Topical Fluoride Application

Policy No: 10A
Originally Created: 01/01/2011
Section: Preventive
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Approved: 01/01/2018
Effective: 01/01/2018


Topical Fluoride application of fluoride varnish (D1206)

Topical Fluoride application of fluoride (D1208)

Interim caries arresting medicament application - per tooth (D1354)
Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.


Procedures are in accordance with generally accepted standards of dental practice.

Brush varnish for application of fluoride, use (D1206)

Brush varnish for desensitizing, use (D9910)

Administrative guidelines

Process to contract benefits.

Note: Brush varnish for application of fluoride is usually done on children ages 17 and under.


CDT - D1000-D1999 - see above.


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