Non-Insured Health Benefits
Endodontic Policy October 2005

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

Endodontic therapy on anterior teeth (13-23 and 33-43 inclusive) (procedure codes 33111 and 33100) may be completed without predetermination. Predetermination for bicuspid and molar teeth remains mandatory. However, it is expected that the provider will ensure that the functionality and restorability of the anterior teeth requiring endodontic therapy will meet the criteria as listed below prior to proceeding with treatment.

Incomplete root canal therapy will be funded to the equivalent of a pulpectomy.

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

Complete Documentation Including:

• a completed Standard Dental Claim Form, l'Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Form, computer generated form, or NIHB DENT-29 Form;
• current radiographs including periapical films specific to the requested treatment, and or bitewings, panoramic radiographs;
• radiographs sho uld identify the client, provider, and must be mounted, dated and of acceptable quality to enable predetermination of the proposed treatment; and
• a comprehensive treatment plan. 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.

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

Determination of Functionality of Teeth:

• The Non-Insured Health Benefits (NIHB) Program 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.

Determination of Restorable Teeth:

• a favourable crown-root ratio (at least 1:1);
• adequate periodontal support, based on alveolar bone levels (greater than 50%) visible on submitted radiographs and degree of furcation involvement, in addition to further supporting documentation, where necessary, indicating mobility and attachment loss.
• 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).