To find a definition, click on the first letter of the corresponding term.
Abrasion – Grinding or wearing away. (See Bruxism)
Abscess – A localized area of inflammation containing pus.
Abutment – A tooth or implant that retains or supports a fixed bridge or a removable prosthesis. The abutments may be crowns, onlays, or inlays. Sometimes referred to as a retainer.
Acid-Etch Technique – In restorative dentistry, a method of etching the tooth enamel with an acid to provide an adhesion of the composite filling material to the tooth surface.
Administrative Services Only (ASO) – An arrangement under which a third party charges a fee to process claims and handle paperwork for a self-funded group. The third party frequently performs all insurance company services (actuarial, underwriting, plan materials and descriptions, claims processing, etc.) except for the assumption of risk and the cost of paying claims. (Compare to CSO)
Aesthetics – In dentistry, refers to procedures that have a particularly evident cosmetic purpose. For example, bleaching or tooth-whitening, composite restorations (white fillings), porcelain prosthetics and veneers.
Align – To move teeth into position for a proper line of occlusion (bite).
Allowance Method – Also called a Claim Allowance Option. The method used on an eligible procedure to determine the maximum covered dollar amount considered. Allowance Methods are an integral part of a plan design and are defined in the group policy contracts and in each member certificate booklet. Some examples of Allowance Methods:
- Usual and Customary (U&C)
- Scheduled Allowances (SCU)
- Maximum Allowable Charge on PPO plan (MAC)
- Maximum Allowable Benefit (MAB)
- Maximum Procedure Allowance (MPA)
Please refer to your certificate booklet to see what Allowance Method design is used for your plan.
Alloy – A mixture of two or more metals, as in silver amalgam fillings.
Alternate Benefit Clause – A provision in a dental plan that allows the third-party payer (insurance company) to determine the benefit payable based on an alternative procedure than the one provided or proposed. This is not intended to determine treatment but to establish benefits payable.
This provision is designed into many dental plans because there are often alternate methods of treatment for the same condition in dentistry. In some cases there may be a less expensive service that is customarily performed for the given situation. In such cases, a more expensive alternate procedure may be preferred by the dental provider or the patient, or may have a cosmetic element involved. For example, a molar tooth that is being restored with a composite (white) filling will be reimbursed at the alternate benefit level of an amalgam (silver) filling.
Alveolar – Of or relating to the bony socket containing the root of a tooth. (See Alveolus)
Alveolar Process – The part of the bone in each arch of the mouth that surrounds and supports the teeth. (See Alveolus)
Alveolar Ridge – In each arch of the mouth, the ridge, line, or junction where the bone supporting the teeth meets the bony sockets containing each tooth root. (See Alveolus)
Alveolectomy – The surgical removal of part of the bone that supports the teeth. (See Alveolus)
Alveoli – Plural of alveolus. (See Alveolus)
Alveolus – In dentistry, the bony socket for the root of the tooth. A small pit or hollow. The plural form is alveoli. The root sockets in each arch are supported and surrounded by a bone structure called the alveolar process. The line or junction where the root sockets meet the surrounding bone structure is the alveolar ridge. Surgical removal, contouring or restructuring of the alveolar process is called alveoplasty.
Alveoplasty – Surgical removal or correction of the alveolar process to restore a normal contour. It can range from surgical removal (alveolectomy) in conjunction with extractions to necessary reconstruction of the ridge in preparation for dentures. (See Alveolus)
Amalgam – Dental amalgam filling is an alloy of silver, tin, mercury, and other metals, used as a restorative material. (See Composite versus Amalgam restorations)
Amputation (Root) – Surgical removal of the root portion of the tooth. It is usually performed on a multi-rooted tooth to eliminate a root that cannot be treated.
Analgesia – Reduction (or loss) of sensibility to pain without loss of consciousness.
Anesthesia – Loss of feeling, or sensation, with or without loss of consciousness.
Anesthetics – Drugs used to produce loss of feeling or sensation, either as local or general anesthesia.
Annual Enrollment -The period of time preceding the effective or anniversary date of a group insurance policy that allows eligible group members to participate or not participate. If a member elects to enroll after his/her initial 31 days of eligibility, even during an Annual Enrollment, there is usually a “Late Entrant” penalty imposed. Annual Enrollment differs from Open Enrollment. Questions about enrollment and Late Entrant provisions should be addressed with your Benefit Administrator. (See Open Enrollment and Late Entrant)
Anterior – In the front. With reference to teeth, the anteriors are incisors and cuspids. (See Mouth Diagram)
Apex – The anatomic end of the tooth root. (See Tooth Diagram)
Apexification – Normally performed on a young patient where the apex of a tooth is incompletely formed. The pulp is removed and the apex treated with calcium hydroxide. This stimulates the growth of cementum, which promotes apical closure. Root canal therapy would usually be performed at a later time.
Apical – Refers to the apex of the tooth root.
Apicoectomy (apicectomy; apiectomy) – Surgical removal of the end portion of the tooth root. It is performed through an opening (or window) made in the overlying labial or buccal alveolar bone.
Arch – In dentistry, a curved structure of the natural dentition or alveolar ridge. The two arches in the mouth are the maxilla (upper jaw) and mandible (lower jaw). (See Mouth Diagram)
Aseptic – Free from germs and infection.
Assignment of Benefits (AOB) – Transferring the insurance payment to the doctor providing the services. Signing the Assignment of Benefits signature line on a claim form authorizes payment directly to the doctor’s office.
Attending Dentist’s Statement – A form the patient receives from the dentist or specialist that has the pertinent information regarding services received. Also called a walk-out statement. Please refer to section #2 of the claim form for more information.
Attrition – The wearing away of a substance, abrasion. (See Bruxism)
Balance Billing – When a dentist or specialist charges the patient the difference between the amount reimbursed or expected from the insurance company and the dentist or specialist fees.
Basic Procedures – A category of coverage for oral procedures. The other categories are Preventive and Major. Each category may have a different coinsurance or deductible applied. See your Certificate Booklet to find out which procedures fall under which category.
Benefit – The amount payable by a third party (insurance company) toward the cost of various covered dental services.
Benefit Administrator – The representative of the Plan Sponsor who coordinates the group policy, working with the insurance carrier(s).
Benefit Credit – Benefit credit is established by the secondary carrier, when an insured member has more than one dental plan. Benefit credit is established when the benefits of both carriers combine to equal more than the actual expenses incurred. When a later claim is received for an eligible procedure that is not paid in full between the two carriers, the amount in benefit credit will be released to pay the difference. When benefit credit is earned or paid, it will be noted on your Benefit Statement. (See Coordination of Benefits)
Benefit Period – The period of time defined in the policy that certain records are kept or individual benefits are paid. Typically, a Benefit Period determines when the yearly maximum and the yearly deductible renew. The beginning date may vary depending on the plan. Please refer to your online benefits, certificate booklet, or Plan Sponsor.
Follow the links for more detailed explanations of Benefit Period types:
- Calendar Year – Jan 1 to Dec 31 of the same year.
- Policy Year – The calendar, policy, benefit or fiscal year on which the records of a plan are kept and/or benefits are paid.
- Plan Year – Usually set by the group’s effective date or a group’s fiscal year.
- Employee Year – Set by the employee/plan member’s effective date and applies to a family.
- Dependent Year – Set by each individual person’s effective date.
Benefit Statement – A statement the insured member receives summarizing the processing of a claim. The statement includes services performed, dates of service, provider identification, a summary of charges and explanations of payment or denial. Also called Explanation of Benefits (EOB) or Claim Explanation.
Bicuspids (Premolars) – The two teeth in each quadrant behind the cuspids and in front of the molars. (See Mouth Diagram)
Bilateral – Involving two quadrants, or both sides of an arch.
Bitewings – Dental X-ray films that normally show approximately the crown portions of both the upper and lower teeth on the same film.
Bleaching – A technique used to restore a discolored tooth to its natural color.
Bridgework – (Fixed) Restores the continuity of the dentition by replacing missing natural teeth with artificial teeth (pontics) which are attached to, and supported by, abutments or retainers. The abutments may be crowns, onlays or inlays. The pontics are usually supported between two abutments; however, a cantilevered bridge has abutments on just one side of the pontic. (Removable) A partial denture retained by attachments permitting its removal. It is generally a one-piece metal casting, with denture teeth to replace missing natural teeth. It is held in place by clasps. Units of removable bridges include the teeth and the clasps.
Bruxism – A clenching or grinding of the teeth, associated with a forceful jaw movement, usually during sleep. It is a habit frequently related to emotional stress, anxiety, fatigue, or bite interference. Bruxism may grind away at and/or fracture teeth. Untreated, the condition may affect a person’s entire bite (occlusion) causing temporomandibular joint (TMJ) problems and/or periodontal disease. Dental plans rarely cover the treatment of Bruxism and TMJ because the underlying cause is typically a condition other than dental decay. Coverage through one’s medical insurance should also be investigated. (See TMD/TMJ)
Bruxism Appliance – See Night Guard and Bruxism.
Buccal – The surface of the tooth toward the cheek. (See Mouth Diagram)
Cafeteria Plan – A type of benefit plan where enrollees select from a list of nontaxable benefit options. The insured members’ premium payments are funded with pre-tax employee contributions. Available plan options may include, but are not limited to, medical, dental, and eye care. The tax code allowing Cafeteria Plans restricts enrollment and cancellation to one opportunity each year plus certain qualifying events. Cafeteria Plans are also called Flex or Section 125 plans.
Calendar Year – The period of time from January 1 of any year through December 31 of the same year. On a Calendar Year plan, the benefit Period for someone who becomes effective on a date other than January 1 is their effective date through December 31 of the same year, then January 1 to December 31 subsequently. (See Benefit Period)
Calendar Year Maximum – A plan’s payment limit in actual dollars toward the services performed during a particular Calendar Year. unless otherwise stated in policy, the limit applies to all payable procedures including routine exams and cleanings. (See Calendar Year)
Canal – A tubular passage or channel. A root canal is the space within the root of a tooth that contains the pulp tissue.
Cantilever – A dental prosthesis, usually a fixed bridge, where the fake tooth (pontic) is supported by abutments or retainers on just one side.
Capitation Plan – See DHMO.
Capitation Payment – Used in the Prepaid or Dental Health Maintenance Organization (DHMO) environment, this amount is paid to each general dentist proportionate to the number of members who have selected him/her as their primary general dentist.
Capping (Pulp Capping) – A covering for a slightly exposed healthy pulp, with a material that will protect and stimulate the formation of secondary dentin. Calcium hydroxide is frequently used.
Direct pulp capping – provides a direct contact between the material used and the pulp.
Indirect pulp capping – is application of the material to diseased dentin, usually not a covered benefit.
Caries – A progressive destruction of the teeth from bacterially produced acids on tooth surfaces. A localized progressive disintegration of tooth structures – tooth decay. An irreversible disease.
Cavity – A carious lesion in a tooth. Damage to a tooth from decay.
Cement – In dentistry, material used to provide a seal and to cement restorations and appliances to teeth.
Cementum -The hard, calcified tissue that covers the anatomic root of a tooth. (See Tooth Diagram)
Certificate Booklet – The booklet issued to an insured member that contains dental benefits and limitations.
CHD – Abbreviation for child found on some dental Benefit Statements.
Claim – A statement listing services rendered, the dates of services, and an itemization of costs. Includes a statement signed by the beneficiary and treating dentist that services have been rendered. The completed form serves as the basis for payment of benefits.
Claim Allowance Option – See Allowance Method.
Claim Explanation – See Benefit Statement.
Claims Service Only (CSO) – An arrangement in which claims are processed and payments released by a contractor rather than by the organization bearing the risk of coverage. Under this arrangement, administrative services are not included with the claim services. A self-insured, self-administered group usually seeks this type of arrangement to take advantage of the claims handling expertise provided by an insurance company, processing service center, or third party administrator. (Compare to ASO)
Clasp – A metal attachment on partial dentures or other removable appliances to hold them in place. They are designed to adapt to the clasping teeth to provide maximum stability. There are many kinds of clasps, but they generally consist of two arms joined by a body that may or may not have an occlusal rest.
COBRA (Consolidated Omnibus Budget Reconciliation Act) – Federal legislation relative to continuation of health benefits for all types of employee plans that are provided by employers having twenty or more employees. The most significant aspect is the requirement that employees and/or their dependents who become ineligible for coverage may purchase continued coverage for an additional 18 months (36 months for dependents in the event of an employee’s death). Employers operating under Multiple Employer Trust (MET) such as Plan Services are treated as maintaining separate plans, and thus each of the employer units having fewer than 20 employees is exempt from COBRA regulations. Benefit Administrators are responsible for coordinating COBRA coverage options for the insured member and/or dependents.
Coinsurance – An arrangement that apportions (assigns) expenses between health plan participants and the insurer. The insured member shares in the cost of covered services, generally on a percentage basis. Coinsurance is based on the plan’s Allowance Method and other plan provisions.
Complete Denture – A denture that replaces all of the teeth in an arch.
Composite versus Amalgam restorations (white or tooth-colored versus silver fillings) – restorations, such as fillings, are typically made of either a composite material or of an amalgam of metals. Composites are tooth-colored or white in appearance and typically have a higher fee and allowance than amalgams, which have a metallic silver appearance. On visible (anterior) teeth requiring restorative treatment, most plans provide benefits for composite (white) fillings. But on molar teeth, most plans will limit the allowance to the equivalent of the silver amalgam filling even if composites are performed. Both materials provide restorative quality. An individual and his or her dentist may decide to place the composite material on a molar tooth for a number of reasons, none of which will change the limitation of the silver amalgam allowance limit on plans with an Alternate Benefit Clause.
Compulsory (Non-Contributory) – A type of plan in which the Plan Sponsor pays the full cost of the premium and has agreed to enroll all eligible members.
Considered Charges – Charges for services rendered or supplies furnished by a dentist or specialist that qualify as covered services and may be paid for in whole or in part by the dental plan. May be subject to deductibles, coinsurance, or Allowance Methods as specified by the terms of the contract.
Contributory – A plan in which a portion or all of the premiums are paid by the insured members.
Coordination of Benefits (COB) – When an insured member is covered by two separate dental plans, the expenses incurred are usually considered by both plans. In order to coordinate, the secondary carrier must obtain a copy of the Benefit Statement issued by the primary carrier. The total payment from all plans is limited to the actual costs due the dentist. Not all plans coordinate benefits. Coordination of Benefits is necessary so that an insured member or dental office does not receive more benefits than the actual expenses incurred.
Covered Amount – The maximum allowed dollar amount per eligible procedure upon which deductibles, coinsurance and other plan options are applied.
Crown – With prosthetic tooth structure, an artificial cap designed to restore proper conditions to a damaged tooth.
Curet (Curette) – A surgical instrument that has a sharp, spoon-shaped blade. It is used for debridement, root planing and gingival curettage.
Curettage – Scraping or removal of diseased tissue with a curet.
Cusp – A pointed or rounded high point on the biting or chewing surface of a tooth.
Cuspids (Canines) – The four pointed teeth located between the lateral incisor and first bicuspid in each quadrant of the mouth. They are considered to be the keystones of the arch. Sometimes referred to as the canine teeth. (See Mouth Diagram)
Date of Service – Generally, the actual date a service was performed. For claim determination, we define dates of services as follows: For prosthetics, the “impression” date rather than the delivery date. For root canals, the start or opening date rather than the completion date. For orthodontic treatment programs, the banding date.
Debridement – Removal of diseased or devitalized tissues and foreign material.
Decay – Decomposed tooth structure; caries or carious lesions of the teeth.
Deciduous – The first teeth to erupt in childhood. Also called the “baby teeth.”
Deductible – A specified amount of eligible expenses that must be incurred and paid by the insured member prior to any benefits being paid. ineligible or non-covered expenses do not count toward satisfaction of a deductible. Deductible may be annual, lifetime, quarterly, or daily and may vary in amount from plan to plan. Your deductible may vary for different procedure categories based on your plan design.
- Individual Deductibles – Deductibles applied per person. They may be limited by a Family Deductible depending on the plan.
- Annual Deductible – Deducted yearly on the plan’s Benefit Period. The amount is reapplied each year. Also called a Yearly Deductible.
- Calendar Year Deductible – An Annual Deductible that resets on January 1st of each year.
- Lifetime Deductible – Deducted once during the duration of the policy. It does not reapply each year.
- Three Month Carryover – Refers to the deductible of this plan. If the insured member satisfies the deductible in the last three months of the current Benefit Period, the deductible will carry over into the next Benefit Period. Because of this, the insured member does not need to satisfy the deductible in the new Benefit Period.
- Quarterly Deductible – Deducted each quarter, usually only used with Calendar Year plans:
- – quarter #1 = January, February, March
– quarter #2 = April, May, June
– quarter #3 = July, August, September
– quarter #4 = October, November, December
- Daily (per-visit) Deductible – Deducted from each billed visit.
- Family Deductibles – A feature of some plans that limits the cumulative dollar amount of an Individual Deductible or the cumulative number of Individual Deductibles that must be met by a family.
- Aggregate Amount Family Deductible – Refers to a specific cumulative dollar amount of Individual Deductibles that when satisfied may waive further application of deductibles for the family. There may be variations.
Aggregate Number Family Deductible – Refers to a specific number of family members who must each fully satisfy their Individual Deductible for remaining Individual Deductibles to be waived on the family. There may be variations.
Dental Prosthetics – The branch of dental science that deals with the replacement of missing teeth and related structures of the mouth.
Dental Surgery – Cutting into or on live tissue in the mouth.
Dentin – The hard tissue that forms the bulk of the tooth. The crown portion is covered with enamel and the root portion with cementum. (See Tooth Diagram)
Dentist – One who has the legal right to treat disease and injuries to the teeth or mouth and construct and insert restorations. (See Specialist)
Dentition – Once erupted, the natural teeth in the dental arch. Dentition may be made up of the primary teeth, permanent teeth or a combination.
Denture – A prosthesis replacing missing teeth.
Dependent – An insured member’s spouse and all unmarried children up to age 19 for whom the Insured member is legally responsible. In some states and/or plans, dependents are defined differently. This definition applies to the majority of states. This also includes an unmarried child 19 to 24 years of age who is a full-time student at an accredited school or college and who is dependent primarily on the Insured for support or maintenance. This definition may also include a mentally or physically handicapped child who is totally disabled since the day before his or her nineteenth birthday and who is totally dependent on the Insured for support and maintenance.
Dependent Year – A type of Benefit Period arranged by the Plan Sponsor where each insured member’s Benefit Period is set by his/her own effective date on the policy. If the insured member covers his/her dependents, they may each have a different Benefit Period renewal date than the insured member depending on when each person became effective.
DHMO (Prepaid, Capitation Plan) – Defined as a Dental Health Maintenance Organization, this is a legal entity consisting of a network of participating dental providers that provide or arrange dental care with fixed fees for a given population. Dental providers receive Capitation payments based on the number of members who have selected them as their primary general dentist. No benefits are payable for dental procedures from a out-of-network dentist. We do not maintain any DHMO networks.
Diagnostic Casts (Study Models) – A positive replica of the teeth and tissues made from an impression.
Distal – Away from the front and center of the mouth or closer to the back of the mouth — the distal surface of a tooth. (See Mouth diagram)
Division – When a Plan Sponsor has multiple locations, plants, subsidiaries, etc., their policy may be categorized into divisions. Divisions may be used to identify differences in benefits among the divisions or simply for a group’s accounting purposes.
Dual Choice – A benefit package from which an eligible individual can choose to enroll in either a traditional (indemnity) or prepaid dental benefit program.
Dysplasia – Developmental abnormality; alteration in size, shape or function.
Edentulous – An area without teeth.
Effective Date – Sometimes referred to as an “eligibility” date. The date an individual or dependent became active under a dental plan. There may be a Late Entrant provision and/or an Elimination Period applicable, as well as other plan provisions.
Eligible Member – A group member who meets the eligibility requirements specified in the group contract to qualify for coverage. It may be necessary to fulfill the group’s eligibility period before becoming eligible. (See Procedure Eligibility)
Eligibility Period – A period of time a person must be a member of a group before qualifying for group benefits. For example, an organization whose health and dental benefit plan has a 90-day eligibility period would require 90 days of qualified employment/membership before benefits could begin. An Eligibility Period should not be confused with an Elimination Period.
Elimination Period – A time period within the structure of a plan beginning immediately on an insured member’s effective date that must be satisfied before benefits on certain procedures become available. Because Elimination Periods are sometimes called Waiting Periods, care should be taken not to confuse the two terms. (See Eligibility Period>)
Employee Contribution – See Member Contribution.
Employee Year – A type of Benefit Period arranged by the Plan Sponsor where each employee/member’s Benefit Period is set by his/her own effective date on the policy. If the member covers his or her dependents, they have the same Benefit Period renewal date as the insured member.
Enamel – Tooth enamel is the white, compact and very hard substance that covers the coronal portion of the tooth and protects the dentin.
Endodontics – The branch of dentistry focusing on diseases of the tooth root, dental pulp chamber, and the surrounding tissue. A “root canal (therapy)” is an endodontic procedure.
Endo-Post – A cast designed to fit into the endodontically treated root canal of a tooth. It provides strength and stability in supporting the crown and surrounding tooth structure.
Erosion – Wearing away of tooth structure by action of a chemical agent or by mechanical wear.
Eruption – Generally, a tooth that has broken through the gingival tissue, becoming visible in the mouth.
Examination – In dentistry, investigating the mouth for diagnostic purpose. There are many distinct types of examinations. The nature of the appointment, the purpose of the examination, the amount of area examined, and the length of the examination are all factors in determining what type of examination was performed.
Existing Space – See Missing Tooth/Existing Space.
Explanation of Benefits (EOB) – See Benefit Statement.
Explanation of Payment (EOP) – A statement the dentist or specialist receives summarizing the processing of the claim. The statement includes services performed, dates of service, provider identification, a summary of charges and explanations of payment or denial. This statement may have more than one patient listed.
Extraction – Removing a tooth from the mouth.
Extraoral – Outside the mouth.
Facial – Pertaining to the face. The surface of a tooth or appliance nearest to the lips or cheeks.
Fee For Service – A system of payment or reimbursement in which the dentist or specialist is paid according to the service performed. This is the reimbursement system used by conventional indemnity insurers.
Filling – Preferred term is restoration. Filling refers to the restorations not requiring crowns.
Fixed Bridge – A prosthesis that replaces one or more teeth and is cemented into place. It consists of one or more pontics held in place by one or more retainers or abutment teeth. (See Bridgework)
Fixed Removable Bridge – A bridge where pontics may be removed in a semi-permanent type of construction by use of a tubes and screws.
Flipper – See Stayplate.
Fluoride – A solution of fluorine that is applied topically to the teeth for the purpose of preventing dental caries.
Freedom of Choice – Used in context with a managed care dental plan, the insured member has the freedom to choose any dentist or specialist whether on the PPO network or not.
Frenectomy – The surgical removal of the mucous membrane that attaches the cheeks and lips to the upper and lower arch or the surgical removal of the lingual tissue (frenum) that attaches the tongue to the floor of the mouth and the alveolar ridge.
Frenum – A fold of mucous membrane in the mouth connecting two parts and limiting motion.
Frequencies – Benefit information that advises how often certain procedures can be covered under the dental plan. For Example: One cleaning every 6 months.
Full Mouth X-ray Series – Usually 14 x-ray films consisting of 10 periapical films and 4 bitewing films.
Full Prior Extraction Coverage – Coverage for the initial placement of any prosthetic appliance (partials or dentures) or fixed ap