Inside Dental Hygiene
March 2019
Volume 15, Issue 3

The Game Changer Code

D4346 Brings Dentists and Hygienists Together

Patti DiGangi, RDH, BS CEO

Synergy is when one plus one can equal more than two. As a hygienist who never much liked math, I like the concept. The Code on Dental Procedures and Nomenclature (CDT code) D4346, barely 2 years old, has the power to bring hygienists and dentists together to create a powerful synergy for the better health of our patients.

Seeing Patients With No Diagnosis

The long tradition in dentistry has been that, after the initial patient visit, the hygienist sees the patient first. Dentistry has conditioned patients to expect prophylaxis, whether or not it is appropriate. Then the dentist comes in at end of the appointment to make a diagnosis. It is somewhat akin to a physician making the diagnosis after a patient has had a diabetic gangrenous foot removed.

Although unquestioned by most, the model could be considered to be nonsense. It can result in opportunities being missed. A major opportunity is blending the expertise of the hygienist with that of the dentist. Our educational backgrounds overlap, yet they are quite different. Dentists' main role is repair, and hygienists' is prevention.

Learning Together Leads to Greater Success

In the 1950s, there were 30 dental hygiene programs.1 Now, dental hygienists receive their education through one of more than 300 academic programs at community colleges, technical colleges, dental schools, and universities. The rapid growth of community college dental hygiene programs, which have made up the majority of programs for some time, has resulted in loss of connection during the educational process between hygienists and dentists.

I am not one to lament the past and wish for the old days, but sometimes the baby does get thrown away with the bath water. It is time for a reset. Learning together can lead to a higher level of understanding of each other and success.

D4346 Game Changer Creates a Reset

The D4346 code can bring us back together. How? The code definition reads, "scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation." The last part is the game changer. Because of those words, it could be argued that the traditional model of diagnosis after care cannot happen. The code specifically reads, "after oral evaluation."2

The code does not mention examination because it is not an examination code. In the CDT Dental Procedure Codes reference manual, under Clinical Oral Evaluations, an evaluation per the general description for that section reads in part, "The codes in this section recognize the cognitive skills necessary for patient evaluation. The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, which includes diagnosis (author emphasis) and treatment planning, is the responsibility of the dentist." An evaluation means a written diagnosis must be made. If it is not written, it is not considered to have been done.

This language in the CDT Codes is problematic for hygienists in Oregon and Colorado. Their practice act and rules allow them to make a diagnosis. The language of CDT has been challenged. CDT codes should not include limitations for a specific provider. This will become more the case as practice acts continue to evolve.3

As of 2018, 42 states allowed dental hygienists to have direct access to patients.4 Direct access, as defined by the American Dental Hygienists' Association, refers to the ability of a dental hygienist to initiate treatment based on their assessment of a patient's needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.

No More Waiting for the Dentist

It requires a change in workflow, the D4346 code represents an opportunity. Hygiene consultant Rachel Wall, RDH, BS, founder of Inspired Hygiene (inspiredhygiene.com),5 identifies the "first 20" as the most significant part of the hygiene appointment. What this means is the first 20 minutes of every hygiene appointment is assessment: fact gathering and creating the dental hygiene diagnosis. This premise says, if a scaler is in your hand earlier than 20 minutes, there has not been a complete assessment. If you are thinking that you will not have time for the prophy, that is because a prophy may not be the correct treatment.

Another related issue is the challenge of waiting for the dentist. This creates stress for everyone-certainly the hygienist and the dentist, but it can also negatively impact assistants, office professionals, and the patient. The question is why this pattern is repeated over and over. There are other choices. When the dentist is performing in repair expertise mode, it usually includes anesthetic. What if the dentist knew and was scheduled to complete the evaluation 20 minutes into each hygiene appointment rather than the frustrating way that has been tradition?

In addition to reducing stress, the change can have many other benefits. It also brings the dentist and hygienist back together to decide the most appropriate treatment based on the diagnosis, as co-diagnosticians.

1 + 1 = 3

Synergy happens in the workplace when two or more people working together produce a better outcome than working alone. It is not a touchy-feely concept, but instead a practical approach to getting results, and it is not all that difficult to create.

The D4346 code is a game changer. Yet the code does not create the change-people create the change. We can be more than the sum of our parts.


1. Dental hygiene education programs FAQ. American Dental Hygienists' Association. http://www.adha.org/resources-docs/72616_Dental_Hygiene_Education_Programs_FAQ.pdf. Published August 2016. Accessed January 16, 2019.

2. CDT 2019: Dental Procedure Codes. American Dental Association; 2019.

3. Dental hygiene diagnosis. American Dental Hygienists' Association. https://www.adha.org/resources-docs/7111_Dental_Hygiene_Diagnosis_Position_Paper.pdf. Revised September 2015. Accessed January 16, 2019.

4. Direct access 2018: 42 states. American Dental Hygienists' Association. http://www.adha.org/resources-docs/7524_Current_Direct_Access_Map.pdf. Revised April 2018. Accessed January 16, 2019.

5. Wall R. Inspired hygiene. https://inspiredhygiene.com. Accessed January 16, 2019.

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