Evidence-Based Denture Approval
Why This Matters
This framework integrates clinical expertise, participant values, and current research to guide PACE organizations in approving or denying full mouth extractions and denture transitions. It addresses gaps in training, regulatory complexity, and medical necessity standards. Each “Yes” answer affirms appropriateness; each “No” flags risk or misalignment.
What You’ll Learn
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Identify key factors influencing denture transition decisions
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Distinguish “unsalvageable” from “non-functional” dentition
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Separate medical indications for extractions vs. dentures
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Assess participant suitability based on health and oral status
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Compare alternatives considering cost, quality of life, and longevity
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Design participant education with feedback loops
The Three-Step Approval Process
Step 1: Consent
- Ptp or caregiver can manage dentures
- Watched educational video
- Has capacity or POA/Guardian consent
- Agrees to extractions and post-procedure care
- Can manage dentures (cleaning, storage)
- No psychiatric or substance use barriers
💡Any no answer informs a possible denial and requires conversation with IDT and/or PACE Provider for conversation
Step 2: Medical Necessity
- Dentures resolve functional impairments (eating, speaking)
- Required for another medically necessary procedure (e.g., chemo, valve replacement)
- Weight loss due to poor dentition, not other causes
- Dentures expected to improve nutrition or resolve health-impacting conditions
💡 Must be determined by PACE Provider; not Dentist or Consultant.
Step 3: Additional Risks
Each item below adds to the risk of multiple denture extractions. Each question is designed to answer as “Yes” if the risk exists. The more “Yes” answers accumulates higher risk and require a discussion regarding the risk and benefit for your ppt.
- Does your patient smoke?
- Does the ppt take pre-procedure antibiotic prophylaxis?
- Does the ppt take an anticoagulant (remove if on anticoagulant: Perioperative Risk calculated) (remove need for bridging…)
- Is the ppt on an antiresorptive agent or an antiangiogenic agent that could risk ONJ (bisphosphonate, RANKL inhibitors, antiangiogenic therapy)?
- Does the ppt have Sjogren’s disease?
- Does the ppt have diabetes control not at an acceptable goal A1C?
- Should life expectancy of ppt play a role?
What Doesn’t Qualify
- “What if” scenarios don’t establish necessity
- Depression or self-esteem are not valid indications
- Extractions ≠ automatic denture approval
- Dentist recommendations must be evidence-based
- Immediate dentures are rarely appropriate
- Lost dentures: responsibility varies by setting
- Implants: not covered by ND Medicaid except in rare cases
Conclusion
• UM recommendation is for IDT to consider denial of dentures in the absence of medical necessity.
• UM recommendation is for IDT to consider approval of dentures given presence of medical necessity.
ND Medicaid does not cover implants unless part of a documented, medically necessary treatment plan often involving:
– Significant oral dysfunction
– Cancer resection
– Trauma-related defects
Click Here to Download the Form and Begin Your Process
For full guidence, please download the complete Evidence-Based Medicine Approach to Denture Approval document by clicking here.