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 1. D2940.A Check Pre-Op Vitality 
 Non-vital or Irreversible pulp...  
 1) Vital and 2) Reversible P...  
 2. D2940.B Establish Restorabilit...  
 Non-restorable 
 Restorable only with a crown 
 Restorable with direct restora...  
 3. D2940.C Caries Removal 
 Exposure 
 No Exposure 
 4. D2940.D Check Post-op Vitality 
 Non-vital or symptomatic 
 Vital & asymptomatic 
 5. D2940.E Definitive Restoration 
 D2940.E Complete  
Sedative Filling D2940
D2940.A Check Pre-Op Vitality D2940.B Establish Restorability D2940.C Caries Removal D2940.D Check Post-op Vitality D2940.E Definitive Restoration
We have traditionally used sedative fillings when a patient has numerous moderate-sized carious lesions.  This approach was developed out of concern that placement of definitive restorations would be so time consuming as to lead to an unworkable delay in restoring all the lesions.  As a result, some of these moderate lesions would progress to a point where endodontic therapy and/or a crown would become necessary.  We are now expanding the use of sedative fillings to help us keep asymptomatic teeth with large carious lesions vital.
There isn't always time at the diagnosis appointment to fully discuss symptoms with your patient and perform pulp testing.  Similarly, the extent of the caries and the restorability of the tooth are hard to accurately determine until at least peripheral caries has been removed. 
Given the difficulty of establishing an accurate and complete diagnosis at this appointment, teeth with large carious lesions and unknown status will be provisionally treatment planned for a sedative filling, and phased and sequenced to be treated ASAP.
1. D2940.A Check Pre-Op Vitality Priority 1
1)  Discuss what, if any, symptoms your patient has experienced.
2)  Cold test with Endo Ice or ice.
If results are clear that the tooth is vital and there are no symptoms of an irreversible pulpitis there is no need to conduct electric pulp testing (EPT).
3)  If results of cold testing are inconclusive conduct EPT and
     percussion testing.
4)  If there are signs and/or symptoms of an irreversible pulpitis, conduct
     EPT and percussion testing.
Non-vital or Irreversible pulpitis
Delete D2940
The provisional treatment plan to place a sedative filling was based on the information available at the time.  Now that it is clear the tooth is non-   vital and/or has an irreversible pulpitis a more definitive plan can be made.  With this additional information it is clear the sedative filling should be deleted.  Use XX discipline code to describe today's procedure and make sure there is no charge.
After conversation with your patient, the tooth should be treatment planned for endodontic therapy or extraction.
Plan endo or extraction
Just as it is for placement of a sedative filling, removal of the peripheral caries and assessment of the restorability of the tooth is required to confirm the appropriateness of endodontic therapy.  Accordingly, even though you have deleted the D2940, continue to remove the peripheral decay and assess restorability.
1) Vital and 2) Reversible Pulpitis
D2940.A Complete
You must use the standardized notes in Axium.  Choose the one note listed below that best matches your clinical situation.  You can include additional information, but place the information following the standardized note.  Other than adding additional information do not change the wording.
1)  Tooth is vital and asymptomatic.  Results of percussion and
     sensitivity tests were as follows:
2)  Tooth is vital with signs and symptoms consistent with a
     reversible pulpitis.  Results of percussion and sensitivity tests
     were as follows:
3)  Tooth is vital with signs and symptoms consistent with an irreversible
     pulpitis.  Results of percussion and sensitivity tests were as follows:
4)  Tooth is non-vital.
Move on to D2940.B
2. D2940.B Establish Restorability Priority 2
First, remove peripheral caries and determine the gingival extension of the caries.  Is:
1) Extension such that the tooth is non-restorable?
2) Extension such that crown lengthening is required?
3) Extension unremarkable?
Second, after peripheral decay is removed determine whether the tooth can be restored with a direct restoration or if the tooth is restorable only with full coverage.
Non-restorable
Delete D2940
The provisional treatment plan to place a sedative filling was based on the information available at the time.  Now that it is clear the tooth is not restorable a more definitive plan can be made. With this additional information it is clear the sedative filling should be deleted.  Use XX discipline code to describe today's procedure and make sure there is no charge.
The tooth should be treatment planned for extraction.
Tx Plan extraction
Restorable only with a crown
There is evidence to support the incomplete removal of caries and placement of a sedative restoration to seal the tooth and arrest the caries process.  At present this technique is not universally accepted.  Because decay can more easily be monitored and the cost of replacing a direct restoration is minimal relative to that of a crown, this approach is reasonable under a direct restoration.
However, given the fact this approach is not universally accepted, the difficult of monitoring decay and the cost of replacing a crown, any tooth that requires a crown will have all caries removed.
Delete D2940
Teeth that require a crown are not suitable candidates for placement of a sedative restoration.  Delete the D2940 code and:
  • If a buildup is started use code D2950 for today's appointment.
  • If the tooth will need extraction or endodontic therapy at a later date, use XX discipline code for today's appointment.
Remove all caries
Pulp exposure
Tx Plan Endo or Extraction
No pulp exposure
Place buildup
Treatment plan crown and crown lengthening procedure if required.
Restorable with direct restoration
D2940.B Complete
You must use the standardized notes in Axium.  Choose the one note listed below that best matches your clinical situation.  You can include additional information, but place the information following the standardized note.  Other than adding additional information do not change the wording.
  • Peripheral caries has been removed.  Tooth is not restorable.
  • Peripheral caries has been removed.  Tooth is restorable.
  • Peripheral caries has been removed.  Tooth is restorable only in conjunction with a crown- lengthening procedure.
Move on to D2940.C
3. D2940.C Caries Removal Priority 3
THE INTENT OF USING A SEDATIVE FILLING APPROACH IS TO AVOID PULP EXPOSURES ON ADULT TEETH THAT, AT PRESENT, ARE VITAL AND ASYMPTOMATIC.
While removal of all caries is typically desirable, a direct pulp cap for even a small pulp exposure on an adult tooth has a poor to guarded prognosis.  There is good evidence that by virtue of obtaining a good seal against microleakage sedative fillings arrest the decay process and allow the tooth to lay down repairative dentin.  Both of these outcomes increase the likelihood of keeping the pulp vital and asymptomatic.
Following removal of peripheral decay, next decay on the axial/pulpal wall(s) will be removed.  If the remaining dentin thickness is approximately 1 mm but decay is still present, no further decay will be removed and a sedative restoration using Fuji II LC will be placed.
Exposure
Carious
Non-carious
> 2 mm
Placement of a direct pulp cap on a pulp exposure greater than 2 mm on an adult tooth has little likelihood of success.  Instead endodontic therapy should be recommended.  Alternatively, if your patient does not wish to have endodontic therapy the tooth should be extracted.
Also of importance is the location of the pulp exposure.  Pulp capping a small exposure of a pulp horn has a reasonable prognosis.  But even a small pulp exposure on an axial wall rather than a pulp horn has a poor prognosis.  Examples would be:  1) exposure of the pulp while treating cervical caries; and 2) during treatment of Class 2 caries, an exposure at the level of the gingival floor rather than of the pulp horn at the level of the pulp-axial line angle.
Consult with your instructor and either place CaOH on the exposure or remove the pulp.  Place a Fuji II LC or IRM provisional.
< or = 2mm
Even on an adult tooth, an exposure of 2 mm or less on a pulp horn has a reasonable prognosis.  A Fuji II LC sedative filling will be placed and the vitality and symptoms re-evaluated after 12 weeks.
Also of importance is the location of the pulp exposure.  Pulp capping a small exposure of a pulp horn has a reasonable prognosis.  But even a small pulp exposure on an axial wall rather than a pulp horn has a poor prognosis.  Examples would be:  1) exposure of the pulp while treating cervical caries; and 2) during treatment of Class 2 caries, an exposure at the level of the gingival floor rather than of the pulp horn at the level of the pulp-axial line angle.
Place CaOH on the exposure and place Fuji II LC sedative filling.
See related topics and documents
D2940.C Complete
No Exposure
Place Fuji II
Wait 12 weeks
D2940.C Complete
You must use the standardized notes in Axium.  Choose the one note listed below that best matches your clinical situation.  You can include additional information, but place the information following the standardized note.  Other than adding additional information do not change the wording.
1)  All caries removed.
2)  All caries removed;  deep caries.
3)  Caries removal resulted in pulp exposure.
4)  With the exception of a small amount of caries over the pulp, all
     caries removed.
Move on to D2940.D
4. D2940.D Check Post-op Vitality Priority 4
1)  Discuss what, if any, symptoms your patient has experienced.
2)  Cold test with Endo Ice or ice.
If results are clear that the tooth is vital and there are no symptoms of an irreversible pulpitis there is no need to conduct electric pulp testing (EPT).
3)  If results of cold testing are inconclusive conduct EPT and
     percussion testing.
4)  If there are signs and/or symptoms of an irreversible pulpitis, conduct
     EPT and percussion testing.
Non-vital or symptomatic
Tx Plan endo or extraction
Complete D2940.D and D2940.E
Use standardized notes in Axium.  You can include additional information, but otherwise do not change the wording.
For D2940.D  choose: 
  • Tooth is vital with signs and symptoms of irreversible pulpitis.
For D2949.E choose:
  • Referral for endodontic treatment has been made.
OR
  • Referral for extraction has been made.
Vital & asymptomatic
D2940.D Complete
You must use the standardized notes in Axium.  Choose the one note listed below that best matches your clinical situation.  You can include additional information, but place the information following the standardized note.  Other than adding additional information do not change the wording.
1)  Tooth is vital and asymptomatic.  Results of percussion and pulp
     testing are as follows:
2)  Tooth is vital with signs and symptoms consistent with a reversible
     pulpitis.  Results of percussion and pulp testing are as follows:
3)  Tooth is vital with signs and symptoms consistent with a irreversible
     pulpitis.  Results of percussion and pulp testing are as follows:
4)  Tooth is non-vital.  Results of percussion and pulp testing are as
     follows:
Move on to D2940.E
5. D2940.E Definitive Restoration Priority 5
Re-assess the clinical situation and decide on a definitive restoration.
D2940.E Complete
You must use the standardized notes in Axium.  Choose the one note listed below that best matches your clinical situation.  You can include additional information, but place the information following the standardized note.  Other than adding additional information do not change the wording.
1)  A direct restoration has been placed.
2)  A buildup has been placed and an indirect restoration planned.
3)  Referral for endodontic treatment has been made.
4)  Referral for extraction has been made.
Please note:  If after re-evaluation of the tooth an indirect restoration is contemplated, it will be necessary to remove the Fuji II LC sedative filling and all remaining decay.
D2940 Complete
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