Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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MDS Lookup
Dental
Item Rationale
Matrix review
3 matrix group(s) are already attached for review on this item.
Answer coverage
3 governed answer row(s) are attached for this item.
Answer Codes
C
Abnormal mouth tissue (ulcers, masses, oral lesions)
Governed answer row attached.
G
Unable to examine
Governed answer row attached.
Z
None of the above
Governed answer row attached.
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section L and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page L-1
- CMS exact locator: Manual page L-1
- This item has 3 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page L-1
CMS exact locator
Manual page L-1
Full CMS Text
Item Rationale
Health-related Quality of Life
Poor oral health has a negative impact on: — quality of life — overall health — nutritional status Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes.
Planning for Care
Assessing dental status can help identify residents who may be at risk for aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes.
DEFINITIONS
CAVITY A tooth with a discolored hole or area of decay that may have debris in it. BROKEN NATURAL TEETH OR TOOTH FRAGMENT Very large cavity, tooth broken off or decayed to gum line, or broken teeth (from a fall or trauma). ORAL LESIONS A discolored area of tissue (red, white, yellow, or darkened) on the lips, gums, tongue, palate, cheek lining, or throat. EDENTULOUS Having no natural permanent teeth in the mouth. Complete tooth loss.
Steps for Assessment
1. Ask the resident about the presence of chewing problems or
mouth or facial pain/discomfort.
2. Ask the resident, family, or significant other whether the
resident has or recently had dentures or partials. (If resident or family/significant other reports that the resident recently had dentures or partials, but they do not have them at the facility, ask for a reason.) 3. If the resident has dentures or partials, examine for loose fit. Ask them to remove, and examine for chips, cracks, and cleanliness. Removal of dentures and/or partials is necessary for adequate assessment.
4. Conduct exam of the resident’s lips and oral cavity with dentures or partials removed, if
applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use their gloved fingers to adequately feel for masses or loose teeth.
5. If the resident is unable to self-report, then observe them while eating with dentures or
partials, if indicated, to determine if chewing problems or mouth pain are present.
6. Oral examination of residents who are uncooperative and do not allow for a thorough oral
exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues.
Coding Instructions
Check L0200A, broken or loosely fitting full or partial denture: if the denture or partial is chipped, cracked, uncleanable, or loose. A denture is coded as loose if the resident complains that it is loose, the denture visibly moves when the resident opens their mouth, or the denture moves when the resident tries to talk. Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth. Check L0200C, abnormal mouth tissue (ulcers, masses, oral lesions): select if any ulcer, mass, or oral lesion is noted on any oral surface. Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen. Check L0200E, inflamed or bleeding gums or loose natural teeth: if gums appear irritated, red, swollen, or bleeding. Teeth are coded as loose if they readily move when light pressure is applied with a fingertip. Check L0200F, mouth or facial pain or discomfort with chewing: if the resident reports any pain in the mouth or face, or discomfort with chewing. Check L0200G, unable to examine: if the resident’s mouth cannot be examined. Check L0200Z, none of the above: if none of conditions A through F is present.
DEFINITIONS
ORAL MASS A swollen or raised lump, bump, or nodule on any oral surface. May be hard or soft, and with or without pain. ULCER Mouth sore, blister or eroded area of tissue on any oral surface.
Coding Tips
Mouth or facial pain coded for this item should also be coded in Section J, items J0100 through J0850, in any items in which the coding requirements of Section J are met. The dental status for a resident who has some, but not all, of their natural teeth that do not appear damaged (e.g., are not broken, loose, with obvious or likely cavity) and who does not have any other conditions in L0200A–G, should be coded in L0200Z, none of the above. Many residents have dentures or partials that fit well and work properly. However, for individualized care planning purposes, consideration should be taken for these residents to make sure that they are in possession of their dentures or partials and that they are being utilized properly for meals, snacks, medication pass, and social activities. Additionally, the dentures or partials should be properly cared for with regular cleaning and by assuring that they continue to fit properly throughout the resident’s stay. Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure. Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. Acknowledging that clinicians may use and documentation may reflect any of these terms, it is acceptable to code pressure-related skin conditions in Section M if different terminology is recorded in the clinical record, as long as the primary cause of the skin alteration is related to pressure. For example, if the medical record reflects the presence of a Stage 2 pressure injury, it should be coded on the MDS as a Stage 2 pressure ulcer.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
Care Area Triggers
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Administrative (Tech Need / Edits / Processing)
Marker: +
supporting item
Locator: MDS Item Matrix v1.20.1 v4
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4