Fluoride varnish.

In May 2006, the American Dental Association's (ADA's) Executive Summary of Evidence-Based Clinical Recommendations was released on the effectiveness of professionally applied topical fluoride for caries prevention. The ADA Council on Scientific Affairs made these clinical recommendations after forming an expert panel and evaluating a collective body of scientific evidence. If you have not taken a look at these recent changes in caries prevention, I encourage you to do so.

The panel of experts came up with the following conclusions: 1) fluoride gel is effective in preventing caries in school-aged children; 2) patients who have a low caries risk may not receive additional benefits from professional application of fluorides; and 3) there is significant evidence that four-minute professional gel fluoride treatments in-office provide additional benefit, but there remains only laboratory and no clinical equivalent data on the effectiveness of one-minute fluoride gel applications. (1) In fact, a more recent study found fluoride varnishes to be 14 percent more effective than topical fluoride gels. (2)

For many years, some dental professionals may have had the misconception that dental caries was under control in many patients and that the need to provide fluoride therapy in the office was not a priority for children or adults. With all the new changes in dental caries research, we now know that dental caries is a bacterial infection that can be passed from mother to infant. We also know that preventing the dental caries process and increasing the remineralization process of the enamel are very important parts of arresting caries regardless of the patient's age. Table I illustrates the drastic changes that define the risk categories for dental caries. (3) Now, if you are treating a child or teenager with three dental caries sites in the last three years, this is considered high risk!

Patients at low caries risk, as defined by Table I, may not receive additional benefits from topical professional fluoride application. For patients at moderate risk, fluoride treatment is recommended every six months. For patients at high risk, fluoride is recommended every three or six months. For children under six years of age, varnish rather than gel is recommended because it contains smaller quantities of fluoride and thus reduces the amount potentially ingested. In addition to elderly patients with xerostomia, we must consider the adult post-periodontal surgery patient with root exposure or a teenager on inhalers, antidepressants or ADHD medications.

When I first saw these changes, I was shocked: this meant dental hygienists would have to make changes in the way we provide dental caries-preventive services to our clients. It also means that the topical fluoride foam and gels that we have been using as therapy for years may not be the most appropriate application for dental caries prevention, depending on the risk factors/dental caries risk category for that patient. We will now need to consider establishing a protocol for topical fluoride varnish application for infants as well as our older patient population. As you know, topical fluoride application prevents demineralization and increases remineralization, and also reduces root sensitivity, so we should be actively promoting the benefits of fluoride applications regardless of the patient's age if they have the factors associated with moderate to high risk. It is not my intent in this column to cover all the different types of fluoride gels and varnishes, or benefits and contraindications for fluoride applications, but to allow you to explore the research on this area to provide appropriate dental caries prevention, apply the fees associated with these services and use the correct insurance reimbursement code.

In the summary from The United States Preventive Services Task Force, researchers reviewed six different fluoride varnishes and showed a range of 30 percent to 63 percent caries reduction. (4) When they compared acidulated phosphate fluoride versus fluoride varnishes, they determined that both were equally effective. (5) As you may know, the U.S. Food and Drug Administration (FDA) approves fluoride varnish only for cavity varnish and the treatment of dentin hypersensitivity. Despite this information, based on various research sources, you can see why ADA has approved the use of fluoride varnish as many as four times a year for high-risk children under six years of age (3) for caries prevention, even though FDA considers this off-label use.

What about root sensitivity or dental caries prevention-isn't it the same, you may ask? No! Remember that if the patient is being treated for root sensitivity and not caries prevention, then the code D9910 "Application of desensitizing medicament" should be used. We know that topical fluorides can create a barrier over dental tubules that blocks sensitivity. (6) The topical fluoride application not only helps with caries prevention, but it also eliminates pain. In this case, applying the fluoride application prior to scaling and root planing to reduce root sensitivity and pain during treatment can be used with the D9910. (7) Of course, be warned, this code typically has poor reimbursement and the patient usually has to pay out-of-pocket for this procedure. Although desensitizing agents are not paid by the insurance companies very well, patients are less likely to resist payment for this procedure if it will help with their pain control.

Fortunately for us, the ADA CDT-2007 edition added two new codes that may help us with carrying out an effective caries prevention program. The new code D1206 "Topical Fluoride Varnish: Therapeutic application for moderate to high caries risk patients" is the code to use when we apply fluoride varnish to the entire dentition in the office, without any age restriction and as a stand-alone procedure. Although it can be applied following the adult or child prophylaxis, it is not necessary. The frequency of application per year will be based on the patient's caries risk factors and caries risk category.

What about the infants and toddlers whom your practice has not yet seen for a child examination or child prophylaxis? If we see a family with a toddler (under three years of age) who may be in the moderate to high caries risk group, we now have the opportunity to assess the toddler to determine if applying fluoride varnish would be appropriate. With the newer codes, we can now evaluate toddlers and infants who are not old enough to sit for a complete oral examination. This should only take a few minutes, and thanks to the ADA Code Revision committee, it now has a billable ADA CDT code to submit to the insurance company. A knee-to-knee approach can be used for the quick evaluation and then placement of the fluoride varnish since these children are too young to sit in the dental chair on their own. For this examination, many of you may find it appropriate to use the new code D0145, which is "the oral evaluation for a patient under three years of age and counseling with primary caregiver." This may help start the dental caries prevention program for your patients who are toddlers or infants and who qualify for the moderate- to high-risk dental caries group. This is a great service to these children and an excellent marketing tool for your practice. When a parent brings an older child to a dental appointment and brings a toddler or infant along, offer to assess the needs of the younger child the same day. This added service can give you an opportunity to educate the caregiver and establish a wonderful lifelong dental bond with that family. The earlier the intervention, the less likely a child will have long-term ramifications from early childhood caries. It only takes a few minutes to determine if the toddler or infant is in a moderate-to-high-risk group and to apply the fluoride varnish while the family is in the office. After educating the caregiver about the need for fluoride varnish reevaluation and reapplication two to four times a year, you can schedule these appointments as well.

The beauty of this new code D0145 is it can be submitted with the D1206 if you assess the child and apply the fluoride varnish four times a year, even though they are not there for a prophylaxis. And one does not have to use a dental operatory or dental chair; in fact, the consultation room may be a less intimidating atmosphere for the toddler. Because the prophylaxis itself removes the outer, fluoride-enriched layer of enamel, it actually prevents optimal fluoride uptake from the fluoride application. For this reason, the parent should not be alarmed that you are only applying the fluoride varnish and not performing a prophylaxis. Remember, you may be applying this to only one tooth or only a few, if they are still in the infant stage.

Many of you have been emailing with additional questions, and we will try and answer some of them in future columns. After the April issue, I had a lot of email messages, which means you are reading this column and trying to help your patients with their dental insurance coverage.

Response to Questions from the 4910 vs. D1110 column:

Hello Tammy, I just read "4910 vs. 1110: Why They Can't Be Altered," in April 2008 Access. Thank you for your explanations. I have a dental hygiene practice for the elderly in Northern California. I am working with Medicaid, (Medi-cal/Denti-cal in California) for reimbursement of these new codes for the RDHAPs in the state. We desperately need the D4910 code to cracking the code continued from page 18 treat Skilled Nursing Facility (SNF) residents on a three-month routine schedule.

Denti-cal in California has recently changed with the CDT-4 codes to allow only the D1110 code once a year for a SNF patient. We are submitting the request for the D4910 code today, with pictures of the patients I treated for the last two days in two different SNFs.

We welcomed the Denti-cal consultant to spend these last two days observing the treatment of these patients. They observed firsthand their conditions, so we hope this will lead to this needed change.

I would greatly appreciate any other information or suggestions you may have to help with issue. What other states already have these codes being used by RDHs? I have submitted recommendations to the Code Revision Committee in the past, but I have never heard anything. Thank you again for your fine article.

Judy Boothby, RDHAP #1, BS

Dental Hygiene Out & About

Dear Judy,

I am glad to know you have been faithfully submitting comments to the ADA Code Revision committee: Kudos to Judy Boothby, RDHAP of California! In regards to your question, I was gravely concerned that Medicaid in your state was still using CDT-4 (remember as of, January 2007 we are using CDT 2007 edition). According to my knowledge, Delta of California is the administrator for the Dentical-CA program (Dental Medicaid) in California and I would question why they are still using the CDT-4 codes. The D4910 is probably not part of their specific contract. The appropriate channel for you and your RDHAP peers would be to change the D4910 coverage in California through educating your State Department of Medical Assistance and the Department of Dental Services agency heads. These departments need to be educated. Let them know that the elderly population you are treating has a dental infection, not healthy dentition (D1110). Lots of statistics and evidence supporting the oral-systemic health link would be part of their education process so that they can amend their contract obligations and help you stride towards better oral health for your clients. Good luck and keep us informed!

Tammy Cahoon, BSDH, RDH 

References

(1.) Hawkins R, Locker D, Noble J, Kay EJ. Prevention. Part 7: Professionally applied topical fluorides for caries prevention. Br Dent J 2003; 195: 313-7.

(2.) Stookey GK. Fighting dental decay. Past, present and future. Access 2006; 20(2): 12-6.

(3.) Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc 2006; 137: 1151-9.

(4.) Bader JD, Rozier RG, Lohr KN, Frame PS. Physicians' roles in preventing dental caries in preschool children: a summary of the evidence for the U.S. Preventive Services Task Force. Am J Prey Med 2004h: 26: 315-25.

(5.) Seppa L. Fluoride varnishes in caries prevention. Med Princ Pract 2004; 13: 307-11.

(6.) Thrash WJ, Jones DL, Dodds WJ. Effect of a fluoride solution on dentinal hypersensitivity. Am J Dent 1992; 5:299-302.

(7.) Wilkins EM. Clinical practice of the dental hygienist. 9th ed. Philadelphia: Lippincott Williams & Wilkins. 2004.

Tammy Glenn Cahoon, BSDH, RDH, is a national consultant, speaker, clinician and president of Cahoon Enterprise Inc. A practicing clinician since 1983 in Richmond, Va., she is an active, enthusiastic member of the ADHA and a past recipient of several awards including the ADHA Distinguished Service Award. She is also the senior dental hygiene consultant with the Consulting Team of Annette Linder of Capital Associates, Inc. For speaker availability, email: [e-mail].

Table 1. Caries Risk Criteria

Patients should be evaluated using caries risk criteria such as
those below.

Low caries risk

All age groups

No incipient or cavitated primary or secondary carious lesions
during the last three years and no factors that may increase
caries risk*

Moderate caries risk

Younger than 6 years

No incipient or cavitated primary or secondary carious lesions
during the last three years but presence of at least one factor
that may increase caries risk *

Older than 6 years (any of the following)

One or two incipient or cavitated primary or secondary carious
lesions in the last three years
No incipient or cavitated primary or secondary carious lesions
in the last three years but presence of at least one factor
that may increase caries risk *

High caries risk

Younger than 6 years (any of the following)

Any incipient or cavitated primary or secondary carious
lesions during the last three years
Presence of multiple factors that may increase caries risk *
Low socioeconomic status
Suboptimal fluoride exposure
Xerostomia [dagger]

Older than 6 years (any of the following)
Three or more incipient or cavitated primary or secondary
carious lesions in the last three years
Presence of multiple factors that may increase caries risk *
Suboptimal fluoride exposure
Xerostamia [dagger]

* Factors increasing risk of developing caries also may include, but
are not limited to, high titers of cariogenic bacteria, poor oral
hygiene, prolonged nursing (bottle or breast), poor family dental
health, developmental or acquired enamel defects, genetic abnormality
of teeth, many multisurface restorations, chemotherapy or
radiation therapy, eating disorders, drug or alcohol abuse,
irregular dental care, cariogenic diet, active orthodontic treatment,
presence of exposed root surfaces, restoration overhangs and open
margins, and physical or mental disability with inability or
unavailability of performing proper oral health care.

[dagger] On the basis of findings from population studies, groups with
low socioeconomic status have been found to have an increased risk of
developing caries. In children too young for their risk to be based on
caries history, low socioeconomic status should be considered as a
caries risk factor.

[dagger] Medication-, radiation-, or disease-induced xerostomia

Source: American Dental Association Council on Scientific Affairs.
Professionally applied topical fluoride. Evidence-based clinical
recommendations. J Am Dent Assoc 2006; 137(8): Box 2, page 1155.
Copyright 2006 American Dental Association. All rights reserved.
Reprinted by permission.