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Anticipatory Guidance and Fluoride Varnish 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 at the 6 month of age visit, physicians should counsel caregivers on oral health, perform a dental screening for visual signs of decay and assess the child’s oral health, and provide anticipatory guidance. Physicians 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 (AAP), the American Dental Association (ADA), and the American Academy of Pediatric Dentists (AAPD).

What is fluoride?

A natural mineral found in water. It strengthens the surface of the tooth against decay.

What is fluoride varnish?

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.

What is the benefit to the medical care provider offering fluoride varnish in the medical setting?

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 seen by a dentist.

Who can apply fluoride varnish?

Medical providers can apply fluoride varnish to infants’ teeth, ages birth to age 3. A doctor, nurse practitioner, physician’s assistant, nurse, registered nurse, and medical assistant (MA) can provide fluoride varnish after receiving the required training.

What does a medical provider need to do to start providing fluoride varnish?

Medical providers should complete the Illinois Bright Smiles from Birth fluoride varnish program or the Course 2 and Course 6 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 emphasizing the importance of oral health care, help to improve self-care practices, and connect to follow up dental care, including periodontal treatment if needed.

What key objectives are in the training modules?

  • Describe the pathogenesis of early childhood caries (ECC)
  • Determine risk factors associated with ECC
  • Conduct an oral health screening and apply fluoride varnish
  • Provide anticipatory guidance to families, including parents
  • Referral to dental home when appropriate
  • State the importance of pediatricians’ role in oral health

What supplies are needed?

  • 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)

Is the fluoride varnish treatment a reimbursable expense?

Upon completion of the training modules, 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 rates is available on the HFS Fee Schedule website.

How is fluoride vanish applied?

  1. Use of the knee-to-knee position with the child under age 3 to provide the oral health assessment is advised.
  2. Clean and dry the teeth with gauze (a child-sized toothbrush can also be used).
  3. Apply the fluoride varnish. Attempt to cover all sides of the clinical crowns.
  4. Instruct the parent to not brush the child’s teeth until the next day. Eating and drinking can resume right away, but avoid hard, crunchy, or hot foods.

Fluoride varnish video can be found here.

What is the effectiveness of fluoride varnish?

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.

When should the medical provider refer to a dentist?

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

What other oral health anticipatory guidance should be discussed?

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, 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 problems with breastfeeding. 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.