Revised Endodontic Funding Policy

August 2004

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The Non-Insured Health Benefits (NIHB) Program for First Nations and Inuit is a public health program that is funded by Health Canada. The Program funds a range of medically necessary goods and services to supplement benefits provided through other private, federal, provincial or territorial health care programs. Benefits are consistent with contemporary practice standards performed in dental offices across Canada. The primary objective of the Program is to improve and maintain the oral health of this population group.

Health Canada sees oral health as a shared responsibility between the individual client, who is expected to play an active role in the maintenance of his/her oral health, the provider, who delivers the appropriate services, and NIHB which provides funding for dental benefits.

The objective of this policy is to clarify the decision making process as currently applied, when funding endodontic treatment.

All endodontic treatment will require predetermination as outlined in the Dental Practitioner Information Kit (DPIK) section 2.9.6. Patients requiring emergency endodontic treatment should be provided immediate care for relief of pain and infection (which may include open and drain procedures, pulpotomies, and/or pulpectomies, etc). Procedures involved with providing immediate relief of pain will be considered for post approval as outlined in the DPIK section 2.9.2.

The following information must be included when requesting funding for endodontic treatment:

1. Complete Documentation

• a completed NIHB DENT - 29 form with a current and correct Part 3B "missing tooth notation";
• current radiographs (including peri-apical films of all teeth for which endodontic treatment is indicated, in addition to bite-wings and/or a panoramic radiograph). All submitted radiographs should identify the client as well as the provider and must be mounted, dated and of acceptable quality to enable predetermination of the proposed treatment; and
• a comprehensive treatment plan for the mouth. If rampant biological disease is present, treatment plans should include all restorative, periodontal, preventive, prosthodontic and endodontic treatment, with the understanding that endodontic treatment will be undertaken only after active caries and/or periodontal disease has been addressed.

In addition, Regional Dental Officers will consider evidence of acceptable oral health/commitment to improvement of oral health by:

• client's claim history. This will support the client's ability to control oral pathogens and maintain a healthy oral environment as evidenced by regular attendance in a dental office for recall appointments and preventive care. Information about previous (adjunct) services to maintain health, as provided by other third parties, should accompany the submission where applicable;
• completion of previously approved treatment plans. Patients with a history of incomplete treatment plans may not be considered for endodontic treatment until such time as required basic care has been completed; and
• any additional supporting information from the client's provider to support the submission for endodontic treatment.

Endodontic treatment will be approved for funding when both the functionality and restorability of the tooth (teeth) requested have been met.

2. Determination of Functionality of Teeth:

• NIHB will consider funding endodontic treatment for teeth numbered #16 to #26 and #36 to #46, inclusive. Teeth numbered #17, 18, 27, 28, 37, 38, 47 and 48 may be considered only if they are deemed to be essential in maintaining a stable occlusion.
• Teeth will be considered functional if they are seen to be a critical abutment for any planned removable prosthodontic treatment. NIHB will favor the maintenance of intact anterior segments, whenever possible.

3. Determination of Restorable Teeth:

• a favourable crown-root ratio (at least 1:1);
• adequate periodontal support, based on alveolar bone levels (at least greater than 50%) visible on submitted radiographs and degree of furcation involvement, in addition to further supporting documentation, where necessary, indicating amount of mobility and loss of attachment.
• adequate remaining non-diseased tooth structure to ensure that biologic width can be maintained during restoration; and
• no need for further complex dental treatment such as crown lengthening, root re-sectioning or orthodontic movement.

Endodontic treatment will not be funded when:

• the functionality and restorability of the tooth/teeth cannot be established; and when
• there is evidence of uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease).