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Cavity Free at Three Caries Risk Assessment for a Medical Office

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Cavity Free at Three Caries Risk Assessment For a Medical Office

How To Use This Form

  • 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.

Risk Factors – Children 0-4 Years

Mother/caregiver of child has had active decay in the past 12 months
Mother/caregiver of child has had active decay in the past 12 months
Child sleeps with a bottle containing juice, formula, or anything other than water
Child sleeps with a bottle containing juice, formula, or anything other than water
Frequent use (between meals) of bottle/non-spill cup containing beverages other than plain water (nothing added)
Frequent use (between meals) of bottle/non-spill cup containing beverages other than plain water (nothing added)

Risk Factors – Children 0-20 Years

Child has special healthcare needs (developmental, physical, medical, or mental that limit performance of adequate oral health by themselves/caregivers)
Child has special healthcare needs (developmental, physical, medical, or mental that limit performance of adequate oral health by themselves/caregivers)
Frequent snacking (greater than 3x day/total) candy, carbohydrates, soda, sugared beverages, fruit juice
Frequent snacking (greater than 3x day/total) candy, carbohydrates, soda, sugared beverages, fruit juice
Child takes saliva-reducing meds (asthma, seizure, hyperactivity), hx of anemia/iron therapy, or daily liquid medications
Child takes saliva-reducing meds (asthma, seizure, hyperactivity), hx of anemia/iron therapy, or daily liquid medications

Risk Factors – Oral Exam/Clinical Findings

Obvious decay present on the child’s teeth
Obvious decay present on the child’s teeth
Dental fillings present
Dental fillings present
Obvious dental plaque present
Obvious dental plaque present
Obvious white spots present
Obvious white spots present

Protective Factors

Child lives in a fluoridated community and drinks tap water
Child lives in a fluoridated community and drinks tap water
Teeth cleaned with fluoridated toothpaste twice daily
Teeth cleaned with fluoridated toothpaste twice daily
Child has a dental home and regular dental care
Child has a dental home and regular dental care

Plan/Assessment

Clinical caries risk? Answer: At least one risk factor indicated, regardless of protective factors
Clinical caries risk? Answer: At least one risk factor indicated, regardless of protective factors
Fluoride varnish applied?
Fluoride varnish applied?
Dental referral?
Dental referral?

Patient-Driven Self Management Goals

Certification Training

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

Engage in a Conversation With Your Patient Around Oral Health

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)

Fluoride

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 the CDPHE Community Water Fluoridation page or ilikemyteeth.org for more information.

Billing Guidance

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.
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