I. Disclaimer

This document is intended to be used as a reference for VA and non-VA providers. It is not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice. 

Eligibility for VA dental care is defined by statute and is to be provided in accordance with the provisions of existing law and VA regulations, specifically 38 U.S.C. §§1710(c) and 1712, and 38 CFR §§17.160 through 17.166. 

II. Dental Clinical Determinations and Indications 

1. Indications for Mucogingival Procedures 
   Mucogingival procedures for the treatment of mucogingival defects may be considered clinically necessary when ALL the following criteria are met: 
   • The Veteran has a diagnosis of gingival recession with root exposure (i.e. Miller Class I-III)  
   • The Veteran has at least ONE of the following functional impairments:  
     • Documented root sensitivity to thermal, tactile, or osmotic stimuli unresponsive to non-surgical therapies  
     • Recurrent inflammation or gingival bleeding due to inadequate keratinized tissue and/or vestibular depth that is 3mm or greater 
     • Progression of recession confirmed through clinical documentation over time 
     • Planned restorative or prosthetic treatment in areas of recession where gingival augmentation is required to achieve long-term stability and health 
     • Preservation of frenum or muscle attachments that cause gingival recession or interfere with oral hygiene 
   • The surgical site must be free of active infection, biofilm, and inflammation at the time of surgery  
   • The Veteran demonstrates the ability and willingness to maintain adequate oral hygiene 

2. Limitations/Exclusions 
   Mucogingival procedures are not indicated and therefore considered not clinically necessary if any of the following conditions are present: 
   • Cosmetic or aesthetic use: Procedures aimed solely at improving gingival contour without functional necessity 
   • Active tobacco use: Current smoking or tobacco use, which reduces regenerative outcomes 
   • Gingival recession classification: Sites with Miller Class IV recession   
   • Poor oral hygiene: Documented inability or unwillingness to maintain adequate oral hygiene 
   • Gingival augmentation: Gingival augmentation around implants in the absence of inflammation, mobility, or prosthetic complications  
   • Uncontrolled systemic conditions: Conditions that impair wound healing, including but not limited to uncontrolled diabetes, autoimmune disorders, chronic corticosteroid use, or immunosuppressive medication use   

   For all other conditions or indications not listed in section II.a. of this document, mucogingival procedures are considered not clinically necessary due to insufficient evidence of efficacy and safety. 

3. Description of Treatment 
   Mucogingival procedures fix problems with the gums and the tissue around the teeth. These problems can be caused by the way the mouth is formed, injuries, or gum disease. The goals of these procedures are to cover exposed roots of the teeth, increase the amount of firm gum tissue, make the space between the lips and gums deeper, and remove any tissue that makes it hard to keep the mouth clean.

III. Background and Supporting Information

The following information is for reference purposes only in accordance with dental eligibility as defined by statute (law). Each subsection supports VA’s determinations for clinical necessity and alignment with generally accepted standards of dental practice. 

1. Background Information
   Mucogingival deformities such as gingival recession, shallow vestibule, and lack of attached gingiva are common findings in periodontal evaluations. Gingival recession can result in root sensitivity, increased risk for root caries, progression of periodontal disease, and poor esthetic outcomes. While not all cases require intervention, clinical evidence supports that in certain indications, mucogingival procedures can provide significant improvements in patient-reported outcomes and periodontal health. 

2. Research, Clinical Trials, and Evidence Summaries
   Consensus reports from the American Academy of Periodontology (2000) and systematic reviews, such as those conducted by Chambrone et al. (2018) and Atieh et al. (2016), have substantiated the efficacy of subepithelial connective tissue grafts and alternative materials like acellular dermal matrix grafts (ADMG) and xenogeneic collagen matrix (XCM) for achieving root coverage and increasing keratinized tissue. The clinical success is notably high in Miller Class I/II defects (Sanz and Simion, 2014). Evidence also indicates substantial functional improvement in oral hygiene, reduction in sensitivity, and prevention of disease progression when these procedures are appropriately indicated (Tonetti and Jepsen, 2014). This comprehensive evidence is critical for the development of effective treatment plans aimed at optimal patient outcomes.    

3. U.S. Food & Drug Administration Information
   VA generally only approves use of medical devices that have received at least Food & Drug Administration (FDA) clearance for 510(k) Premarket Notification. The FDA has determined these Class II devices are substantially equivalent (SE) to legally marketed predicate devices, in terms of safety and effectiveness, and may be marketed in the U.S. Manufacturers must adhere to FDA regulations on labeling, manufacturing practices, and post-market surveillance. The FDA monitors adverse event reports and can mandate recalls. Manufacturer’s Instructions for Use (MIFU) must be followed. 

   Materials and biologics used in mucogingival grafting procedures are regulated by the FDA’s Center for Devices and Radiological Health (CDRH) or Center for Biologics Evaluation and Research (CBER), these are typically classified as Class II medical devices or biologics. Materials must comply with FDA standards for biocompatibility, safety, and efficacy under functional loads. 

   To search for devices that have received FDA 510(k) clearance or Premarket Approval (PMA), please visit the FDA Devices database. 

4. American Dental Association Current Dental Terminology Coding Information 
   The following CDT codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Dental Association (ADA) code updates may occur more frequently than dental CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for clinical necessity. 

   CDT Code	Description
   D4270	Pedicle soft tissue graft procedure
   D4273	Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft
   D4274	Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)
   D4275	Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft
   D4276	Combined connective tissue and pedicle graft, per tooth
   D4278	Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site
   D4283	Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site
   D4285	Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

   Current Dental Terminology (CDT) Copyright ^© 2026 American Dental Association. All rights reserved.

IV. Definitions

Term	Definition
Attached gingiva	The portion of gingiva tightly bound to the underlying alveolar bone
Biofilm	A complex, structured community of microorganisms that adhere to surfaces within the oral cavity, particularly the teeth and gingival tissues
Gingival recession	Apical migration of the gingival margin exposing the root surface
Guided tissue regeneration	A regenerative surgical technique using a barrier membrane to direct the growth of new bone and periodontal ligament at sites with insufficient hard or soft tissue
Keratinized tissue	Gingiva that is keratinized, including both attached and free gingiva
Miller Class I	Marginal tissue recession not extending to the mucogingival junction. No loss of interdental bone or soft tissue. Complete root coverage can be anticipated
Miller Class II	Marginal tissue recession extending to or beyond the mucogingival junction. No loss of interdental bone or soft tissue. Complete root coverage can be anticipated
Miller Class III	Marginal tissue recession extending to or beyond the mucogingival junction. Loss of interdental bone or soft tissue is apical to the cementoenamel junction but coronal to the apical extent of the marginal tissue recession. Partial root coverage can be anticipated
Miller Class IV	Marginal tissue recession extending to or beyond the mucogingival junction. Severe loss of interdental bone or soft tissue apical to the extent of the marginal tissue recession. Root coverage is unlikely
Mucogingival defect	An anatomic anomaly of the gingiva and/or alveolar mucosa
Mucogingival junction	The junction between alveolar mucosa and gingiva

V. References

American Academy of Periodontology. (2000). Parameters of Care Supplement: Parameter on mucogingival conditions. Journal of Periodontology, 71, 861-862. 

American Academy of Periodontology. (2025). Glossary of Periodontal Terms. Retrieved April 24, 2025. 

Atieh, M. A., Alsabeeha, N., Tawse-Smith, A., & Payne, A. G. (2016). Xenogeneic collagen matrix for periodontal plastic surgery procedures: a systematic review and meta-analysis. Journal of periodontal research, 51(4), 438–452.

Bassetti, M., Kaufmann, R., Salvi, G. E., Sculean, A., & Bassetti, R. (2015). Soft tissue grafting to improve the attached mucosa at dental implants: A review of the literature and proposal of a decision tree. Quintessence international (Berlin, Germany : 1985), 46(6), 499–510. 

Chambrone, L., Salinas Ortega, M. A., Sukekava, F., Rotundo, R., Kalemaj, Z., Buti, J., & Pini Prato, G. P. (2018). Root coverage procedures for treating localised and multiple recession-type defects. The Cochrane database of systematic reviews, 10(10), CD007161. 

CMS.gov. (n.d.). Medicare Dental Coverage. Retrieved April 24, 2025,  

Defense Health Agency reference to: Defense Health Agency. (2024). TRICARE Dental Program Reference Document. Defense Health Agency. 

Herrick, K. R., Terrio, J. M., & Herrick, C. (2021). Medical Clearance for Common Dental Procedures. American family physician, 104(5), 476–483.  

Jepsen, S., Caton, J. G., Albandar, J. M., Bissada, N. F., Bouchard, P., Cortellini, P., Demirel, K., de Sanctis, M., Ercoli, C., Fan, J., Geurs, N. C., Hughes, F. J., Jin, L., Kantarci, A., Lalla, E., Madianos, P. N., Matthews, D., McGuire, M. K., Mills, M. P., Preshaw, P. M., … Yamazaki, K. (2018). Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of periodontology, 89 Suppl 1, S237–S248. 

Joshi, G. P., Chung, F., Vann, M. A., Ahmad, S., Gan, T. J., Goulson, D. T., Merrill, D. G., Twersky, R., & Society for Ambulatory Anesthesia (2010). Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesthesia and analgesia, 111(6), 1378–1387. 

Kinane, D. F., & Marshall, G. J. (2001). Periodontal manifestations of systemic disease. Australian dental journal, 46(1), 2–12. 

Leong, D. J., & Wang, H. L. (2011). A decision tree for soft tissue grafting. The International journal of periodontics & restorative dentistry, 31(3), 307–313. 

Sanz, M., Simion, M., & Working Group 3 of the European Workshop on Periodontology (2014). Surgical techniques on periodontal plastic surgery and soft tissue regeneration: consensus report of Group 3 of the 10th European Workshop on Periodontology. Journal of clinical periodontology, 41 Suppl 15, S92–S97. 

Takei, H., Scheyer, E. T., Azzi, R. R., et al. (2023). Periodontal plastic and esthetic surgery. In Newman and Carranza’s Clinical Periodontology and Implantology (14th ed., pp. 775–779). St. Louis: Elsevier.  

Tonetti, M. S., Jepsen, S., & Working Group 2 of the European Workshop on Periodontology (2014). Clinical efficacy of periodontal plastic surgery procedures: consensus report of Group 2 of the 10th European Workshop on Periodontology. Journal of clinical periodontology, 41 Suppl 15, S36–S43. 

United Concordia. (n.d.). Surgical Periodontics: Mucogingival Procedures. Retrieved April 24, 2025. 

Zucchelli, G., Mounssif, I., Mazzotti, C., Stefanini, M., Marzadori, M., Petracci, E., & Montebugnoli, L. (2014). Coronally advanced flap with and without connective tissue graft for the treatment of multiple gingival recessions: a comparative short- and long-term controlled randomized clinical trial. Journal of clinical periodontology, 41(4), 396–403. 

Zucchelli, G., Tavelli, L., McGuire, M. K., Rasperini, G., Feinberg, S. E., Wang, H. L., & Giannobile, W. V. (2020). Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction. Journal of periodontology, 91(1), 9–16. 

Zuhr, O., Bäumer, D., & Hürzeler, M. (2014). The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and execution. Journal of clinical periodontology, 41 Suppl 15, S123–S142. 

VI. Dental CDI History/Revision Information

Date	Summary of Updates
10/01/2026	New dental CDI created describing clinically necessary indications / not clinically necessary indications

---