APPENDIX C
Medically Necessary Dental Services

B.Alex White, D.D.S., Dr.P.H., Lauren L.Patton, D.D.S., William G.Kohn, D.D.S., and James A.Lipton, D.D.S., Ph.D.

OVERVIEW

The Balanced Budget Act of 1997 directed the Secretary of Health and Human Services to request the National Academy of Sciences to analyze “the short- and long-term benefits, and costs to Medicare” of extending Medicare coverage for certain preventive and other services. Congress directed that the report include specific findings with respect to coverage of a number of services, including medically necessary dental services.

The purpose of this background paper is to present scientific evidence related to medically necessary dental services for selected medical conditions or in conjunction with certain medical procedures. This review is not intended to make specific recommendations about the clinical management of oral conditions or the prevention of oral complications or to address the entire range of diseases, conditions, or procedures for which medically necessary dental services may be indicated. Rather the intent is to review the evidence about certain oral health interventions in preventing or reducing morbidity and/or mortality for selected medical conditions. For a very limited set of medical diagnoses or under very specific clinical conditions, dental services are covered under Medicare. Evidence on the effectiveness of dental services in these circumstances is not covered in this review, although some information may be included for clar-

Senior Investigator, Center for Health Research, Kaiser Permanente Northwest Division; Associate Professor, Department of Dental Ecology, University of North Carolina at Chapel Hill; Associate Director for Science, Division of Oral Health, Centers for Disease Control and Prevention; Assistant Director for Training and Career Development, Division of Extramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health.



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Extending Medicare Coverage for Preventive and Other Services APPENDIX C Medically Necessary Dental Services B.Alex White, D.D.S., Dr.P.H., Lauren L.Patton, D.D.S., William G.Kohn, D.D.S., and James A.Lipton, D.D.S., Ph.D. OVERVIEW The Balanced Budget Act of 1997 directed the Secretary of Health and Human Services to request the National Academy of Sciences to analyze “the short- and long-term benefits, and costs to Medicare” of extending Medicare coverage for certain preventive and other services. Congress directed that the report include specific findings with respect to coverage of a number of services, including medically necessary dental services. The purpose of this background paper is to present scientific evidence related to medically necessary dental services for selected medical conditions or in conjunction with certain medical procedures. This review is not intended to make specific recommendations about the clinical management of oral conditions or the prevention of oral complications or to address the entire range of diseases, conditions, or procedures for which medically necessary dental services may be indicated. Rather the intent is to review the evidence about certain oral health interventions in preventing or reducing morbidity and/or mortality for selected medical conditions. For a very limited set of medical diagnoses or under very specific clinical conditions, dental services are covered under Medicare. Evidence on the effectiveness of dental services in these circumstances is not covered in this review, although some information may be included for clar- Senior Investigator, Center for Health Research, Kaiser Permanente Northwest Division; Associate Professor, Department of Dental Ecology, University of North Carolina at Chapel Hill; Associate Director for Science, Division of Oral Health, Centers for Disease Control and Prevention; Assistant Director for Training and Career Development, Division of Extramural Research, National Institute of Dental and Craniofacial Research, National Institutes of Health.

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Extending Medicare Coverage for Preventive and Other Services ity. The primary focus is on the effectiveness of dental services not currently covered by Medicare. What Are Medically Necessary Dental Services? Several definitions of medically necessary dental services have been proposed. In 1995, the National Alliance for Oral Health held a consensus conference on medically necessary dental services and proposed the following definition: “that care that is a direct result of, or has a direct impact on, an underlying medical condition and/or its resulting therapy” (Consensus Conference, 1995). The consensus conference also noted that such care was integral to comprehensive treatment to ensure optimum health outcomes and could potentially reduce health care expenditures for treatment of complications. In 1990, the American Dental Association’s House of Delegates adopted the following comprehensive definition of medically necessary dental services: the reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances, and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of controlling or eliminating infection, pain, and disease; and restoring facial disfiguration, or function necessary for speech, swallowing, or chewing. Several important points are implied by these definitions, which are illustrated in Figure C-1. First, medically necessary dental services can be provided across a continuum of underlying diseases or conditions. Medically necessary dental services may be provided to prevent the onset of a disease FIGURE C-1 A model of medically necessary dental services.

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Extending Medicare Coverage for Preventive and Other Services or condition, to manage oral conditions that can impact medical care (e.g., fungal or bacterial infections from oral sources), or to manage the oral manifestations of treatment (e.g., xerostomia secondary to radiation therapy). Medically necessary dental services are not restricted to or defined by an established set of medical diseases or conditions. Rather, it is the potential impact of oral health on medical outcomes, including the onset of certain diseases and the effect of medical treatment on oral health, that defines medically necessary dental services. Second, medically necessary dental services include preventive, diagnostic, and treatment services and are not limited only to diagnosis or selected procedures. Identification of potential oral sources of infection through an oral examination alone, for example, will not eliminate the infection. Additional treatment will be necessary to improve health outcomes. Finally, medically necessary dental services should have a measurable impact on morbidity and/or mortality and improve physiological, clinical, and/or behavioral outcomes of care for the defined medical disease or condition. Selected Clinical Conditions Under Consideration Numerous medical diseases and conditions may require medically necessary dental services to improve health outcomes, including developmental and acquired maxillofacial defects, developmental disabilities, diabetes, hemophilia, orphaned diseases (e.g., ectodermal dysplasia), and anesthesia for uncooperative pediatric and other patients. Time and resource constraints required that only a limited number of diseases and conditions be considered. Consequently, this background paper focuses on these five diseases or conditions: head and neck cancer, leukemia, lymphoma, organ transplantation, and repair or replacement of heart valve defects. The five conditions are a subset of a much larger set of diseases and conditions for which medically necessary dental services may be indicated. These were selected based in part on their prevalence and on the level of evidence for clinical management. The potential oral complications associated with these conditions are shown in Table C-1. Currently Covered Dental Services Under Medicare With certain exceptions, Medicare does not cover dental services. Figure C-2 illustrates current Medicare coverage policy for dental services. First, Medicare does not cover any services that are beyond the scope of the dental practice. Each state determines which services fall within and outside the scope of dental practice. Reimbursement for dental services under Medicare cannot go beyond what is allowed in each state.

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Extending Medicare Coverage for Preventive and Other Services TABLE C-1 Selected Medical Diseases and Conditions and Potential Oral Complications Associated with Treatment Clinical Condition Potential Complication(s) Head and neck neoplasms Secondary to radiotherapy: xerostomia, rampant dental caries, mucositis, osteoradionecrosis, infection Secondary to surgery: hard- and soft-tissue defects Leukemia and lymphoma Stomatotoxicity of chemotherapy and total-body irradiation; early septicemia from oral organisms; possibility of acute and chronic graft-versus-host disease (for bone marrow transplantation); hemorrhage Organ transplantation Infection from oral organisms secondary to immunosuppression; gingival hyperplasia secondary to immunosuppressive drugs Heart valve repair or replacement Valvular infection from oral organisms FIGURE C-2 Overview of current Medicare coverage policy for dental services. Given the scope of dental practice, services that are covered for physicians are also covered for dentists. The term “physician,” when used in connection with the performance of any function or action, includes a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the state in which he or she performs such function and who is acting within the scope of his or her license when performing such functions (section 1861(r)(2)

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Extending Medicare Coverage for Preventive and Other Services of the Social Security Act (42 USC 1395x)). Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy, and dentistry (e.g., dental examinations to detect infections prior to certain surgical procedures; treatment of oral infections, hemorrhage, and mucositis; and interpretations of diagnostic x-ray examinations in connection with covered services). Specific dental services that are usually provided only by dentists are not covered. Under current Medicare statute, no payment can be made under Part A (hospital) or Part B (physician) for any expenses incurred for items or services: where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth, except that payment may be made under Part A in the case of inpatient hospital services in connection with the provision of dental services if the individual, because of his/her underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services. (Section 1862(a)(12) of the Social Security Act (42 USC 1395y)) The coverage or exclusion of any given dental service is not affected by the professional designation of the physician rendering the services (i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy). The limited exceptions to coverage for dental services under Medicare are summarized in Table C-2. Under Part B (physician services), if an otherwise noncovered procedure or service (e.g., removal of teeth) is performed by a dentist as “incident to” and as an integral part of a covered procedure or service performed by the same dentist (e.g., surgery of the jaw), the total service performed by the dentist on such an occasion is covered. For example, the reconstruction of a ridge performed primarily to prepare the mouth for dentures is a noncovered procedure. However, when the reconstruction of a ridge is performed as a result of, and at the same time as, the surgical removal of a tumor (for other than dental purposes), the totality of surgical procedures is a covered service. Likewise, the wiring of teeth is a covered service when it is done in connection with the reduction of a jaw fracture if the reduction and wiring are performed by the same practitioner. Second, tooth extractions to prepare the jaw for radiation treatment of neoplastic disease are covered services. This is an exception to the requirement that to be covered, a noncovered procedure or service performed by a dentist must be incident to and an integral part of a covered procedure or service performed by him or her. Ordinarily, the dentist extracts the patient’s teeth, but another physician (e.g., a radiation oncologist) administers the radiation treatments.

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Extending Medicare Coverage for Preventive and Other Services TABLE C-2 Current Medicare Coverage for Dental Services Clinical Condition Covered Service Part A (hospital) Part B (physician) Underlying medical condition and clinical status require hospitalization for dental care Inpatient hospital services only X   Severity of dental procedure requires hospitalization for dental care Inpatient hospital services only X   Any oral condition for which nondental services are covered All dental services if incident to and an integral part of covered procedure or service   X Neoplastic jaw disease Extractions prior to radiation   X Renal transplant surgery Oral or dental examination on an inpatient basis Xa Xb aIf the dentist is on staff at the hospital where the service is provided. bOutpatient payment for physicians only. Finally, an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery is a covered service. The purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but also expose the patient to additional risks in undergoing such surgery. Such a dental or oral examination would be covered under Part A of the program if performed by a dentist on the hospital’s staff or under Part B if performed by a physician. (When performing a dental or oral examination, a dentist is not recognized as a physician under section 1861(r) of the law; see Carriers Manual section 2020.3.) Whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends on whether the primary procedure being performed by the dentist is itself covered. Thus, an x-ray taken in connection with the reduction of a fracture of the jaw or facial bone is covered. However, a single x-ray or x-ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered. Based on current statute, regulations, and the Coverage Issues and Carriers Manuals, it appears that an oral examination would be a covered service for a person with certain oral conditions if (1) the management of the condition in-

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Extending Medicare Coverage for Preventive and Other Services cluded a covered service and (2) the person providing the covered service also performed the oral examination. For example, individuals with a fractured mandible would require an oral examination as an integral part of the management of the fracture. The oral examination would be covered for the dentist if that dentist is also treating the fracture. Another example might include crowns on teeth for individuals requiring an obturator following head and neck surgery if the crowns are a necessary part of obturator placement. Likewise, for persons with neoplastic jaw disease, oral examination would be covered if they required extractions prior to radiation. For persons with neoplastic jaw disease who were edentulous or who did not require an extraction, the examination would not be covered. For the five medical conditions considered here, currently covered and noncovered services are shown in Table C-3. The information presented here on coverage for dental services is contained within current statute, regulations, and coverage manuals. Certain Medicare fiscal intermediaries have made exceptions for coverage of certain procedures such as examinations for persons with head and neck neoplasms regardless of whether the person had an extraction. Given the lack of clarity and variability among carriers, this information is not included here. Increasing Number of Persons 65 and Above Who Are Retaining Natural Teeth During the next 10 years, the number of persons 65 years of age and over who are eligible for Medicare will increase from an estimated 34.5 million in 1999 to about 39.4 million in 2010 (Figure C-3) (U.S. Bureau of the Census Statistics, www.census.gov/population/www/index.html). By 2010, individuals 65 years of age and older will represent about 13.2% of the U.S. population, up from about 12.7% in 1999. Not only will the number of persons 65 and above increase, the proportion maintaining some or all of their natural dentition will also increase, as suggested by epidemiological data spanning the past 35 years. The first National Health Examination Survey, conducted in 1960–1962, found that about 45.1% of men and 53.0% of women aged 65–74 years were edentulous (without teeth) (NCHS, 1973). For 75- to 79-year-old men, the percentage edentulous was 55.7%; for 75- to 79-year-old women, the percentage edentulous was 65.6%. The National Health and Nutrition Examination Survey, conducted between 1971 and 1974, found that the edentulism prevalence declined to about 45.5% among persons 65 to 74 years of age, 43.6% among men and 47.0% among women (NCHS, 1981). An epidemiological study conducted by the National Institute of Dental Research in 1985–1986 found that among persons 65 years old and over attending senior centers, 41.1% were edentulous (NIDR, 1987).

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Extending Medicare Coverage for Preventive and Other Services FIGURE C-3 Number and percentage of persons 65 years of age and above, United States, 1990–2010.

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Extending Medicare Coverage for Preventive and Other Services TABLE C-3 Summary of Dental Services Currently Covered and not Covered Under Medicare for Selected Diseases or Conditions Disease or Condition Dental Services Currently Covered Under Medicare Dental Services not Currently Covered Under Medicare Head and neck neoplasms Extraction of teeth prior to radiation Oral examination if extractions are to be performed Oral examination if no extractions are to be done prior to radiation Preventive care to reduce risk of radiation caries (e.g., fluoride trays, supplemental topical fluoride) Treatment of radiation caries Leukemia and lymphoma Management of mucositis, hemorrhage, and related side effects of underlying disease Oral examination prior to treatment Dental treatment to reduce risk of infection or eliminate infection prior to or following treatment Organ transplantation Management of infection following transplantation Oral examination prior to renal transplant surgery on an inpatient basis Oral examination for transplants other than kidney Oral examination for renal transplants on an outpatient basis Dental treatment to reduce risk of infection or eliminate infection for any transplantation prior to or following transplant Heart valve repair or replacement None Oral examination prior to repair or replacement Dental treatment to reduce risk of infection or eliminate infection prior to or following repair or replacement of valve The 1989 National Health Interview Survey found that self-reported edentulism had declined to about 28.4% among persons 65 to 74 years of age and 43.0% among persons 75 years of age and over (Bloom et al., 1992). The Third National Health and Nutrition Examination Survey, Phase I, conducted between 1988 and 1991, reported an edentulism rate of 26.0% among persons 65 to 69

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Extending Medicare Coverage for Preventive and Other Services years of age, 31.1% among persons 70 to 74 years of age, and 43.9% among persons 75 years of age and older (Marcus et al., 1996). Most recently, data from the 46 states that participated in the oral health module of the 1995–1997 Behavioral Risk Factor Surveillance System (BRFSS) indicated that about 22.9% of persons 65–74 years of age and 26.7% of persons 75 years of age or over were edentulous (MMWR, 1999). Given this trend, one would hypothesize that the proportion of Medicare-eligible persons 65 years of age or over who may require medically necessary dental services will increase. Decision Framework for Medically Necessary Dental Services Figure C-4 illustrates a generic decision model for medically necessary dental services that applies to each of the five diseases and conditions under consideration here and serves as a framework for the literature review and synthesis. As noted earlier, medically necessary dental services can occur in the context of a disease or condition. Among persons with selected diseases or conditions, following the diagnosis and prior to initiation of medical therapy, a pretreatment oral assessment may or may not be provided. An explicit decision is required to provide the care, which is represented by the filled square in Figure C-4. This assessment may include a clinical examination and radiographs. Some of those assessed will have potential oral sources of infection or other complications. Dental care prior FIGURE C-4 Decision model for medically necessary dental services.

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Extending Medicare Coverage for Preventive and Other Services to medical treatment may be indicated and provided. The chance nature of this event is represented by the filled circle in Figure C-4. In conjunction with, or as a consequence of, medical therapy, individuals may develop oral complications associated with the medical treatment (e.g., mucositis or xerostomia), systemic complications from oral sources (e.g., infection or hemorrhage), or some combination thereof. Each of these can adversely affect the outcome of medical therapy by increasing morbidity, mortality, and cost. The purpose of this background paper is to review and assess the literature to determine the extent to which medically necessary dental services can reduce the likelihood of these complications or lessen their effect. Decision Analytical Framework Specific analytic questions guided our literature search and synthesis efforts. For each of the conditions under consideration, we initially sought to address the following question: Is there direct evidence that medically necessary dental care—including screening, diagnostic and preventive services, and treatment—provided to persons with a defined medical diagnosis prior to or during acute therapy for that diagnosis improves health outcomes? Direct evidence is evidence that relates a diagnostic strategy or therapeutic intervention to the occurrence of a principal health outcome (Eddy et al., 1992). Outcomes by definition are multidimensional. In this context, principal health outcomes refer to those outcomes that are of most interest to the patient, such as symptoms, functional status, morbidity, and death (Fleming and DeMets, 1996). Our goal, then, was to identify studies that related a specific dental intervention—oral examination and treatment prior to organ transplantation, for example—to an outcome—improved quality-of-life and decreased mortality, for example. When direct evidence was not identified, we sought to identify indirect evidence that related to medically necessary dental services for each of the conditions being considered. Indirect evidence requires two or more bodies of evidence to relate the diagnostic strategy, exposure, or therapeutic intervention to the principal health outcome (Eddy, et al., 1992). For example, one study may demonstrate that a screening and treatment protocol for patients prior to heart valve replacement eliminates potential sources of oral infection. A second study may demonstrate that oral sources of infection are important contributors to valve failure. Neither study alone provides direct evidence that screening and treatment prior to heart valve replacement reduce morbidity or mortality; together, the two studies provide indirect evidence that screening and treatment to eliminate oral sources of infection prior to heart valve replacement improve principal health outcomes. A number of questions guided our efforts to survey and synthesize indirect evidence to support medically necessary dental services. These questions reflect the various components of the decision framework illustrated in Figure C-4.

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Extending Medicare Coverage for Preventive and Other Services Head and Neck Cancer Al-Joburi W, Clark DC, Fisher R. A comparison of the effectiveness of two systems for the prevention of radiation caries. Clinical Preventive Dentistry 1991; 13:15–19. Allison PJ, Locker D, Feine JS. The relationship between dental status and health-related quality of life in upper aerodigestive tract cancer patients. Oral Oncology 1999; 35:138–143. Bedwinek JM, Shukovsky LJ, Fletcher GH, Daley TE. Osteoradionecrosis in patients treated with definitive radiotherapy for squamous cell carcinomas of the oral cavity and naso- and oropharynx. Radiology 1976; 119:665–667. Beumer III J, Silverman Jr S, Benak SB. Hard and soft tissue necroses following radiation therapy for oral cancer. Journal of Prosthetic Dentistry 1972; 27:640–644. Beumer III J, Curtis T, Harrison RE. Radiation therapy of the oral cavity: Sequelae and management, part 1. Head and Neck Surgery 1979a; 1:301–312. Beumer III J, Curtis T, Harrison RE. Radiation therapy of the oral cavity: Sequelae and management, part 2. Head and Neck Surgery 1979b; 1:392–408. Beumer J, Harrison R, Sanders B, Kurrasch M. Osteoradionecrosis: Predisposing factors and outcomes of therapy. Head and Neck Surgery 1984; 6:819–827. Brown RS, Miller JH, Bottonley WK. A retrospective oral/dental evaluation of 92 head and neck oncology patients, before, during and after irradiation therapy. Gerodontology 1990; 9:35–39. Bruins HH, Koole R, Jolly DE. Pretherapy dental decisions in patients with head and neck cancer. A proposed model for dental decision support. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1998; 86:256–267. Bundgaard T, Tandrup O, Elbrond O. A functional evaluation of patients treated for oral cancer. A prospective study. International Journal of Oral and Maxillofacial Surgery 1993; 22:28–34. Clayman L. Management of dental extractions in irradiated jaws: A protocol without hyperbaric oxygen therapy. Journal of Oral and Maxillofacial Surgery 1997; 55:275–281. Coffin F. The incidence and management of osteoradionecrosis of the jaws following head and neck radiotherapy. British Journal of Radiology 1983; 56:851–857. Curi MM, Dib LL. Osteoradionecrosis of the jaws: A retrospective study of the background factors and treatment in 104 cases. Journal of Oral and Maxillofacial Surgery 1997; 55:540–544. De Graeff A, de Leeuw JRJ, Ros WJG, Hordijk GJ, Blijham GH, Winnubst JAM. A prospective study on quality of life of patients with cancer of the oral cavity or oropharynx treated with surgery with or without radiotherapy. Oral Oncology 1999; 35:27–32. Dreizen S. Description and incidence of oral complications. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. Consensus Development Conference on Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. National Cancer Institute Monographs 1990; 9:11–15. Dreizen S, Brown LR, Daly TE, Drane JB. Prevention of xerostomia-induced dental caries in irradiated cancer patients. Journal of Dental Research 1977; 56:99–104.

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Extending Medicare Coverage for Preventive and Other Services Epstein JB, Emerton S, Kolbinson DA, Le ND, Phillips N, Stevenson-Moore P, Osoba D. Quality of life and oral function following radiotherapy for head and neck cancer. Head and Neck 1999; 21:1–11. Epstein JB, van der Meij EH, Emerton SM, Le ND, Stevenson-Moore P. Compliance with fluoride gel use in irradiated patients. Special Care in Dentistry 1995; 15:218–222. Epstein JB, van der Meij EH, Lunn R, Stevenson-Moore P. Effects of compliance with fluoride gel application on caries and caries risk in patients after radiation therapy for head and neck cancer. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1996; 82:268–275. Epstein JB, van der Meij EH, McKenzie M, Wong F, Lepawsky M, Stevenson-Moore P. Postradiation osteonecrosis of the mandible. A long-term follow-up study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1997; 83:657–662. Epstein JB, Wong FLW, Stevenson-Moore P. Osteoradionecrosis: Clinical experience and a proposal for classification. Journal of Oral and Maxillofacial Surgery 1987; 45:104–110. Funegard U, Franzen L, Ericson T, Henriksson R. Parotid saliva composition during and after irradiation of head and neck cancer. Oral Oncology, European Journal of Cancer 1994; 30B:230–233. Grant BP, Fletcher GH. Analysis of complications following megavoltage therapy for squamous cell carcinomas of the tonsillar area. American Journal of Roentgenology 1966; 96:28–36. Health Care Financing Administration (HCFA). Medicare Carrier’s Manual, Part B. Coverage and Limitations, Section 2136: Dental Services. Horiot JC, Bone MC, Ibrahim E, Castro JR. Systemic dental management in head and neck irradiation. International Journal of Radiation Oncology, Biology and Physics 1981; 7:1025–1029. Horiot JC, Schraub S, Bone MC, Bain Y, Ramadier J, Chaplain G, Nabid N, Thevenot B, Bransfield D. Dental preservation in patients irradiated for head and neck tumors: A 10-year experience with topical fluoride and a randomized trial between two fluoridation methods. Radiotherapy and Oncology 1983; 1:77–82. Jansma J, Vissink A, Spijkervet FK, Roodenburg JL, Panders AK, Vermey A, Szabo BG, Gravenmade EJ. Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy. Cancer 1992; 70:2172–2180. Keys HM, McCasland JP. Techniques and results of a comprehensive dental care program in head and neck cancer patients. International Journal of Radiation Oncology, Biology and Physics 1976; 1:859–865. Kluth EV, Jain PR, Stuchell RN, Frich JC Jr. A study of factors contributing to the development of Osteoradionecrosis of the jaws. Journal of Prosthetic Dentistry 1988; 59:194–201. Kumar HS, Bihani V, Kumar V, Chaundhary RK, Kumar L, Punia DP. Osteoradionecrosis of mandible in patients treated with definitive radiotherapy for carcinomas of oral cavity and oropharynx. A retrospective study. Indian Journal of Dental Research 1992; 3:47–50.

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Extending Medicare Coverage for Preventive and Other Services Lambert PM, Intriere N, Eichstaedt R. Management of dental extractions in irradiated jaws: A protocol with hyperbaric oxygen therapy. Journal of Oral and Maxillofacial Surgery 1997; 55:268–274. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA—A Cancer Journal for Clinicians 1999; 49:8–31. Liu RP, Fleming TJ, Toth BB, Keene HJ. Salivary flow rates in patients with head and neck cancer 0.5 to 25 years after radiotherapy. Oral Surgery, Oral Medicine and Oral Pathology 1990; 70:724–729. Lockhart PB, Clark J. Pretherapy dental status of patients with malignant conditions of the head and neck. Oral Surgery, Oral Medicine and Oral Pathology 1994; 77:236–241. Maier H, Zoller J, Hermann A, Kreiss M, Heller W-D. Dental status and oral hygiene in patients with head and neck cancer. Otolaryngology, Head and Neck Surgery 1993; 108:655–661. Makkonen TA, Kiminki A, Makkonen TK, Nordman E. Dental extractions in relation to radiation therapy of 224 patients. International Journal of Oral and Maxillofacial Surgery 1987; 16:56–64. Manciani RD, Ownby HE. Osteoradionecrosis of the jaws. Journal of Oral and Maxillofacial Surgery. 1986; 44:218–223. Manciani RD, Plezia RA. Osteoradionecrosis of the mandible. Journal of Oral Surgery 1974; 32:435–440. Markitziu A, Zafiropoulos G, Tsalikis L, Cohen L. Gingival health and salivary function in head and neck-irradiated patients. A five-year follow-up. Oral Surgery, Oral Medicine and Oral Pathology 1992; 73:427–433. Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: A randomized prospective clinical trial of hyperbaric oxygen versus penicillin. Journal of the American Dental Association 1985; 111:49–54. Maxymiw WG, Wood RE, Liu F-F. Postradiation dental extractions without hyperbaric oxygen. Oral Surgery, Oral Medicine and Oral Pathology 1991; 72:270–274. Murray CG, Herson J, Daly TE, Zimmerman S. Radiation necrosis of the mandible: A 10-year study. Part I. Factors influencing the onset of necrosis. International Journal of Radiation Oncology, Biology and Physics 1980a; 6:543–548. Murray CG, Herson J, Daly TE, Zimmerman S. Radiation necrosis of the mandible: A 10-year study. Part II. Dental factors; onset, duration and management of necrosis. International Journal of Radiation Oncology, Biology and Physics 1980b; 6:549–553. Myers RAM, Marx RE. Use of hyperbaric oxygen in postradiation head and neck surgery. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health. Consensus Development Conference on Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. National Cancer Institute Monographs 1990; 9:151–157. National Institutes of Health (NIH). National Institutes of Health Consensus Development Conference Statement: Oral complications of cancer therapies: Diagnosis, prevention, and treatment. Journal of the American Dental Association 1989; 119:179–183. Niewald M, Barbie O, Schnabel K, Engel M, Schedler M, Nieder C, Berberich W. Risk factors and dose-effect relationship for osteoradionecrosis after hyperfractionated

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