1/14/2003
Dental Report for:
John Doe
DOB 12/25/58
SS#xxx-xx-xxxx
Claim # X1234567
Date of injury 10/31/01
Mr. Doe presented on 12/9/02 for a brief exam. He explained that on October 31, 2001 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 5/4/01), 20 (extracted 6/30/00), 28 (extracted 8/11/00).
- 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:
4/30/01 Tooth #11 fractured off at gumline; referred to Oral Surgeon for extraction.
8/7/00 Toothache #28; deep caries; referred to Oral Surgeon for extraction.
6/21/00 Toothache #20; deep caries; referred to Oral Surgeon for extraction.
12/19/95 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.
Randy Otterholt, D.D.S.
Dental Treatment Option 1
John Doe
Treatment provided by General Dentist:
Tooth |
Code |
Description |
Charges |
Date of Completion |
All |
D0150 |
*Initial Examination |
42 |
1/13/03 |
All |
D0210 |
*X-rays, Full Mouth Series |
85 |
1/13/03 |
Lower |
D1110 |
Cleaning, adult |
78 |
1/13/03 |
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 |
1/13/03 |
All |
D0210 |
*X-rays, Full Mouth Series |
85 |
1/13/03 |
Lower |
D1110 |
Cleaning, adult |
78 |
1/13/03 |
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 |
1/13/03 |
All |
D0210 |
*X-rays, Full Mouth Series |
85 |
1/13/03 |
Lower |
D1110 |
Cleaning, adult |
78 |
1/13/03 |
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.