber is eligible for benefits under more than one plan. A dental benefit contract provision relieving the third-party payer of liability for cost of services if the services are covered under another program. Distinct from a coordination of benefits provision, because reimbursement would be limited to the greater level allowed by the two plans, rather than a total of 100% of the charges. Also referred to as "benefit-less-benefit" or "carve-out".

Orthodontics - a dental specialty concerned with straightening or moving misaligned teeth and/or jaws with braces and/or surgery. An orthodontist is a dental specialist in this field.

Out of pocket maximum - the maximum amount and insured will have to pay for covered expenses under a plan during a benefit period.

Panoramic radiograph - a single large x-ray of the jaws taken by a machine that rotates around the head.

Pedodontics - a dental specialty concerned with treatment of children. A pedodontist is a dental specialist in this field (also known as: pediatric dentist).

Periodontics - a dental specialty concerned with treatment of gums, tissue and bone that supports the teeth. A periodontist is a dental specialist in this field.

Periodontitis - inflammation and loss of connective tissue of the supporting or surrounding structure of the teeth (also known as: gum disease).

Plaque - a bacteria-containing substance that collects on the surface of teeth. Plaque can cause decay and gum irritation when it is not removed by daily brushing and flossing.

Policy Holder - an individual or group that has entered into an insurance contract.

Point-of-service - arrangements in which patients with a managed care dental plan have the option of seeking treatment from an "out-of-network" provider. The reimbursement for the patient is usually based on a lower table of allowances with significantly reduced benefits than if the patient had selected an "in-network" provider.

Policy Holder - an individual or group that has entered into an insurance contract.

Preauthorization - statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract.

Precertification - confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program.

Predetermination - an administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient's eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, co-payment and/or maximum limitation. Under some programs. predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200.

Pre-existing Conditions - Oral health condition of an enrollee which existed before his/her enrollment in a dental program.

Premium - amount charged by a dental benefit organization for coverage of a level of benefits for a specified time.

Prevailing fee - fee most commonly charged for a dental service in a given area.

Preventive services - dental procedures concerned with the prevention of dental diseases by protective and educational measures. May include examination, cleanings, x-rays and fluoride.

Prophylaxis - (prophy) a professional cleaning to remove plaque, calculus (mineralized plaque) and stains to help prevent dental disease.

Prosthodontics - dental specialty concerned with restoration and/or replacement of missing teeth with artificial materials. A prosthodontist is a dental specialist in this field.

Provider - unique individual dentist (preferred providers, general dentists, specialty providers, practicing providers).

Radiograph - x-ray.

Reasonable and Customary (R & C) Plan - dental benefit plan that determines benefits based only on "Reasonable and Customary" fee criteria.

Reasonable fee - fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances. Therefore, it may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee (also see customary fee, reasonable fee).

Reimbursement - Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for a service covered by the contractual arrangement.

Restoration - a broad term applied to any inlay, crown, bridge, partial denture, or complete denture that restores or replaces loss of tooth structure, teeth or oral tissue. The term applies to the end result of repairing and restoring or reforming the shape, form and function of part or all of a tooth or teeth.

Root Canal Therapy - (endodontic therapy) the treatment of a tooth having a damaged pulp. Root Canal Therapy usually includes completely removing the pulp, sterilizing the pulp chamber and root canals, and filling these spaces with sealing material.

Scaling - removal of plaque, calculus, and stain from teeth.

Schedule of allowances - list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service.

Schedule of benefits - listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid.

Sealant - thin plastic material used to cover the biting surface of a child's tooth to prevent tooth decay.

Specialist - dentist or other health professional whose training and expertise are in a specific area of dentistry. Recognized clinical specialties in dentistry are: endodontists, oral and maxillofacial surgeons, oral patholigists, orthodontists, pediatric dentists, periodontists, prosthodontists and public health dentists.

Subscriber - person, usually the employee, who represents the family unit in relation to the dental benefit program (also known as: primary subscriber, enrollee, insured, covered person, beneficiary).

Table of allowances - list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service (also known as: schedule of allowances, indemnity schedule).

Termination date - 1) the date on which the dental benefit contract expires. 2) The date and individual cease to be eligible for benefits.

Third-Party Administrator (TPA) - person or organization providing certain administrative services to benefit plans, including record keeping, premium collection, claims review and payment, claims utilization review and maintenance of eligibility records.

TMJD - temporomandibular Joint is the joint formed by the two condyles of the mandible.

TMJD Syndrome - symptoms consisting of pain n the muscles of the mastication and jaw joints, clicking in the jaw joints, and limitation in the jaw movements.

UCR (Usual, Customary and Reasonable) Plan - dental benefit plan that determines benefits based on "Usual, Customary, and Reasonable" fee criteria (see Usual fee, Customary fee and Reasonable fee).

Usual fee - fee that an individual dentist most frequently charges for a given dental service (see Customary fee and Reasonable fee).

Waiting Period - period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.