• Complete oral examination, once every 36 months
• Recall oral examination, once every 6 months
• Specific oral examination, once every 6 months
• Emergency oral examination

• Complete series of periapical films or panoramic radiographs, limited to one series every 36 months
• Intra oral films, including bitewing films, and radiographs to diagnose a symptom or examine progress of a particular course of treatment
• Interpretation of radiographs from another source
• Photography
• Radiograph of the hand and wrist as a diagnostic aid for dental treatment

• Bacteriologic cultures/smears to determine pathological agents
• Biopsies
• Pulp vitality tests
• Unmounted Diagnostic casts

• Consultation with an insured person (a day other than the examination date)

• Oral hygiene instruction, once every 6 months
• Polishing, once every 6 months
• Light scaling for preventive purposes rather than therapeutic, limited to a maximum of 2 units per coverage period
• Topical application of fluoride, once every 6 months
• Finishing restorations
• Pit and fissure sealants, for children under age 16
• Interproximal discing
• Space maintainers for missing primary teeth, for children under age 16
• Prophylactic odontotomy/enameloplasty

• Extractions – impacted tooth

• Amalgam (silver)
• Composite restorations performed on posterior teeth are limited to the fees for amalgam restorations
• Retentive pins for amalgam and composite restorations
• Preformed stainless steel and polycarbonate crowns, for children under age 16
• Caries / trauma / pain control, separate procedure from restoration

• Treatment of disease of the pulp chamber and pulp canals (root canal therapy)

Treatment of the gums (soft tissue) and bone supporting the teeth. However, the following expenses are limited:

1. post-operative visits, 4 visits per coverage period
2. curettage performed by a dentist, once per period of 60 months
3. periodontal treatment including root planning, limited to a maximum of 8 units per coverage period
4. adjustments to periodontal appliance to control bruxism only, limited to one adjustment per coverage period
5. occlusal equilibration, limited to 8 units per coverage period

• Repair
• Structure addition (to an existing removable denture)
• Relining
• Rebasing
• Adjustments to dentures, 3 months after insertion
• Denture adjustments including minor adjustments, once every 6 months

• Extractions - uncomplicated and complex (except impacted tooth)
• Removal of residual roots
• Surgical exposure of teeth
• Alveolectomy, alveoplasty, stomatoplasty and osteoplasty
• Alveolar ridge reconstruction
• Extension of mucous folds
• Excisions
• Incisions
• Frenectomy
• Miscellaneous surgical procedures

Replacement of an existing denture or bridge by a permanent denture or bridge:

1. if the replacement was necessary because of the extraction of one or more natural teeth while the insured is covered under this Benefit or a comparable benefit in force immediately before the effective date of this Benefit, or
2. if the existing denture or bridge is at least 5 years old; or
3. 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.

A temporary appliance which is at least 12 months old will be considered to be a permanent denture or bridge for the purposes of this provision.

• Complete denture
• Immediate complete denture
• Complete or partial overdenture
• Transitional denture
• Partial denture including cast in chrome (but not in gold)
• Partial denture remake
• Remount with occlusal equilibration
• Therapeutic tissue conditioning

• Abutments and pontics
• Repairs
• Bridge removal
• Recementation

• Onlays, veneers applications, inlays, crowns
1. for a tooth that is fractured due to caries or traumatic injury and cannot be filled by amalgam or composite
2. temporary crowns are considered to be part of the final restoration
3. replacement of an existing onlay, veneer application, inlay or crown is included if such restoration is at least 5 years old
4. only metal crowns on molars are reimbursed
• Porcelain repair
• Retentive pins, pivots, cast posts
• Recementation
• Removal of an inlay or crown