Eligible expenses

• Anesthesia
  • Expenses incurred for anesthesia performed in conjunction with oral or periodontal surgery, fractures or dislocations, as listed below:
    • combined techniques of inhalation plus intravenous and/or intramuscular injection;
    • conscious sedation:
      • nitrous oxide by inhalation;
      • nitrous oxide with oral sedation;
      • oral sedation;
      • parenteral;
    • deep sedation;
    • general anesthesia;
    • local anesthesia;
    • provision of facilities, equipment and supplies for general anesthesia when provided by a separate practitioner.

• Case presentation and explanation - general services
  • Emergency treatment not otherwise specified.
  • House calls (emergency or non-emergency visit).
  • Office visits and institutional visits, after regular office hours.
  • Palliative dental treatment, unclassified pain treatments or minor emergency procedures.
  • Professional consultation (with a member of the profession).
  • Treatment planning and case presentation.

• Examination and diagnosis
  • Complete oral examination, once every 36 months.
  • Dental examination for children under age 10, not payable under the Régie de l’assurance-maladie du Québec (RAMQ).
  • Emergency oral examination and diagnosis.
  • Diagnosis cast.
  • Preventive dental examination, previous patient (recall), once every 6 months.
  • Complete periodontal examination, once every 6 months.
  • Specific oral examination and diagnosis.

• Laboratory procedures
  • Commercial laboratory procedures.
  • In-office laboratory procedures.

• Lab tests and examinations
  • Bacteriologic cultures/genetic tests to determine pathological agents.
  • Biopsies of soft or bone tissue, by puncture, incision or aspiration.
  • Cytological test and analysis:
    • cytological smear from oral cavity;
    • vital staining of oral mucosal tissues.
  • Pulp vitality and interpretation, tests and analysis.

• Preventive services
  
  
  

  If scaling treatment is covered under both preventive and periodontic services, the insurer will determine whether such treatment is payable under the preventive or periodontic services based on the following:

  1. The scaling treatment will be considered preventive scaling provided the charge for such treatment is for less than 2 units of time.
  2. The scaling treatment will be considered periodontal scaling provided the charge for such treatment is for 2 units of time or more.
  3. Combined preventive or periodontic scaling treatments should not exceed 16 time units per benefit year.
• Appliances to control harmful oral habits (including bruxism appliance):
  • fixed and cemented appliances (maxillary or mandibular);
  • removable appliances (maxillary or mandibular);
  • repairs, once per benefit year, only for bruxism appliance.
• Interproximal disking (tooth grinding).
• Finishing restorations.
• Pit and fissure sealants, once per tooth, for children under age 18.
• Preventive restorations, resin.
• Prefabricated crowns (restorations), for children under age 18:
  • stainless steel crowns (metal), primary anterior or posterior teeth;
  • stainless steel crowns (metal), primary anterior or posterior teeth, open face / acrylic veneer;
  • plastic, primary anterior and posterior teeth.
• Prophylaxix - polishing, once every 6 months.
• Space maintainers; for missing primary teeth, for children under age 18:
  • acrylic removable;
  • band type;
  • bonded (acid-etched) pontic type;
  • cast type;
  • stainless steel crown type.
• Topical application of fluoride for children under age 18, once every 6 months.

• Radiographs (X-rays)
• Complete series intra oral pedodontic radiographs, once every 36 months.
• Complete series of periapical intra oral films, once every 36 months.
• Extra oral radiographs.
• Interpretation of radiographs from another source.
• Intra oral occlusal radiographs.
• Intra oral bitewing radiographs, 4 per benefit year.
• Panoramic radiographs, once every 36 months.
• Radiopaque dyes to demonstrate lesions.
• Sialography radiographs.
• Sinus examination and diagnosis, identified as:
  • basal;
  • Caldwell;
  • lateral skull;
  • Waters.
• Skull and facial radiographs as a diagnostic aid for dental treatment.
• Temporomandibular joint dysfunction films.

• Laboratory procedures
  • Commercial laboratory procedures.
  • In-office laboratory procedures.

• Oral surgeries
  • Extraction of erupted tooth with surgical approach requiring surgical flap and/or sectioning of tooth.
  • Extraction, removal of erupted teeth - uncomplicated.
  • Removal of erupted residual roots.
  • Removal of impaction requiring incision of overlying soft tissue and removal of tooth.
  • Removal of impaction requiring incision of overlying soft tissue, evaluation of flap and either removal of bone and tooth or sectioning and removal of tooth.
  • Removal of impaction requiring incision of overlying soft tissue, evaluation of flap, removal of bone and sectioning of the tooth for removal.
  • Removal of impaction requiring incision of overlying soft tissue, evaluation of flap, removal of bone, and/or sectioning of the tooth for removal and/or presents unusual difficulties and circumstances.
  • Removal of residual root with soft-tissue or bone-tissue coverage.

• Restorations
  • Acrylic and composite.
    Composite restorations in accordance with the plan limitations:
    • permanent anterior, tooth-coloured, bonded or non-bonded;
    • permanent bicuspid, permanent molar, tooth-coloured/plastic with/without silver fillings, bonded or non-bonded;
    • primary anterior and posterior, , tooth-coloured, bonded or non-bonded;
    • primary anterior and posterior, tooth-coloured/plastic with/without silver fillings, bonded or non-bonded.
  • Amalgam:
    • permanent bicuspids and anterior, permanent molars, bonded or non-bonded;
    • primary teeth (anterior or posterior), bonded or non-bonded.
  • Retentive pins for amalgam and composite restorations.

• Endodontics
  Treatment of disease of the pulp chamber and pulp canals (root canal therapy).
  • Apical curettage / apicoectomy.
  • Caries, trauma and pain control.
  • Endodontic procedures below:
    • banding and/or coronal buildup of tooth/teeth and/or contouring of tissue surrounding tooth/teeth to maintain aseptic operating field (per tooth);
    • open and drain, anterior and bicuspid or molar.
  • Miscellaneous surgical services:
    • enlargement of canal and/or pulp chamber (preparation of post space), in previously filled tooth when root canal treatment was done by another practitioner or in calcified canals;
    • hemisection;
    • intentional removal of tooth, apical filling and replantation;
    • root amputation (includes recontouring (tooth and furca)).
  • Other endodontic procedures:
    • opening through artificial crown, anterior and bicuspid or molar.
  • Pulp capping, direct, performed in conjunction with permanent restoration of first tooth or for each additional tooth of the same quadrant.
  • Pulpectomy.
  • Pulpotomy.
  • Retreatment (apicoectomy or apical curettage).
  • Retrofilling.
  • Root canal therapy of permanent teeth and/or primary teeth:
    • apexification/apexogenesis;
    • ongoing treatment aborted by referring (previous) dentist;
    • obturation of apexified canal;
    • reinsertion of dentogenic media;
    • retreatment of previously completed therapy of permanent or primary teeth.
  • Trauma control, smoothing of fractured surfaces of first tooth or for each additional tooth of the same quadrant.

• Laboratory procedures
  • Commercial laboratory procedures.
  • In-office laboratory procedures.

• Major surgeries
  • Alveoplasty:
    • alveolectomy;
    • alveoplasty in conjunction with extraction;
    • alveoplasty not in conjunction with extraction;
    • excision (nasal spine, torus palatinus, torus mandibularis unilateral or bilateral);
    • reduction of bone, tuberosity, unilateral or bilateral reduction;
    • removal of bone, exostosis, multiple.
  • Dislocation management of temporomandibular joint:
    • closed reduction uncomplicated or with general anesthesia.
  • Excision, malignant or benign tumour, soft tissue or bone tissue.
  • Excision of cyst or granuloma.
  • Fractures and reductions:
    • closed reduction of malar bone;
    • closed reduction of mandibular;
    • closed reduction of maxillary, horizontal Le Fort I and pyramidal Le Fort II;
    • closed reduction, alveolar, with teeth, 3 cm or less;
    • fracture, alveolar, debridement, teeth removed, 3 cm or less;
    • lacerations, uncomplicated intra oral or extra oral repairs, 2 cm or less;
    • replantation avulsed tooth;
    • repositioning of traumatically displaced teeth.
  • Gingivoplasty and/or stomatoplasty:
    • excision of pericoronal gingivea;
    • gingivoplasty in conjunction with tooth removal;
    • independent procedures.
  • Incision intra oral:
    • in major anatomical area, with drain;
    • soft tissue;
    • surgical exploration - soft tissue.
  • Intraoral abscess, hard tissue, trephination and drainage.
  • Frenectomy:
    • lower lingual;
    • upper or lower labial.
  • Post-surgical care:
    • post-surgical care (minor and major) by other than treating dentist;
    • post-surgical care, subsequent to initial post-surgical treatment (minor and major) by the treating dentist;
    • post-surgical care, treatment of alveolitis with or without anesthesia.
  • Surgical exposure of tooth:
    • complex exposure of tooth with bone-tissue coverage;
    • enucleation of unerupted tooth and follicle;
    • exposure of unerupted tooth, bone-tissue coverage, positioning of attached gingivea;
    • exposure of unerupted tooth, soft-tissue coverage, positioning of attached gingivea;
    • repositioning of a tooth;
    • uncomplicated exposure of unerupted tooth with soft-tissue coverage (includes operculectomy).
  • Surgical incision and drainage and/or exploration of extraoral abscess, superficial or deep.
  • Vestibuloplasty.

• Periodontics
  Treatment of the soft tissue (gums) and bone supporting the teeth.
  • Adjunctive procedures:
    • provisional extra coronal splint or ligation:
      • bonded (acid-etched) joint restoration;
      • bonded, intraproximal enamel splint;
      • cast / soldered / ceramic / polymer glass, splint-bonded;
      • orthodontic band splint;
      • periodontal appliances, manibular or maxillary;
      • wire ligation, acrylic-covered;
      • wire ligation;
    • provisional intra coronal splint, "A" splint.
  • Application of displacement dressing.
  • Desensitization.
  • Nervous and muscular disorders.
  • Occlusal adjustments/equilibration.
  • Oral manifestations of systemic disease or complications of medical therapy.
  • Oral manifestations, oral mucusal disorders.
  • Periodontal reevaluation or evaluation.
  • Periodontal scaling, including gingival curettage and root planing, not exceeding 16 time units per benefit year.
    
    
    

    If scaling treatment is covered under both preventive and periodontic services, the insurer will determine whether such treatment is payable under the preventive or periodontic services based on the following:

    1. The scaling treatment will be considered preventive scaling provided the charge for such treatment is for less than 2 units of time.
    2. The scaling treatment will be considered periodontal scaling provided the charge for such treatment is for 2 units of time or more.
    3. Combined preventive or periodontic scaling treatments should not exceed 16 time units per benefit year.
  • Post-surgical treatments, visit for dressing change.
  • Surgical services:
    • flap approach:
      • exploratory and diagnosis;
      • with curettage of osseous defect;
      • with curettage of osseous defect and osteoplasty;
      • with osteoplasty and/or ostectomy;
      • with osteoplasty and/or ostectomy for crown lengthening;
    • gingivectomy with curettage;
    • gingivoplasty or gingivectomy;
    • graft:
      • free connective tissue (for root coverage);
      • free soft tissue;
      • osseous tissue graft, autograft or allograft;
      • soft tissue, pedicle;
    • periodontal surgery, miscellaneous procedures:
      • periodontal surgery, proximal wedge procedures with flap curettage;
      • periodontal surgery, proximal wedge procedures with flap curettage, with ostectomy/osteoplasty;
    • recontouring of tissue;
    • supra cretal fibrotomy;
    • surgical curettage, including root planing (gingival curettage).

• Fixed prosthodontics (permanent dentures/bridges/pontics)
  Coverage for bridgework involving one or more permanent molars is limited to the cost of a full metal pontic or retainer.
  • Additions to bridges, limited to once every 36 months.
  • Bridges/pontics:
    • acrylic/composite/compomer:
      • bonded to adjacent teeth, direct (provisional);
      • indirect, provisional;
      • processed to metal;
    • cast metal;
    • cast metal framework with separate porcelain / ceramic / polymer glass jacket pontic;
    • natural tooth crown, direct, bonded to adjacent teeth (provisional);
    • porcelain / ceramic / polymer glass, fused to metal or aluminous;
    • precision attachments and telescoping crown units for fixed bridge work;
    • prosthetics with precision attachments or stress breakers;
    • transfer coping for crowns;
    • prefabricated attachable facing.
  • Other prosthetic services:
    • additions, retentive pins, limited to once every 36 months;
    • provisional coverage - abutments (tooth or pontic).
  • Repairs, once every 36 consecutive months, unless they were installed at least 3 years before the date of repair:
    • adjustments (including minor adjustments);
    • fixed bridge or prosthesis, porcelain / ceramic / polymer glass / acrylic / composite / compomer, direct;
    • fractured porcelain/metal pontic with telescoping type crown;
    • repairs, recementation and/or reinsertion;
    • repairs, removal fixed bridge or prosthesis, to be recemented;
    • repairs, solder indexing to repair broken solder joint;
    • replace broken prefabricated attachable facing.
  • Retainers - abutments:
    • 3/4 cast metal;
    • abutment preparation under existing partial-denture clasps;
    • abutment, plastic (acrylic), direct transitional during healing, chair-side;
    • abutment, plastic (acrylic), processed or processed to metal;
    • compomer/composite, resin/acrylic, processed to cast metal;
    • cast metal onlay, with or without perforations, bonded to abutment tooth;
    • cast metal onlay;
    • cast metal, inlays (2 surfaces, 3 surfaces or more);
    • full cast metal;
    • porcelain / ceramic / polymer glass, full coverage, complicated;
    • porcelain / ceramic / polymer glass, full coverage;
    • porcelain / ceramic / polymer glass, fused to metal base.

• Laboratory procedures
  • Commercial laboratory procedures.
  • In-office laboratory procedures.

• Partial (removable) and complete dentures
  • Additions to dentures, once every 36 months:
    • no impression required;
    • impression required.
  • Adjustments, partial or complete dentures, maxillary and/or mandibular, adjustments including minor adjustments:
    • major;
    • minor.
  • Complete dentures, maxillary and/or mandibular:
    • provisional complete denture;
    • standard denture;
    • standard immediate surgical denture.
  • Partial dentures:
    • acrylic with metal wrought palatal/lingual bar and clasps and/or rests;
    • acrylic with metal wrought/cast clasps and/or rests;
    • acrylic with resilient retainer;
    • cast partial denture with precision or semi-precision attachments;
    • cast partial maxillary or mandibular denture with stress breaker attachments;
    • equilibrated, free-end dentures, cast frame/connector, clasps and rests;
    • equilibrated, tooth borne, cast frame/connector, clasps and rests;
    • free-end denture, cast frame/connector, clasps and rests;
    • free-end, swing lock/connector;
    • immediate, acrylic base (includes first tissue conditioner);
    • immediate, acrylic with metal wrought palatal/lingual bar and clasps and/or rests (includes fist tissue conditioner);
    • immediate, acrylic with metal wrought/cast clasps and/or rests (includes first tissue conditioner);
    • immediate, acrylic with resilient retainer (includes first tissue conditioner);
    • immediate, free-end denture, cast frame/connector, clasps and rests (includes first tissue conditioner);
    • immediate, tooth borne, cast frame/connector, clasps and rests, maxillary and/or mandibular and unilateral, one-piece casting, clasps and pontics (includes first tissue conditioner);
    • partial, cast frame/connectors, clasps, rests, plus complete opposing arch denture;
    • provisional, acrylic base with/without clasps;
    • tooth borne, cast frame/connector, clasps and rests, maxillary and/or mandibular and unilateral, one-piece casting, claps and pontics.
  • Partial or complete denture repairs, maxillary and/or mandibular, are limited to once every 36 months, unless they were installed at least 3 years before the date of repairs. This limitation will be waived when repair is required by an accidental blow to the mouth by an object that was not placed in the mouth (wittingly or unwittingly):
    • no impression required;
    • impression required.
  • Relining, rebasing and tissue conditioning are limited to once every 36 consecutive months:
    • relining or rebasing of partial or complete dentures, maxillary and/or mandibular:
      • direct;
      • processed;
      • processed, functional impression requiring three appointments;
    • therapeutic tissue conditioning for partial or complete dentures, maxillary and/or mandibular.
  • Remakes of equilibrated partial denture, maxillary and/or mandibular, using existing framework.

• Prosthodontics
  • A temporary appliance that is at least 12 months old will be considered to be a permanent denture or bridge for the purposes of this provision.
  • Expenses incurred for a permanent initial prosthodontic appliance, such as partial or full removable denture or fixed bridge, are covered if the appliance was necessary because of the extraction of at least one natural tooth.
  • Replacement of an existing denture (partial or complete) or bridge by a permanent denture or bridge:
    • if the replacement was necessary because of the extraction of one or more natural teeth; or
    • if the existing denture or bridge is at least 5 years old and cannot be made serviceable, limited to a maximum eligible expense of the value and quality of the original denture or bridge; or
    • if the existing denture or bridge is temporary and is being replaced with a permanent denture or bridge within 12 months of the installation of the temporary appliance. With respect to a permanent appliance that replaces a temporary one, the amount eligible for reimbursement will be reduced by the amount previously reimbursed by the insurer for the temporary appliance. This provision will not apply in the case of accidental injury involving a covered dependent child under age 18; or
    • if the existing removable denture is being replaced with a permanent bridge, the present benefit provides only for an existing removable denture to be replaced by another removable denture; however, the benefit equal to the cost of a new denture may be applied toward the treatment of choice.

• Single restorations - crowns, inlays, onlays
  
  
  

  Expenses incurred for crowns, inlays or onlays, as listed below:

  1. if a tooth is fractured due to caries or traumatic injury and cannot be filled by amalgam or composite;
  2. if temporary crowns are considered to be part of the final restoration; and
  3. replacement of an existing crown, inlay or onlay is an eligible expense if it is required to replace an existing crown, inlay or onlay that was installed at least 5 years before replacement, limited to a maximum eligible expense of the value and quality of the original crown, inlay or onlay.

  Coverage for a crown, inlay or onlay placed on a permanent molar is limited to the cost of a full metal crown, inlay or onlay.

  • Crowns and posts:
    • 3/4 crown, cast metal;
    • 3/4 crown, cast metal, complicated;
    • 3/4 crown, cast metal, with direct tooth-coloured corner;
    • 3/4 crown, porcelain / ceramic / polymer glass;
    • crown, acrylic/composite/compomer, indirect, complicated;
    • crown, acrylic/composite/compomer, provisional (long term), indirect;
    • crown, acrylic/composite/compomer, direct, provisional (chairside);
    • crown, plastic/transitional, indirect;
    • crown, porcelain / ceramic / polymer glass;
    • crown, porcelain / ceramic / polymer glass, fused to metal base;
    • crown, porcelain / ceramic / polymer glass, fused to metal base, complicated;
    • crown, transitional restoration of fractured anterior;
    • full crown, cast metal;
    • full crown, cast metal complicated;
    • posts, cast as part of a crown;
    • posts, cast metal (including core);
    • posts, cast metal (including core) concurrent with impression of crown.
  • Dentures therapeutic tissue conditioning, provided one year has elapsed since the appliance was installed.
  • Inlays:
    • composite/compomer, indirect, bonded;
    • metal;
    • porcelain / ceramic / polymer glass;
    • porcelain / ceramic / polymer glass, bonded.
  • Onlays:
    • cast metal, indirect;
    • cast metal, indirect (bonded external retention type);
    • composite/compomer, indirect (bonded);
    • porcelain / ceramic / polymer glass, bonded.
  • Other restorative services:
    • additional cost for preparation of crown under existing partial denture clasp;
    • amalgam core, bonded or non-bonded in conjunction with crown;
    • coping, metal/acrylic, transfer (thimble);
    • crowns made to an existing partial denture clasp;
    • posts, prefabricated, one post, two or three posts and cast core (same tooth);
    • posts, prefabricated, with non-bonded amalgam core and pin(s), 1 to 3 posts;
    • posts, prefabricated, with non-bonded composite core and pin(s), 1 to 3 posts;
    • posts, prefabricated, retentive (for inlays, onlays and crown per tooth);
    • posts, prefabricated;
    • restoration, tooth-coloured, bonded or non-bonded core, in conjunction with crown.
  • Prefabricated crowns (restorations), once per tooth every 60 months:
    • plastic, permanent, anterior or posterior teeth;
    • stainless steel crowns (metal), permanent and posterior teeth, open face / acrylic veneer;
    • stainless steel crowns (metal), permanent anterior or posterior teeth.
  • Recementation/rebonding, inlays, onlays, crowns, veneers, posts, natural tooth fragments.
  • Removal of inlays, onlays, crowns or veneers.
  • Repairs:
    • acrylic/composite/compomer, direct;
    • porcelain / ceramic / polymer glass, direct;
    • porcelain / ceramic / polymer glass, indirect.
  • Partial (removable) and complete dentures, fixed prosthodontics and crowns attached to the implant or supported by implant are limited to the rate corresponding to the removable or fixed prosthesis without implant.

If, while you are insured under this plan, you incur eligible expenses that are for necessary dental treatment, which has as its objective the correction of malocclusion of the teeth, as listed below, the insurer will reimburse such expenses in accordance with the provisions of the plan policy and subject to any maximums specified in the BENEFIT SCHEDULE.

Diagnosis, observation and adjustment

• Orthodontic treatments:
  • fixed appliance or removable, Class I malocclusion, Class II malocclusion and Class III malocclusion and malocclusion not requiring complete banding (permanent, mixed or primary dentition);
  • neonatal dento-facial orthopedic appliances for infants with cleft palate (comprehensive treatment for first six months of life):
    • expansion appliance;
    • extraoral retraction appliance;
    • stage I, initial expansion;
    • stage II, anterior alignment;
    • stage III, final alignment (complete banding).

• Fixed space-regaining appliances, mandibular or maxillary:
  • alignment of incisor teeth, simple or complex;
  • closure of diastemas, simple or complex;
  • cross-bite correction, anterior or posterior;
  • dental arch expansion or including rapid expansion;
  • fixed;
  • fixed, unilateral;
  • grassline or elastic ligatures;
  • headgear;
  • mechanical eruption of teeth/tooth, impaction or erupted teeth;
  • two-molar band, hooked and elastics.

• Laboratory procedures:
  • commercial laboratory procedures;
  • in-office laboratory procedures.

• Orthodontic observations and adjustments:
  • Observations, development for tooth guidance (i.e., tooth position, eruption sequence, serial extraction supervision, etc.);
  • to orthodontic appliances and/or the reduction of proximal surfaces of teeth per appointment.

• Payment instalment for treatment in progress.

• Active removable appliances, maxillary or mandibular, for tooth guidance or minor tooth movement:
  • alignment of anterior teeth, simple or complex;
  • closure of diastemas, simple or complex;
  • cross-bite correction, simple or complex;
  • dental arch expansion, simple or complex (including rapid expansion);
  • space regaining, unilateral or bilateral, simple or complex.

• Repairs and alterations:
  • alteration of fixed appliances;
  • recementation of fixed appliances;
  • removal of fixed orthodontic appliances by a practitioner other than the original treating practice or practitioner;
  • repairs to removable or fixed appliances;
  • separation.

• Retention or retaining appliances, removable or fixed/cemented:
  • maxillary;
  • mandibular;
  • tooth positioner.

• Services for diagnostic purposes:
  • cephalometric radiographs with or without tracing and interpretation;
  • diagnosis photographs;
  • general examination and diagnosis;
  • specific examination.

• Surgical exposures, unerupted tooth with orthodontic attachment.

The plan will cover dental treatment received while travelling outside Canada, to the extent that payment would have been made under this plan if:

• such treatment had been received in your province of residence; and
• such treatment was rendered for emergency purposes only.