Question

How to Write a Crown Narrative in Less Than a Minute

It is probably no surprise that many dentists do not enjoy writing narratives. In fact, dentists often complain that narratives take too long to write, and they are not sure what the dental consultant needs to know.

Concern #1—It takes too long to write

Keep in mind that if a narrative takes too long to write, it also takes too long to read. When reviewing claims for a dental insurance carrier several years ago, I remember a call with an office manager who complained that her boss didn’t have time to write a three page letter explaining why the patient needed a crown. I replied, “I can certainly appreciate that the dentist doesn’t have time to write a three page letter, and I’m glad he doesn’t as I don’t have time to read a three page letter. I just need to know the pertinent details regarding this crown.” So, the first thing to know about narratives is that they should be brief.

You can be brief because it is another dentist who will be reading the narrative, and since you both speak “dental,” you can write your narrative using the dental abbreviations that all dentists understand.

Concern #2—Not sure what the dental consultant needs to know

The dentist reviewing your claim needs to know the specific diagnosis or condition for which the treatment is being performed. In the case of a crown or an onlay, issues that need to be addressed in a narrative include the following: Is there decay? If so, how much? Is there an existing restoration? If so, which surfaces are involved, and what is the condition of the restoration? Is any part of the tooth or restoration fractured off? How much healthy tooth structure is left?

Given this list of questions, you are probably wondering how writing a narrative in less than a minute is possible. You have performed a visual exam, a radiographic exam, a periodontal exam, and any needed pulp vitality tests of the tooth in question. However, the dental consultant doesn’t need all of the information you have gathered about the patient—just the part that explains why you determined that the tooth is best treated with a crown, onlay, or veneer (the criteria for benefit plan payment is generally the same for all of these procedures).

But how exactly do you relay this in less than a minute? Think about the last patient for whom you recommended a crown. After you gathered the clinical information about the patient, how long did it take you to decide the patient would be best served by placing a crown or an onlay? Based on my own experience and conversations with other dentists, I would estimate that it takes less than a minute.

After all of our years of training, dentists make those decisions so quickly, and for the most part so easily, that we barely realize how many pieces of information we sift through to come to that decision. To create a narrative for a single crown or onlay a dentist must separate out those particular pieces of information that are integral to making that recommendation and put those facts in a brief narrative.

For example: A patient comes in with the chief complaint that part of his tooth fell off. During the oral evaluation you review the patient’s health history and note that #30 has an MOD amalgam, and the ML and DL cusps have fractured off at the gum line. You order and evaluate the necessary radiographs. You perform six-point periodontal probing and other periodontal evaluations as necessary to determine the periodontal status of the tooth. You confirm the endodontic status of the tooth. You determine that a crown is necessary on #30, that #30 is periodontally and endodontically healthy, and that the patient’s general health is such that he can withstand the procedure. You recommend the crown to the patient, and the patient agrees to proceed with treatment.

Now it is time to write the narrative:

You have many pieces of information. Which do you include in your narrative? You include the information that made you decide to recommend a crown. Just by looking at the radiograph, could you have determined the need for the crown? No. The amalgam would obscure the fact that the ML and DL cusps were missing. If you can’t see the problem in the radiograph, neither can the dental consultant. So, your narrative only needs to communicate what cannot be seen in the radiograph. Your complete narrative would read, “ML and DL cusp fractured off at gum line.” Sending clinical photos of the tooth (along with your narrative) may also be helpful.

Do you need to tell the dental consultant about the periodontal and endodontic status of the tooth? If the periapical radiograph you send shows that the tooth is periodontally and endodontically healthy, you do not need to state this in your narrative. However, if there is significant bone loss then you need to explain what periodontal treatment has been completed or is planned. If there is an apical lucency, or if the existing root canal is short, overextended, etc., a brief explanation of the endodontic status of the tooth is also necessary.

The treating dentist has the privilege of seeing the patient, hearing his/her story, examining his/her mouth, and reviewing the radiographs and any clinical photos before making a decision. With just a radiograph it is impossible for the dental consultant to know as much about the tooth as the treating dentist does. Writing a brief narrative allows the treating dentist to tell and/or show the dentist reviewing the claim what could be seen clinically that is not obvious on the radiograph.

The next time you write a narrative for a single crown or onlay, remember the less-than-a-minute rule. What specific pieces of information did you use to make your decision? Which of those are not clearly evident in the images you sent with the claim? These images must include a periapical radiograph and may include a photo. Put those specific pieces of information in your narrative. With practice you will soon be writing narratives for single crowns and onlays in less than a minute. 

By: Christina Gore, DMD, FAGD, CDC