Please note: the codes to document Perio Tray™ prescriptions changed January 1, 2021.  

Perio Tray™ prescriptions can be documented in your office with these codes:

  • D5995 Periodontal medicament carrier with peripheral seal – maxillary.
    • A custom fabricated, laboratory processed carrier that covers the teeth and alveolar mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.
  • D5996 Periodontal medicament carrier with peripheral seal – mandibular.
    • A custom fabricated, laboratory processed carrier that covers the teeth and alveolar mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.

When submitting a claim for D5995 and D5996, it may be important to document the rational for periodontal medicament delivery. This documentation could include the periodontal diagnosis, pocket probing depth charts, the extent of the tissue ulceration in the form of bleeding points, patient health history of systemic diseases, and/or brief description of prior periodontal treatment history.

Perio Gel and Perio GelXcan be submitted with this code:

  • D9630 Drugs or medicaments dispensed in the office for home use.
    • Includes but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.

D9630 is used for all medication dispensed from your office, so you may want to establish a specific identifying number or name for Perio Gel  in your practice management software. It is important to track how much Perio Gel a patient uses to be sure patients get enough gel over time. Patients using Perio Tray delivery with gel 1x/day will need approximately 8 tubes a year (2 tubes every 13 weeks).


For Perio Gel submissions, you can put an explanation like this one in the remarks field: D9630, Supplies and Materials = OTC Perio Gel, 3.0oz (85g). Antiseptic Oral Cleanser with active ingredient Hydrogen peroxide 1.7%, used as a debriding agent.


Talking to Patients about Perio Protect

With any insurance plan, there can be no guarantee of payment. Many patients, especially those with complete treatment plans will maximize their insurance benefits and still have some out-of-pocket expenses. It is important to discuss this with patients and explain the importance of their treatment. Patients must understand that dental insurance pays only a percentage of the fee charged, and only until the maximum annual benefit has been exhausted. Listed below are ideas to help you talk to the patients. 

  • Patients need to know how important dental care and management is to their health and wellness. Chronic infections and inflammation of the gingival tissues can make it harder for type 2 diabetics to manage blood sugar, can lead to inflammation in the cells lining the arteries, and appears to speed up the progression of dementia. Gum disease is also associated with other chronic systemic inflammatory conditions like ED, pulmonary diseases, cancers, rheumatoid arthritis, and pregnancy complications. Be sure to refer to the patient's health history. 
  • Tactfully explain that a disease should be treated. Gum disease is caused by a chronic infection and is the leading cause of tooth loss and can impact a person’s smile, appearance, and ability to chew and enjoy food. As time goes by, untreated disease will get progressively worse.
  • Be sure to present treatment plans showing the long term savings with Perio Protect. The goal is to avoid another scaling or surgical procedure. Addressing the disease and improving health now can save a lot of money in the future.
  • Discuss the cost of your whitening services and explain that gradual whitening is a positive side effect of the hydrogen peroxide in Perio Tray therapy. It's like free whitening and without the sensitivity. 
  • For fearful patients, you can emphasize the uniquely non-invasive delivery technique offered by the Perio Tray®.
  • The possible lack of coverage should not discourage anyone from performing a procedure that is known to provide a positive result. With or without reimbursement, Perio Tray therapy provide preventive therapy at a modest cost to the patient. Happy patients are referring patients, they will grow dental practices.
  • You may also want to explain that new therapeutic concepts are not readily accepted by insurance carriers until the procedure becomes so pervasive it can no longer be ignored. (As an example you can remind patients dental implants were being performed for more than 20 years before the first insurance carriers began to provide coverage for them).
  • If you charge $800 for a set of Perio Tray carriers, homecare kit, and 4 tubes of Perio Gel, that works out to $67/month for 12 months. After that, the cost of Perio Gel ($25/tube) is $.54/day. (Less than a postage stamp!)

Medical Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA)

For patients with a medical FSA or HSA, Perio Tray carriers and the medicaments prescribed for use in them will often apply. The Perio Tray carrier is cleared by the FDA as a prescription medical device and the medications for use are often obtained with a written prescription. Please see the below template explaining this to patients

The Internal Revenue Service specifically states in Publication 502 that whitening treatments are not valid for FSA, but under subhead Dental Treatment, it is clear that “You can include in medical expenses the amounts you pay for the prevention and alleviation of dental diseases.” .


If there are any questions, be sure to have patients check their account plans.

Medical Billing Information and Codes

The Canadian Dental Association recommends that offices contact provincial associations to confirm code information. The suggested USC&LS codes (not available in Quebec) follow here:

  • 12701 Medication, custom appliance, maxillary arch +L
  • 12702 Medication, custom appliance, mandibular arch +L
  • Lab fees should be reported using the appropriate codes from the 99000 Laboratory and expense procedures Class of codes, most likely 99111 +L Commercial laboratory procedures
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