In der zahnärztlichen Therapie sind verschiedene bimaxilläre Schienen für unterschiedliche Einsatzgebiete etabliert. Je nach Indikation werden diese auch als Schnarcherschienen, Schlafapnoe-Schienen, Positionierungsschienen oder Simulationsschienen bezeichnet. Diese Behandlungsmittel haben mittlerweile einen festen Platz in der Zahnheilkunde, abgesichert durch Leitlinien und wissenschaftliche Mitteilungen. Sie sind in der amtlichen deutschen Gebührenordnung für Zahnärzte aber nicht aufgeführt und es sind jüngst hierzu verschiedene neue Beschlüsse gefasst worden. Der vorliegende Beitrag stellt diese Vorgaben und Beschlüsse vor und erläutert sie im Rahmen einer kritischen Auseinandersetzung. Keywords: Okklusionsschienen, bimaxilläre Poisitionierungsschienen, Unterkieferprotrusionsschienen, bimaxilläre Simulationsschienen, Schlafapnoe, Schnarchen, Arthropathie

Der Beitrag beschreibt zunächst die Unterschiede zwischen Mundhygieneinstruktion, professioneller Zahnreinigung und unterstützender Parodontitistherapie bezüglich Inhalt, Nutzen und Indikation. Anschließend werden die Konsequenzen für die Delegation und die Berechnung entsprechender Leistungen in der Bundesrepublik Deutschland aufgezeigt. Keywords: Mundhygieneinstruktion, professionelle Zahnreinigung, unterstützende Parodontitistherapie, Delegation, Abrechnung

Grundlage vieler funktionsanalytischer und funktionstherapeutischer Behandlungsmaßnahmen ist die Erhebung einer klinischen Funktionsanalyse. Insofern nimmt auch die GOZ-Nummer 8000 eine zentrale Stellung bei der Berechnung funktionsanalytischer und -therapeutischer Maßnahmen ein. Die Weiterentwicklung der fachlichen Grundlagen der Funktionsdiagnostik wird dabei selten so deutlich wie bei der Betrachtung der Leistungslegende der GOZ-Nummer 8000, der „klinische[n] Funktionsanalyse einschließlich Dokumentation“. Offensichtlich wird die Diskrepanz zwischen Gebührenordnung einerseits und fachlichem Stand andererseits insbesondere dann, wenn man sich die Berechnungsbestimmung dieser Gebührennummer, die 2012 bei der GOZ-Reform unverändert aus der GOZ von 1988 übernommen wurde, vergegenwärtigt: „Die Leistung nach der Nummer 8000 umfasst auch folgende zahnärztliche Leistungen: prophylaktische, prothetische, parodontologische und okklusale Befunderhebung, funktionsdiagnostische Auswertung von Röntgenaufnahmen des Schädels und der Halswirbelsäule, klinische Reaktionstests (z. B. Resilienztest, Provokationstest).“ Zahnärzte sind in Deutschland nach dem Zahnheilkundegesetz verpflichtet, die Zahnheilkunde nach aktuellem Stand der Wissenschaft auszuüben. Diese Berufsausübung in Übereinstimmung zu bringen mit der in Teilen inhaltlich veralteten Gebührenordnung ist schwierig. Der vorliegende Beitrag schildert am Beispiel der GOZ-Nummer 8000 auch dieses Problem im Detail. Im Zusammenhang mit der klinischen Funktionsanalyse ist es wichtig, die wissenschaftlichen Neuerungen inhaltlich von der GOZ-Nummer 8000 abzugrenzen, zumal in den letzten Dekaden genau in diesem Bereich enorme Weiterentwicklungen und Auffächerungen der zahnärztlichen Funktionsdiagnostik erfolgt sind. Keywords: klinische Funktionsanalyse, craniomandibuläre Dysfunktion (CMD), Gebührenordnung, GOZ

Further development of the foundations of the specialty of Craniomandibular Function and Disorders has in some cases made it necessary to redefine the positions of systematized entities of this specialty that had previously been relegated to other positions or causal contexts. Consequently, the first AWMF Guideline on Bruxism Diagnosis and Treatment was published on 2 May 2019 (Register No. 083-027) by the German Society of Craniomandibular Function and Disorders (DGFDT), together with the German Society of Dental, Oral and Craniomandibular Sciences (DGZMK) as well as around three dozen professional societies. The guideline, which was assigned an S3 ranking (reflecting the highest stage of development), recognizes bruxism as a potentially independent disease entity, placing it on a similar footing with craniomandibular dysfunction. The Bruxism Screening Index (BSI), an instrument for the diagnosis of bruxism, was developed by a DGFDT working group based on the current literature, parallel to the S3 Guideline. Restructuring of the specialty in this manner has led to a need for changes in the billing of bruxism diagnostic services. These aspects are discussed in this article. Keywords: craniomandibular dysfunction (CMD), bruxism, Bruxism Screening Index (BSI), clinical functional analysis, German Dental Fee Schedule, GOZ, analogous billing

Dental functional analysis and treatment specialists have also been impacted by a growing number of disputes over the legal basis for billing various examination and treatment services in recent years. This problem is rooted in the fact that the German Dental Fee Schedule (GOZ), which was reformed by the Federal Government in 2012, is generally binding, so dentists are legally obligated to abide by its provisions without exception (Article §1 GOZ) unless otherwise provided by law. As craniomandibular function and disorders-related services do not fall under the contract dental services provided for under Article §28 (2) 8 of German Social Code V, this impacts all patients in need of functional analysis and treatment. In and of itself, this regulation is clear. Nevertheless, the billing of functional analysis and treatment services is problematic because the fee schedule contains a table of fees for a list of services that is incomplete, especially in this area. This peculiarity is formally recognizable by the fact that Article §6 (1) of the GOZ contains a provision that expressly allows dentists to set fees for independent services not included in the Dental Fee Schedule commensurate with the fees charged for similar analogous services included in the fee schedule ('analogous billing' procedure). The legislators inserted this provision to circumvent the need for periodic short-term updates to the fee schedule; at the same time, the analogous billing procedure allows dentists to meet their obligation to provide treatment consistent with the standards of the current state of science, as specified in the Dentistry Act. The 'List of Analogous Dental Services' published by the German Dental Association serves as a reference for dentists who provide independent services not included in the GOZ fee schedule and thus do their invoicing based on the analogous billing procedure. The list is updated semiannually but is presented without commentary or explanations of the contents. The Commentary to BEMA & GOZ1, a detailed independent fee schedule commentary introduced decades ago and recognized by the German Dental Chambers and courts, is one publication that takes on this task. The present article, written by one of its co-authors, describes the extent to which condylar position analysis is an independent dental service, and the billing procedure for this service. Keywords: craniomandibular dysfunction (CMD), instrumental functional analysis, condylar position analysis, German Dental Fee Schedule, GOZ, fee schedule, analogous billing

Progressive tooth surface loss unrelated to caries or trauma has been an increasing focus of dentistry over the last several decades. New clinical diagnostic procedures had to be established to address this problem. Established procedures for the measurement and classification of tooth wear and its pathological relevance for the individual patient now exist in the form of a two-stage examination procedure comprising tooth wear screening followed by an in-depth tooth wear status assessment, if indicated. This was not taken into account in the 2012 update of the German Dental Fee Schedule (GOZ), whose list of functional diagnostic services remained largely unchanged compared to the previous version of 1988. The German Dentistry Act, on the other hand, requires dentists to practice dentistry in Germany according to the current state of science. Dentists would be unable to meet the requirements of the German Dentistry Act if limited solely to the services listed in the GOZ fee schedule. Therefore, legislators drafting the new GOZ fee schedule gave dentists the option to bill for independent services not included in the fee schedule commensurate with the fees charged for analogous services of similar type, cost, complexity, and time requirement. Based on the example of tooth wear screening and tooth wear status assessment, this article describes the legal and scientific background as well as the consequences of implementing the GOZ 2012 fee schedule in daily clinical practice. Keywords: temporomandibular dysfunction (TMD), tooth wear, tooth wear screening, tooth wear status assessment, fee schedule, GOZ, analogous billing

As the evidence base for functional diagnostics expands with continuous research and development, this area of dentistry is becoming more and more integrated and interwoven with other medical fields such as psychosomatics and orthopedics. By now, many scientific studies exist in which tests have demonstrated associations between potential co-factors from these medical specialties and temporomandibular dysfunction (TMD). Even after the reform in 2012 of the German Dental Fee Schedule (GOZ), there is almost no change in the list of functional diagnostic services included in the new GOZ compared to the previous version of 1988. While the German Dentistry Act obligates dentists to practice dentistry in Germany according to the current state of scientific knowledge, it is impossible for dentists to do so if they are limited solely to the services included in the outdated contents of the official GOZ. However, German legislators deliberately drafted the new GOZ so as to include provisions for dentists to charge fees for separate services not included in its catalog of services, according to the type, cost, time requirement, and degree of difficulty of comparable services ('analogous billing procedure'). This article explains the legal framework and professional background for the implementation of this practice as well as the consequences thereof based on the example of tests to identify psychological co-factors that contribute to functional disorders of the temporomandibular system. Keywords: temporomandibular disorder (TMD), tests for the identification of psychological co-factors, clinical functional analysis, German Dental Fee Schedule (GOZ), analogous billing procedure, 

Die funktionelle Analyse des Bewegungsverhaltens des Unterkiefers auf Grundlage einer elektronischen Bewegungsaufzeichnung (elektronische Axiographie bzw. Kondylographie) ist im Gebührenverzeichnis der Gebührenordnung für Zahnärzte (GOZ) 2012 nicht enthalten. Es wurde lediglich die Leistung Nr. "806" aus der GOZ von 1988 inhaltlich unverändert in die GOZ Nr. 8060 überführt und dabei auf die Anwendung mechanischer Registriersysteme eingegrenzt. Hinzu kam die inhaltlich vergleichbare Leistung GOZ Nr. 8065 für die Anwendung elektronischer Registriersysteme. Abgesehen von der Unterscheidung mechanischer von elektronischen Registriersystemen sind beide Leistungen somit 2012 bei der GOZ-Reform im Vergleich zur Vorgängerversion aus dem Jahr 1988 fast unverändert geblieben. Weiterhin grenzt der Leistungstitel von beiden den Umfang der Leistungen unmissverständlich auf die Bewegungsaufzeichnung zur Programmierung von Artikulatoren ein. Für restaurative Anwendungen ist dies ausreichend und sinnvoll. Die mittlerweile entwickelten Verfahren zur funktionellen Auswertung des Bewegungsverhaltens des Unterkiefers sind hingegen in diesen Leistungen nicht abgebildet. Gleichzeitig sind diese Verfahren aber in der wissenschaftlichen Literatur gut begründet und mittlerweile auch in der Leitlinie Instrumentelle Funktionsanalyse (S2k) beschrieben1. Da Zahnärzte in Deutschland nach dem Zahnheilkundegesetz verpflichtet sind, die Zahnheilkunde nach aktuellem Stand der Wissenschaft auszuüben, wäre das allein mit den im Gebührenverzeichnis der Gebührenordnung katalogisierten Leistungen unmöglich. Der Gesetzgeber hat dafür in der neuen GOZ in § 6,1 explizit die Möglichkeit verankert, im Leistungskatalog nicht enthaltene selbstständige Leistungen entsprechend nach Art, Kosten- und Zeitaufwand und Schwierigkeit vergleichbarer Leistungen abzurechnen ("Analogleistungen"). Der vorliegende Beitrag schildert am Beispiel der funktionellen Bewegungsanalyse des Unterkiefers die rechtlichen und fachlichen Hintergründe sowie die Konsequenzen für die Umsetzung in der Praxis. Keywords: kraniomandibuläre Dysfunktion (CMD), Bewegungsanalyse des Unterkiefers, Registrieren der Unterkieferbewegung, klinische Funktionsanalyse, Gebührenordnung, GOZ, Analogberechnung

The further development of the principles of functional diagnostics also concerns the inclusion and integration of the issues in this dentistry sector with those of other medical sectors such as orthopaedic or psychosomatic medicine. Some scientific studies are now available that underscore the significance of appropriate tests for identifying any existing co-factors from these sectors of medicine. The list of service items contained in the German Dental Fee Schedule (GOZ) were hardly altered with regard to functional diagnostics by the GOZ fee reform in 2012, so that they differ very little from the previous version of 1988. Consequently, in this regard the GOZ is outdated, and since dentists in Germany are required by law to practice dentistry according to the current state of science, they cannot do so based solely on the service items listed in the GOZ. The legislator is aware of this problem and has, therefore, included the possibility in the new GOZ of invoicing those dental services not listed therein as independent service items according to the type of service, cost, and time input involved as well as the degree of difficulty of comparable services (referred to as "analogous services"). With reference to the example of tests for the determination of orthopaedic co-factors relating to a dysfunction of the stomatognathic system, this article describes the legal and functional background to the GOZ fees, and the consequences for their implementation in clinical practice. Keywords: temporomandibular dysfunction (TMD), tests for determining orthopaedic co-factors, clinical functional analysis, Dental Fee Schedule (GOZ), analogous billing

The further development of the principles of functional diagnostics frequently also has an effect on new diagnostic instrumental procedures. Diagnostic occlusal indicator splints for the visual analysis of occlusal parafunctions are an example of this. These were developed to record the intensity and distribution of tooth contacts over time throughout the period of splint wearing, and to enable their objective visual evaluation at a later date. The list of service items contained in the German Dental Fee Schedule (GOZ) were hardly altered with regard to functional diagnostics by the GOZ fee reform in 2012, so that they differ very little from the previous version of 1988. Consequently, in this regard the GOZ is outdated, and since dentists in Germany are required by law to practice dentistry according to the current state of science, they cannot do so based solely on the service items listed in the GOZ. The legislator is aware of this problem and has, therefore, included the possibility in the new GOZ of invoicing those dental independent services not listed in the fee code as analogous service items according to the type of service, cost, and time input involved, as well as the degree of difficulty of comparable services (referred to as "analogous services"). On the basis of the example of diagnostic occlusal indicator splints and their evaluation, this article describes the legal and functional background to the GOZ fees, and the consequences for their implementation in clinical practice. Keywords: occlusal parafunctions, diagnostic occlusal indicator splints, dental fee schedule (GOZ), analogous services