Date

Office Name, Address

Dental Report for:

John Doe

DOB 12/25/59

SS#xxx-xx-xxxx

Claim # X1234567

Date of injury 10/31/2009

 

Mr. Doe presented on 12/9/12 for a brief exam.  He explained that on October 31, 2009 he tripped at work, hitting his chin on some iron.  He went to the Emergency Room, where he was referred to an Oral Surgeon, Dr. OS.  Dr. OS diagnosed multiple jaw fractures and broken teeth.  She splinted the upper and lower jaws together, and extracted teeth #12 and 29.

 

Significant clinical findings:

  • Fractured enamel on teeth 3, 4, 10, 13, 14, 15.
  • Sensitive upper and lower anterior teeth.
  • Previously missing teeth 11 (extracted 5/4/08), 20 (extracted 6/30/07), 28 (extracted 8/11/06).
  • Missing teeth 12 & 29 since accident.
  • Generalized increased tooth mobility.
  • Caries on 6, and under old crowns on 18, 19, 30.

 

Recent past dental history:

4/30/10            Tooth #11 fractured off at gumline; referred to Oral Surgeon for extraction.

8/7/09              Toothache #28; deep caries; referred to Oral Surgeon for extraction.

6/21/09            Toothache #20; deep caries; referred to Oral Surgeon for extraction.

12/19/05          Cleaning; complete exam

 

Various treatment plans are possible to treat this case.  Choice of treatment will depend on:

  • Patient’s desire and ability to fix pre-existing conditions at the same time as accident-caused conditions.
  • Patient’s ability to schedule and keep numerous dental appointments over an extended time period, with multiple specialists.

 

Sincerely,

 

Dr. ________


 

Dental Treatment Option 1

John Doe

Treatment provided by General Dentist:

Tooth

Code

Description

Charges

Date of Completion

All

D0150

*Initial Examination

42

 

All

D0210

*X-rays, Full Mouth Series

85

 

Lower

D1110

Cleaning, adult

78

 

Upper

D1110

Cleaning, adult, w/ anesthetic

78

 

3

D2750

*Crown, porcelain + high noble metal

775

 

4

D2750

*Crown, porcelain + high noble metal

775

 

4

D2950

*Core build-up

137

 

6

D2331

Composite filling, 2-surface

154

 

11

D6056

Implant Abutment

385

 

11

D6059

Crown, implant-supported

775

 

12

D6056

*Implant Abutment

385

 

12

D6059

*Crown, implant-supported

775

 

13

D2750

*Crown, porcelain + high noble metal

775

 

13

D2950

*Core build-up

137

 

14

D2750

*Crown, porcelain + high noble metal

775

 

14

D2950

*Core build-up

137

 

15

D2750

*Crown, porcelain + high noble metal

775

 

15

D2950

*Core build-up

137

 

18

D2750

Crown, porcelain + high noble metal

775

 

19

D2750

Crown, porcelain + high noble metal

775

 

20

D6056

Implant Abutment

385

 

20

D6059

Crown, implant-supported

775

 

28

D6056

Implant Abutment

385

 

28

D6059

Crown, implant-supported

775

 

29

D6056

*Implant Abutment

385

 

29

D6059

*Crown, implant-supported

775

 

30

D2750

Crown, porcelain + high noble metal

775

 

31

D6056

Implant Abutment

385

 

31

D6059

Crown, implant-supported

775

 

 

 

Total:

$14,145

 

*Asterisk lines are accident-related.            Total Accident-related:  $6, 870 (+ specialist’s fees)

 

Treatment to be provided and billed by Endodontist specialist:

  • Possible root canal treatment on teeth #4, 13, 14, 15.

 

Treatment to be provided and billed by Periodontist specialist:

  • Periodontal crown lengthening surgery, upper left quadrant;
  • Implants to replace missing teeth #11, 12, 20, 21, 28, 29.

Dental Treatment Option 2

John Doe

 

Treatment provided by General Dentist:

Tooth

Code

Description

Charges

Date of Completion

All

D0150

*Initial Examination

42

 

All

D0210

*X-rays, Full Mouth Series

85

 

Lower

D1110

Cleaning, adult

78

 

Upper

D1110

Cleaning, adult, w/ anesthetic

78

 

3

D2750

*Crown, porcelain + high noble metal

775

 

4

D2750

*Crown, porcelain + high noble metal

775

 

4

D2950

*Core build-up

137

 

6

D2331

Composite filling, 2-surface

154

 

13

D2750

*Crown, porcelain + high noble metal

775

 

13

D2950

*Core build-up

137

 

14

D2750

*Crown, porcelain + high noble metal

775

 

14

D2950

*Core build-up

137

 

15

D2750

*Crown, porcelain + high noble metal

775

 

15

D2950

*Core build-up

137

 

18

D2750

Crown, porcelain + high noble metal

775

 

19

D2750

Crown, porcelain + high noble metal

775

 

30

D2750

Crown, porcelain + high noble metal

775

 

Lower

D5214

*Partial Denture, removable

1155

 

Upper

D5213

*Partial Denture, removable

1155

 

 

 

Total:

$9,495

 

*Asterisk lines are accident-related.            Total Accident-related:  $6,860 (+ specialist’s fees)

 

Treatment to be provided and billed by Endodontist specialist:

  • Possible root canal treatment on teeth #4, 13, 14, 15.

 

Treatment to be provided and billed by Periodontist specialist:

  • Periodontal crown lengthening surgery, upper left quadrant;
  • Implants to replace missing teeth #11, 12, 20, 21, 28, 29.

 


Dental Treatment Option 3

John Doe

 

Treatment provided by General Dentist:

Tooth

Code

Description

Charges

Date of Completion

All

D0150

*Initial Examination

42

 

All

D0210

*X-rays, Full Mouth Series

85

 

Lower

D1110

Cleaning, adult

78

 

Upper

D1110

Cleaning, adult, w/ anesthetic

78

 

3

D2750

*Crown, porcelain + high noble metal

775

 

4

D2750

*Crown, porcelain + high noble metal

775

 

4

D2950

*Core build-up

137

 

6

D2331

Composite filling, 2-surface

154

 

18

D2750

Crown, porcelain + high noble metal

775

 

19

D2750

Crown, porcelain + high noble metal

775

 

30

D2750

Crown, porcelain + high noble metal

775

 

Lower

D5214

*Partial Denture, removable

1155

 

Upper

D5213

*Partial Denture, removable

1155

 

 

 

Total:

$6,759

 

*Asterisk lines are accident-related.            Total Accident-related:  $4,124 (+ specialist’s fees)

 

Treatment to be provided and billed by Oral Surgeon specialist:

  • Extraction of teeth #13, 14, 15.