CurrentDelta Dental of OhioPolicy 282.42.v2

Clinical Criteria for Caries Arresting and Preventive Medicaments

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This policy establishes clinical criteria, documentation requirements, coverage considerations, and coding guidance for applying caries arresting medicaments, including silver diamine fluoride, and tooth-specific caries preventive medicaments. It applies to providers seeking benefit payment when Delta Dental of Ohio must determine whether these services are medically necessary and clinically appropriate.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Caries Arresting and Preventive Medicaments

Policy CodePolicy 282.42.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionDocument a generally accepted indication when the dental plan requires medical necessity and clinical appropriateness review before benefit payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Applicable CDT procedure codes

6 lifetimeMaximum D1354 applications

1 unitD1354 payment limit per date of service

Per tooth

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CurrentDelta Dental of OhioPolicy 282.42.v2

Clinical Criteria for Caries Arresting and Preventive Medicaments

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Sign up for deltadentalofohio Policy 282.42.v2 alerts

Get alerted when Policy 282.42.v2 changes without checking for updates manually.

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Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Caries Arresting and Preventive Medicaments

Policy CodePolicy 282.42.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionDocument a generally accepted indication when the dental plan requires medical necessity and clinical appropriateness review before benefit payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Applicable CDT procedure codes

6 lifetimeMaximum D1354 applications

1 unitD1354 payment limit per date of service

Per tooth

Unit of service for D1354 and D1355

No same-tooth restoration or crownD1354 payment restriction

Primary or permanentDentition addressed

Clinical Coverage Criteria

Caries Arresting Medicaments

Caries arresting medicaments may be considered when the patient's record documents a generally accepted indication and the treatment is medically necessary and clinically appropriate, subject to the member's dental benefit program.

Caries arresting indication

Qualifying circumstances: Conventional restoration would be difficult, including caries in hard-to-access areas such as furcations or restoration margins; the patient lacks access to or has difficulty finding conventional dental treatment; the patient has cognitive, behavioral, or compliance issues such as young age, autism, or dementia; or multiple carious lesions cannot be treated in one appointment.
Additional potentially beneficial circumstances: Vulnerable tooth surfaces such as roots exposed by periodontal disease; conservative secondary treatment for anterior or posterior teeth susceptible to decay; stand-alone treatment of dentinal hypersensitivity; elevated caries risk due to disease- or drug-induced xerostomia; or active, non-symptomatic lesions in a patient with limited life expectancy or a disqualifying medical condition precluding conventional restorative care.

Individualized application: Frequency of application is based on patient characteristics, ongoing caries risk assessment, and medical and dental health status.

Coverage remains subject to the individual's dental benefit program and any program-specific criteria or limitations.

Caries Preventive Medicaments

Caries preventive medicaments may be considered when the patient's record documents a generally accepted indication and the treatment is medically necessary and clinically appropriate, subject to the member's dental benefit program.

Caries preventive indication: The patient has an elevated risk of developing caries, and one or more primary or permanent teeth have no evidence of a carious lesion and are diagnosed as needing primary prevention or remineralization of unrestored tooth surfaces to prevent caries initiation.

The procedure is tooth-specific and does not include full-mouth topical fluoride application.

Evidence limitation for SDF prevention: SDF use for primary caries prevention on undecayed teeth is supported by limited evidence; the AAPD stated in 2021 that insufficient efficacy evidence prevents support for SDF as a primary preventive agent.

Coverage remains subject to the individual's dental benefit program and any program-specific criteria or limitations.

Caries arresting medicaments are not appropriate when the involved teeth have no evidence of dental caries, have non-incipient advanced caries, show pulpal involvement or pathology, have been or need to be restored, are near exfoliation, or are planned for extraction.

Application may be considered not medically necessary or inadvisable for a patient with an allergy to silver or another medicament component, current mucosal ulcers or irritation, or a condition predisposing to desquamative gingivitis or mucositis. These considerations also apply when the patient is pregnant or breastfeeding, cannot cooperate with effective application, or has anterior caries in which esthetics are a primary concern.

Primary preventive use of a caries arresting medicament is excluded from the qualifying indications because current evidence is insufficient. Coverage may also be disapproved when an alternative treatment is more appropriate for the patient's condition or circumstances under accepted standards of care.

D1354 is not payable when billed in conjunction with a restoration or crown on the same tooth.

Application may be determined not medically necessary, inadvisable, or deficient in clinical quality when a listed contraindication or nonqualifying circumstance is present, including absent caries, non-incipient advanced caries, pulpal pathology, a planned restoration or extraction, inability to cooperate, pregnancy or breastfeeding, anterior caries where esthetics are a primary concern, or use of an alternative treatment that is more appropriate under accepted standards of care.

SDF applied to undecayed teeth for primary caries prevention may be determined unsupported because evidence of efficacy is insufficient. The AAPD stated in 2021 that it could not support SDF for primary prevention of caries on undecayed teeth.

Procedure Codes and Billing Limits

Applicable Dental Procedure CodesCDT

D1354	Application of caries arresting medicament - per tooth. 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.
D1355	Caries preventive medicament application - per tooth. For primary prevention or remineralization. Medicaments applied do not include topical fluorides.

D1354 Lifetime Application Limit

Procedure codeD1354 — Interim caries arresting medicament application

Lifetime limit6 applications per lifetime

Application typeCaries arresting medicament application

D1354 Date-of-Service Payment Limit

Procedure codeD1354 — Interim caries arresting medicament application

Payment limitOne flat-rate unit per patient per date of service

Applies regardless of

Authorization, Documentation, and Payment Considerations

Prior Authorization

Plan-Required Medical Necessity Review

When the member’s dental plan requires Delta Dental of Ohio to determine whether a caries arresting medicament is medically necessary and clinically appropriate before benefit payment, document a generally accepted indication in the dental record and submit the required supporting records with the claim.

Coverage may be subject to government regulations and the specific provisions of the member’s dental plan, which may take precedence over these clinical criteria.
For caries arresting medicaments, generally accepted indications include conservative treatment of active, anterior or posterior, nonsymptomatic carious lesions in primary or permanent teeth; difficult-to-restore lesions; limited access to conventional treatment; cognitive, behavioral or compliance issues; multiple lesions not treatable in one visit; vulnerable tooth surfaces; conservative secondary treatment; or stand-alone treatment of dentinal hypersensitivity.
For caries preventive medicaments, document elevated caries risk and the specific teeth requiring primary prevention or remineralization of unrestored surfaces; plan-specific medical-necessity and coverage criteria apply.

Clinical Background

Caries arresting medicaments provide a conservative option for managing active, non-symptomatic carious lesions through topical application without mechanically removing sound tooth structure. This approach may be useful when physical, developmental, psychosocial, access, or medical barriers limit conventional restorative care.

Key Terms

Caries Arresting Medicament Application

Treatment conceptConservative treatment of an active, non-symptomatic carious lesion

Application methodTopical application of a caries arresting or inhibiting medicament

What is avoidedMechanical removal of sound tooth structure

Caries Preventive Medicament Application

Application purposePrimary prevention or remineralization

ScopeTooth-specific application

Excluded medicamentsTopical fluorides are not included

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Caries Arresting and Preventive Medicaments

Policy CodePolicy 282.42.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionDocument a generally accepted indication when the dental plan requires medical necessity and clinical appropriateness review before benefit payment.

SourceLink

On This Page

Units billed or teeth treated

Documentation Required

Document the Diagnostic Rationale

Submit documentation explaining why a caries arresting medicament was selected instead of conventional caries removal and restoration. For preventive medicaments, explain the elevated risk of caries development and identify the specific teeth involved, with relevant dental and medical history.

The rationale must be consistent with the patient record and the proposed treatment plan.
Include supporting information from the patient’s dental and medical histories.

Documentation Required

Submit Diagnostic Imaging

Base the decision to apply a caries arresting or preventive medicament on a thorough clinical and radiographic examination. Include recent diagnostic-quality preoperative radiographs of involved teeth when applicable, and add intraoral photographs when radiographs do not adequately demonstrate the need for the submitted services.

Radiographs should clearly show the caries involved, if applicable.
Intraoral photographs should document the involved teeth when needed to support the submitted service.

Documentation Required

Complete the Examination and Maintain Records

Complete and retain a thorough clinical examination and appropriate treatment plan before applying the medicament. When coverage depends on medical necessity or clinical appropriateness, Delta Dental of Ohio may request additional clinical information relevant to the patient’s care; inability to provide applicable records may result in disapproval of benefit payment.

Submit applicable records from the patient’s dental record with the claim.
Ensure the examination and treatment plan support the selected medicament and the patient’s condition.
Respond to requests for other clinical information needed to make a coverage determination.

Denial Risk

Caries Arresting Medicament Disapproval Risks

Benefits may be disapproved when application of a caries arresting medicament is not medically necessary, not clinically appropriate, inadvisable, or deficient in clinical quality. For patients outside the published qualifying criteria, relevant clinicians may submit documentation explaining why coverage is necessary for the condition.

Allergy to silver or another medicament component; current mucosal ulcers, irritation, or conditions predisposing to desquamative gingivitis or mucositis.
No evidence of caries, non-incipient advanced caries, pulpal involvement or pathology, or a tooth that has been or needs to be restored.
Teeth near exfoliation or planned for extraction; pregnancy or breastfeeding; or inability to cooperate with effective application.
Anterior caries when esthetics are a primary concern, or use as a primary preventative agent; current evidence is insufficient for primary prevention.
An alternative treatment is more appropriate under accepted standards of care.
Coverage may be considered for progression management in patients with elevated caries risk due to disease- or drug-induced xerostomia, depending on the individual’s condition and circumstances.

Denial Risk

Preventive Medicament Coverage Risks

Coverage for a caries preventive medicament depends on the member’s specific dental benefit program. The program may allow, limit, or exclude the procedure, may cover only specified medicaments or circumstances, or may exclude coverage in all circumstances.

Confirm benefit eligibility under the individual dental benefit program before relying on payment.
Apply any program-specific medical-necessity criteria or other limitations established for caries preventive medicaments.
Evidence supporting SDF for primary prevention on undecayed teeth is limited; the AAPD stated in its 2021 Policy and Fact Summary that insufficient evidence prevents support for this use.

Billing Rule

D1354 Benefit Limitations

For D1354, apply the payment restrictions when submitting interim caries arresting medicament application. These limits apply regardless of the number of units billed or teeth treated.

No payment is made in conjunction with a restoration or crown on the same tooth.
Payment is limited to one flat-rate unit per patient, per date of service.
Coverage is limited to six applications per patient lifetime.

Silver Diamine Fluoride (SDF)

AgentTopical caries arresting agent

CompositionApproximately 25% silver, 5% fluoride, and 8% ammonia by weight

MechanismSilver provides antimicrobial activity, fluoride promotes remineralization, and ammonia stabilizes the solution