Cavity Free at Three Caries Risk Assessment for a Medical Office

• This form can be used to guide you through providing preventive oral health services during a well child check.
• The questions on this assessment determine clinical risk. See section below for billing guidance.
• Clinical Caries Risk is determined by the indication of one or more risk factors, regardless of protective factors.
• A caries risk assessment is required every time you address oral health and apply fluoride varnish.
• This form is for required documentation, it is not meant to be patient-facing.

To deliver oral health services in the medical setting, certification is required. If you have not been certified please visit the “Contact Us” tab at www.CavityFreeAtThree.org to request training information. Online options available.

Like any patient-centered visit, ideally an oral health screening begins with a conversation that organically elicits information on oral health risk, provides affirmations about what they are doing right, includes open-ended questions, and helps your patient formulate oral health goals. For example:

• What are your goals for your child’s teeth?
• Is there one thing you want to work on between now and the next time I see you? This should be a goal that is important to you and also feels like something you can actually get done. (Prompt from self-management goal list if needed)

If you’re deciding whether or not to prescribe fluoride for your patient, find out if their community water supply is fluoridated. Search your browser for “my water’s fluoride” to find county-level information published by the Centers for Disease Control (CDC).

Community water fluoridation has been proven safe and effective. Go to www.colorado.gov/cdphe/community-water-fluoridation or ilikemyteeth.org for more information.

The DentaQuest Office Reference manual provides definitions of high risk for billing purposes. Exact language must be used in documentation to qualify a child ages 0 – 4 as eligible for reimbursement of screening/fluoride varnish 4 times/year. Otherwise, the standard is 2 times/year. Child members ages 5 through 20 years may receive fluoride varnish 3 times/year regardless of risk. Refer to Medicaid guidelines for most recent information.

High Risk of Caries is indicated if a member has one or more of the following four criteria:

1. Presents with demonstrable caries, has a history of restorative treatment, or has a history of dental plaque AND has a history of enamel demineralization, OR
2. Is a child member (age 0 through 20 years old) of mothers with a high caries rate, especially with untreated caries, OR
3. Is a child member (age 0 through 20 years old) who sleeps with a bottle containing anything other than water, or who is breastfeed throughout the night (at-will nursing), OR
4. Is a child member (age 0 through 20 years old) who has special health needs.

• CavityFreeAtThree.org click on “Resources” tab
• SmilesForLifeOralHealth.org 
• DentaQuest Office Reference Manual (for most updated billing guidance) dentaquest.com/state-plans/regions/colorado/health-first-colorado/provider-page/