Fluoride Varnish Manual

State of Nevada Department of Human Resources Health Division Bureau of Family Health Services Oral Health Program 3427 Goni Road, Suite 108 Carson City, NV 89706 Judith M. Wright (775) 684-4285 Jim Gibbons Governor Michael J. Willden Director Richard Whitley, MS Administrator

State Health Officer

April 2008

Nevada State Health Division Oral Health Program Fluoride Varnish Manual
Table of Contents
Advantages Protocol Approval from the Nevada State Board of Dental Examiners Approval from the Nevada State Board of Medical Examiners Approval from the Nevada State Board of Nursing Sample RX Ordering Supplies Information for Parents English Spanish Consent Forms English Spanish Application Positioning Post-Application Instructions Post Application Information for Parents English Spanish 3 4 6

8 9 10 11

12 13

14 15 16 17 18

19 20

Billing Information

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Fluoride Varnish Advantages Does not require special dental equipment. Does not require a professional dental cleaning prior to application. Is easy to apply. Dries immediately upon contact with saliva. Is safe and well tolerated by infants, young children, and individuals with special needs. Is inexpensive. Requires minimal training. Nevada Medicaid will reimburse dental and medical providers $53.30 per application for feefor-service providers. Managed care providers should contact their Managed Care Group for the reimbursement rate.

Fluoride Varnish Application Protocol

Introduction Fluoride varnish is a thin coating of resin that is applied to the tooth surface to protect it from decay. According to the FDA, fluoride varnish falls under the category of drugs and devices that presents minimal risk and is subject to the lowest level of regulation. Purpose The purpose of applying fluoride varnish is to retard, arrest, and reverse the process of cavity formation. Indications Infants and children with a moderate or high risk of developing cavities. A child is considered at risk if he/she: Has had cavities in the past or has white spot lesions and stained fissures. Continues to use the bottle past 1 year of age or sleeps with a bottle containing liquids other than water. Breastfeeds on demand at night. Has a developmental disability. Chronically uses high sugar oral medications. Have family members with a history of caries. Engages in prolonged or ad lib use throughout the day of a bottle or sippy cup containing liquids other than water. Contraindications Children with a low risk of cavity formation, who consume optimally fluoridated water or children who receive routine fluoride treatments through a dental office. Application procedure Pre-application instructions: Remind the parent to give the child something to eat and drink before coming to receive a fluoride application. Advise the parent that the childs teeth may become discolored temporarily as fluoride varnish has a dull or yellow-ish tinge. Tell the parent that the varnish can be brushed off the following day. You will need to have: Disposable gloves Gauze sponges (2 x 2) Fluoride varnish Small disposable fluoride applicator Paper towels or disposable bids to place under the childs head (optional) 4

Position the child: For an infant place the child on the parents lap with the childs head on the parents knees and the childs legs around the parents waist. Position yourself knee-to-knee with the parent and treat the child from behind the head. Or, place the infant on an exam table and work from behind the head. Or, as you gain experience, do whatever works for you. For a young child place the child in a prone or sitting position and work from above the head as with an infant. Or, adapt a method that works best for you. The application: Using gentle finger pressure, open the childs mouth. Remove excess saliva with a gauze sponge. Use your fingers and sponges to isolate the dry teeth and keep them dry. You will usually be able to isolate a quadrant of teeth at a time, but may have to work with fewer teeth in some children. Infants are easiest because they have only anterior teeth. Apply a thin layer of the varnish to all surfaces of the teeth. Avoid applying varnish on the gums, or on large open cavities where there may be pulp involvement. Once the varnish is applied, you need not worry about moisture (saliva) contamination. The varnish sets quickly. Post-application instructions: Eat a soft, non-abrasive diet for the rest of the day. Do not brush or floss until the next morning, or for at least four hours.

Remember: Even though the child may fuss, the varnish application is not unpleasant. Tell the parent that the teeth will not be white and shiny until the next day. The varnish application should be repeated at three-month intervals for high-risk children and at six-month intervals for children who are not at high risk.

Nevada State Board of Dental Examiners

Larry L. Champagne, D.M.D. President A. Ted Twesme, D.D.S. Secretary-Treasurer

2295-B Renaissance Drive Las Vegas, NV 89119 (702) 486-7044 (800) DDS-EXAM Fax (702) 786-7046

April 23, 2002

Chris Forsch, R.D.H. Nevada State Health Department 4801 Ramcreek Trail Reno, NV 89509 Dear Ms. Forsch: This letter will serve as correction of Terminology in my letter of April 10, 2002. As previously stated, your presentation brought before the Telephone Conference Call of the Nevada State Board of Dental Examiners on March 26, 2002, requesting approval of certain medical providers to apply fluoride varnish to childrens teeth as part of wellchild and Early Periodic Screening Diagnosis and Treatment (EPSDT) was unanimously approved on that date. Approval provides that Physician Assistants and Advanced Practice Nurses licensed in Nevada may prescribe and/or apply fluoride vanish to childrens teeth as part of wellchild and Early Periodic Screening Diagnosis and Treatment (EPSDT) visits. This approval includes medical providers including nurses approval to apply fluoride varnish to childrens teeth as part of the same programs. I apologize for any confusion that my previous letter may have caused. As always, if you have any concerns or questions feel free to contact me at the Board office. Sincerely,

William J. Busch, D.D.S Executive Director /lr [email protected] 6

KENNY C. GUINN Governor MICHAEL J. WILLDEN Director

STATE OF NEVADA

YVONNE SYLVA Administrator VACANT State Health Officer

DEPARTMENT OF HUMAN RESOURCES

HEALTH DIVISION
BUREAU OF FAMILY HEALTH SERVICES MATERNAL AND CHILD HEALTH
505 E. King Street, Room 200 Carson City, Nevada 89706 (775) 684-4285 h Fax (775) 684-4245

December 18, 2001 Larry Leslie Executive Director/Special Counsel Nevada State Board of Medical Examiners 1105 Terminal Way, Suite 301 Reno, NV 89502 Dear Mr. Leslie: This letter confirms our telephone conversation of December 13 and my understanding that if the State Board of Dental Examiners approves doing so, a Physician Assistant licensed in Nevada may prescribe and apply fluoride varnish if his supervising physician has authorized him to do so. I appreciate your taking the time to clarify statute and regulations related to prescribing by Physicians Assistants. Sincerely,

Christine Forsch, RDH Contractor

Building and Strengthening Public Health through Communication and Partnerships

KENNY C. GUINN Governor MICHAEL J. WILLDEN Director

STATE OF NEVADA

YVONNE SYLVA Administrator VACANT State Health Officer

DEPARTMENT OF HUMAN RESOURCES

HEALTH DIVISION
BUREAU OF FAMILY HEALTH SERVICES MATERNAL AND CHILD HEALTH
505 E. King Street, Room 200 Carson City, Nevada 89706 (775) 684-4285 h Fax (775) 684-4245

December 18, 2001 Jeanie Jenkins Management Assistant II Nevada State Board of Nursing 4330 South Valley View, Suite 106 Las Vegas, NV 89103 Dear Ms. Jenkins This letter confirms our telephone conversation of December 14th and my understanding that if the State Board of Dental Examiners approves doing so, an Advanced Practice Nurse licensed in Nevada may prescribe and apply fluoride varnish if the following requirements are met: 1. The Advanced Practice Nurse must have prescribing privileges. 2. Fluoride varnish is listed in a protocol signed by the collaborating physician. I appreciate your taking the time to clarify statute and regulations related to prescribing by Advanced Practice Nurses in Nevada. Sincerely,

Christine Forsch, RDH Contractor 8

Building and Strengthening Public Health through Communication and Partnerships

Example of an RX
DEA # ________ John Q. Doe, M.D. 123 Somewhere Street Anywhere, NV 89000

Name _____________________________ Date _______ Address________________________________________ Rx Little Peoples Head Start and Early Head Fluoride Varnish #80 children sig: 1 application per child Q 3-4 months

Label Refill 0-1-2-3-4-PRN _____________________ M.D.

Dispense Only as Written

Fluoride Varnish Ordering Information

AllSolutions (5% NaF in a natural resin) Available in a unit-dose with an applicator Dentsply Professional 1-800-989-8826 Cavity Shield (5% NaF in a natural colophonium resin) Available in a unit-dose with an applicator Omni Products 1-800-445-3386 Durafluor (5% NaF in a natural colophonium resin) Medicom 1-800-435-9267 Duraphat (5% NaF in a natural colophonium resin) Colgate Oral Pharmaceuticals 1-800-225-3756 1-800-2-COLGATE Fluor-Protector (0.1% difluorosilane in a polyurethane base) Ivoclar North America-Vivadent 1-800-327-4688 VarnishAmerica (5% NaFin a natural colophonium resin) Available in a unit-dose with an applicator Medical Products Laboratories, Inc. 1-800-523-0191, Ext 326 Premier Dental (5%NaF) Enamel Pro Varnish with ACP Available in a unit-dose with an applicator Premier Dental at 888-670-6100 or 610-239-6000

Revised 6-07

Supplies
Disposable gloves Paper towel or disposable bibs (to place under the childs head if the childs head is being cradled in the providers lap) Gauze squares (2 X 2) Fluoride Varnish

Disposable applicator brush (if not

included with the varnish)

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Information for Parents About Fluoride Varnish

Why do we recommend putting fluoride varnish on childrens teeth? Tooth decay is one of the most common preventable diseases seen in children. Children as young as 12-18 months can get cavities. Cavities in baby teeth can cause pain and effect childrens ability to eat, speak, sleep and learn properly. Children do not lose all their baby teeth until they are about 12 to 13 years old. What is fluoride varnish? Fluoride varnish is a protective coating that is painted on teeth to help prevent new cavities and to help stop cavities that have already started. Is fluoride varnish safe? Yes, fluoride varnish can be used on babies from the time they have their first teeth. Only a very small amount of fluoride varnish is used. This method of providing fluoride to teeth has been used in Europe for more than 30 years. Fluoride varnish is approved by the FDA and is endorsed by the American Dental Association. How is it put on the teeth? The varnish is painted on the teeth. It is quick and easy to apply and does not have a bad taste. There is no pain, but your child may cry just because babies and children dont like having things put in their mouths, especially by people they dont know! Your childs teeth may be dull or yellow after the fluoride varnish is painted on, but this will come off when you brush your childs teeth tomorrow. How long does the fluoride last? The fluoride coating will work best if it is painted on the teeth 3-4 times a year.

Baby Teeth are Important!

Remember, do not clean your childs teeth today and do not give them hot, hard or sticky foods. Start cleaning your childs teeth tomorrow morning. The dull, yellow color will come off when you brush your childs teeth

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Informacin para los padres Sobre el esmalte de fluoruro

Porque nosotros recomendamos la aplicacin del esmalete de fluoruro en los dientes de los nios? Las caries es una de las enfermedades preventibles mas comunes vista en los nios. Los nios pequeos desde los 12-18 meses pueden tener cavidades. Las cavidades en los dientes de leche pueden causar dolor y aun hasta evitar a los nios a poder comer, hablar, dormir y aprender apropiadamente. Los nios no pierden todos sus dientes de leche hasta que tienen como de 11 a 12 aos de edad. Que es el esmalte de fluoruro? El esmalte de fluoruo es una capa protectora que es pintada sobre los dientes para ayudar a prevenir nuevas cavidades y para ayudar a detener a las cavidades que ya hallan comenzado. Es el esmalte de fluoruro seguro? Si, el esmalte de fluoruro puede ser usado en bebs desde que ellos tienen sus primeros dientes. Solamente una cantidad pequea de esmalte de fluoruro es usada. Este metodo de proveer fluoruo a los dientes a sido usado en Europa por mas de 25 aos. El esmalte de fluoruro es aprovado por la FDA y es respaldado por la Asociacin Dental Americana. Como es el fluoruro aplicado en los dientes? El esmalte es pintado sobre los dientes. Es rapido y fcil de aplicar y no tiene mal sabor. No hay dolor, pero su nio/a puede llorar simplemente porque a los bebs y nios no les gusta que les pongan cosas en su boca especialmente por gente que ellos no conocen! Los dientes de su nio/a estaran amarillos despues que el esmalte de fluoruro sea aplicado, pero el color amarillo se caera cuando usted cepille los dientes de su nio/a maana. Cuanto tiempo dura el fluoruro? La capa de fluoruro trabajara mejor si es aplicada en los dientes de 3-4 vecez al ao.

Los dientes de leche son importantes!

Recuerde, no limpie los dientes de su nio/a hoy y no les de comidas duras o pegajosas. Comienze a limpiar los dientes de su nio/a maana en la maana. El color amarillo se caera cuando usted cepille los dientes de su nio/a. 13

FLUORIDE VARNISH PROGRAM Dear Parent:

Agency Name

A preventive dental program is available through the___________________________. A licensed professional will apply a protective coating called fluoride varnish to your childs teeth as a preventive measure against tooth decay. To receive these no-cost services you must provide consent. __ Yes, I want my child to receive fluoride varnish (please fill in the bottom of the form). __ No, I do not want my child to receive these preventive fluoride varnish services. Name of Child:__________________________________ Date of Birth:_____________ Male: __________ Female: ___________ Race: ___________ School: ______________ Teacher: ___________________________________________ Room: ______________ Home Address: ________________________________ City: ________ Zip: ________ Do you have dental insurance? Yes: ___ No: ___ If yes, name of insurance: __________ Parent/Guardians name: ___________________________________________________
Please print

HEALTH HISTORY 1. Has your child ever had serious health problems? No: __ Yes: __If yes, please explain:

2. Does your child have any allergies? No: ____ Yes: ____ If yes, please list: _______

Parent Signature: _________________________________

Date: _________________

*** This service does not replace a comprehensive evaluation. It is our recommendation that a dentist regularly examine your child ***

FOR OFFICE USE ONLY

Comments________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Varnish placed on: ____________ by: ________________________________________ 14

PROGRAMA DE BARNIZ DE FLUORURO Estimados Padres:

Agency Name

Un programa dental estar disponibleen el _________________________________________. El programa ayuda a prevenir las caries en los dientes de los nios. Una persona con licencia applicara una barrera protectora llamada barniz de fluoruro. Este barniz fortalece los dientes y los hace mas resistente contra las caries. Para recibir estos servicios sin-costo usted nos debe proveer este consentimiento. ____ Si, quiero que mi hijo (a) recibe el barniz de fluoruro (por favor, complete la parte de abajo de esta forma) ____ No, deseo que mi hijo (a) recibe este servicipo de barniz de fluoruro sin-costo. Nombre del Nio (a):_______________________ Fecha de nacamiento:____________________ Masculino: _________ Feminina: ____________ Raza: ___________ Centro: _____________ Maestra:___________________________________________ Saln: _____________________ Domicilio: ________________________________ Ciudad: ____________ Zona: __________ Tiene aseguranza dental? Si: ___ No: ___si, Nombre de la aseguranza:____________________ Nombre de los Padres/Guardin: ___________________________________________________

Historial Medica 1. Su hijo (a) alguna vez a tenido algn problema de salud serio? __________________________ ______________________________________________________________________________ 1. Tiene su nio (a) allejias? ______________________________________________________

Firma de los Padres______________________________ Fecha: __________________ *** Este servicio no reemplaza un examen para una completa evaluacion. Es nuestra recomendacion es que su dentista lo(a) vea regularmente.*****

FOR OFFICE USE ONLY

Comments________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Varnish placed on: _________________________ by: ___________________________________________

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Application
Using gentle finger pressure, open the childs mouth. Remove excess saliva from the teeth with a gauze sponge.

Apply a thin layer of varnish to all

surfaces of the teeth. (The varnish will harden immediately once it comes in contact with saliva).

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Positioning the Provider and Child

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Post-Application Instructions
The child should eat a soft, nonabrasive diet for the rest of the day. Do not brush or floss the childs teeth until the next morning.
Inform the caregiver that it is

normal for the teeth to appear dull or yellow until they are brushed.

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Dont Delay Prevent Decay

When your child leaves today, his/her teeth will have been coated with fluoride varnish and will not look as bright and shiny as usual. They will look as they usually do tomorrow when the varnish has had time to have its maximum effect and has worn off. To keep the varnish on the teeth as long as possible and to achieve the best result: Your child should eat soft foods for the rest of the day. Teeth should not be cleaned until tomorrow morning. In the morning, clean the mouth and teeth as usual.

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No se Demore Prevenga las Caries

Cuando su nio/a se valla de aqui hoy, sus dientes de el o de ella habran sido baados con esmalte de fluoruro y no se veran tan brillantes y resplandecientes como de costumbre. El da de maana sus dientes se veran como de costumbre cuando el esmalte alla tenido tiempo de tener su maximo efecto y el efecto haya pasado. Para mantener el esmalte en los dientes por el tiempo mayor posible y para conseguir el mejor resultado: Su nio/a debe de comer comidas blandas por el resto del da de hoy. Los dientes no se deben de limpiar hasta maana en la maana. En la maana, limpie los dientes como de costumbre.

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NEVADA MEDICAID POLICY

TOPICAL APPLICATION OF FLUORIDE EFFECTIVE DATE: January 1, 2007 ATTN. PROVIDERS DESCRIPTION: Topical fluoride applications are one of the most effective ways to prevent, slow down, arrest and even reverse early cavities. Dentists have been providing fluoride services for decades. Fluoride varnish provides physicians, nurse practitioners, and physician assistants with a superior method of fluoride application, especially for children 0-6 years of age. Fluoride varnish is simply applied with a small brush and hardens immediately upon contact with saliva. Minimal training is needed and no special equipment is required. Medicaid encourages physicians, nurse practitioners and physician assistants to provide this highly effective, easy-to-provide service.

MEDICAID POLICY: Nevada Medicaid pays dentists, physicians, nurse practitioners and physician assistants to administer topical Fluoride to the teeth of Medicaid clients who are under 21 years of age. The provider need not seek authorization for payment of this service for these young Medicaid recipients.

INDICATIONS AND LIMITATIONS OF COVERAGE: There are no service limits for fluoride varnish.

COVERED CPT CODES: D01206 Topical Fluoride Varnish

Fee for Service Managed Care

$ 53.30 Contact your provider

CODING/BILLING GUIDELINES: For questions concerning this policy call: First Health Services Corporation, Provider Relations Department at 877.638.3472. The web site is https://nevada.fhsc.com/ Contact Nevada Medicaid at 775.684.3700. The web site is http://dhcfp.state.nv.us/ The Nevada State Health Divisions Bureau of Family Health Services (775.684.4285) can provide information and training on the use of this product and its availability.

(Revised 3-08)

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Billing for Fluoride Varnish Application

CPT Code
D01206 Topical Fluoride Varnish ; therapeutic application for moderate to high caries risk

The Medical provider delivers a fluoride treatment in the office and will bill on a CMS 1500. Check the Oral screening on the EPSTD form. The Dental provider will bill on the ADA form. Rate: Fee-for service: $53.30 Managed Care: Contact Managed Care Provider for reimbursement rate

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