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Fluoride disks for precise, interproximal application: Why you should use them and how to code for it

June 27, 2017
Patti DiGangi, RDH, BS, explains how Phocal fluoride disks can be used for precise, interproximal fluoride application and how you can code for them.
Patti DiGangi, RDH, BS, explains how Phocal fluoride disks can be used for precise, interproximal fluoride application and how you can code for them.
A recent bout of laryngitis and mandated voice rest gave me the opportunity to binge-watch Netflix. But my Netflix binge-watching does not mean I have no desire or need for traditional TV services, especially as I'm a bit of a news junkie.

Fluoride is the most common preventive agent used in dentistry. Phocalfluoride disks (Phocal Therapy) represent a significant breakthrough in the prevention and treatment of interproximal caries infections. This precise fluoride delivery system does not mean there is no need for traditional fluoride systems. Just like Netflix offers us another choice for watching TV, Phocal disks offer us another choice for fluoride application.

Incipient caries infections

The goal of taking annual bitewing radiographs has been to discover carious lesions as early as possible. Margherita Fontana, DDS, PhD, a professor in the department of cariology, restorative sciences, and endodontics at the University of Michigan School of Dentistry defines incipient lesions as early lesions or white spot lesions that have demineralized without evidence of cavitation. (1)

Despite being the standard of caries detection, bitewing radiographs tend to underestimate the depths of lesions. (2) A lesion that appears confined to the inner enamel on an image is often actually in the dentin.(2) This often leads to late diagnosis because a minimum of 40% demineralization is required for a lesion to be evident on a radiograph. (3) This can lead to insufficient or improper treatment. After all, 40% demineralization is fairly advanced for a lesion!

New technologies, materials, and procedures are constantly evolving for earlier arrest and prevention of oral disease. A new code was added for Current Dental Terminology (CDT) 2017 for calibrated instruments that can help us monitor the caries infection process and cavitation. These instruments do not use ionizing radiation. The new code, D0600, can be used for a "nonionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in the structure of enamel, dentin, and cementum."

More than flossing and traditional fluoride

Our traditional approach to incipient lesions has been a flossing lecture and fluoride application.This is insufficient and often fails. What's more is that, when there is progression of the caries infection, the patient is blamed for noncompliance.

The limitations of flossing hit the national media in 2016 when an Associated Press report was published on the subject. (4) After the report was published, many dental professionals reacted to what felt like an attack on our long-held tradition, but multiple systematic reviews support the report's claims about the limitations of flossing, particularly for prevention of interproximal caries infections. (5)

Another issue is the ineffective penetration of active agents. Penetration of active agents is significantly poorer in the interproximal space due to the negative pressure between teeth called isocaps. (6) An isocap is a bubble created between two flat surfaces that prevents liquids from entering it. (6) Basically, isocaps prevent traditional fluoride treatments from reaching between the teeth. (6)

Phocal disks precise fluoride application

Phocal disks are semipermeable fluoride contained in a unique disk form for insertion between the teeth. They represent a precise fluoride application system. Once positioned interproximally, they disrupt the isocaps, then soften and expand to form a gel. The gel created by the Phocal disks prevents and repairs early interproximal decay at the microscopic, nanoscopic, and molecular levels.

Phocal disks are an excellent option for treatment of incipient lesions. There are two types of Phocal disks, each of which contains 0.1135 mg of sodium fluoride:

• Phocal Apf acidulated phosphate fluoride disks induce an optimized, low-pH environment that cleans and etches tooth surfaces. They facilitate deep fluoride penetration and stimulate remineralization.

• Phocal pHn nonacidic sodium fluoride disks are less acidic and will not etch ceramic crowns or tooth-colored restorations. They also induce fluoridation and remineralization.

Caries infections are multifactorial. The caries process is dependent on the interaction of protective and pathologic factors in saliva and plaque biofilm as well as the balance between the cariogenic and noncariogenic microbial populations residing in saliva. (2) Risk assessment will assist in determining of the appropriate choice for this type of fluoride application.

Research indicates that treating incipient lesions with both Phocal fluoride disks and fluoride varnish proves most beneficial. (6) In other words, like Netflix and traditional TV, a combination of fluoride therapies may be ideal.

Accurate codes

When new products and technologies are introduced, a frequently asked question is, "Will insurance cover it?"

Coding and coverage are not the same. Accurate coding does not guarantee coverage under a particular policy. Dental professionals are obligated to use the most accurate code available. CDT codes are risk- and diagnosis-based, not product-based.

Because Phocal is a fluoride product, you might automatically think you should use "D1208—Topical application of fluoride, excluding varnish." The delivery system is not specified, so any professionally applied fluoride qualifies for this code. It does not accurately describe Phocal's unique disk form.

The dual application of Phocal and traditional fluoride varnish proves most beneficial, yet both "D1208—Topical application of fluoride, excluding varnish" and"D1206—Topical application of fluoride varnish"used together would probably be denied, based on contractual language limitations.

A code was added in CDT 2016 that more accurately describes Phocal fluoride disks. It is "D1354—Interim caries arresting medicament application,"which is used for "conservative treatment of [an] active, nonsymptomatic carious lesion by topical application of a caries-arresting or -inhibiting medicament and without mechanical removal of sound tooth structure."(Note:Although many consider this code to be specific to the application of silver diamine fluoride, codes are not product-specific.)D1354 can be submitted for the placement of Phocal disks along with D1206.

Phocal Therapy can provide more information on coding.Ask for the 2017 Codes Submission for Phocal Disks, which includes information on risk assessment, dental-medical necessity narratives, and sample submissions (P. DiGangi, unpublished data, February 2017).

Staying current

The Code Maintenance Committee met on March 9, 2017, and voted to add "per tooth" to the D1354 nomenclature in CDT 2018. This change will not occur until January 1, 2018. (7) Staying current on CDT coding is important for optimizing dental benefits submission and accurate metrics.

Staying current on the variety of programs available to binge-watch can be challenging. Staying current on the variety of preventive options in dentistry can also be challenging. Dental professionals must be lifelong learners. As the saying goes, "Change is the only constant in life." We must always plan and prepare for change in every aspect of our lives. Opportunity is everywhere—even during a bout of laryngitis.

Editor's note: This article first appeared in Pearls for Your Practice: The Product Navigator. Click here to subscribe. Click here to submit a products article for consideration.


1. Cariology, Restorative Sciences, and Endodontics: Margherita Fontana, DDS, PhD. University of Michigan School of Dentistry website. Updated January 2, 2014. Accessed April 22, 2017.

2. Hurlbutt M. CAMBRA: Best practices in dental caries management. RDH magazine website. Published August 2011. Accessed April 22, 2017.

3. Ongole R, Praveen BN, eds. Textbook of Oral Medicine, Oral Diagnosis and Oral Radiology. 2nd ed. New Delhi, India: Elsevier; 2013. Accessed April 22, 2017.

4. Donn J. Medical benefits of dental floss unproven. AP News website. Published August 2, 2016. Accessed June 27, 2017.

5. Hujoel PP, Cunha-Cruz J, Banting DW, Loesche WJ. Dental flossing and interproximal caries: a systematic review. J Dent Res. 2006;85(4):298-305. Accessed April 22, 2017.

6. Jodaikin A, Cooley WE, Lippert F, Martinez-Mier EA. In Vitro Interproximal Enamel Fluoride Uptake as a Function of Fluoride Delivery Vehicles. Compend Contin Educ Dent. 2013;34(4). Accessed April 22, 2017.

7. American Dental Association Code Maintenance Committee. Substantive Action Report: March 2017 – CDBP Code Maintenance Committee (CMC) Meeting – Submissions for CDT 2018. American Dental Association website. Published March 27, 2017. Accessed April 22, 2017.

Patti DiGangi, RDH, BS, is an international speaker and author helping dental professionals to embrace the opportunities and understand the metrics that accurate insurance coding provides. This increases practice profitability while improving the oral-systemic health of the patients we serve. Patti holds publishing and speaking licenses with the American Dental Association (ADA) for Current Dental Terminologyand SNODENT diagnostic coding. She is an ADA Evidence-Based Champion and a member of the National Speaker’s Association. She is the author of the DentalCodeology series of bite-sized books to help dental professionals prepare for the transition toward oral medicine efficiently and profitably. Patti can be reached at [email protected].
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