Primary occlusal trauma

This code represents damage to the periodontium (the tissues supporting the teeth) resulting from excessive occlusal forces on teeth with otherwise healthy periodontal support. It is characterized by features such as increased tooth mobility, fremitus, and widening of the periodontal ligament space, without pre-existing periodontal disease.

Use this code when documentation clearly indicates that the occlusal trauma is the primary cause of the periodontal damage, and there is no underlying periodontitis. This typically applies to situations involving parafunctional habits (e.g., bruxism, clenching), high restorations, or malocclusion leading to excessive force on specific teeth. Documentation should specify the absence of significant bone loss or pocketing indicative of periodontitis.

• Differentiate from secondary occlusal trauma, which occurs on a reduced periodontium due to pre-existing periodontal disease.
• Ensure documentation explicitly states "primary" occlusal trauma or describes a healthy periodontium subjected to excessive force.
• Avoid using this code if the occlusal trauma is exacerbating existing periodontitis; a code for periodontitis would be more appropriate, potentially with an additional code for the occlusal factor if specified.