AAP: Fluoride varnish is billable and implementable

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

Christine Kilgore

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

Courtesy Dr. Rocio Quinonez

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

Courtesy Dr. Rocio Quinonez

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

Courtesy Dr. Rocio Quinonez

Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.

The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.

Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.

The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.

Courtesy Dr. Rocio Quinonez

Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.

Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”

Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.

Courtesy Dr. Rocio Quinonez

The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.

“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”

State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

Christine Kilgore

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

Courtesy Dr. Rocio Quinonez

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

Courtesy Dr. Rocio Quinonez

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

Courtesy Dr. Rocio Quinonez

Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.

The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.

Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.

The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.

Courtesy Dr. Rocio Quinonez

Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.

Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”

Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.

Courtesy Dr. Rocio Quinonez

The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.

“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”

State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

Christine Kilgore

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

Courtesy Dr. Rocio Quinonez

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

Courtesy Dr. Rocio Quinonez

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

Courtesy Dr. Rocio Quinonez

Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.

The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.

Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.

The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.

Courtesy Dr. Rocio Quinonez

Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.

Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”

Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.

Courtesy Dr. Rocio Quinonez

The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.

“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”

State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.