Fluoride Application for the Medical Provider

Improving access to dental care for at-risk infants is a considerable task, one that requires an interdisciplinary approach. Medical providers see this age group more frequently, so they are in a unique position to support the dentist’s efforts to educate and to intervene when poor oral health is diagnosed.

Beginning upon the eruption of the first tooth, physicians, nurse practioners, physician assistants, and all other health care providers should counsel parents/caregivers on oral health, perform a dental screening for visual signs of decay, and assess the child’s oral health, and provide anticipatory guidance.

Health care providers should refer children to a dental home for routine and periodic preventive dental care within six months of the eruption of the first tooth or by age 1, as per recommendations by the American Academy of Pediatrics, the American Dental Association, and the American Academy of Pediatric Dentists.

A natural mineral when present in water at optimal concentrations strengthens developing teeth and strengthen surfaces of developed teeth against decay.

A thin coating of 5% sodium fluoride varnish resin applied to surfaces of teeth to protect from decay. Over time, varnish releases fluoride which “re-mineralizes” and strengthens the teeth.

Medical providers have the earliest, most consistent contact with children. The medical provider may identify a problem, such as advanced tooth decay that can be slowed down by applying fluoride varnish until the child is able to be cared for by a dentist.

Medical providers can apply fluoride varnish to infants’ teeth, ages birth to age 6. A doctor, nurse practitioner, physician’s assistant, nurse, registered nurse, and medical assistant can provide fluoride varnish after receiving the required training.

Medical providers should complete Child Oral Health and Caries Risk Assessment, Fluoride Varnish, and Counseling of the Smiles for Life, an Oral Health Curriculum. Once completed, providers will be able to bill for fluoride varnish services. This activity offers medical providers a “whole health” strategy that emphasizes the importance of oral health care, helps to improve self-care practices, and connects to follow up dental care, including, if needed, periodontal treatment.

• Describing the pathogenesis of early childhood caries (ECC)
• Determining risk factors associated with ECC
  
• Conducting an oral health screening and apply fluoride varnish
  
• Providing anticipatory guidance to families, including parents
  
• Referrals to dental home when appropriate
  
• Stating the importance of pediatricians’ role in oral health
  

• Consent for treatment
• Risk assessment form
  
• Fluoride varnish
  
• Application brush
  
• Non-latex gloves
  
• Gauze
  
• Mouth mirror or tongue depressor
  
• Light source
  
• Child-sized toothbrush (optional)
  

• For an infant, place the child on the parent or caregiver’s lap with the head on their knees and the child’s legs wrapped around the waist of the parent/caregiver. Position yourself knee-to-knee with the parent and treat the child from above the head.
• Or place an infant or young child on an exam table and work from above the head.
  
• Or adapt a method that works for you.
  

• Use of the knee-to-knee position, exam table, or the method that works best for the under the age of 3 child to provide the oral health assessment.
• Using gentle finger pressure, open the child’s mouth.
  
• Clean and dry the teeth with a gauze sponge. The teeth must be relatively dry.
  
• Use your fingers and sponges to isolate the dry teeth. You will usually be able to isolate a quadrant of teeth at a time. Note there will be fewer teeth to work with in younger children.
  
• Apply a thin layer of the varnish to all surface of the teeth.
  
• Once applied, the varnish sets quickly. You need not to worry about saliva contamination or the child swallowing the varnish.
  
• A fluoride varnish video can be found here.
  

• Eat a soft, non-abrasive diet for the rest of the day
• Do not brush until the next day
  
• Tell the parent/caregiver the teeth will not be white or shiny until the next day
  

Upon completion of the training modules Child Oral Health and Caries Risk Assessment, Fluoride Varnish, and Counseling of the Smiles for Life, an Oral Health Curriculum, primary care providers in Illinois are eligible to receive Medicaid reimbursement for the application of fluoride varnish on children under 3 years of age.

Current protocol for reimbursement for fluoride varnish application by non-oral health medical staff can be found here.

The procedure code for application of varnish is D1206. Information about the Illinois Department of Healthcare and Family Services’ (HFS) reimbursement rate is available on the HFS Fee Schedule website.

• Fluoride varnish prevents or reduces caries in the primary teeth of young children
• Fluoride varnish may arrest early active enamel lesions in the primary dentition
  
• The preventive effect is strongest when fluoride varnish applications begin before the onset of detectable dental caries in high-risk populations
  

An oral health screening is part of the physical examination but does not replace referral to a dentist. Dental benefits for children include services for treatment of early childhood caries, relief of pain and infections, restoration of teeth, dental sealants, prophylaxis, and maintenance of dental health, including instruction in self-care oral hygiene procedures. Dental care for children is not limited to emergency services.

Parents should be encouraged to establish a dental home for infants by 12 months of age and receive all necessary dental care services to include:

• A thorough oral examination
• Performance of an age-appropriate tooth and gum cleaning demonstration
  
• Fluoride varnish treatment, if indicated
  
• Assessing the infant’s risk of developing caries and determining a prevention plan
  
• Anticipatory guidance regarding the effects of diet on the dentition
  
• Use of fluoride toothpaste
  
• Determination for periodic re-evaluation

Caries management of infants and toddlers with known risk factors for early childhood caries should receive anticipatory guidance for the following:

• Injury prevention counseling to prevent orofacial trauma. Discussions should include play objects, pacifiers, car seats, strollers, and electric cords.
• Counseling regarding teething. While many children have no apparent difficulties, teething can lead to intermittent localized areas of discomfort, irritability, and excessive salivation.
  
• Use of topical anesthetics, including over-the-counter teething gels, to relieve discomfort should be avoided due to potential toxicity of these products in infants.
  
• Discussion regarding atypical frenum attachments that may be associated with breastfeeding problems. In some cases, frenuloplasty or frenectomy may be a successful approach to facilitate breastfeeding.
  
• Counseling regarding non-nutritive oral habits (e.g., digit or pacifier sucking, bruxism, abnormal tongue thrust) that may apply forces to teeth and dentoalveolar structures. It is important to discuss the need for early sucking and the need to wean infants from these habits before malocclusion or skeletal dysplasia’s occur.
  

• American Academy of Pediatrics