When our practice was contacted about training for applying fluoride varnish a couple of years ago, it sounded like a great service to provide our patients.  But, we were worried about working in another component to well baby visits.  How do you apply it?  Who would apply it?  How long does it take?  Can you bill for the service?  What needs to be documented?

We took advantage of a Lunch and Learn training funded by (DentaQuest) offered by the From the First Tooth program to learn more about oral health assessments in primary care.  Trained oral health professionals came to our office and reviewed the components of oral health assessments, how to recognize signs of tooth decay on oral exams, and how to apply fluoride varnish.  We practiced applying the varnish on each other (classic “see one-do one-teach one” approach) and all of our questions were answered.

Then, we made it happen.  We talked through the workflow and decided we needed the following materials in every exam room:  Bright Futures handouts which include anticipatory guidance on oral health to reinforce our in person advice, lists of pediatric dental providers-one for commercial and one for RIte Smiles insurance plans - to be given routinely at the 12 month visit, fluoride varnish information handouts, and fluoride varnish and application supplies.

We made templates in our EHR for oral health assessment documentation and fluoride varnish application billing codes.  We added a prompt in the well child visit templates from 9 months to 3 years to remind providers to assess for fluoride varnish application.  And, we decided as a group where we would document the fluoride varnish application in the EHR to make sure that we were keeping to the insurer guidelines (for the RI Medicaid plans, varnish can be applied up to four times per year for children up to 4 years old.  Coverage by commercial plans varies).

In our practice, the pediatricians apply the varnish during the visit, but I have colleagues in other practices where other staff members apply the varnish.  For us, it was a matter of keeping the flow of the visit.  Since we are examining the child and it doesn’t add much time to the exam (maybe 2 minutes for applying the varnish) we opted to apply the varnish ourselves during the physical exam. 

I can’t emphasize how easy it is to apply fluoride varnish during well visits and how little it impacts the length of the visit.  It is so satisfying to be able to offer a hands-on preventive service that isn’t painful and actually tastes pretty good! 

Dr. Clyne is the Medical Director at the Rhode Island Department of Health and a Pediatrician at Coastal Medical Pediatrics.